Diagnosis under pressure

It is true to say that our judgement is not always at it’s best when we are stressed or under time pressure. In a recent paper (Plessas et al., 2019 ) a research team  placed 40 dentist under time pressure to assess a number of dental radiographs and compared it to the same groups results if they has as much time as they felt necessary.  Their conclusion was:

Time pressure negatively impacts one aspect of dentists’ diagnostic performance, namely sensitivity (increased diagnostic errors and omissions of pathology), which can potentially affect patient safety and the quality of care delivered.

Since this study was based about diagnostic test accuracy (DTA) I felt it might be interesting to express this result graphically, and the author was kind enough to provide me with the raw data from the research. The  data was extracted into  excel and then analysed using the statistical package ‘mada’ in R to  create a summary receiver operator characteristic (sROC).

The Results

The ellipse with circle surrounded by the solid line represents the summary estimate for diagnosis with time pressure (TP) and 95% confidence interval, and the ellipse with triangle surrounded by the dotted line represents the summary estimate for diagnosis with no time pressure (NTP).

Diagnostic test accuracy (sROC curve)Time pressure

Sensitivity = 0.551 (95%CI: 0.439 to 0.658)

False positive rate = 0.006 (95%CI: 0.004 to 0.01)

No time pressure

Sensitivity = 0.797 (95% CI: 0.692 to 0.873)

False positive rate = 0.009 (95%CI: 0.006 to 0.13)

Summary result

The difference between TP and NTP are statistically significant p=0.0007

In absolute terms there was a 24.6% reduction in correct diagnosis under TP.

In relative terms there was a 40% reduction in correct diagnosis under TP.

My conclusion

When under stress or significant time pressure there was a significant reduction in the clinician ability to diagnose pathology (from 80% to 55%) but a misdiagnosis of ‘normal’ was very low in both scenarios.

Acknowledgements

I would like to thank the authors for allowing me access to their data

Plessas, A., Nasser, M., Hanoch, Y., O’Brien, T., Bernardes Delgado, M. and Moles, D. (2019) ‘Impact of time pressure on dentists’ diagnostic performance’, Journal of Dentistry, 82, pp. 38–44. doi: 10.1016/j.jdent.2019.01.011.

How well do different treatments perform?

How successful are your treatment options

I have compiled a short list of risk relating to advanced dental treatment. Most marketing material relating to dentistry tends to only show success and how they will improve you health, well being and looks. What they don’t mention is the how long that treatment is going to last and the risk of it not working. It is extremely important that the patient can make an educated decision with their dentist as to the amount of risk they are prepared to accept before staring any advanced dental treatments

The figures are given in terms of Success

Implant placement (after 5 years)

Implant retained crown/bridge 96 in 100 at 5 years

Conventional crown and bridge

Back teeth 95 in 100 at 5 years

Front teeth 86 in100 at 5 years

Resin bonded bridge 87 in 100 at 5 years

Post retained 80 in 100 at 5 years

Treatment to resolve gum disease

Non surgical gum treatment 90 in 100 at 5 years

Surgical gum treatment 80 in 100 at 5 years

Root fillings

Root fill + crown (back tooth) 93 in 100 at 5 years

Root fill only (back teeth) 75 in 100 at 5 years

If you want to read further follow this link to Evidence Based Dentisty

Click to access 6400565a.pdf

EAO Conference 2010