Oby: From the campus of Harvard Medical School, this is ThinkResearch, a podcast devoted to the stories behind clinical research. I'm Oby, your host. Think Research is brought to you by Harvard Catalyst, Harvard University's Clinical and Translational Science Center, and by NCATS, the National Center for Advancing Translational Sciences.

Join us today as we hear from Dr. Christina Cifra about diagnostic safety specific to reducing and eliminating diagnostic error. Dr. Cifra is an assistant professor of pediatrics at Harvard Medical School and is a health and services patient safety researcher in the field of diagnostic excellence. She is a practicing pediatric intensivist in the Division of Medical Critical Care at Boston Children's Hospital.

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Christina Cifra: Hi. My name is Tina Cifra. I'm Filipino. I grew up in Manila in the Philippines. Never really wanted to leave the Philippines, but fate has other plans and led me here. My mother was the biggest influence of all in my life and my work. My mother was a pediatric intensivist, as I am now. I'm also a health services researcher focusing on patient safety, specifically diagnostic safety and diagnostic error and how to prevent it.

My original plan really was to train with her in the Philippines and really practice intensive care there. However, she died before these plans came to pass. I was in my third year of residency at the Philippine General Hospital when she passed away. And I decided to come here instead.

Her name was Herminia Lopez Cifra, and she was a force. She was not only a pediatric intensivist. She was one of the founders of pediatric critical care as a specialty in the Philippines. Basically cobbled together her pediatric critical care training from Australia and Europe to become a pediatric intensivist because back in those days, they didn't really have training for pediatric critical care.

She was a neonatologist by training but became a pediatric intensivist and started the pediatric intensive care unit in the Philippine General Hospital and also at the Philippine Children's Medical Center, which is a freestanding children's hospital in Manila. She also started fellowship programs and invited renowned people from around the world to build a field in the Philippines.

She was such an inspiration to me, although she wasn't really involved with research. She was a clinician through and through. What really inspired me with her was that I saw how slowly but surely a vision can be brought to life and that big things can happen through incremental change. And I think my mother was such a good example of that.

When I moved to the United states, I had the intention of becoming an intensivist like my mom. I redid my pediatric residency at the University of Maryland in Baltimore. After that, I did my fellowship at Johns Hopkins. At Johns Hopkins, I was turned into the world of patient safety. That was in 2014.

It had been 14 years, at that time, since the landmark National Academy of Medicine report To Err is Human was published. And that was the landmark publication based on the Harvard medical practice study by Lucian Leape and David Bates that showed how big of a problem medical error has been for US health care. It showed how patient safety needed to be a priority for clinicians, researchers, administrators, the government, and ordinary citizens.

And when I was a fellow in 2014 at Hopkins, they had just received funding to build the Armstrong Patient Safety Institute. I believe the whole name of the institute was Johns Hopkins Armstrong Institute for Patient Safety and Quality. And they had all of these programs educating clinicians and researchers on patient safety and how to do rigorous scholarly work on patient safety. So that was a big influence on me.

What I really came away with that is that patient harm is not the status quo. Patient harm and medical error is not the price of doing business in medicine. It's something that we should strive to reduce and to get to zero if we can. At that time, I also started seeing patient safety as a field of scholarly work. During my time at Hopkins, I did a lot of training in quality improvement and clinical research, and I tried to marry the two. That was kind of like my awakening as a researcher.

As you can see, I came to it pretty late because I was already a fellow by the time that I started doing research, as opposed to other folks who have been doing research from their undergraduate years.

I thought that diagnostic safety and diagnostic error was the most interesting of all medical errors. And I think it's interesting to understand, very complicated to disentangle as two contributing factors and how to mitigate it. It's also extra interesting for me because I feel like it provides a window into the mind of a physician-- and not just physicians, into clinicians in general.

I really enjoy thinking about it because it combines both cognitive processes and systems processes that combine to either create excellent diagnosis, meaning diagnosis that is accurate and timely, versus diagnostic error. We all know the consequences of diagnostic error, which can be truly devastating.

When I was a fellow, I was assigned to coordinate the pediatric ICU's Morbidity and Mortality Conference. At that time, my focus, really, just getting my feet wet in patient safety work, was to transform the M and M Conference into a venue for improving safety, for improving systems. I like to think that we've accomplished that. But a happy-- or maybe fortuitous is the better word accident of my being involved in the M and M is that I noticed just how many diagnostic errors were being volunteered by physicians.

So we can talk about it at M and M. And there were two things that I got from that. One is that diagnostic error is something that's not easy to discern. The most common error surveillance mechanisms at that time, which is really mostly incident reporting, didn't really surface diagnostic errors. Physicians don't really want to write about their diagnostic errors, but they do want to talk about it. And the M and M provides that venue.

The second thing I thought was that diagnostic errors were quite complex, and it requires much conversation to understand why a diagnostic error occurred. And M and M provided that space for clinicians to discuss it. And if they think that space is safe, or at least not dangerous to their careers or their reputation, they will be more than willing to talk about it and find ways to mitigate it.

After these big influences, after I had had a taste of studying patient safety and knowing that I can transform it into scholarly work and research and finding a topic of patient safety that I was really passionate about, like diagnostic safety, at that point, I was off to the races.

My research has mainly focused on the epidemiology of diagnostic error in pediatric critical care. My interest is in understanding the diagnostic process for critically ill children throughout their continuum of care-- so not necessarily just in the pediatric intensive care unit. I was really interested in knowing how the diagnostic process works from the time the child becomes critically ill, mostly in community settings, in emergency departments across the country, and what happens when they get transported and transferred to a higher level of care, which is usually to a pediatric intensive care unit.

And then, when they get admitted, how do pediatric intensivists and the rest of the PICU clinical team think about them and think about their diagnosis? I was interested in piecing out what the vulnerabilities are in the diagnostic process and how can I develop interventions to address that.

My research has been heavily retrospective to this point, with lots of qualitative work sprinkled in between, where I've done multicenter retrospective studies of the epidemiology of diagnostic error, looking at potential contributions and associations to error and consequences of error and quantifying the harm from diagnostic error.

A recent multicenter study that we just published studying diagnostic errors in four tertiary referral pediatric intensive care units across the country showed that the rate of errors was actually small. It was less than 2%. But we were very conservative in determining what a diagnostic error is. So I really do think that that is most likely an undercount.

What was really interesting about this study was that we found that diagnostic uncertainty, which is defined as a clinician's subjective perception, that they're unable to explain a patient's presenting problem or they are unsure of what could be causing a patient's specific set of symptoms. So we found that diagnostic uncertainty is associated, highly associated with diagnostic error.

And I think that gave us the opening as something that can be measured and screened for at admission. I do think that looking for or identifying diagnostic uncertainty and finding systematic ways to mitigate it and address it at the outset of a child's PICU admission would help us prevent diagnostic errors down the line.

One other thing that my research has led me to was that when we were doing ethnography, meaning observations and interviews of PICU staff, patients, and parents when patients get admitted to the ICU-- when we are doing this qualitative work, one of the things that we found that was quite vulnerable in the diagnostic process on admission was that interface between the community setting and the pediatric ICU for external transfers.

So when children are admitted to the pediatric intensive care unit from other settings, usually physicians talk to each other about their findings, the results of their diagnostic testing, what they think is going on, and what they predict the patient will need in the future and what the appropriate management would be. This conversation is called a handoff of care.

In my mind, to me, for these patients, it's more of a diagnostic process handoff. It's a way of coming to the same mental model of a patient and conveying to someone else and that other person, making sure that they receive a similar mental model as the other person and then refining their own mental model on their end.

So I think the process is very interesting for me in terms of what I'm studying currently, which is how to improve that interfacility transfer of information, that creation of shared mental models across institutions, between clinicians who might have different expertise and different backgrounds and training for the benefit of the critically ill patient.

What we're currently working on right now includes looking for understanding diagnostic uncertainty in the pediatric intensive care unit, finding ways to mitigate and address this uncertainty. We're also studying the interfacility referral communication process, finding ways in which the diagnostic process handoff can be improved throughout this process. And on the back end, finding ways to feed back patient outcomes to referring clinicians so that they can find out what happened to their patients, which will only improve their practice moving forward.

I got started with patient safety work a lot of the time because I wanted to fix those little things that annoyed me so much about clinical work, that I know could be fixed by making systems changes. Some people work on medication prescribing and administration, for example, as a workflow that they're trying to improve. What I'm trying to improve is the systems of diagnosis that forms a through line from patients, their families, clinicians, teams, all the way to systems.

I think that improving diagnosis, making sure that we're striving for diagnostic excellence will improve the lives not just of patients, but their families, will avoid adverse events, will avoid unnecessary treatments, will allow them more time to enjoy life and their families, and will also improve the lives of clinicians by making the diagnostic process more knowable and more tractable.

I think it will also be very beneficial for students and trainees who are just learning how to diagnose to find ways to be able to make diagnoses more transparent or the process, if not easier, but more understandable. I think that this research also will help us better study diagnosis and that intricate process that we engage in as clinicians every day.

I think that this work provides a window into the minds of clinicians, but it also provides a window into the systems of diagnosis that we move around in and how those two integrate together. And I think this will illuminate research moving forward into improving diagnosis.

In terms of everyday life, the National Academy of Medicine said that every American, at least once in their lifetime, will likely experience a diagnostic error, some of which will have devastating consequences. And I think making an impact in this field will affect everyone in terms of ensuring that the diagnostic process goes as planned whenever we go to see our physician.

Everyone deserves an optimal diagnostic process. And I think some of the more recent work on equity and diagnosis has been quite poignant in showing that improving this process can also improve equity for marginalized people.

What do I hope people will understand from my research? A few things. The first is that diagnosis is a team sport, and I think doctors for sure need to understand this. It used to be that there was an idea of a master clinician, the master diagnostician. And I don't think that's true anymore. I don't think anybody practices in a vacuum anymore.

I think that most physicians practice in teams, and we deliver therapy as a team. We perform surgery as a team. I think the same is true for diagnosis. We make diagnoses together. We think together. And the more that we work towards working as a team for better diagnosis, the better our diagnosis will be.

The other thing that I've learned that I hope people will understand is that diagnosis can be improved by systems improvements the same way that other processes in medicine has been improved by system changes because diagnosis does not merely occur between the two ears of the clinician. It definitely means that we can track the process. Therefore, we can improve it.

And when I declared to a few senior folks before, years ago, that I wanted to study diagnostic error, they tried to dissuade me from it. And I think they had my best interests in mind because they know that it's a hard topic to study. What I want people to take away from my work is that hard things are worth studying. And I think the diagnostic process is difficult to grasp. But nevertheless, we need to strive for diagnostic excellence. Therefore, we need to study it to be able to improve it.

And the last thing that I want people to take away from my work is that being able to improve the outcomes of critically ill children and theirs and their families' lives, we have to look beyond the ICU. So what I've learned with my work on interfacility communication is that critical illness does not only occur within the four walls of a pediatric ICU. You can make such a big impact in the outcomes of the critically ill, even before, for example, they get to the unit or maybe even after, when they go into rehab.

I think that intensivists should be able to leverage their place within the continuum of care to be able to provide-- to be able to strive for the best outcome possible for their patients. And I think my work in looking at how the diagnostic process is handed off from clinical team to clinical team across the continuum of care for critically ill kids will illustrate that.

I think I'm at the point where I'm fast approaching the tail end of being a junior investigator. I think my next step is really scaling up my work. And this involves building multicenter research networks, which we've started to do, and providing a bigger stage for this work.

Training the next generation of diagnostic excellence scholars is also one of my goals so that the next cohort of diagnostic safety researchers can be ready to receive the torch.

Another one of my goals for the next few years would be to build and strengthen a diagnostic excellence community here in New England. There are a lot of people around here, not just physicians, but nurses, patient advocates, patient representatives, hospital administrators, social workers, lots of different people who need a voice in the diagnostic excellence community.

And I think to build that and strengthen that community here in New England would be a great step forward into continuing this research and for it to have a broader reach.

Oby: Thank you for listening. If you enjoyed this episode, please rate us on iTunes and help us spread the word about the amazing research taking place across the Harvard community and beyond. We are always looking to connect and collaborate with the research community and would like to hear from you. Please feel free to email us at onlineeducation.catalyst.harvard.edu to inquire about being a guest on the podcast.

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