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Dhaliwal G. 'This time is different': physician knowledge in the age of artificial intelligence. BMJ Qual Saf 2024; 33:549-551. [PMID: 38702181 DOI: 10.1136/bmjqs-2024-017141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 05/06/2024]
Affiliation(s)
- Gurpreet Dhaliwal
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
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2
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Boyle JG, Walters MR, Jamieson S, Durning SJ. Reframing context specificity in team diagnosis using the theory of distributed cognition. Diagnosis (Berl) 2023; 10:235-241. [PMID: 37401783 DOI: 10.1515/dx-2022-0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 05/17/2023] [Indexed: 07/05/2023]
Abstract
Context specificity refers to the vexing phenomenon whereby a physician can see two patients with the same presenting complaint, identical history and physical examination findings, but due to specific situational (contextual) factors arrives at two different diagnostic labels. Context specificity remains incompletely understood and undoubtedly leads to unwanted variance in diagnostic outcomes. Previous empirical work has demonstrated that a variety of contextual factors impacts clinical reasoning. These findings, however, have largely focused on the individual clinician; here we broaden this work to reframe context specificity in relation to clinical reasoning by an internal medicine rounding team through the lens of Distributed Cognition (DCog). In this model, we see how meaning is distributed amongst the different members of a rounding team in a dynamic fashion that evolves over time. We describe four different ways in which context specificity plays out differently in team-based clinical care than for a single clinician. While we use examples from internal medicine, we believe that the concepts we present apply equally to other specialties and fields in health care.
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Affiliation(s)
- James G Boyle
- Undergraduate Medical School, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Matthew R Walters
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Susan Jamieson
- Health Professions Education Programme, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Steven J Durning
- Center for Health Professions Education, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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3
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Boyle JG, Walters MR, Jamieson S, Durning SJ. Sharing the Bandwidth in Cognitively Overloaded Teams and Systems: Mechanistic Insights from a Walk on the Wild Side of Clinical Reasoning. TEACHING AND LEARNING IN MEDICINE 2022; 34:215-222. [PMID: 34167387 DOI: 10.1080/10401334.2021.1924723] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 06/13/2023]
Abstract
IssuePrevious work from the diagnostic error literature has provided indirect evidence that faulty clinical reasoning may be the most frequent cause of error when attaching a diagnostic label. The precise mechanisms underlying diagnostic error are unclear and continue to be subject to considerable theory informed debate in the clinical reasoning literature. Evidence: We take a theoretical approach to merging these two worlds of literature by first zooming out using distributed cognition as a social cognitive lens (macro theory) to develop a view of the process and outcome of clinical reasoning occurring in the wild - defined as the integrated clinical workplace - the natural habitat of clinicians working within teams. We then zoom in using the novel combination of cognitive load theory and distributed cognition to provide additional theoretical insights into the potential mechanisms of error. Implications: Through the lenses of distributed cognition and cognitive load theory, we can begin to prospectively investigate how cognitive overload is represented and shared within interprofessional teams over time and space and how this influences clinical reasoning performance and leads to error. We believe that this work will help teams manage cognitive load and prevent error.
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Affiliation(s)
- James G Boyle
- Undergraduate Medical School, School of Medicine, Dentistry and Nursing, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Matthew R Walters
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Susan Jamieson
- Health Professions Education Programme, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Steven J Durning
- Center for Health Professions Education, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Schaller-Paule MA, Steinmetz H, Vollmer FS, Plesac M, Wicke F, Foerch C. Lessons in clinical reasoning - pitfalls, myths, and pearls: the contribution of faulty data gathering and synthesis to diagnostic error. Diagnosis (Berl) 2021; 8:515-524. [PMID: 33759405 DOI: 10.1515/dx-2019-0108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/08/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Errors in clinical reasoning are a major factor for delayed or flawed diagnoses and put patient safety at risk. The diagnostic process is highly dependent on dynamic team factors, local hospital organization structure and culture, and cognitive factors. In everyday decision-making, physicians engage that challenge partly by relying on heuristics - subconscious mental short-cuts that are based on intuition and experience. Without structural corrective mechanisms, clinical judgement under time pressure creates space for harms resulting from systems and cognitive errors. Based on a case-example, we outline different pitfalls and provide strategies aimed at reducing diagnostic errors in health care. CASE PRESENTATION A 67-year-old male patient was referred to the neurology department by his primary-care physician with the diagnosis of exacerbation of known myasthenia gravis. He reported shortness of breath and generalized weakness, but no other symptoms. Diagnosis of respiratory distress due to a myasthenic crisis was made and immunosuppressive therapy and pyridostigmine were given and plasmapheresis was performed without clinical improvement. Two weeks into the hospital stay, the patient's dyspnea worsened. A CT scan revealed extensive segmental and subsegmental pulmonary emboli. CONCLUSIONS Faulty data gathering and flawed data synthesis are major drivers of diagnostic errors. While there is limited evidence for individual debiasing strategies, improving team factors and structural conditions can have substantial impact on the extent of diagnostic errors. Healthcare organizations should provide the structural supports to address errors and promote a constructive culture of patient safety.
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Affiliation(s)
- Martin A Schaller-Paule
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Hesse, Germany
| | - Helmuth Steinmetz
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Hesse, Germany
| | - Friederike S Vollmer
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Hesse, Germany
| | - Melissa Plesac
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Felix Wicke
- Department of Psychosomatic Medicine and Psychotherapy, Johannes Gutenberg University Mainz, Mainz, Rhineland-Palatinate, Germany
| | - Christian Foerch
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Hesse, Germany
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Seidl E, Seidl O. Do my feelings fit the diagnosis? Avoiding misdiagnoses in psychosomatic consultation services. J Healthc Risk Manag 2021; 41:9-17. [PMID: 33434403 DOI: 10.1002/jhrm.21456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Misdiagnoses are a major concern with far-reaching consequences, which have rarely been studied systematically. Therefore, the present study evaluated factors causing misdiagnoses identified by psychosomatic consultation services. METHODS Over a period of 5 years, all patients referred to the psychosomatic consultation services of a large university hospital were analyzed consecutively for misdiagnoses. We analyzed the reasons for suspecting a misdiagnosis through systematic introspection during peer supervision and evaluated the causes during semistructured interviews with the referring physician. RESULTS In 165 psychosomatic consultations, 24 disorders were misdiagnosed (15%). The reasons for questioning the initial diagnoses were the consulting physician's feelings and thoughts resulting from the patients' inappropriate behavior during the consultation and unusual clinical features. In eight cases, the misdiagnosis resulted from availability bias, and in three cases each it resulted from confirmation bias, search satisfaction bias, and framing effect and attribution bias. However, lack of medical knowledge played only a minor role. CONCLUSION This study highlights the nonrational elements of the diagnostic process. In the context of psychosomatic consultation services, introspection and intuitive thought processes are helpful in identifying misdiagnoses. Self-satisfaction (availability bias) and overconfidence (confirmation bias) are most likely to result in misdiagnoses.
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Affiliation(s)
- Elias Seidl
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Otmar Seidl
- Department of Psychiatry and Psychotherapy, University Hospital, Germany
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6
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Seidl O, Seidl E, Schwerthöffer D. [The Role of Gut Feeling as an Alarm Signal for Identifying Misdiagnoses in the Psychosomatic Consultation]. Psychother Psychosom Med Psychol 2021; 72:26-33. [PMID: 34311487 DOI: 10.1055/a-1506-3515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND A psychosomatic consultation service offers an opportunity to correct misdiagnoses. The doctor's non-analytical, experience-based gut feeling plays an essential role as diagnostic trailblazer. METHODOLOGY In a case series study, the procedures of 165 psychosomatic consultations and the emotional and cognitive processes occurring in the consultant were recorded. The diagnostic process was analysed with reference to the dual process theory. With gut feeling, a distinction was made between a sense of alarm and a sense of reassurance. As an example, the processes that led to the discovery of misdiagnoses were presented at four consultations. RESULTS A misdiagnosis was found in 24 consultations (16%). The reason for this was always a sense of alarm, which appeared in 29 of 165 consultations (18%). In 11 consultations (7%) there was a sense of reassurance, which in ten consultations was associated with a confirmation of the diagnosis and only in one case gave way to a sense of alarm and led to a later correction of the diagnosis. CONCLUSIONS Paying attention to gut feeling and its sense of alarm is an effective method of recognizing misdiagnosis. Training programs should not only promote rational-analytical thinking, but also the doctor's self-critical introspection skills.
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Affiliation(s)
- Otmar Seidl
- Sektion für Psychosomatische Medizin und Psychotherapie der Klinik und Poliklinik für Psychiatrie und Psychotherapie der LMU München
| | - Elias Seidl
- Integriertes Sozialpädiatrisches Zentrum im Dr. Von Haunerschen Kinderspital der LMU München
| | - Dirk Schwerthöffer
- Sektion für Psychosomatische Medizin und Psychotherapie der Klinik und Poliklinik für Psychiatrie und Psychotherapie der LMU München
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7
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Schmidt HG, Mamede S. How cognitive psychology changed the face of medical education research. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2020; 25:1025-1043. [PMID: 33244724 PMCID: PMC7704490 DOI: 10.1007/s10459-020-10011-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 10/27/2020] [Indexed: 05/25/2023]
Abstract
In this article, the contributions of cognitive psychology to research and development of medical education are assessed. The cognitive psychology of learning consists of activation of prior knowledge while processing new information and elaboration on the resulting new knowledge to facilitate storing in long-term memory. This process is limited by the size of working memory. Six interventions based on cognitive theory that facilitate learning and expertise development are discussed: (1) Fostering self-explanation, (2) elaborative discussion, and (3) distributed practice; (4) help with decreasing cognitive load, (5) promoting retrieval practice, and (6) supporting interleaving practice. These interventions contribute in different measure to various instructional methods in use in medical education: problem-based learning, team-based learning, worked examples, mixed practice, serial-cue presentation, and deliberate reflection. The article concludes that systematic research into the applicability of these ideas to the practice of medical education presently is limited and should be intensified.
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Affiliation(s)
- Henk G Schmidt
- Department of Psychology, Erasmus University, P.O. Box 1738, 3000, DR, Rotterdam, the Netherlands.
| | - Silvia Mamede
- Department of Psychology, Erasmus University, P.O. Box 1738, 3000, DR, Rotterdam, the Netherlands
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8
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Trowbridge RL, Rencic JJ, Wijesekera TP, Olson APJ. Avoiding Cognitive Errors in Clinical Decision Making. Ann Intern Med 2020; 173:678-679. [PMID: 33075248 DOI: 10.7326/l20-1059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Robert L Trowbridge
- Maine Medical Center and Tufts University School of Medicine, Portland, Maine, and Boston, Massachusetts (R.L.T.)
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9
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Abstract
Inferring hidden structure from noisy observations is a problem addressed by Bayesian statistical learning, which aims to identify optimal models of the process that generated the observations given assumptions that constrain the space of potential solutions. Animals and machines face similar "model-selection" problems to infer latent properties and predict future states of the world. Here we review recent attempts to explain how intelligent agents address these challenges and how their solutions relate to Bayesian principles. We focus on how constraints on available information and resources affect inference and propose a general framework that uses benefit(accuracy) and accuracy(cost) curves to assess optimality under these constraints.
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Affiliation(s)
- Gaia Tavoni
- Department of Neuroscience, University of Pennsylvania, Philadelphia, PA 19104.,Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA 19104
| | - Vijay Balasubramanian
- Department of Neuroscience, University of Pennsylvania, Philadelphia, PA 19104.,Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA 19104
| | - Joshua I Gold
- Department of Neuroscience, University of Pennsylvania, Philadelphia, PA 19104
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10
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Connor DM, Durning SJ, Rencic JJ. Clinical Reasoning as a Core Competency. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:1166-1171. [PMID: 31577583 DOI: 10.1097/acm.0000000000003027] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Diagnostic error is a challenging problem; addressing it effectively will require innovation across multiple domains of health care, including medical education. Diagnostic errors often relate to problems with clinical reasoning, which involves the cognitive and relational steps up to and including establishing a diagnostic and therapeutic plan with a patient. However, despite a call from the National Academies of Sciences for medical educators to improve the teaching and assessment of clinical reasoning, the creation of explicit, theory-informed clinical reasoning curricula, faculty development resources, and assessment tools has proceeded slowly in both undergraduate and graduate medical education. To accelerate the development of this critical element of health professions education and to promote needed research and innovation in clinical reasoning education, the Accreditation Council for Graduate Medical Education (ACGME) should revise its core competencies to include clinical reasoning. The core competencies have proven to be an effective means of expanding educational innovation across the United States and ensuring buy-in across a diverse array of institutions and disciplines. Reformulating the ACGME core competencies to include clinical reasoning would spark much-needed educational innovation and scholarship in graduate medical education, as well as collaboration across institutions in this vital aspect of physicianship, and ultimately, could contribute to a reduction of patient suffering by better preparing trainees to build individual, team-based, and system-based tools to monitor for and avoid diagnostic error.
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Affiliation(s)
- Denise M Connor
- D.M. Connor is associate professor of clinical medicine, Department of Medicine, and director of the Diagnostic Reasoning Block, School of Medicine, University of California, San Francisco, and associate program director of PRIME, an area of distinction for internal medicine residents based at the San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Steven J Durning
- S.J. Durning is professor, Departments of Medicine and Pathology, and director, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Joseph J Rencic
- J.J. Rencic is professor, Department of Internal Medicine, Tufts University School of Medicine, and associate program director, Internal Medicine Residency Program, Tufts Medical Center, Boston, Massachusetts
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11
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Durning SJ, Trowbridge RL, Schuwirth L. Clinical Reasoning and Diagnostic Error: A Call to Merge Two Worlds to Improve Patient Care. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:1159-1161. [PMID: 31625997 DOI: 10.1097/acm.0000000000003041] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Numerous and substantial challenges exist in the provision of safe, cost-effective, and efficient health care. The prevalence and consequences of diagnostic error, one of these challenges, have been established by the literature; however, these errors persist, and the pace of improvement has been slow. One potential reason for the lack of needed progress is that addressing delayed and wrong diagnoses will require contributions from 2 currently distinct worlds: clinical reasoning and diagnostic error. In this Invited Commentary, the authors argue for merging the diagnostic error and clinical reasoning fields as the perspectives, frameworks, and methodologies of these 2 fields could be leveraged to yield a more aligned approach to understanding and subsequently to mitigating diagnostic error. The authors focus on the problem of diagnostic labeling (a categorization task where one has to choose the correct label or diagnosis). The authors elaborate on why this alignment could help guide health care improvement efforts, using the vexing problem of context specificity that leads to unwanted variance in health care as an example.
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Affiliation(s)
- Steven J Durning
- S.J. Durning is professor and director, Graduate Programs in Health Professions Education, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ORCID: https://orcid.org/0000-0001-5223-1597
| | - Robert L Trowbridge
- R.L. Trowbridge is associate professor of medicine, Tufts University School of Medicine, Portland, Maine; ORCID: https://orcid.org/0000-0002-0460-2733
| | - Lambert Schuwirth
- L. Schuwirth is strategic professor in medical education, Flinders University, Adelaide, South Australia, Australia; ORCID: https://orcid.org/0000-0002-6279-5158
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12
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Hinz L, Sigal RJ, Paolucci EO, McLaughlin K. Factors Influencing Inpatient Insulin Management of Adults With Type 1 and Type 2 Diabetes by Residents and Medical Students. Can J Diabetes 2020; 45:167-173.e1. [PMID: 33039327 DOI: 10.1016/j.jcjd.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/15/2020] [Accepted: 07/15/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The day-to-day management of diabetes is often the responsibility of resident physicians in teaching hospitals, yet studies have consistently shown that learners lack confidence and knowledge of inpatient insulin titration. We sought to elucidate factors that influence inpatient management of diabetes by medical learners. We predicted that there would be conscious and unconscious variables at play, and we sought to determine the process by which learners arrived at insulin titration decisions. METHODS We administered a survey using a hypothetical case based on script concordance testing in 88 medical students and residents at the University of Calgary. We used multilevel, mixed-effects linear regression and random-effects meta-analysis to compare clerks' and residents' insulin prescribing, confidence in prescribing decisions and concordance with endocrinologists. RESULTS Residents had higher confidence than clerks, yet were less concordant with the insulin decisions of staff endocrinologists. Both residents and clerks prescribed more insulin when the reported blood glucose was higher, or the patient had positive ketones and prescribed less insulin when the patient had hypoglycemic unawareness. Residents prescribed a higher dose of insulin when the charge nurse reported the result compared with a student nurse, but this variable did not significantly impact prescribing by clerks. CONCLUSIONS We propose a model in which learner factors (knowledge, confidence, experience), patient variables and perceived expectations influence insulin titration decisions via analytical and heuristic processes. We propose that educational interventions designed to improve inpatient glycemic control must, therefore, address both knowledge and systems factors.
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Affiliation(s)
- Laura Hinz
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Ronald J Sigal
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Kevin McLaughlin
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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13
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Zavala AM, Day GE, Plummer D, Bamford-Wade A. Decision-making under pressure: medical errors in uncertain and dynamic environments. AUST HEALTH REV 2019; 42:395-402. [PMID: 28578757 DOI: 10.1071/ah16088] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 04/03/2017] [Indexed: 11/23/2022]
Abstract
Objective This paper provides a narrative overview of the literature concerning clinical decision-making processes when staff come under pressure, particularly in uncertain, dynamic and emergency situations. Methods Studies between 1980 and 2015 were analysed using a six-phase thematic analysis framework to achieve an in-depth understanding of the complex origins of medical errors that occur when people and systems are under pressure and how work pressure affects clinical performance and patient outcomes. Literature searches were conducted using a Summons Search Service platform; search criteria included a variety of methodologies, resulting in the identification of 95 papers relevant to the present review. Results Six themes emerged in the present narrative review using thematic analysis: organisational systems, workload, time pressure, teamwork, individual human factors and case complexity. This analysis highlights that clinical outcomes in emergency situations are the result of a variety of interconnecting factors. These factors may affect the ability of clinical staff in emergency situations to provide quality, safe care in a timely manner. Conclusions The challenge for researchers is to build the body of knowledge concerning the safe management of patients, particularly where clinicians are working under pressure. This understanding is important for developing pathways that optimise clinical decision making in uncertain and dynamic environments. What is known about the topic? Emergency departments (EDs) are characterised by high complexity, high throughput and greater uncertainty compared with routine hospital wards or out-patient situations, and the ED is therefore prone to unpredictable workflows and non-replicable conditions when presented with unique and complex cases. What does this paper add? Clinical decision making can be affected by pressures with complex origins, including organisational systems, workload, time constraints, teamwork, human factors and case complexity. Interactions between these factors at different levels of the decision-making process can increase the complexity of problems and the resulting decisions to be made. What are the implications for practitioners? The findings of the present study provide further evidence that consideration of medical errors should be seen primarily from a 'whole-of-system' perspective rather than as being primarily the responsibility of individuals. Although there are strategies in place in healthcare organisations to eliminate errors, they still occur. In order to achieve a better understanding of medical errors in clinical practice in times of uncertainty, it is necessary to identify how diverse pressures can affect clinical decisions, and how these interact to influence clinical outcomes.
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Affiliation(s)
- Alicia M Zavala
- School of Medicine, Griffith University, Gold Coast Campus, 58 Parklands Drive, Southport, Qld 4215, Australia. Email
| | - Gary E Day
- School of Medicine, Griffith University, Gold Coast Campus, 58 Parklands Drive, Southport, Qld 4215, Australia. Email
| | - David Plummer
- College of Public Health, Medical & Veterinary Sciences, James Cook University, Townsville, Qld 4811, Australia. Email
| | - Anita Bamford-Wade
- Ministry of Public Health, Republica del Salvador Avenue 36-64 and Suecia Postal code 170515, Quito, Ecuador
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14
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Hautz WE, Kämmer JE, Hautz SC, Sauter TC, Zwaan L, Exadaktylos AK, Birrenbach T, Maier V, Müller M, Schauber SK. Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room. Scand J Trauma Resusc Emerg Med 2019; 27:54. [PMID: 31068188 PMCID: PMC6505221 DOI: 10.1186/s13049-019-0629-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 04/12/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Diagnostic errors occur frequently, especially in the emergency room. Estimates about the consequences of diagnostic error vary widely and little is known about the factors predicting error. Our objectives thus was to determine the rate of discrepancy between diagnoses at hospital admission and discharge in patients presenting through the emergency room, the discrepancies' consequences, and factors predicting them. METHODS Prospective observational clinical study combined with a survey in a University-affiliated tertiary care hospital. Patients' hospital discharge diagnosis was compared with the diagnosis at hospital admittance through the emergency room and classified as similar or discrepant according to a predefined scheme by two independent expert raters. Generalized linear mixed-effects models were used to estimate the effect of diagnostic discrepancy on mortality and length of hospital stay and to determine whether characteristics of patients, diagnosing physicians, and context predicted diagnostic discrepancy. RESULTS 755 consecutive patients (322 [42.7%] female; mean age 65.14 years) were included. The discharge diagnosis differed substantially from the admittance diagnosis in 12.3% of cases. Diagnostic discrepancy was associated with a longer hospital stay (mean 10.29 vs. 6.90 days; Cohen's d 0.47; 95% confidence interval 0.26 to 0.70; P = 0.002) and increased patient mortality (8 (8.60%) vs. 25(3.78%); OR 2.40; 95% CI 1.05 to 5.5 P = 0.038). A factor available at admittance that predicted diagnostic discrepancy was the diagnosing physician's assessment that the patient presented atypically for the diagnosis assigned (OR 3.04; 95% CI 1.33-6.96; P = 0.009). CONCLUSIONS Diagnostic discrepancies are a relevant healthcare problem in patients admitted through the emergency room because they occur in every ninth patient and are associated with increased in-hospital mortality. Discrepancies are not readily predictable by fixed patient or physician characteristics; attention should focus on context. TRIAL REGISTRATION https://bmjopen.bmj.com/content/6/5/e011585.
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Affiliation(s)
- Wolf E. Hautz
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Freiburgstrasse, 3010 Berne, Switzerland
- Centre for Educational Measurement, University of Oslo, Gaustadallén 30, 0373 Oslo, Norway
| | - Juliane E. Kämmer
- Max Planck Institute for Human Development, Center for Adaptive Rationality (ARC), Lentzeallee 94, 14195 Berlin, Germany
- AG Progress Test Medizin, Charité Medical School, Hannoversche Straße 19, 10115 Berlin, Germany
| | - Stefanie C. Hautz
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Freiburgstrasse, 3010 Berne, Switzerland
| | - Thomas C. Sauter
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Freiburgstrasse, 3010 Berne, Switzerland
- Skills Lab Lernzentrum, Charité Universitätsmedizin Berlin, Chariteplatz 1, 10117 Berlin, Germany
| | - Laura Zwaan
- Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Aristomenis K. Exadaktylos
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Freiburgstrasse, 3010 Berne, Switzerland
| | - Tanja Birrenbach
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Freiburgstrasse, 3010 Berne, Switzerland
- Department of General Internal Medicine, Inselspital University Hospital, University of Berne, Freiburgstrasse, 3010 Berne, Switzerland
| | - Volker Maier
- Department of General Internal Medicine, Inselspital University Hospital, University of Berne, Freiburgstrasse, 3010 Berne, Switzerland
| | - Martin Müller
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Freiburgstrasse, 3010 Berne, Switzerland
| | - Stefan K. Schauber
- Centre for Educational Measurement, University of Oslo, Gaustadallén 30, 0373 Oslo, Norway
- Centre for Health Sciences Education, Faculty of Medicine, University of Oslo, Oslo, Norway
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15
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Grubenhoff JA, Ziniel SI, Bajaj L, Hyman D. Pediatric faculty knowledge and comfort discussing diagnostic errors: a pilot survey to understand barriers to an educational program. Diagnosis (Berl) 2019; 6:101-107. [DOI: 10.1515/dx-2018-0056] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 01/21/2019] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Improving Diagnosis in Healthcare calls for improved training in diagnostic reasoning and establishing non-judgmental forums to learn from diagnostic errors arising from heuristic-driven reasoning. Little is known about pediatric providers’ familiarity with heuristics or the culture surrounding forums where diagnostic errors are discussed. This study aimed to describe pediatric providers’ familiarity with common heuristics and perceptions surrounding public discussions of diagnostic errors.
Methods
We surveyed pediatric providers at a university-affiliated children’s hospital. The survey asked participants to identify common heuristics used during clinical reasoning (five definitions; four exemplar clinical vignettes). Participants answered questions regarding comfort publicly discussing their own diagnostic errors and barriers to sharing them.
Results
Seventy (30.6% response rate) faculty completed the survey. The mean number of correctly selected heuristics was 1.60/5 [standard deviation (SD)=1.13] and 1.01/4 (SD=1.06) for the definitions and vignettes, respectively. A low but significant correlation existed between correctly identifying a definition and selecting the correct heuristic in vignettes (Spearman’s ρ=0.27, p=0.02). Clinicians were significantly less likely to be “pretty” or “very” comfortable discussing diagnostic errors in public vs. private conversations (28.3% vs. 74.3%, p<0.01). The most frequently cited barriers to discussing errors were loss of reputation (62.9%) and fear of knowledge-base (58.6%) or decision-making (57.1%) being judged.
Conclusions
Pediatric providers demonstrated limited familiarity with common heuristics leading to diagnostic error. Greater years in practice is associated with more comfort discussing diagnostic errors, but negative peer and personal perceptions of diagnostic performance are common barriers to discussing errors publicly.
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Affiliation(s)
- Joseph A. Grubenhoff
- University of Colorado Denver School of Medicine , Aurora, CO , USA
- Children’s Hospital Colorado , Aurora, CO , USA
| | - Sonja I. Ziniel
- University of Colorado Denver School of Medicine , Aurora, CO , USA
- Children’s Hospital Colorado , Aurora, CO , USA
| | - Lalit Bajaj
- University of Colorado Denver School of Medicine , Aurora, CO , USA
- Children’s Hospital Colorado , Aurora, CO , USA
| | - Daniel Hyman
- University of Colorado Denver School of Medicine , Aurora, CO , USA
- Children’s Hospital Colorado , Aurora, CO , USA
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Royce CS, Hayes MM, Schwartzstein RM. Teaching Critical Thinking: A Case for Instruction in Cognitive Biases to Reduce Diagnostic Errors and Improve Patient Safety. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2019; 94:187-194. [PMID: 30398993 DOI: 10.1097/acm.0000000000002518] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Diagnostic errors contribute to as many as 70% of medical errors. Prevention of diagnostic errors is more complex than building safety checks into health care systems; it requires an understanding of critical thinking, of clinical reasoning, and of the cognitive processes through which diagnoses are made. When a diagnostic error is recognized, it is imperative to identify where and how the mistake in clinical reasoning occurred. Cognitive biases may contribute to errors in clinical reasoning. By understanding how physicians make clinical decisions, and examining how errors due to cognitive biases occur, cognitive bias awareness training and debiasing strategies may be developed to decrease diagnostic errors and patient harm. Studies of the impact of teaching critical thinking skills have mixed results but are limited by methodological problems.This Perspective explores the role of clinical reasoning and cognitive bias in diagnostic error, as well as the effect of instruction in metacognitive skills on improvement of diagnostic accuracy for both learners and practitioners. Recent literature questioning whether teaching critical thinking skills increases diagnostic accuracy is critically examined, as are studies suggesting that metacognitive practices result in better patient care and outcomes. Instruction in metacognition, reflective practice, and cognitive bias awareness may help learners move toward adaptive expertise and help clinicians improve diagnostic accuracy. The authors argue that explicit instruction in metacognition in medical education, including awareness of cognitive biases, has the potential to reduce diagnostic errors and thus improve patient safety.
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Affiliation(s)
- Celeste S Royce
- C.S. Royce is instructor, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. M.M. Hayes is assistant professor, Department of Medicine, Shapiro Institute for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. R.M. Schwartzstein is professor, Department of Medicine, Shapiro Institute for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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17
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Chew KS, van Merrienboer JJG, Durning SJ. Perception of the usability and implementation of a metacognitive mnemonic to check cognitive errors in clinical setting. BMC MEDICAL EDUCATION 2019; 19:18. [PMID: 30630472 PMCID: PMC6327396 DOI: 10.1186/s12909-018-1451-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 12/28/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Establishing a diagnosis is a complex, iterative process involving patient data gathering, integration and interpretation. Premature closure is a fallacious cognitive tendency of closing the diagnostic process before sufficient data have been gathered. A proposed strategy to minimize premature closure is the use of a checklist to trigger metacognition (the process of monitoring one's own thinking). A number of studies have suggested the effectiveness of this strategy in classroom settings. This qualitative study examined the perception of usability of a metacognitive mnemonic checklist called TWED checklist (where the letter "T = Threat", "W = What if I am wrong? What else?", "E = Evidence" and "D = Dispositional influence") in a real clinical setting. METHOD Two categories of participants, i.e., medical doctors (n = 11) and final year medical students (Group 1, n = 5; Group 2, n = 10) participated in four separate focus group discussions. Nielsen's 5 dimensions of usability (i.e. learnability, effectiveness, memorability, errors, and satisfaction) and Pentland's narrative network were adapted as the framework to study the usability and the implementation of the checklist in a real clinical setting respectively. RESULTS Both categories (medical doctors and medical students) of participants found that the TWED checklist was easy to learn and effective in promoting metacognition. For medical student participants, items "T" and "W" were believed to be the two most useful aspects of the checklist, whereas for the doctor participants, it was item "D". Regarding its implementation, item "T" was applied iteratively, items "W" and "E" were applied when the outcomes did not turn out as expected, and item "D" was applied infrequently. The one checkpoint where all four items were applied was after the initial history taking and physical examination had been performed to generate the initial clinical impression. CONCLUSION A metacognitive checklist aimed to check cognitive errors may be a useful tool that can be implemented in the real clinical setting.
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Affiliation(s)
- Keng Sheng Chew
- Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Kota Samarahan, Malaysia
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18
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Trowbridge RL, Reilly JB, Clauser JC, Durning SJ. Using computerized virtual cases to explore diagnostic error in practicing physicians. Diagnosis (Berl) 2018; 5:229-233. [PMID: 30205638 DOI: 10.1515/dx-2017-0044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 07/25/2018] [Indexed: 11/15/2022]
Abstract
Background Diagnostic errors are a significant cause of patient harm. Cognitive processes often contribute to diagnostic errors but studying and mitigating the effects of these errors is challenging. Computerized virtual patients may provide insight into the diagnostic process without the potential for patient harm, but the feasibility and utility of using such cases in practicing physicians has not been well described. Methods We developed a series of computerized virtual cases depicting common presentations of disease that included contextual factors that could result in diagnostic error. Cases were piloted by practicing physicians in two phases and participant impressions of the case platform and cases were recorded, as was outcome data on physician performance. Results Participants noted significant challenges in using the case platform. Participants specifically struggled with becoming familiar with the platform and adjusting to the non-adaptive and constraining processes of the model. Although participants found the cases to be typical presentations of problems commonly encountered in practice, the correct diagnosis was identified in less than 33% of cases. Conclusions The development of virtual patient cases for use by practicing physicians requires substantial resources and platforms that account for the non-linear and adaptive nature of reasoning in experienced clinicians. Platforms that are without such characteristics may negatively affect diagnostic performance. The novelty of such platforms may also have the potential to increase cognitive load. Nonetheless, virtual cases may have the potential to be a safe and robust means of studying clinical reasoning performance.
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Affiliation(s)
- Robert L Trowbridge
- Department of Medicine, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA, Phone: +(207) 662-4618.,Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - James B Reilly
- Allegheny Health Network Medical Education Consortium, Vice Chair for Education, Department of Medicine, Allegheny Health Network, Pittsburgh, PA, USA.,Temple University School of Medicine, Philadelphia, PA, USA
| | | | - Steven J Durning
- Department of Medicine, Division of Graduate Programs in Health Professions Education, Uniformed Services University of Health Sciences School of Medicine, Bethesda, MD, USA
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19
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Surry LT, Torre D, Trowbridge RL, Durning SJ. A mixed-methods exploration of cognitive dispositions to respond and clinical reasoning errors with multiple choice questions. BMC MEDICAL EDUCATION 2018; 18:277. [PMID: 30470223 PMCID: PMC6251119 DOI: 10.1186/s12909-018-1372-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 10/31/2018] [Indexed: 05/13/2023]
Abstract
BACKGROUND Cognitive dispositions to respond (i.e., cognitive biases and heuristics) are well-established clinical reasoning phenomena. While thought by many to be error-prone, some scholars contest that these cognitive dispositions to respond are pragmatic solutions for reasoning through clinical complexity that are associated with errors largely due to hindsight bias and flawed experimental design. The purpose of this study was to prospectively identify cognitive dispositions to respond occurring during clinical reasoning to determine whether they are actually associated with increased odds of an incorrect answer (i.e., error). METHODS Using the cognitive disposition to respond framework, this mixed-methods study applied a constant comparative qualitative thematic analysis to transcripts of think alouds performed during completion of clinical-vignette multiple-choice questions. The number and type of cognitive dispositions to respond associated with both correct and incorrect answers were identified. Participants included medical students, residents, and attending physicians recruited using maximum variation strategies. Data were analyzed using generalized estimating equations binary logistic model for repeated, within-subjects measures. RESULTS Among 14 participants, there were 3 cognitive disposition to respond categories - Cognitive Bias, Flaws in Conceptual Understanding, and Other Vulnerabilities - with 13 themes identified from the think aloud transcripts. The odds of error increased to a statistically significant degree with a greater per-item number of distinct Cognitive Bias themes (OR = 1.729, 95% CI [1.226, 2.437], p = 0.002) and Other Vulnerabilities themes (OR = 2.014, 95% CI [1.280, 2.941], p < 0.001), but not with Flaws in Conceptual Understanding themes (OR = 1.617, 95% CI [0.961, 2.720], p = 0.070). CONCLUSION This study supports the theoretical understanding of cognitive dispositions to respond as phenomena associated with errors in a new prospective manner. With further research, these findings may inform teaching, learning, and assessment of clinical reasoning toward a reduction in patient harm due to clinical reasoning errors.
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Affiliation(s)
- Luke T Surry
- Department of Medicine, Uniformed Services University of the Health Sciences - F. Hébert School of Medicine, Bethesda, MD, 20814, USA.
| | - Dario Torre
- Department of Medicine, Uniformed Services University of the Health Sciences - F. Hébert School of Medicine, Bethesda, MD, 20814, USA
| | - Robert L Trowbridge
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
- Maine Medical Centre, Portland, ME, USA
| | - Steven J Durning
- Department of Medicine, Uniformed Services University of the Health Sciences - F. Hébert School of Medicine, Bethesda, MD, 20814, USA
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20
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Wright B, Martin GP, Ahmed A, Banerjee J, Mason S, Roland D. How the Availability of Observation Status Affects Emergency Physician Decisionmaking. Ann Emerg Med 2018; 72:401-409. [PMID: 29880439 DOI: 10.1016/j.annemergmed.2018.04.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 02/17/2018] [Accepted: 04/19/2018] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE This study seeks to understand how emergency physicians decide to use observation services, and how placing a patient under observation influences physicians' subsequent decisionmaking. METHODS We conducted detailed semistructured interviews with 24 emergency physicians, including 10 from a hospital in the US Midwest, and 14 from 2 hospitals in central and northern England. Data were extracted from the interview transcripts with open coding and analyzed with axial coding. RESULTS We found that physicians used a mix of intuitive and analytic thinking in initial decisions to admit, observe, or discharge patients, depending on the physician's individual level of risk aversion. Placing patients under observation made some physicians more systematic, whereas others cautioned against overreliance on observation services in the face of uncertainty. CONCLUSION Emergency physicians routinely make decisions in a highly resource-constrained environment. Observation services can relax these constraints by providing physicians with additional time, but absent clear protocols and metacognitive reflection on physician practice patterns, this may hinder, rather than facilitate, decisionmaking.
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Affiliation(s)
- Brad Wright
- Department of Health Management and Policy, University of Iowa, Iowa City, IA.
| | - Graham P Martin
- SAPPHIRE Group, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Azeemuddin Ahmed
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Jay Banerjee
- Emergency Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Suzanne Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Damian Roland
- Pediatric Emergency Medicine Academic Group, University Hospitals of Leicester NHS Trust, Leicester, UK
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21
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Trowbridge RL, Olson AP. Becoming a teacher of clinical reasoning. Diagnosis (Berl) 2018; 5:11-14. [DOI: 10.1515/dx-2018-0004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 03/14/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Diagnostic reasoning is one of the most challenging and rewarding aspects of clinical practice. As a result, facility in teaching diagnostic reasoning is a core necessity for all medical educators. Clinician educators’ limited understanding of the diagnostic process and how expertise is developed may result in lost opportunities in nurturing the diagnostic abilities of themselves and their learners. In this perspective, the authors describe their journeys as clinician educators searching for a coherent means of teaching diagnostic reasoning. They discuss the initial appeal and immediate applicability of dual process theory and cognitive biases to their own clinical experiences and those of their trainees, followed by the eventual and somewhat belated recognition of the importance of context specificity. They conclude that there are no quick fixes in guiding learners to expertise of diagnostic reasoning, but rather the development of these abilities is best viewed as a long, somewhat frustrating, but always interesting journey. The role of the teacher of clinical reasoning is to guide the learners on this journey, recognizing true mastery may not be attained, but should remain a goal for teacher and learner alike.
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Affiliation(s)
- Robert L. Trowbridge
- Department of Medicine, Maine Medical Center, 22 Bramhall Street , Portland, ME 04102 , USA , Phone: +(207) 662-4618
- Tufts University School of Medicine , Boston, MA , USA
| | - Andrew P.J. Olson
- Departments of Medicine and Pediatrics , University of Minnesota Medical School , Minneapolis, MN , USA
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22
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Koyama A, Ohtake Y, Yasuda K, Sakai K, Sakamoto R, Matsuoka H, Okumi H, Yasuda T. Avoiding diagnostic errors in psychosomatic medicine: a case series study. Biopsychosoc Med 2018; 12:4. [PMID: 29563965 PMCID: PMC5848591 DOI: 10.1186/s13030-018-0122-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 02/19/2018] [Indexed: 12/24/2022] Open
Abstract
Background Non-organic lesions or diseases of unknown origin are sometimes misdiagnosed as “psychogenic” disorders or “psychosomatic” diseases. For the quality of life and safety of patients, recent attention has focused on diagnostic error. The aim of this study was to clarify the factors that affected misdiagnoses in psychosomatic medicine by examining typical cases and to explore strategies that reduce diagnostic errors. Case presentation The study period was from January 2001 to August 2017. The data of patients who had visited the Department of Psychosomatic Medicine, Kindai University Hospital and its branches, Sakai Hospital and Nihonbashi Clinic, were collected. All patients were aged 16 years or over. Multiple factors, such as age, sex, presenting symptoms, initial diagnosis, final diagnosis, sources of re-diagnosis and types of diagnostic errors were retrospectively analyzed from the medical charts of 20 patients. Among them, four typical cases can be described as follows. Case 1; a 79-year-old woman, initially diagnosed with psychogenic vomiting due to depression that was changed to gastric torsion as the final diagnosis. Case 2; a 24-year-old man, diagnosed with an eating disorder that was later changed to esophageal achalasia. Case 10; a 60-year-old woman’s diagnosis changed from conversion disorder to localized muscle atrophy. Case 19; a 68-year-old man, appetite loss from depression due to cancer changed to secondary adrenal insufficiency, isolated ACTH deficiency (IAD). Conclusion This study showed that multiple factors related to misdiagnoses were combined and had a mutual influence. However, they can be summarized into two important clinical observations, diagnostic system-related problems and provider issues. Provider issues contain mainly cognitive biases such as Anchoring, Availability, Confirmation bias, Delayed diagnosis, and Representativeness. In order to avoid diagnostic errors, both a diagnostic system approach and the reduction of cognitive biases are needed. Psychosomatic medicine doctors should pay more attention to physical symptoms and systemic examination and can play an important role in accepting a perception of patients based on a good, non prejudicial patient/physician relationship.
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Affiliation(s)
- Atsuko Koyama
- 1Department of Psychosomatic Medicine, Faculty of Medicine, Kindai University, 377-2, Ohno-higashi, Osaskasayama City, Osaka, 589-8511 Japan
| | - Yoichi Ohtake
- General Internal Medicine, Sakai City Medical Center, 1-1-1 Ebaraji-cho, Nishi-ku Sakai, Osaka, 593-8304 Japan
| | - Kanae Yasuda
- 3Department of Psychosomatic Medicine, Sakai Hospital, Kindai University, 2-7-1, Harayamadai, Minami-ku Sakai, Osaka, 590-0132 Japan
| | - Kiyohiro Sakai
- 1Department of Psychosomatic Medicine, Faculty of Medicine, Kindai University, 377-2, Ohno-higashi, Osaskasayama City, Osaka, 589-8511 Japan
| | - Ryo Sakamoto
- 1Department of Psychosomatic Medicine, Faculty of Medicine, Kindai University, 377-2, Ohno-higashi, Osaskasayama City, Osaka, 589-8511 Japan
| | - Hiromichi Matsuoka
- 1Department of Psychosomatic Medicine, Faculty of Medicine, Kindai University, 377-2, Ohno-higashi, Osaskasayama City, Osaka, 589-8511 Japan
| | - Hirokuni Okumi
- 1Department of Psychosomatic Medicine, Faculty of Medicine, Kindai University, 377-2, Ohno-higashi, Osaskasayama City, Osaka, 589-8511 Japan
| | - Toshiko Yasuda
- 1Department of Psychosomatic Medicine, Faculty of Medicine, Kindai University, 377-2, Ohno-higashi, Osaskasayama City, Osaka, 589-8511 Japan
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Huang GC, Kriegel G, Wheaton C, Sternberg S, Sands K, Richards J, Johnston K, Aronson M. Implementation of diagnostic pauses in the ambulatory setting. BMJ Qual Saf 2018; 27:492-497. [PMID: 29306903 DOI: 10.1136/bmjqs-2017-007192] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 11/23/2017] [Accepted: 12/15/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Diagnostic errors result in preventable morbidity and mortality. The outpatient setting may be at increased risk, where time constraints, the indolent nature of outpatient complaints and single decision-maker practice models predominate. METHODS We developed a self-administered diagnostic pause to address diagnostic error. Clinicians (physicians and nurse practitioners) in an academic primary care setting received the tool if they were seeing urgent care patients who had previously been seen in the past two weeks in urgent care. We used pre-post-intervention surveys, focus groups and chart audits 6 months after the urgent care visit to assess the impact of the intervention on participant perceptions and actions. RESULTS We piloted diagnostic pauses in two phases (3 months and 6 months, respectively); 9 physicians participated in the first phase, and 16 physicians and 2 nurse practitioners in the second phase. Subjects received 135 alerts for diagnostic pauses and responded to 82 (61% response). Thirteen per cent of alerts resulted in clinicians reporting new actions as a result of the diagnostic pauses. Thirteen per cent of cases at a 6-month chart audit resulted in diagnostic discrepancies, defined as differences in diagnosis from the initial working diagnosis. Focus groups reported that the diagnostic pauses were brief and fairly well integrated into the overall workflow for evaluation but would have benefited as a real-time application for patients at higher risk for diagnostic error. CONCLUSION This pilot represents the first known examination of diagnostic pauses in the outpatient setting, and this work potentially paves the way for more broad-based systems and/or electronic interventions to address diagnostic error.
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Affiliation(s)
- Grace C Huang
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Gila Kriegel
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Carolyn Wheaton
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Scot Sternberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kenneth Sands
- Hospital Corporation of America Healthcare, Nashville, Tennessee, USA
| | - Jeremy Richards
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Katherine Johnston
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital, Boston, USA
| | - Mark Aronson
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Juriga LL, Murray DJ, Boulet JR, Fehr JJ. Simulation and the diagnostic process: a pilot study of trauma and rapid response teams. Diagnosis (Berl) 2017. [DOI: 10.1515/dx-2017-0010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractBackground:Simulation is frequently used to recreate many of the crises encountered in patient care settings. Teams learn to manage these crises in an environment that maximizes their learning experiences and eliminates the potential for patient harm. By designing simulation scenarios that include conditions associated with diagnostic errors, teams can experience how their decisions can lead to errors. The purpose of this study was to assess how trauma teams (TrT) and pediatric rapid response teams (RRT) managed scenarios that included a diagnostic error.Methods:We developed four scenarios that would require TrT and pediatric RRT to manage an error in diagnosis. The two trauma scenarios (spinal cord injury and tracheobronchial tear) were designed to not respond to the heuristic management approach frequently used in trauma settings. The two pediatric scenarios (foreign body aspiration and coarctation of the aorta) had an incorrect diagnosis on admission. Two raters independently scored the scenarios using a rating system based on how teams managed the diagnostic process (search, establish and confirm a new diagnosis and initiate therapy based on the new diagnosis).Results:Twenty-one TrT and 17 pediatric rapid response managed 51 scenarios. All of the teams questioned the initial diagnosis. The teams were able to establish and confirm a new diagnosis in 49% of the scenarios (25 of 51). Only 23 (45%) teams changed their management of the patient based on the new diagnosis.Conclusions:Simulation can be used to recreate conditions that engage teams in the diagnostic process. In contrast to most instruction about diagnostic error, teams learn through realistic experiences and receive timely feedback about their decision-making skills. Based on the findings in this pilot study, the majority of teams would benefit from an education intervention designed to improve their diagnostic skills.
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25
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Cardiac Arrest and Gastrointestinal Bleeding: A Case of Medical Heuristics. Case Rep Med 2016; 2016:9621390. [PMID: 27366152 PMCID: PMC4913064 DOI: 10.1155/2016/9621390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 05/17/2016] [Indexed: 11/17/2022] Open
Abstract
Insufficient clinical data from patients is a major cause of errors in medical diagnostics. In an attempt to make a diagnosis, initial clinical information provided to the physician may be overly relied on as the only information required in making diagnosis leading to anchoring. Failure to rely on differential diagnoses in spite of new signs and symptoms or rethinking of initial hypothesis may lead to fixation on a certain diagnosis, which may lead to significant morbidity and mortality. In the event that there is an anchoring heuristic, like in our patient, it is important to consider differential diagnoses; however, it is not wrong to rely on some form of anchor. We report a case of a 62-year-old male with a history of multiple medical conditions and a history of acetaminophen overdose who presented to the hospital with large amounts of coffee ground emesis. He was subsequently transferred to the liver transplant center on discovery that he was in fulminant hepatic failure and died two days later in spite of aggressive medical treatment.
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Rotgans JI, Low-Beer N, Rosby LV. The relevance of neuroscientific research for understanding clinical reasoning. HEALTH PROFESSIONS EDUCATION 2016. [DOI: 10.1016/j.hpe.2016.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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27
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Nurse Practitioners’ Versus Physicians’ Diagnostic Reasoning Style and Use of Maxims: A Comparative Study. J Nurse Pract 2016. [DOI: 10.1016/j.nurpra.2016.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Hautz SC, Schuler L, Kämmer JE, Schauber SK, Ricklin ME, Sauter TC, Maier V, Birrenbach T, Exadaktylos A, Hautz WE. Factors predicting a change in diagnosis in patients hospitalised through the emergency room: a prospective observational study. BMJ Open 2016; 6:e011585. [PMID: 27169743 PMCID: PMC4874162 DOI: 10.1136/bmjopen-2016-011585] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Emergency rooms (ERs) generally assign a preliminary diagnosis to patients, who are then hospitalised and may subsequently experience a change in their lead diagnosis (cDx). In ERs, the cDx rate varies from around 15% to more than 50%. Among the most frequent reasons for diagnostic errors are cognitive slips, which mostly result from faulty data synthesis. Furthermore, physicians have been repeatedly found to be poor self-assessors and to be overconfident in the quality of their diagnosis, which limits their ability to improve. Therefore, some of the clinically most relevant research questions concern how diagnostic decisions are made, what determines their quality and what can be done to improve them. Research that addresses these questions is, however, still rare. In particular, field studies that allow for generalising findings from controlled experimental settings are lacking. The ER, with its high throughput and its many simultaneous visits, is perfectly suited for the study of factors contributing to diagnostic error. With this study, we aim to identify factors that allow prediction of an ER's diagnostic performance. Knowledge of these factors as well as of their relative importance allows for the development of organisational, medical and educational strategies to improve the diagnostic performance of ERs. METHODS AND ANALYSIS We will conduct a field study by collecting diagnostic decision data, physician confidence and a number of influencing factors in a real-world setting to model real-world diagnostic decisions and investigate the adequacy, validity and informativeness of physician confidence in these decisions. We will specifically collect data on patient, physician and encounter factors as predictors of the dependent variables. Statistical methods will include analysis of variance and a linear mixed-effects model. ETHICS AND DISSEMINATION The Bern ethics committee approved the study under KEK Number 197/15. Results will be published in peer-reviewed scientific medical journals. Authorship will be determined according to ICMJE guidelines. TRIAL REGISTRATION NUMBER The study protocol Version 1.0 from 17 May 2015 is registered in the Inselspital Research Database Information System (IRDIS) and with the IRB ('Kantonale Ethikkomission') Bern under KEK Number 197/15.
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Affiliation(s)
- Stefanie C Hautz
- Medical Faculty, Department of Evaluation and Assessment, Institute of Medical Education, University of Bern, Bern, Switzerland
| | - Luca Schuler
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Juliane E Kämmer
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany
- AG Progress Test Medizin, Charité Medical School, Berlin, Germany
| | - Stefan K Schauber
- Faculty of Educational Sciences, Centre for Educational Measurement, University of Oslo, Oslo, Norway
| | - Meret E Ricklin
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Volker Maier
- Department of General Internal Medicine, Inselspital, Bern, Switzerland
| | - Tanja Birrenbach
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern, Switzerland
| | | | - Wolf E Hautz
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
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Lambe KA, O'Reilly G, Kelly BD, Curristan S. Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. BMJ Qual Saf 2016; 25:808-20. [DOI: 10.1136/bmjqs-2015-004417] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 01/17/2016] [Indexed: 11/04/2022]
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Affiliation(s)
- David J Einstein
- Department of Medicine, Tufts Medical Center, 800 Washington Street, Boston, MA, 02111, USA
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Norman G. The Bias in researching cognitive bias. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2014; 19:291-295. [PMID: 24903584 DOI: 10.1007/s10459-014-9517-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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