Reflection in Medical Diagnosis: A Literature Review

Medical students' knowledge about human papillomavirus (HPV), HPV vaccine and head and neck cancer

The Human Papillomavirus (HPV) is a sexually transmitted infection that significantly affects the population worldwide. HPV preventive methods include vaccination, prophylactics, and education. Different types of cancers associated with HPV usually take years or decades to develop after infections, such as Head and Neck Cancer(HNC). Therefore, HPV prevention can be considered cancer prevention. A sample of medical students in Puerto Rico was evaluated to assess their knowledge about HPV, HPV vaccine, and HNC through two previously validated online questionnaires composed of 38 dichotomized questions, we measured HPV, HPV vaccination(HPVK), and HNC knowledge (HNCK). Out of 104 students surveyed, the mean HPVK score obtained was 20.07/26, SD = 3.86, while the mean score for HNCK was 6.37/12, SD = 1.78. Bidirectional stepwise regression showed study year and HPV Vaccine name had been the most influential variables on HPVK and HNCK. MS1 participants scored lower than MS2-MS4 participants, with no significant difference between MS2-MS4 scores. The results reveal knowledge gaps in HPV/HPV Vaccine and HNC among surveyed medical students. Our findings also suggest an association between knowledge of personal vaccination status, self-perceived risk, and how uncertainty in these factors may affect the medical students' understanding of HPV, HPV vaccination, and associated cancers.

Evaluating ChatGPT-4's Accuracy in Identifying Final Diagnoses Within Differential Diagnoses Compared With Those of Physicians: Experimental Study for Diagnostic Cases

BACKGROUND

The potential of artificial intelligence (AI) chatbots, particularly ChatGPT with GPT-4 (OpenAI), in assisting with medical diagnosis is an emerging research area. However, it is not yet clear how well AI chatbots can evaluate whether the final diagnosis is included in differential diagnosis lists.

OBJECTIVE

This study aims to assess the capability of GPT-4 in identifying the final diagnosis from differential-diagnosis lists and to compare its performance with that of physicians for case report series.

METHODS

We used a database of differential-diagnosis lists from case reports in the American Journal of Case Reports, corresponding to final diagnoses. These lists were generated by 3 AI systems: GPT-4, Google Bard (currently Google Gemini), and Large Language Models by Meta AI 2 (LLaMA2). The primary outcome was focused on whether GPT-4's evaluations identified the final diagnosis within these lists. None of these AIs received additional medical training or reinforcement. For comparison, 2 independent physicians also evaluated the lists, with any inconsistencies resolved by another physician.

RESULTS

The 3 AIs generated a total of 1176 differential diagnosis lists from 392 case descriptions. GPT-4's evaluations concurred with those of the physicians in 966 out of 1176 lists (82.1%). The Cohen κ coefficient was 0.63 (95% CI 0.56-0.69), indicating a fair to good agreement between GPT-4 and the physicians' evaluations.

CONCLUSIONS

GPT-4 demonstrated a fair to good agreement in identifying the final diagnosis from differential-diagnosis lists, comparable to physicians for case report series. Its ability to compare differential diagnosis lists with final diagnoses suggests its potential to aid clinical decision-making support through diagnostic feedback. While GPT-4 showed a fair to good agreement for evaluation, its application in real-world scenarios and further validation in diverse clinical environments are essential to fully understand its utility in the diagnostic process.

'Oh yes, that is also reflection'-Using discursive psychology to describe how GP registrars construct reflection

INTRODUCTION

Learners in medical education generally perceive that reflection is important, but they also find that reflection is not always valuable or practically applicable. We address the gap between the potential benefits of reflection and its practical implementation in medical education. We examined the perspective of Dutch GP registrars who (must) reflect for their GP specialty training to understand their participant perspective on reflection. Our aim is stimulating alignment between reflective activities that occur in a medical curriculum and the ideals of reflection as a valuable educational activity.

METHODS

We conducted, video-recorded and transcribed seven focus group sessions with GP registrars in 2021 across two Dutch GP educational programmes. We used discursive psychology to analyse the focus group data by focusing on 'assessments of reflection'. We analysed their discursive features (how something was said) and content features (what was said) and related these to each other to understand how GP registrars construct reflection.

RESULTS

Participants constructed reflection with nuance; they combined negative and positive assessments that displayed varied orientations to reflection. First, their combined assessments showed complex orientations to norms and experiences with reflecting in practice and that these are not simply negative or positive. Second, GP registrars constructed reflection as a negotiable topic and showed how reflection and its value can be variably understood. Third, through combined assessments, they displayed an orientation to the integration of reflection with other educational tasks, which impacts its value.

CONCLUSIONS

Generally, GP registrars speak positively about reflection, but the value of reflection partly depends on its proper integration with other educational tasks. When meaningful integration fails, activities to stimulate reflection can overshoot their own goal and hamper learner motivation to reflect. Developing a healthy 'reflection culture' could mitigate some challenges. Therein, reflection is treated as important while learners also have adequate autonomy.

Enhancing Medical Students' Reflective Capacity: Utilizing Reflective Practice Questionnaire as an Action Research Diagnostic Tool

Introduction Reflection is the intentional evaluation of one's beliefs or understanding in consideration of the available evidence. Reflection has been noted to enhance profound learning and critical thinking and is an essential foundation of experiential learning. The Reflective Practice Questionnaire (RPQ) is a valid and reliable tool for assessing reflective capacity among medical students. It assesses not only reflective capacity but also other psychological constructs relevant to reflective practice, such as job satisfaction, confidence while interacting with patients, stress during patient interaction, desire for improvement, and feelings of uncertainty. The use of RPQ as a diagnostic tool for improving reflective capacity among medical students is scarcely available in the literature. Thus, the present study aimed to utilize the RPQ for identifying discrete action points for training and future improvement in reflective capacity. Materials and methods The present cross-sectional descriptive study was conducted among 300 medical students of a medical college. To identify the clusters or meaningful subgroups within the study population, cluster analysis was done. Inter-correlation between subscales of RPQ was performed by forming Pearson's correlation matrix to understand the dynamics between various subscales of RPQ. Results Five groups were identified in the cluster analysis: typical (25.6%), reflective (27%), non-reflective (16.7%), unconfident (14%), and overconfident (16.7%). This sets the template for specific action points for each group identified above. Reflective capacity was positively correlated with Desire for Improvement (DfI), General Confidence (CG), Communication Confidence (CC), and Job Satisfaction (JS). It was also positively correlated with negative outcomes such as Uncertainty (Unc) and Stress when Interacting with Patients (SiC). Conclusion RPQ can be used as a diagnostic tool in terms of reflective capacity for action research.

Reflection on medical errors: A thematic analysis

BACKGROUND

As there is a need to prepare doctors to minimize errors, we wanted to determine how doctors go about reflecting upon their medical errors.

METHODS

We conducted a thematic analysis of the published reflection reports of 12 Dutch doctors about the errors they had made. Three questions guided our analysis: What triggers doctors to become aware of their errors? What topics do they reflect upon to explain what happened? What lessons do doctors learn after reflecting on their error?

RESULTS

We found that the triggers which made doctors aware of their errors were mostly death and/or a complication. This suggests that the trigger to recognize that something might be wrong came too late. The 12 doctors cited 20 topics' themes that explained the error and 16 lessons-learnt themes. The majority of the topics and lessons learnt were related more to the doctors' inner worlds (personal features) than to the outer world (environment).

CONCLUSION

To minimize errors, doctors should be trained to become earlier and in time aware of distracting and misleading features that might interfere with their clinical reasoning. This training should focus on reflection in action and on discovering more about doctors' personal inner world to identify vulnerabilities.

Diagnostic Reasoning Competency and Accuracy by Nurse Practitioner Students Following the Use of Structured Reflection in Simulation: A Mixed-Methods Experiment

AIM

The aim of this study was to examine the effect of structured reflection used during a simulated patient's diagnostic workup on diagnostic reasoning competency and accuracy and explore participants' cognitive bias experience and perceived utility of structured reflection.

BACKGROUND

Reasoning flaws may lead to diagnostic errors. Medical learners who used structured reflection demonstrated improved diagnosis accuracy.

METHOD

Embedded mixed-methods experiment examined diagnostic reasoning competency and accuracy of nurse practitioner students who did and did not use structured reflection. Cognitive bias experience and perceptions of structured reflection's utility were explored.

RESULTS

Diagnostic Reasoning Assessment mean competency scores and categories were not changed. Accuracy trended toward improvement with structured reflection. The theme, diagnostic verification, prompted diagnosis change by both structured reflection users and control participants.

CONCLUSION

Despite no changes in quantitative outcomes, explicit users of structured reflection believed that this strategy is helpful to their reasoning, and control participants used the strategy's components with the same noted benefits.

Mind The Gap: A Philosophical Analysis of Reflection's Many Benefits

Issue: Expectations of reflection run high in medical practice and medical education; it is claimed as a means to many ends. In this article, the authors do not reject the value of reflection for medical education and medical practitioners, but they still ask why reflection can (potentially) yield so many different benefits, and what that implies for the status of reflection in medical education practice. Evidence: Based on a conceptual analysis of debates about reflection in the philosophical tradition, the authors argue that there are two quintessential gaps that play a role in the proliferation of (potential) benefits. First, reflection deals with bridging the gap between theory and practice; second, it deals with bridging the gap between the individual sense and communal sense. These gaps prevent the systematization of reflection, and they are fundamental to human thinking and experience in any situated environment, which led contemporary research on reflection to list a wide variety of benefits. Implications: The authors argue that if reflection resists systematization, it cannot be learned by following rules or protocols, but only practiced. Then, reflection should no longer be taught and researched as an individual skill one learns, nor as a means to some particular, beneficial end. Rather, one should practice reflection, and experience what it means to be part of a community wherein professionals jump the theory-practice gap constantly in a myriad of situations. Based on their analysis, the authors provide three concrete recommendations for reflection in medical education. First, to give precedence to reflective activities that encompass both gaps wherein situated examples can flourish; second, to use reflective guidelines as sources of inspiration; third, to show reserve about assessing reflection.

Effect on diagnostic accuracy of cognitive reasoning tools for the workplace setting: systematic review and meta-analysis

BACKGROUND

Preventable diagnostic errors are a large burden on healthcare. Cognitive reasoning tools, that is, tools that aim to improve clinical reasoning, are commonly suggested interventions. However, quantitative estimates of tool effectiveness have been aggregated over both workplace-oriented and educational-oriented tools, leaving the impact of workplace-oriented cognitive reasoning tools alone unclear. This systematic review and meta-analysis aims to estimate the effect of cognitive reasoning tools on improving diagnostic performance among medical professionals and students, and to identify factors associated with larger improvements.

METHODS

Controlled experimental studies that assessed whether cognitive reasoning tools improved the diagnostic accuracy of individual medical students or professionals in a workplace setting were included. Embase.com, Medline ALL via Ovid, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar were searched from inception to 15 October 2021, supplemented with handsearching. Meta-analysis was performed using a random-effects model.

RESULTS

The literature search resulted in 4546 articles of which 29 studies with data from 2732 participants were included for meta-analysis. The pooled estimate showed considerable heterogeneity (I2=70%). This was reduced to I2=38% by removing three studies that offered training with the tool before the intervention effect was measured. After removing these studies, the pooled estimate indicated that cognitive reasoning tools led to a small improvement in diagnostic accuracy (Hedges' g=0.20, 95% CI 0.10 to 0.29, p<0.001). There were no significant subgroup differences.

CONCLUSION

Cognitive reasoning tools resulted in small but clinically important improvements in diagnostic accuracy in medical students and professionals, although no factors could be distinguished that resulted in larger improvements. Cognitive reasoning tools could be routinely implemented to improve diagnosis in practice, but going forward, more large-scale studies and evaluations of these tools in practice are needed to determine how these tools can be effectively implemented.

PROSPERO REGISTRATION NUMBER

CRD42020186994.

Learning to diagnose accurately through virtual patients: do reflection phases have an added benefit?

BACKGROUND

Simulation-based learning with virtual patients is a highly effective method that could potentially be further enhanced by including reflection phases. The effectiveness of reflection phases for learning to diagnose has mainly been demonstrated for problem-centered instruction with text-based cases, not for simulation-based learning. To close this research gap, we conducted a study on learning history-taking using virtual patients. In this study, we examined the added benefit of including reflection phases on learning to diagnose accurately, the associations between knowledge and learning, and the diagnostic process.

METHODS

A sample of N = 121 medical students completed a three-group experiment with a control group and pre- and posttests. The pretest consisted of a conceptual and strategic knowledge test and virtual patients to be diagnosed. In the learning phase, two intervention groups worked with virtual patients and completed different types of reflection phases, while the control group learned with virtual patients but without reflection phases. The posttest again involved virtual patients. For all virtual patients, diagnostic accuracy was assessed as the primary outcome. Current hypotheses were tracked during reflection phases and in simulation-based learning to measure diagnostic process.

RESULTS

Regarding the added benefit of reflection phases, an ANCOVA controlling for pretest performance found no difference in diagnostic accuracy at posttest between the three conditions, F(2, 114) = 0.93, p = .398. Concerning knowledge and learning, both pretest conceptual knowledge and strategic knowledge were not associated with learning to diagnose accurately through reflection phases. Learners' diagnostic process improved during simulation-based learning and the reflection phases.

CONCLUSIONS

Reflection phases did not have an added benefit for learning to diagnose accurately in virtual patients. This finding indicates that reflection phases may not be as effective in simulation-based learning as in problem-centered instruction with text-based cases and can be explained with two contextual differences. First, information processing in simulation-based learning uses the verbal channel and the visual channel, while text-based learning only draws on the verbal channel. Second, in simulation-based learning, serial cue cases are used to gather information step-wise, whereas, in text-based learning, whole cases are used that present all data at once.

A dual process model for paleopathological diagnosis

OBJECTIVES

This paper aims to provide an explicit theoretical model for the cognitive processes involved in paleopathological diagnosis.

METHODS

The approach adopted is a dual process model (DPM). DPMs recognize that cognition is a result of both Type 1 (intuitive) and Type 2 (analytical) processes. DPMs have been influential for understanding decision-making in a range of fields, including diagnosis in clinical medicine. Analogies are drawn between diagnosis in a clinical and a paleopathological setting.

RESULTS

In clinical medicine, both Type 1 and Type 2 processes play a part in diagnosis. In paleopathology the role of Type 1 processes has been unacknowledged. However, like clinical diagnosis, paleopathological diagnosis is inherently a result of a combination of both Type 1 and Type 2 processes. A model is presented by which Type 1 processes can be explicitly incorporated into a scientific approach to diagnosis from skeletal remains, and in which diagnosis is formalized as a process of hypothesis testing.

SIGNIFICANCE

Accurately modelling our diagnostic processes allows us to understand the biases and limitations in our work and potentially helps us to improve our procedures, including how we impart diagnostic skills in pedagogical settings.

LIMITATIONS

This work provides a theoretical model for paleopathological diagnosis. However, such models are by their nature dynamic and developing rather than static entities; it is hoped that this work stimulates further debate and discussion in this important area.

Teaching heuristics and mnemonics to improve generation of differential diagnoses

Background: Differential diagnosis (DDx) is one of the key cognitive skills that medical learners must develop. However, little is known regarding the best methods for teaching DDx skills. As metacognition plays a fundamental role in the diagnostic process, we hypothesized that the teaching of specific heuristics and mnemonics collectively termed metamemory techniques (MMTs) would enhance the capacity of medical students to generate differential diagnoses.Methods: In a 90-min DDx workshop, third-year medical students (N = 114) were asked to generate differentials before and after learning each of four MMTs. Differential sizes were compared using a linear mixed-effect model. Students also completed a post-session questionnaire which included a subjective ranking of the MMTs, as well as Likert-scale and free-text sections for course feedback.Results: One MMT (the Mental CT Scan, an anatomic visualization technique) significantly increased the size of student differentials (+13.3%, p =.0005). However, a marked cumulative increase across all four MMTs was noted (+36.5%, p <.0001). A majority of students ranked the Mental CT Scan the most useful MMT (51.5%). They found the workshop both worthwhile (4.51/5, CI 4.33-4.69) and enjoyable (4.33/5, CI 4.12-4.55), and considered the MMTs they learned useful and practical (4.49/5, CI 4.32-4.67).Conclusion: The MMT-based DDx workshop was effective in enhancing the skill of DDx generation, and was rated very favorably by students.

Diagnostic Activities and Diagnostic Practices in Medical Education and Teacher Education: An Interdisciplinary Comparison

In this article, we investigate diagnostic activities and diagnostic practices in medical education and teacher education. Previous studies have tended to focus on comparing knowledge between disciplines, but such an approach is complicated due to the content specificity of knowledge. We compared 142 learners from medical education and 122 learners from teacher education who were asked to (a) diagnose eight simulated cases from their respective discipline in a simulation-based learning environment and (b) write a justificatory report for each simulated case. We coded all justificatory reports regarding four diagnostic activities: generating hypotheses, generating evidence, evaluating evidence, and drawing conclusions. Moreover, using the method of Epistemic Network Analysis, we operationalized diagnostic practices as the relative frequencies of co-occurring diagnostic activities. We found significant differences between learners from medical education and teacher education with respect to both their diagnostic activities and diagnostic practices. Learners from medical education put relatively more emphasis on generating hypotheses and drawing conclusions, therefore applying a more hypothesis-driven approach. By contrast, learners in teacher education had a stronger focus on generating and evaluating evidence, indicating a more data-driven approach. The results may be explained by different epistemic ideals and standards taught in higher education. Further research on the issue of epistemic ideals and standards in diagnosing is needed. Moreover, we recommend that educators think beyond individuals' knowledge and implement measures to systematically teach and increase the awareness of disciplinary standards.

Challenges in mitigating context specificity in clinical reasoning: a report and reflection

Objectives Diagnostic error is a growing concern in U.S. healthcare. There is mounting evidence that errors may not always be due to knowledge gaps, but also to context specificity: a physician seeing two identical patient presentations from a content perspective (e.g., history, labs) yet arriving at two distinct diagnoses. This study used the lens of situated cognition theory - which views clinical reasoning as interconnected with surrounding contextual factors - to design and test an instructional module to mitigate the negative effects of context specificity. We hypothesized that experimental participants would perform better on the outcome measure than those in the control group. Methods This study divided 39 resident and attending physicians into an experimental group receiving an interactive computer training and "think-aloud" exercise and a control group, comparing their clinical reasoning. Clinical reasoning performance in a simulated unstable angina case with contextual factors (i.e., diagnostic suggestion) was determined using performance on a post-encounter form (PEF) as the outcome measure. The participants who received the training and did the reflection were compared to those who did not using descriptive statistics and a multivariate analysis of covariance (MANCOVA). Results Descriptive statistics suggested slightly better performance for the experimental group, but MANCOVA results revealed no statistically significant differences (Pillai's Trace=0.20, F=1.9, df=[4, 29], p=0.15). Conclusions While differences were not statistically significant, this study suggests the potential utility of strategies that provide education and awareness of contextual factors and space for reflective practice.

The Application of Forensic Podiatry to Clinical Practice

The practice of the clinical podiatrist traditionally focuses on the diagnosis and treatment of conditions of the foot, ankle, and related structures of the leg. Clinical podiatrists are expected to be mindful of "the principles and applications of scientific enquiry." This includes the evaluation of treatment efficacy and the research process. In contrast, the forensic podiatrist specializes in the analysis of foot-, ankle-, and gait-related evidence in the context of the criminal justice system. Although forensic podiatry is a separate, specialized field, many aspects of this discipline can be useful in the clinical treatment and management of foot and ankle problems. The authors, who are forensic podiatrists, contend that the clinical podiatrist can gain significant insights from the field of forensic podiatry. This article aims to provide clinical podiatrists with an overview of the principles and methods that have been tested and applied by forensic podiatrists in their practice, and suggests that the clinical practice of the nonforensic foot practitioner may benefit from such knowledge.

Why health professions education needs functional linguistics: the power of 'stealth words'

CONTEXT

Language is one of the primary modalities for teaching and learning in the health professions in contexts ranging from the more formal teaching relationships of medical school to the guided practice of trainees through continuing education and the deliberate practice of lifelong learning. Yet linguistic analysis, with the possible exception of discourse analysis, has not become a core methodological tool in the field of health professions education (HPE). The purpose of this paper is to argue for the more widespread adoption of one particular approach to linguistics, one that examines less of what learners and instructors say and looks more at how they say it: functional linguistics.

FUNCTIONAL LINGUISTICS

THE POWER OF 'STEALTH WORDS': This approach theorises and structures the functions of language, regularly focusing attention on 'stealth words' such as I, but and was. Drawing on a rich body of literature in linguistics, psychology, the learning sciences and some early work in HPE, we demonstrate how functional linguistic tools can be applied to better understand learners' and instructors' beliefs, reasoning processes, values and emotions.

FUNCTIONAL LINGUISTICS AND REFLECTION

AN APPLICATION OF STEALTH WORDS: A brief qualitative analysis of one tool - analysis of the generic use of 'you' to mean 'one' or 'anyone' - demonstrates how functional linguistics can offer insight into physicians' bids for credibility and alignment as they think aloud about their clinical reasoning.

FUNCTIONAL LINGUISTICS AND HPE

FUTURE DIRECTIONS: Finally, we offer suggestions for how functional linguistic tools might address questions and gaps in four active research areas in HPE: reflection; emotion and reasoning; learning in simulated contexts, and self-regulated learning.

CONCLUSIONS

We argue that the words used by learners, instructors and practitioners in the health professions as they move through undergraduate and graduate training into practice can offer clues that will help researchers, instructors and colleagues to better support them.

Understanding diagnosis through ACTion: evaluation of a point-of-care checklist for junior emergency medical residents

Background Avoiding or correcting a diagnostic error first requires identification of an error and perhaps deciding to revise a diagnosis, but little is known about the factors that lead to revision. Three aspects of reflective practice, seeking Alternative explanations, exploring the Consequences of missing these alternative diagnoses, identifying Traits that may contradict the provisional diagnosis, were incorporated into a three-point diagnostic checklist (abbreviated to ACT). Methods Seventeen first and second year emergency medicine residents from the University of Toronto participated. Participants read up to eight case vignettes and completed the ACT diagnostic checklist. Provisional and final diagnoses and all responses for alternatives, consequences, and traits were individually scored as correct or incorrect. Additionally, each consequence was scored on a severity scale from 0 (not severe) to 3 (very severe). Average scores for alternatives, consequences, and traits and the severity rating for each consequence were entered into a binary logistic regression analysis with the outcome of revised or retained provisional diagnosis. Results Only 13% of diagnoses were revised. The binary logistic regression revealed that three scores derived from the ACT tool responses were associated with the decision to revise: severity rating of the consequence for missing the provisional diagnosis, the percent correct for identifying consequences, and the percent correct for identifying traits (χ2 = 23.5, df = 6, p < 0.001). The other three factors were not significant predictors. Conclusions Decisions to revise diagnoses may be cued by the detection of contradictory evidence. Education interventions may be more effective at reducing diagnostic error by targeting the ability to detect contradictory information within patient cases.

Applications of the reflective practice questionnaire in medical education

BACKGROUND

We sought to determine whether the Reflective Practice Questionnaire (RPQ) is a reliable measure of reflective capacity and related characteristics in medical students. We also planned to learn how the RPQ could be used in medical education.

METHODS

The RPQ is a 40 item self-report questionnaire that includes a multi-faceted approach to measuring reflective capacity. It also includes sub-scales on several other theoretically relevant constructs such as desire for improvement, confidence, stress, and job satisfaction. The reliabilities of reflective capacity and other sub-scales were determined by calculating their Cronbach alpha reliability values. In the present study, the RPQ was answered by 98 graduating fourth-year medical students from an American University, and these RPQ scores were compared with general public and mental health practitioner samples from a prior study using ANOVA and Bonferroni adjusted comparisons.

RESULTS

Medical students reported a higher reflective capacity than the general public sample, but students were statistically indistinguishable from the mental health practitioner sample. For medical students, reflective capacity was associated with features of confidence, stress, and desire for improvement. Job satisfaction was positively associated with confidence in communication with patients, and negatively associated with stress when interacting with patients. A cluster analysis revealed that around 19% of the medical students exhibited a relatively high level of anxiety interacting with patients, 23% were less engaged, 5% were dissatisfied, and 7% expressed a level of over-confidence in their knowledge and skills that was concerning.

CONCLUSIONS

The RPQ is a reliable measure of reflective capacity (Chronbach's alpha value = 0.84) and related characteristics (Cronbach's alpha values from 0.75 to 0.83) in medical students. The RPQ can be used as part of pre-post evaluations of medical education initiatives, to complement student self-reflection activities in the curriculum, and to identify students who might benefit from targeted intervention.

Teaching Critical Thinking: A Case for Instruction in Cognitive Biases to Reduce Diagnostic Errors and Improve Patient Safety

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.

Role of intuitive knowledge in the diagnostic reasoning of hospital specialists: a focus group study

BACKGROUND AND OBJECTIVE

Intuition is an important part of human decision-making and can be explained by the dual-process theory where analytical and non-analytical reasoning processes continually interact. These processes can also be identified in physicians' diagnostic reasoning. The valuable role of intuition, including gut feelings, has been shown among general practitioners and nurses, but less is known about its role among hospital specialists. This study focused on the diagnostic reasoning of hospital specialists, how they value, experience and use intuition.

DESIGN AND PARTICIPANTS

Twenty-eight hospital specialists in the Netherlands and Belgium participated in six focus groups. The discussions were recorded, transcribed verbatim and thematically coded. A circular and iterative analysis was applied until data saturation was achieved.

RESULTS

Despite initial reservations regarding the term intuition, all participants agreed that intuition plays an important role in their diagnostic reasoning process. Many agreed that intuition could guide them, but were cautious not to be misguided. They were especially cautious since intuition does not have probative force, for example, in medicolegal situations. 'On-the-job experience' was regarded as a precondition to relying on intuition. Some participants viewed intuition as non-rational and invalid. All participants said that intuitive hunches must be followed by analytical reasoning. Cultural differences were not found. Both the doctor as a person and his/her specialty were seen as important determinants for using intuition.

CONCLUSIONS

Hospital specialists use intuitive elements in their diagnostic reasoning, in line with general human decision-making models. Nevertheless, they appear to disagree more on its role and value than previous research has shown among general practitioners. A better understanding of how to take advantage of intuition, while avoiding pitfalls, and how to develop 'skilled' intuition may improve the quality of hospital specialists' diagnostic reasoning.

Guided Reflection Interventions Show No Effect on Diagnostic Accuracy in Medical Students

Background: Guided reflection interventions, in an effort to reduce diagnostic error, encourage diagnosticians to generate alternative diagnostic hypotheses and gather confirming and disconfirming evidence before making a final diagnosis. This method has been found to significantly improve diagnostic accuracy in recent studies; however, it requires a significant investment of time, and psychological theory suggests the possibility for unintended consequences owing to cognitive bias. This study compared a short and long version of a guided reflection task on improvements in diagnostic accuracy, change in diagnostic confidence, and rates of corrected diagnoses.

Methods: One hundred and eighty-six fourth- and fifth-year medical students diagnosed a series of fictional clinical cases, by first impressions (control condition) or by using a short or long guided reflection process, and rated their confidence in their initial diagnostic hypothesis at intervals throughout the process. In the “short” condition, participants were asked to generate two alternatives to their initial diagnostic hypothesis; in the “long” condition, six alternatives were required.

Results: The reflective intervention did not elicit more accurate final diagnoses than diagnosis based on first impressions only. Participants who completed a short version of the task performed similarly to those who completed a long version. Neither the short nor long form elicited significant changes in diagnostic confidence from the beginning to the end of the diagnostic process, nor did the conditions differ on the rate of corrected diagnoses.

Conclusions: This study finds no evidence to support the use of the guided reflection method as a diagnostic aid for novice diagnosticians, who may already use an analytical approach to diagnosis and therefore derive less benefit from this intervention than their more experienced colleagues. The results indicate some support for a shorter, less demanding version of the process, and further study is now required to identify the most efficient process to recommend to doctors.

Diagnostic Errors: Impact of an Educational Intervention on Pediatric Primary Care

INTRODUCTION

The purpose of our study was to determine the impact of an educational program on a provider's knowledge related to diagnostic errors and diagnostic reasoning strategies.

METHODS

A quasi-experimental interventional study with a multimedia approach, case study discussion, and trigger-generated medical record review at two time points was conducted. Measurement tools included a test developed by the National Patient Safety Foundation, Reducing Diagnostic Errors: Strategies for Solutions Quiz, additional diagnostic reasoning questions, and a trigger-generated process to analyze medical records.

RESULTS

Knowledge related to diagnostic errors statistically improved from the pretest to posttest scores with sustained 60-day differences (p < .025). Although there was a decline in the proportion of patients returning with the same chief complaint within 14 days, this was not statistically significant (p < .15). When providers were confronted with an unrecognizable clinical presentation, they reported an increased use of a "diagnostic timeout" (p < .038).

DISCUSSION

Providers developed an increased awareness of the presence of diagnostic errors in the primary care setting, the contributing risk factors for a diagnostic error, and possible strategies to reduce diagnostic errors. These factors had an unexpected impact on changing the primary care practice model to enhance the continuity of patient care.