Misdiagnosis at a university hospital in 4 medical eras

The Role of Cue-Based Strategies in Skilled Diagnosis Among Pathologists

OBJECTIVE

This research was designed to test whether behavioral indicators of pathology-related cue utilization were associated with performance on a diagnostic task.

BACKGROUND

Across many domains, including pathology, successful diagnosis depends on pattern recognition that is supported by associations in memory in the form of cues. Previous studies have focused on the specific information or knowledge on which medical image expertise relies. The target in this study is the more general ability to identify and interpret relevant information.

METHOD

Data were collected from 54 histopathologists in both conference and online settings. The participants completed a pathology edition of the Expert Intensive Skills Evaluation 2.0 (EXPERTise 2.0) to establish behavioral indicators of context-related cue utilization. They also completed a separate diagnostic task designed to examine related diagnostic skills.

RESULTS

Behavioral indicators of higher or lower cue utilization were based on the participants' performance across five tasks. Accounting for the number of cases reported per year, higher cue utilization was associated with greater accuracy on the diagnostic task. A post hoc analysis suggested that higher cue utilization may be associated with a greater capacity to recognize low prevalence cases.

CONCLUSION

This study provides support for the role of cue utilization in the development and maintenance of skilled diagnosis amongst pathologists.

APPLICATION

Pathologist training needs to be structured to ensure that learners have the opportunity to form cue-based strategies and associations in memory, especially for less commonly seen diseases.

Phenotype clustering in health care: A narrative review for clinicians

Human pathophysiology is occasionally too complex for unaided hypothetical-deductive reasoning and the isolated application of additive or linear statistical methods. Clustering algorithms use input data patterns and distributions to form groups of similar patients or diseases that share distinct properties. Although clinicians frequently perform tasks that may be enhanced by clustering, few receive formal training and clinician-centered literature in clustering is sparse. To add value to clinical care and research, optimal clustering practices require a thorough understanding of how to process and optimize data, select features, weigh strengths and weaknesses of different clustering methods, select the optimal clustering method, and apply clustering methods to solve problems. These concepts and our suggestions for implementing them are described in this narrative review of published literature. All clustering methods share the weakness of finding potential clusters even when natural clusters do not exist, underscoring the importance of applying data-driven techniques as well as clinical and statistical expertise to clustering analyses. When applied properly, patient and disease phenotype clustering can reveal obscured associations that can help clinicians understand disease pathophysiology, predict treatment response, and identify patients for clinical trial enrollment.

Ideal algorithms in healthcare: Explainable, dynamic, precise, autonomous, fair, and reproducible

Established guidelines describe minimum requirements for reporting algorithms in healthcare; it is equally important to objectify the characteristics of ideal algorithms that confer maximum potential benefits to patients, clinicians, and investigators. We propose a framework for ideal algorithms, including 6 desiderata: explainable (convey the relative importance of features in determining outputs), dynamic (capture temporal changes in physiologic signals and clinical events), precise (use high-resolution, multimodal data and aptly complex architecture), autonomous (learn with minimal supervision and execute without human input), fair (evaluate and mitigate implicit bias and social inequity), and reproducible (validated externally and prospectively and shared with academic communities). We present an ideal algorithms checklist and apply it to highly cited algorithms. Strategies and tools such as the predictive, descriptive, relevant (PDR) framework, the Standard Protocol Items: Recommendations for Interventional Trials-Artificial Intelligence (SPIRIT-AI) extension, sparse regression methods, and minimizing concept drift can help healthcare algorithms achieve these objectives, toward ideal algorithms in healthcare.

Physiologic signatures within six hours of hospitalization identify acute illness phenotypes

During the early stages of hospital admission, clinicians use limited information to make decisions as patient acuity evolves. We hypothesized that clustering analysis of vital signs measured within six hours of hospital admission would reveal distinct patient phenotypes with unique pathophysiological signatures and clinical outcomes. We created a longitudinal electronic health record dataset for 75,762 adult patient admissions to a tertiary care center in 2014-2016 lasting six hours or longer. Physiotypes were derived via unsupervised machine learning in a training cohort of 41,502 patients applying consensus k-means clustering to six vital signs measured within six hours of admission. Reproducibility and correlation with clinical biomarkers and outcomes were assessed in validation cohort of 17,415 patients and testing cohort of 16,845 patients. Training, validation, and testing cohorts had similar age (54-55 years) and sex (55% female), distributions. There were four distinct clusters. Physiotype A had physiologic signals consistent with early vasoplegia, hypothermia, and low-grade inflammation and favorable short-and long-term clinical outcomes despite early, severe illness. Physiotype B exhibited early tachycardia, tachypnea, and hypoxemia followed by the highest incidence of prolonged respiratory insufficiency, sepsis, acute kidney injury, and short- and long-term mortality. Physiotype C had minimal early physiological derangement and favorable clinical outcomes. Physiotype D had the greatest prevalence of chronic cardiovascular and kidney disease, presented with severely elevated blood pressure, and had good short-term outcomes but suffered increased 3-year mortality. Comparing sequential organ failure assessment (SOFA) scores across physiotypes demonstrated that clustering did not simply recapitulate previously established acuity assessments. In a heterogeneous cohort of hospitalized patients, unsupervised machine learning techniques applied to routine, early vital sign data identified physiotypes with unique disease categories and distinct clinical outcomes. This approach has the potential to augment understanding of pathophysiology by distilling thousands of disease states into a few physiological signatures.

Computerized history-taking improves data quality for clinical decision-making-Comparison of EHR and computer-acquired history data in patients with chest pain

Patients’ medical histories are the salient dataset for diagnosis. Prior work shows consistently, however, that medical history-taking by physicians generally is incomplete and not accurate. Such findings suggest that methods to improve the completeness and accuracy of medical history data could have clinical value. We address this issue with expert system software to enable automated history-taking by computers interacting directly with patients, i.e. computerized history-taking (CHT). Here we compare the completeness and accuracy of medical history data collected and recorded by physicians in electronic health records (EHR) with data collected by CHT for patients presenting to an emergency room with acute chest pain. Physician history-taking and CHT occurred at the same ED visit for all patients. CHT almost always preceded examination by a physician. Data fields analyzed were relevant to the differential diagnosis of chest pain and comprised information obtainable only by interviewing patients. Measures of data quality were completeness and consistency of negative and positive findings in EHR as compared with CHT datasets. Data significant for the differential of chest pain was missing randomly in all EHRs across all data items analyzed so that the dimensionality of EHR data was limited. CHT files were near complete for all data elements reviewed. Separate from the incompleteness of EHR data, there were frequent factual inconsistencies between EHR and CHT data across all data elements. EHR data did not contain representations of symptoms that were consistent with those reported by patients during CHT.

Trial registration: This study is registered at https://www.clinicaltrials.gov (unique identifier: NCT03439449).

Discrepancies between clinical diagnosis and hospital autopsy: A comparative retrospective analysis of 1,112 cases

Aims

The aim of this study was to compare discrepancies between diagnosed and autopsied causes of death in 1,112 hospital autopsies and to determine the factors causing this discrepancies.

Methods

1,112 hospital autopsies between 2010 and 2013 were retrospectively studied. Ante-mortem diagnoses were compared to causes of death as determined by autopsy. Clinical diagnoses were extracted from the autopsy request form, and post-mortem diagnoses were assessed from respective autopsy reports. Variables, such as sex, age, Body Mass Index, category of disease, duration of hospital stay and new-borns were studied in comparison to discrepancy. P-values were derived from the Mann-Whitney U test for the constant features and chi-2 test, p-values < 0,05 were considered significant.

Results

73.9% (n = 822) patients showed no discrepancy between autopsy and clinical diagnosis. The duration of hospitalisation (6 vs. 9 days) and diseases of the cardiovascular system (61.7%) had a significant impact on discrepancies.

Conclusion

Age, cardiovascular diseases and duration of hospital stay significantly affect discrepancies in ante- and post-mortem diagnoses.

Diagnostic reasoning in internal medicine: a practical reappraisal

The practice of clinical medicine needs to be a very flexible discipline which can adapt promptly to continuously changing surrounding events. Despite the huge advances and progress made in recent decades, clinical reasoning to achieve an accurate diagnosis still seems to be the most appropriate and distinctive feature of clinical medicine. This is particularly evident in internal medicine where diagnostic boundaries are often blurred. Making a diagnosis is a multi-stage process which requires proper data collection, the formulation of an illness script and testing of the diagnostic hypothesis. To make sense of a number of variables, physicians may follow an analytical or an intuitive approach to clinical reasoning, depending on their personal experience and level of professionalism. Intuitive thinking is more typical of experienced physicians, but is not devoid of shortcomings. Particularly, the high risk of biases must be counteracted by de-biasing techniques, which require constant critical thinking. In this review, we discuss critically the current knowledge regarding diagnostic reasoning from an internal medicine perspective.

Clinical Skill: The Ebbing Art of Medicine

Clinical history taking and physical examination are the essence of clinical medicine. However, the glare of modern diagnostic tools and techniques has overshadowed these basic but indispensable steps of diagnosis. Deterioration of clinical skills is a burning issue in this era due to over-reliance on high-end technology. Poor clinical judgment not only leads to mismanagement but also results in over-utilisation of health care resources. Moreover, with lesser time at the bedside, the physician-patient relationship is also getting compromised.

Significant differences in written assessments as a result of a blended learning approach used in a clinical examination course in internal medicine: a randomized controlled pilot study

Background: Taking a medical history and performing a physical examination represent basic medical skills. However, numerous national and international studies show that medical students and physicians-to-be demonstrate substantial deficiencies in the proper examination of individual organ systems. Aim: The objective of this study was to conduct a randomized controlled pilot study to see if, in the context of a bedside clinical examination course in internal medicine, an additional app-based blended-learning strategy resulted in (a) higher satisfaction, better self-assessments by students when rating their history-taking skills (b1) and their ability to perform physical examinations (b2), as well as (c) higher multiple-choice test scores at the end of the course, when compared to a traditional teaching strategy. Methods: Within the scope of a bedside course teaching the techniques of clinical examination, 26 students out of a total of 335 students enrolled in the 2012 summer semester and 2012/2013 winter semester were randomly assigned to two groups of the same size. Thirteen students were in an intervention group (IG) with pre- and post-material for studying via an app-based blended-learning tool, and another 13 students were in a control group (CG) with the usual pre- and post-material (handouts). The IG was given an app specifically created for the history-taking and physical exam course, an application program for smartphones enabling them to view course material directly on the smartphone. The CG received the same information in the form of paper-based notes. Prior to course begin, all of the students filled out a questionnaire on sociodemographic data and took a multiple-choice pretest with questions on anamnesis and physical examination. After completing the course, the students again took a multiple-choice test with questions on anamnesis and physical examination. Results: When compared to the CG, the IG showed significantly more improvement on the multiple-choice tests after taking the clinical examination course (p=0.022). This improvement on the MC tests in the IG significantly correlated with the amount of time spent using the app (Spearman's rho=0.741, p=0.004). Conclusion: When compared to conventional teaching, an app-based blended-learning approach leads to improvement in test scores, possibly as a result of more intensive preparation for and review of the clinical examination course material.

Point-of-care ultrasound augments physical examination learning by undergraduate medical students

BACKGROUND

Little is known about the impact of the provision of handheld point-of-care ultrasound (POCUS) devices on physical examination skills of medical students.

METHODS

We describe an educational initiative that comprised a POCUS workshop followed by allocation of a POCUS device to medical students for use over the subsequent 8 weeks. They were encouraged to scan patients and correlate their physical examination findings. A mobile instant messaging group discussion platform was set to provide feedback from instructors. Physical examination skills were assessed by means of clinical examination.

RESULTS

210 final-year medical students from the University of Hong Kong participated in the programme. 46.3% completed the end of programme electronic survey: 74.6% enjoyed using the POCUS device, 50.0% found POCUS useful to validate physical examination findings and 47.7% agreed that POCUS increased their confidence with physical examination. 93.9% agreed that the programme should be incorporated into the medical curriculum and 81.9% would prefer keeping the device for longer time from 16 weeks (45.6%) to over 49 weeks (35.3%). Medical students who participated in the POCUS programme had a higher mean score for abdominal examination compared with those from the previous academic year with no POCUS programme (3.65±0.52 vs 3.21±0.80, p=0.014), but there was no statistically significant difference in their mean score for cardiovascular examination (3.62±0.64 vs 3.36±0.93, p=0.203).

CONCLUSION

The POCUS programme that included provision of a personal handheld POCUS device improved students' attitude, confidence and ability to perform a physical examination.

Diagnostic discrepancies between emergency department admissions and hospital discharges among older adults: secondary analysis on a population-based survey

BACKGROUND

Older adults frequently experience nonspecific clinical features. However, there is limited evidence on how often admission diagnoses for hospitalized older patients are incorrect, potentially leading to treatment delays.

OBJECTIVES

To determine the consistency between hospital admission and discharge diagnoses, and identify factors associated with diagnostic discrepancies in older adults.

DESIGN AND SETTING

Population-based cohort study in the United States. We included adults aged ≥ 18 years who were admitted from emergency departments (EDs) to hospitals, identified using the 2005-2010 National Hospital Ambulatory Medical Survey, a nationally representative survey.

METHODS

Three admission diagnoses and the principal discharge diagnosis were captured and classified as discrepant if they involved considerably different conditions within the same organ system, or different organ systems altogether.

RESULTS

Each year, 12 million adults were hospitalized following ED visits in the United States; 45% were aged ≥ 65 years. These patients' mean age was 79 years and 58% were women. Diagnostic discrepancies between admission and discharge were more common among adults ≥ 65 years (12.5 versus 8.3%; P < 0.001). Certain admission diagnoses had particularly high rates of diagnostic discrepancies: 26-27% of patients presenting with mental disorders or with endocrine and metabolic diseases had substantial diagnostic discrepancies between admission and discharge. Substantial diagnostic discrepancy was independently associated with longer hospitalization and higher in-hospital mortality.

CONCLUSION

One out of eight older adults hospitalized from EDs was discharged with a principal diagnosis differing considerably from the admission diagnosis. Given that missed or delayed diagnoses are a critical safety problem, clinicians should be vigilant and frequently cogitate alternative diagnostic possibilities.

Decision analysis and reinforcement learning in surgical decision-making

BACKGROUND

Surgical patients incur preventable harm from cognitive and judgment errors made under time constraints and uncertainty regarding patients' diagnoses and predicted response to treatment. Decision analysis and techniques of reinforcement learning theoretically can mitigate these challenges but are poorly understood and rarely used clinically. This review seeks to promote an understanding of decision analysis and reinforcement learning by describing their use in the context of surgical decision-making.

METHODS

Cochrane, EMBASE, and PubMed databases were searched from their inception to June 2019. Included were 41 articles about cognitive and diagnostic errors, decision-making, decision analysis, and machine-learning. The articles were assimilated into relevant categories according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines.

RESULTS

Requirements for time-consuming manual data entry and crude representations of individual patients and clinical context compromise many traditional decision-support tools. Decision analysis methods for calculating probability thresholds can inform population-based recommendations that jointly consider risks, benefits, costs, and patient values but lack precision for individual patient-centered decisions. Reinforcement learning, a machine-learning method that mimics human learning, can use a large set of patient-specific input data to identify actions yielding the greatest probability of achieving a goal. This methodology follows a sequence of events with uncertain conditions, offering potential advantages for personalized, patient-centered decision-making. Clinical application would require secure integration of multiple data sources and attention to ethical considerations regarding liability for errors and individual patient preferences.

CONCLUSION

Traditional decision-support tools are ill-equipped to accommodate time constraints and uncertainty regarding diagnoses and the predicted response to treatment, both of which often impair surgical decision-making. Decision analysis and reinforcement learning have the potential to play complementary roles in delivering high-value surgical care through sound judgment and optimal decision-making.

The Modern Physical Exam - A Transatlantic Perspective from the Resident Level

Issue: The physical examination has been in decline for many years and poorer skills contribute to medical errors and adverse events. Diagnostic error is also increasing with the complexity of medicine. Comparing the physical examination in Ireland and the United States with a focus on education, assessment, culture, and health systems may provide insight into the decline of the physical exam in the United States, uncover possible strategies to improve clinical skills, and limit diagnostic error. Evidence: The physical exam is a core component of both undergraduate and postgraduate medical education in Ireland. This is reflected by the time and effort invested by medical schools and medical societies in Ireland in teaching and assessing skills. This high standard of skills results in the physical exam being a key component of the diagnostic process and a gatekeeper to expensive investigations essential in a resource-limited health system such as Ireland. Use of the physical exam in the United States is hindered by the high-tech transformation of healthcare and a more litigious society. Known strategies to highlight the role of the physical exam in clinical practice include creating an evidence base to show that better physical exam skills improve outcomes, identifying accurate physical exam maneuvers, stressing the therapeutic alliance the physical exam brings to the patient encounter, and the incorporation of technology into the bedside exam. Implications: Contrasting the education and clinical use of the physical examination in the United States with Ireland allowed us to identify a number of strategies which could be used to promote the physical exam among learners in both countries. Highlighting simple and pragmatic physical exam maneuvers combined with evidence-based physical exam diagnostic data may renew confidence in the physical exam as a core diagnostic tool. Use of the hypothesis-driven approach may streamline a clinician's physical exam during a patient encounter, focusing on the key examination components and avoiding unnecessary and low yield maneuvers. The absence of assessment of physical exam skills using real patients in United States licensing exams communicates to learners that these skills are not important. However, steps to introduce a culture of assessment to drive learning are being introduced. One area Ireland could learn from the United States is incorporating more technology into the bedside exam. Enhanced physical examination skills in both countries could reduce reliance on expensive investigations and improve diagnostic accuracy.

Can low autopsy rates be increased? Yes, we can! Should postmortem examinations in oncology be performed? Yes, we should! A postmortem analysis of oncological cases

Ever declining autopsy rates have been a concern of pathologists as well as clinicians for decades. Notably, in the field of oncology, data on autopsies and discrepancies between clinical and autoptic diagnoses are particularly scarce. In this retrospective study, we show the effect of a simple catalog of measures consisting of a different approach to obtain consent for autopsy, structured conferencing, and systematic teaching of residents, as well as a close collaboration between clinicians and pathologists on the numbers of autopsies, especially of oncological patients. Additionally, postmortem examination protocols from the years 2015 until 2019 were analyzed, regarding rates of discrepancies between clinical and autoptic causes of death in this category of patients. Autopsy numbers could be significantly increased from a minimum in 2014 (60 autopsies) to a maximum in 2018 (142 autopsies) (p < 0.0001). In the 67 autopsies of oncological cases, a high rate of 51% of major discrepancy between clinical and autoptic causes of death could be detected. In contrast to the general reported decline of autopsy rates, we present rising autopsy numbers over the past 5 years with an increasing number of oncological cases who underwent a postmortem examination. The high percentage of major discrepancies between clinical and autopsy diagnosis is in contrast to an expected decrease of major discrepancies in times of precise diagnostic methods and underlines the importance of autopsies to ensure high quality in diagnostics and therapy not only in the field of oncology.

Pulmonary Embolism in Intensive Care Unit

Management of pulmonary embolism (PE) has become more complex due to the expanded role of catheter-based therapies, surgical thrombectomies, and cardiac assist technologies, such as right ventricular assist devices and extracorporeal support. Due to the heterogeneity of PE, a multidisciplinary team approach is necessary. The manifestation of PE response teams are in response to this complex need and similar to the proliferation of stroke, trauma, and rapid response teams. Intensive care units are an ideal location for formulating a comprehensive treatment plan that necessitates an interaction between multiple specialties. This article addresses the unique needs of critically ill patients with PE.

The Role of EEG in the Erroneous Diagnosis of Epilepsy

Errors in diagnosis are relatively common in medicine and occur in all specialties. The consequences can be serious for both patients and physicians. Errors in neurology are often because of the overemphasis on 'tests' over the clinical picture. The diagnosis of epilepsy in general is a clinical one and is typically based on history. Epilepsy is more commonly overdiagnosed than underdiagnosed. An erroneous diagnosis of epilepsy is often the result of weak history and an 'abnormal' EEG. Twenty-five to 30% of patients previously diagnosed with epilepsy who did not respond to initial antiepileptic drug treatment do not have epilepsy. Most patients misdiagnosed with epilepsy turn out to have either psychogenic nonepileptic attacks or syncope. Reasons for reading a normal EEG as an abnormal one include over-reading normal variants or simple fluctuations of background rhythms. Reversing the diagnosis of epilepsy is challenging and requires reviewing the 'abnormal' EEG, which can be difficult. The lack of mandatory training in neurology residency programs is one of the main reasons for normal EEGs being over-read as abnormal. Tests (including EEG) should not be overemphasized over clinical judgment. The diagnosis of epilepsy can be challenging, and some seizure types may be underdiagnosed. Frontal lobe hypermotor seizures may be misdiagnosed as psychogenic events. Focal unaware cognitive seizures in elderly maybe be blamed on dementia, and ictal or interictal psychosis in frontal and temporal lobe epilepsies may be mistaken for a primary psychiatric disorder.

[From symptom to diagnosis-symptom checkers re-evaluated : Are symptom checkers finally sufficient and accurate to use? An update from the ENT perspective]

BACKGROUND

Every seventh diagnosis is a misdiagnosis. Each year, 1.5 million lives could be saved worldwide with the correct diagnosis. Physicians have to consider over 20,000 diseases. A study from Harvard University published in 2015 tested 19 symptom checkers and found them to be insufficient, with only 29-71% accuracy in diagnosis.

OBJECTIVE

The current study investigates the diagnostic accuracy of new symptom checkers from an ENT perspective.

MATERIALS AND METHODS

The authors update the abovenamed diagnostic accuracy comparison by (1) including the five new symptom checkers Symptoma, Ada, FindZebra, Mediktor, and Babylon; and (2) normalizing results of the previously tested symptom checkers as to reflect each diagnostic accuracy based on the same set of patient vignettes. The winner is then compared to the two symptom checkers with the most scientific evidence, namely Isabel and FindZebra, on the basis of an ENT-specific test with patient vignettes sourced from the British Medical Journal.

RESULTS

Most of the new symptom checkers demonstrated diagnostic accuracy rates within the previously established range, with the exception of Symptoma, which scored the right diagnosis in 82.2% of cases at the top of the list (+38% points), and in 100% of cases in the top 3 (+29% points) and the top 10 (+16% points), thus raising the bar in this field. The cross-validation with ENT cases resulted in a diagnostic accuracy of 64.3 vs. 21.4 vs. 26.2% (top 1), 92.9 vs. 40.5 vs. 42.9% (top 3), and 100 vs. 61.9 vs. 54.8% (top 10) for Symptoma vs. Isabel vs. FindZebra, respectively.

CONCLUSIONS

Symptoma is the first and only viable solution in this market. Large-scale studies should be conducted to further validate these results as well as to assess the actual practical performance of the symptom checkers and their ability to diagnose rare diseases.

Autopsy and clinical discrepancies in patients undergoing extracorporeal membrane oxygenation: a case series

BACKGROUND

Extracorporeal life support is used as a salvage procedure to treat refractory cardiopulmonary failure. There are limited data addressing discrepancies between pre- and postmortem findings in patients undergoing extracorporeal membrane oxygenation (ECMO). We investigated discrepancies between clinical and autopsy findings in patients placed on ECMO to assess in what proportion of patients were there significant cardiovascular or other pathologies present that were not clinically apparent prior to death.

METHODOLOGY

After institutional review board approval, a list of deceased ECMO patients who underwent autopsy examination from 2004 through 2015 was obtained from our institutional database. Retrospective analyses of findings on clinical investigations done while patients were on ECMO and findings on autopsy examination were compared and stratified according to modified Goldman Criteria, which classify discrepancies into four grades depending on their impact on patient's management and mortality.

RESULTS

Of 19 patients, 18 patients had venoarterial ECMO (9 central + 5 peripheral + 4 conversions of ECMO type) and 1 patient received venovenous ECMO. Clinically unrecognized findings were found on autopsy in all patients. 56.6% of total discrepancies found were major [class I/II; e.g., myocardial infarction (MI), intracranial bleeding]. All patients had major discrepancies (class I/II) with an average of 4.21 class I discrepancies per patient. Class I discrepancies are findings which could have altered the course of treatment and survival of the patient if recognized premortem. The most common discrepancies were cardiovascular (MI 63.2%, marked cardiac remodeling 42.1%, severe coronary disease 31.6%) in nature across four classes of discrepancies.

CONCLUSIONS

We found major discrepancies between premortem and postmortem diagnoses in patients who underwent ECMO. Our findings underscore difficulties in clinically diagnosing events on ECMO as well as the need for enhanced surveillance and better diagnostic techniques in ECMO patients. Further prospective studies are necessary to understand effects of ECMO on major organs.

Forensic Autopsy Experience and Core Entrustable Professional Activities: A Structured Introduction to Autopsy Pathology for Preclinical Student

The forensic and autopsy pathology service within the Department of Pathology at University of North Dakota School of Medicine provides an optional, structured autopsy experience for medical students during the second year of the curriculum. This experience reinforces forensic autopsy pathology as the practice of medicine and highlights the American Association of Medical Colleges Core Entrustable Professional Activities. Students self-select for this optional, noncredit autopsy observership. Prior to the experience, interested students participate in a session that reviews the professional and educational expectations of the autopsy experience, autopsy safety training, and logistics of call. Groups of up to 4 students are on call for an autopsy. Student groups observe and participate in an autopsy, ideally from scene through autopsy performance, slide review, and toxicology results. The student groups use a structured presentation format for summarizing their autopsy experience, forming a differential and final diagnosis, completing the death certificate, and discussing quality management or learning issues in the case. At the end of the semester, all students participating in the experience meet and each group presents a 10-minute, structured review of their case. At least 6 core entrustable professional activities were addressed in every autopsy review; some had more when advanced clinical questions or safety issues were identified. Additionally, one student presented his case at a national meeting with a resultant publication. The experience provided (1) a positive introduction to autopsy pathology, (2) reinforced the role of pathology in medicine, and (3) provided concrete examples of American Association of Medical Colleges Core Entrustable Professional Activities within pathology for students in preclinical years.

Diagnostic Errors in Tuberculous Patients: A Multicenter Study from a Developing Country

Although there is still much to learn about the types of errors committed in health care and why they occur, enough is known today to recognize that a serious concern exists for patients. Tuberculosis (TB) is an infectious disease that is frequently subject to diagnostic errors. Missed or delayed diagnosis of TB can affect patients and community adversely. Our aim in the present study was at evaluating the type of diagnostic errors in TB patients from symptom onset to diagnosis. This was a multicenter cross-sectional study conducted in three university hospitals in Mashhad, Iran. We showed a long delay in diagnosing TB that is mostly related to the time from first medical visit to diagnosis. Errors in the diagnostic process were identified in 97.5% of patients. The most common type of error in diagnosing TB was failure in hypothesis generation (72%), followed by history taking and physical examination. In conclusion, it seems likely that efforts to improve public awareness of and health literacy for TB, to coordinate the referral and follow-up systems of patients, and to improve physicians' skills in history taking and physical examination and clinical reasoning will result in reduced delay in diagnosis of TB and, perhaps, improved patient safety and community health.

Identifying Hesitation and Discomfort with Diagnosing Sepsis: Survey of a Pediatric Tertiary Care Center

Supplemental Digital Content is available in the text.

Objective:

Pediatric sepsis remains a significant cause of morbidity and mortality despite the development of strategies proven to improve diagnosis and treatment. Specifically, early recognition and urgent therapy initiation are consistently associated with improved outcomes. However, providers bring these principles inconsistently to the bedside. The objective of this study was to describe practitioner knowledge of, and attitudes toward, sepsis as a means of identifying potentially modifiable factors delaying life-saving treatment. We hypothesized there would be difficulties with sepsis recognition and self-reported discomfort with making the diagnosis among all provider groups in a pediatric tertiary care center.

Methods:

Emergency department and inpatient pediatric physicians, nurses, and respiratory therapists in a single, freestanding children’s hospital received an electronic survey. Likert scales permitted anonymous self-reporting of comfort and diagnostic delays. Seven clinical vignettes assessed diagnostic knowledge. Independent sample t tests and Chi-square compared responses.

Results:

Three hundred two staff participated (73% response rate), 41% of whom had at least 10 years of clinical experience. One in 5 was uncomfortable alerting coworkers to a patient with suspected sepsis or septic shock, and almost half were uncomfortable doing so in cases of compensated shock. Every role self-reported diagnostic delays, including faculty physicians. On average, physicians answered a greater percentage of vignette questions correctly (66%), compared with nurses (58%; P = 0.013) and respiratory therapists (52%; P = 0.005).

Conclusions:

Sepsis knowledge deficits, provider discomfort, and diagnostic delays are prevalent within a tertiary care children’s hospital. Their presence and scale suggest areas for future research and targeted intervention.

The impact of speed and bias on the cognitive processes of experts and novices in medical image decision-making

Training individuals to make accurate decisions from medical images is a critical component of education in diagnostic pathology. We describe a joint experimental and computational modeling approach to examine the similarities and differences in the cognitive processes of novice participants and experienced participants (pathology residents and pathology faculty) in cancer cell image identification. For this study we collected a bank of hundreds of digital images that were identified by cell type and classified by difficulty by a panel of expert hematopathologists. The key manipulations in our study included examining the speed-accuracy tradeoff as well as the impact of prior expectations on decisions. In addition, our study examined individual differences in decision-making by comparing task performance to domain general visual ability (as measured using the Novel Object Memory Test (NOMT) (Richler et al. Cognition 166:42–55, 2017). Using signal detection theory and the diffusion decision model (DDM), we found many similarities between experts and novices in our task. While experts tended to have better discriminability, the two groups responded similarly to time pressure (i.e., reduced caution under speed instructions in the DDM) and to the introduction of a probabilistic cue (i.e., increased response bias in the DDM). These results have important implications for training in this area as well as using novice participants in research on medical image perception and decision-making.

Unexpected findings and misdiagnoses in coroner's autopsies performed for trauma at the University of the West Indies, Kingston, Jamaica

There has been significant improvement in medical diagnostic technology, but discrepancy rates between clinical and postmortem diagnoses remain relatively high. This study aimed to identify misdiagnoses and missed (unexpected) findings documented during complete coroner's autopsies performed for trauma at the University of the West Indies (UWI) and evaluate their influence on patient outcome. We retrospectively reviewed the reports of all coroner's autopsies performed for trauma, between 2003 and 2012, at the UWI. For each case, we extracted age, gender, trauma type, mechanism and topography, clinical and postmortem diagnoses and hospitalization duration. The data were used to calculate frequencies, proportions and discrepancy rates. 955 coroner's autopsies were performed during the 10-year period; reports were available for 933. 396 of these were performed for trauma; 365 met the inclusion criteria. 260 (71.2%) of the 365 autopsies had at least one discrepancy. There were 746 clinical and 1118 autopsy diagnoses; 382 were discrepant (372 missed [unexpected] diagnoses, 6 mis-diagnoses and 4 over-diagnoses). The discrepancy rate (misdiagnoses and missed diagnoses) was 33.8%, and the majority (55%) occurred in patients hospitalized for <1 day. Cardiopulmonary diseases were the most commonly missed diagnoses. The discrepancy rate was intermediate to those previously reported in the literature. The short hospitalization duration in most patients suggests that limited time for clinical investigation may be a contributor to discrepancy. However, increased awareness among clinicians of the common major missed diagnoses should enhance their early diagnosis, even when clinical signs are subtle, hopefully producing improved patient outcome.

Errors in diagnosis of infective endocarditis

Infective endocarditis (IE) is now the third or fourth most common life-threatening infectious disease. The high morbidity and mortality rates in the absence of appropriate care necessitate a thorough understanding of the obstacles towards the early diagnosis and management of IE. The aim of this study was to evaluate the frequency of discrepancy in diagnosis (i.e. discrepancy between the reason for admission and discharge diagnosis) and associated factors in patients with IE. It was a retrospective review of hospital records of all adult patients admitted in a 1000-bed academic general hospital in Mashhad, Iran with the discharge diagnosis of IE. Discrepancy in diagnosis on admission was observed in 64 (54.2%) of 118 episodes of IE. For patients with discrepant diagnosis, the odds of poor outcome were more than two times higher than the odds of those with the non-discrepant diagnosis. Multivariate analysis identified the only history of prosthetic valve replacement as an independent factor in predicting non-discrepant diagnosis. We suggest that in facing a patient with the complex clinical scenario, proposing a comprehensive clinical syndrome that includes predisposing factors instead of a symptom or finding-based diagnosis can help making the differential diagnosis more accurate.

Network-based analysis of diagnosis progression patterns using claims data

In recent years, several network models have been introduced to elucidate the relationships between diseases. However, important risk factors that contribute to many human diseases, such as age, gender and prior diagnoses, have not been considered in most networks. Here, we construct a diagnosis progression network of human diseases using large-scale claims data and analyze the associations between diagnoses. Our network is a scale-free network, which means that a small number of diagnoses share a large number of links, while most diagnoses show limited associations. Moreover, we provide strong evidence that gender, age and disease class are major factors in determining the structure of the disease network. Practically, our network represents a methodology not only for identifying new connectivity that is not found in genome-based disease networks but also for estimating directionality, strength, and progression time to transition between diseases considering gender, age and incidence. Thus, our network provides a guide for investigators for future research and contributes to achieving precision medicine.

[Adult autopsies during the past decade in Germany : Data from two university hospitals]

BACKGROUND

The clinical autopsy is the ultimate medical service for a patient and plays a crucial role in the education of physicians and other medical personnel, as well as in the context of quality control. Nevertheless, the number of autopsies is constantly decreasing. Numerous factors, such as the personal attitude of relatives and also clarification of relatives, as well as the increasing application of imaging methods while the patient is still alive, play a central role in this decline.

OBJECTIVE

This study aimed to demonstrate the development of autopsy services over the past decade in two university hospitals in Germany and therefore to underline the importance of this investigation procedure in pathology.

MATERIAL AND METHODS

Autopsy reports between the years 2005 and 2014 from 2 university institutes of pathology were analyzed regarding a diverse dataset, including age and sex of the deceased as well as the clinical and pathological causes of death.

RESULTS

The data showed that the number of autopsies has continuously decreased over the past decade; however, the distribution of characteristics of the deceased remained relatively stable. In this cohort the clinically assumed cause of death differed from the pathological cause of death in 6% of the autopsies. Frequently occurring discrepant diagnoses were cardiac tamponade, aortic dissection and endocarditis/myocarditis.

DISCUSSION

Our results show that, despite significant improvements in imaging methods, findings do not yield more accurate results than does autopsy. This underscores once again the need to encourage the performance of this final medical act on patients.

Comparison of Clinical and Pathological Diagnoses in Cats and Dogs

The comparison of clinical ante-mortem and pathological post-mortem diagnoses is a prerequisite for quality control, but is rarely done in veterinary medicine. This study reports the occurrence and concurrence of clinical and pathological diagnoses linked to death in 1,000 cats and 1,000 dogs examined and subjected to necropsy examination at the University of Zurich, Switzerland. Potential factors influencing the correlation between diagnoses were examined retrospectively. In 5.8% of cats and 5.2% of dogs no diagnosis was made; in 2.6% and 3.8% of cases only a clinical, and in 17.8% and 11.2%, respectively, only a pathological diagnosis was available. Of the 73.8% of cats and 79.8% of dogs with both diagnoses present, 38.3% and 36.2% were in agreement, while there was disagreement in 17.9% and 16.0%, respectively. The remaining cases (43.8% and 47.8%) had different levels of further diagnostic procedures following necropsy examination. In both species, the manner of death, the clinical discipline submitting the animal for necropsy examination and the quality of the necropsy submission request, as well as the timespan between death and necropsy examination in dogs, proved to influence the concurrence between diagnoses. In contrast, the organ system affected and the type of disease entity were, for both species, the most influential factors in the concurrence of diagnoses. Therefore, in veterinary medicine, even in times of improving diagnostic abilities, necropsy examination still reveals important information for quality control and education.

Prime time to resuscitate clinical medicine and kill diagnostic greed?

Modern healthcare faces the challenges of rising costs, increasing expectations of patients and changing disease patterns. Physicians practise medicine in an era of easy availability and access to a plethora of modern and sometimes expensive diagnostic aids. The powerful utility of clinical skills cannot be underestimated nor lost. The physician has a powerful platform to encourage the rational use of tests, prevent wasteful overutilisation and ensure that tests do not cause more harm than benefit in physical, emotional or financial terms. Diagnostic skills should not be substituted by diagnostic greed. It is possible to do more for the patient rather than to the patient.

How well do final year undergraduate medical students master practical clinical skills?

INTRODUCTION

The clinical examination and other practical clinical skills are fundamental to guide diagnosis and therapy. The teaching of such practical skills has gained significance through legislative changes and adjustments of the curricula of medical schools in Germany. We sought to find out how well final year undergraduate medical students master practical clinical skills.

METHODS

We conducted a formative 4-station objective structured clinical examination (OSCE) focused on practical clinical skills during the final year of undergraduate medical education. Participation was voluntary. Besides the examination of heart, lungs, abdomen, vascular system, lymphatic system as well as the neurological, endocrinological or orthopaedic examination we assessed other basic clinical skills (e.g. interpretation of an ECG, reading a chest X-ray). Participants filled-out a questionnaire prior to the exam, inter alia to give an estimate of their performance.

RESULTS

214 final year students participated in our study and achieved a mean score of 72.8% of the total score obtainable. 9.3% of participants (n=20) scored insufficiently (<60%). We found no influence of sex, prior training in healthcare or place of study on performance. Only one third of the students correctly estimated their performance (35.3%), whereas 30.0% and 18.8% over-estimated their performance by 10% and 20% respectively.

DISCUSSION

Final year undergraduate medical students demonstrate considerable deficits performing practical clinical skills in the context of a formative assessment. Half of the students over-estimate their own performance. We recommend an institutionalised and frequent assessment of practical clinical skills during undergraduate medical education, especially in the final year.

Improved self- and external assessment of the clinical abilities of medical students through structured improvement measures in an internal medicine bedside course

BACKGROUND

Bedside courses are of outstanding importance when training medical students. The fact that less and less teaching is taking place nowadays at the patient's bedside makes it all the more important that the available time be put to effective use. The aim of this study was to check whether structured improvement measures in the course (scripts, lecturer briefing, e-learning cases) would improve the abilities of the students on the basis of a subjective self-assessment as well as an external assessment by the lecturers with respect to clinical abilities.

METHODS

Bedside teaching takes place in the fourth study year in the Medical Clinics of the TU Munich. Both students and lecturers had the chance to hand in an anonymous, quantitative self- and external assessment of the clinical abilities of the students (German grading system) after every course date. This assessment took place online in the three categories "Medical history & examination", "Diagnosis" and "Therapy". An overall period of four semesters, each with 6 course dates, was investigated. After two of the total of four semesters in the study, the course was changed by introducing scripts, lecturer briefing as well as interactive e-learning cases. The self- and external assessment was compared both within the semester (date 1-3: A; date 4-6: B), during the course as well as before and after introducing the improvement measures ("before" (T0): SS 2012, SS 2013, "after" (T1): WS 2013/2014, SS 2014).

RESULTS

There was a significant improvement in one's own abilities on the basis of the self-assessment within each semester when comparing the first (A) and the last (B) course dates. Moreover, there was a significant improvement in the performances in all three categories when T0 was compared with T1, from both the point of view of the students ("Medical history & examination": T0 =2.5±0.9, T1=2.2±0.7, pp<0.001; "Diagnosis" T0=3.1±1.0, T1=2.8 ±0.9, pp<0.001; "Therapy": T0=3.8±1.3, T1=3.5±1.2, pp<0.018) and in two of the three categories from the point of view of the lecturers ("Diagnosis": T0=3.0±1.0, T1=2.7±0.7, p.=0.028; "Therapy": T0=3.8±1.1, T1=3.1±1.0, p<0.001).

SUMMARY

The structured measures to improve the course including the interactive e-learning cases could have contributed to improved practical abilities with respect to the medical history and examination techniques as well as diagnostic and therapeutic thinking. The external evaluation by lecturers confirmed the improvement with respect to the diagnostic and therapeutic abilities. They only saw no dynamic change in the student's taking histories and clinical examinations.

"First, know thyself": cognition and error in medicine

Although error is an integral part of the world of medicine, physicians have always been little inclined to take into account their own mistakes and the extraordinary technological progress observed in the last decades does not seem to have resulted in a significant reduction in the percentage of diagnostic errors. The failure in the reduction in diagnostic errors, notwithstanding the considerable investment in human and economic resources, has paved the way to new strategies which were made available by the development of cognitive psychology, the branch of psychology that aims at understanding the mechanisms of human reasoning. This new approach led us to realize that we are not fully rational agents able to take decisions on the basis of logical and probabilistically appropriate evaluations. In us, two different and mostly independent modes of reasoning coexist: a fast or non-analytical reasoning, which tends to be largely automatic and fast-reactive, and a slow or analytical reasoning, which permits to give rationally founded answers. One of the features of the fast mode of reasoning is the employment of standardized rules, termed "heuristics." Heuristics lead physicians to correct choices in a large percentage of cases. Unfortunately, cases exist wherein the heuristic triggered fails to fit the target problem, so that the fast mode of reasoning can lead us to unreflectively perform actions exposing us and others to variable degrees of risk. Cognitive errors arise as a result of these cases. Our review illustrates how cognitive errors can cause diagnostic problems in clinical practice.

Sudden death of a child due to respiratory diphtheria

A four-year-old girl presented to the emergency department with respiratory distress. Death occurred despite attempted resuscitation. The illness was not clinically diagnosed. Her father revealed that she had a fever and sore throat for the last four days and was not immunised for diphtheria. Characteristic gross and microscopic pathology of respiratory diphtheria and microbiological findings were observed. The cause of death was acute respiratory failure consequent upon upper airway obstruction from diphtheria. Forensic pathologists should remember that the diphtheria cases can cause sudden death especially in developing countries.

Understanding Decision Making in Critical Care

BACKGROUND

Human decision making involves the deliberate formulation of hypotheses and plans as well as the use of subconscious means of judging probability, likely outcome, and proper action.

RATIONALE

There is a growing recognition that intuitive strategies such as use of heuristics and pattern recognition described in other industries are applicable to high-acuity environments in medicine. Despite the applicability of theories of cognition to the intensive care unit, a discussion of decision-making strategies is currently absent in the critical care literature.

CONTENT

This article provides an overview of known cognitive strategies, as well as a synthesis of their use in critical care. By understanding the ways by which humans formulate diagnoses and make critical decisions, we may be able to minimize errors in our own judgments as well as build training activities around known strengths and limitations of cognition.

Teaching clinical medicine: the key principals

BACKGROUND

Many studies analyse the diagnostic process, diagnostic errors and diagnostic excellence but few provide a broad, yet practical view of this complex and highly context-dependent challenge.

METHODS

A personal, experience- and research-based selection of the principles of data collection, processing and clinical reasoning found to be most useful in achieving an efficient, timely and patient-centered diagnosis.

RESULTS

Twenty-four principles were identified and each one is presented followed by a brief commentary.

CONCLUSIONS

No single strategy can provide a solution for all diagnostic problems. However, the 24 principles have proven validity and can be applied for solving diagnostic problems in varied settings and as a scaffold in teaching diagnosis at all levels of medical education.

Analysis of Forensic Autopsy in 120 Cases of Medical Disputes Among Different Levels of Institutional Settings

Despite advances in medical science, the causes of death can sometimes only be determined by pathologists after a complete autopsy. Few studies have investigated the importance of forensic autopsy in medically disputed cases among different levels of institutional settings. Our study aimed to analyze forensic autopsy in 120 cases of medical disputes among five levels of institutional settings between 2001 and 2012 in Wenzhou, China. The results showed an overall concordance rate of 55%. Of the 39% of clinically missed diagnosis, cardiovascular pathology comprises 55.32%, while respiratory pathology accounts for the remaining 44. 68%. Factors that increase the likelihood of missed diagnoses were private clinics, community settings, and county hospitals. These results support that autopsy remains an important tool in establishing causes of death in medically disputed case, which may directly determine or exclude the fault of medical care and therefore in helping in resolving these cases.

Diagnostic influence of routine point-of-care pocket-size ultrasound examinations performed by medical residents

OBJECTIVES

We aimed to investigate the potential benefit of adding goal-directed ultrasound examinations performed by on-call medical residents using a pocket-size imaging device in patients admitted to a medical department.

METHODS

A total of 992 emergency admissions to the medical department at a nonuniversity hospital in Norway were included. Patients admitted on dates with an on-call medical resident randomized to use a pocket-size imaging device were eligible for pocket-size cardiac and abdominal ultrasound examinations or standard care. The cardiac examination included estimation of right and left ventricular sizes and global systolic function and regional left ventricular systolic function, evaluation for pleural and pericardial effusion, and valvular disease. The abdominal examination looked for signs of gross abnormalities of the liver, gallbladder, abdominal aorta, inferior vena cava, and urinary system. Six of 12 medical residents with limited ultrasound experience were randomized to perform the examinations. Diagnostic corrections were made, and findings were confirmed by reference standard diagnostics.

RESULTS

A total of 199 patients were examined. Median times used were 5.7 minutes for the cardiac examination and 4.7 minutes for the abdominal examination. In 13 patients (6.5%), the examination resulted in a major change in the primary diagnosis. In 21 patients (10.5%), the diagnosis was verified, and in 48 (24.0%), an additional important diagnosis was made.

CONCLUSIONS

By implementing pocket-size ultrasound examinations that took less than 11 minutes to the usual care, we corrected, verified, or added important diagnoses in more than 1 of 3 emergency medical admissions. Point-of-care examinations with a pocket-size imaging device increased medical residents' diagnostic accuracy and capability.

Discrepancies between autopsy and clinical findings among patients requiring extracorporeal membrane oxygenator support

Discrepancy between clinical and autopsy diagnosis in children supported on extracorporeal membrane oxygenation (ECMO) has not been previously described. To assess the utility of autopsy examination in children supported on ECMO and assess discrepancies between premortem and postmortem diagnosis in these patients. Retrospective chart review. General pediatric and cardiac intensive care units (ICUs) in a tertiary children's hospital. The hospital's ECMO database was queried for patients supported on ECMO from 2000 through 2010 who died and underwent autopsy examination. Fifty-four autopsies were performed in 139 nonsurvivors (28%) who required ECMO support in the pediatric and cardiac ICU. Major discrepancies between premortem and postmortem diagnoses were found in 29 patients (53.7%). The commonest missed diagnosis was myocardial infarction that occurred in 16 patients, followed by adrenal hemorrhage in three patients. Five patients with a cardiac diagnosis had both major (type 1 discrepancy) and minor (type 2 discrepancy) discrepancies. Surgical complications were noted in four postmortem study with three of them being class 1 discrepancy. We report significant discrepancy between autopsy and clinical findings among ECMO-supported pediatric patients. Our findings underscore the need for enhanced premorbid surveillance in patients supported on ECMO.

Reexamining our bias against heuristics

Using heuristics offers several cognitive advantages, such as increased speed and reduced effort when making decisions, in addition to allowing us to make decision in situations where missing data do not allow for formal reasoning. But the traditional view of heuristics is that they trade accuracy for efficiency. Here the authors discuss sources of bias in the literature implicating the use of heuristics in diagnostic error and highlight the fact that there are also data suggesting that under certain circumstances using heuristics may lead to better decisions that formal analysis. They suggest that diagnostic error is frequently misattributed to the use of heuristics and propose an alternative view whereby content knowledge is the root cause of diagnostic performance and heuristics lie on the causal pathway between knowledge and diagnostic error or success.

Outcome Assessments in Clinical Trials of Cryptococcal Meningitis: Considerations on Use of Early Fungicidal Activity as a Potential Surrogate Endpoint for All-Cause Mortality

Cryptococcal meningitis (CM) is a common disease in resource-challenged settings, with a high mortality within weeks of disease onset. Mortality remains high with current treatments, so more effective interventions are needed to decrease mortality. There has been interest in using the outcome assessment of quantification of fungus from cerebrospinal fluid as a replacement (surrogate) endpoint for all-cause mortality (ACM) as a means of decreasing sample size in randomized clinical trials in CM. To evaluate a biomarker as a potential surrogate endpoint to replace ACM requires several steps. This paper discusses the issues of determining whether the context of a disease is one where a potential surrogate endpoint is rational, the types of outcome assessments that might qualify as potential surrogates, and the process for evaluation of the evidence that a chosen biomarker is a valid replacement for ACM in the given context of use. We then apply those principles to the context of randomized clinical trials of CM.

Feasibility and accuracy of point-of-care pocket-size ultrasonography performed by medical students

BACKGROUND

Point-of-care ultrasound performed by clinicians is a useful supplement in the treatment and assessment of patients. We aimed to investigate whether medical students with minimal training were able to successfully acquire and interpret ultrasound images using a pocket-size imaging device (PSID) as a supplement to their clinical practice.

METHODS

Thirty 5th year (of six) medical students volunteered to participate. They were each given a personal PSID device to use as a supplement to their physical examination during their allocated hospital terms. Prior to clinical placement the students were given three evenings of hands-on training with PSID by a board certified radiologist/cardiologist, including three short lectures (<20 min). The students were shown basic ultrasound techniques and taught to assess for basic, clinically relevant pathology. They were specifically instructed to assess for the presence or absence of reduced left ventricular function (assessed as mitral annular excursion < 10 mm), pericardial effusion, pleural effusion, lung comets, hydronephrosis, bladder distension, gallstones, abdominal free-fluid, cholecystitis, and estimate the diameter of abdominal aorta and inferior vena cava.

RESULTS

A total of 211 patients were examined creating 1151 ultrasound recordings. Acceptable organ presentation was 73.8% (95% CI 63.1-82.6) for cardiovascular and 88.4% (95% CI: 80.6-93.6) for radiological structures. Diagnostic accuracy was 93.5% (95% CI: 89.0-96.2) and 93.2% (95% CI: 87.4-96.5) respectively.

CONCLUSION

Medical students with minimal training were able to use PSID as a supplement to standard physical examination and successfully acquire acceptable relevant organ recordings for presentation and correctly interpret these with great accuracy.

The clinical encounter revisited

The patient-physician encounter is the pivotal starting point of any healthcare delivery, but it is subject to multiple process breakdowns and prevalent suboptimal performance. An overview of the techniques and components of a successful encounter valid for every setting and readily applicable is presented, stressing 7 rules: (1) ensuring optimal environment, tools, and teamwork; (2) viewing each encounter not only as a cognitive/biomedical challenge, but also as a personal one, and a learning opportunity; (3) adopting an attitude of curiosity, concentration, compassion, and commitment, and maintaining a systematic, orderly approach; (4) "simple is beautiful"-making the most of the basic clinical data and their many unique advantages; (5) minding "the silent dimension"-being attentive to the patient's identity and emotions; (6) following the "Holy Trinity" of gathering all information, consulting databases/colleagues, and tailoring gained knowledge to the individual patient; and (7) using the encounter as a "window of opportunity" to further the patient's health-not just the major problem, by addressing screening and prevention; promoting health literacy and shared decision-making; and establishing proper follow-up. Barriers to implementation identified can be overcome by continuous educational interventions. A high-quality encounter sets a virtuous cycle of patient-provider interaction and results in increasing satisfaction, adherence, and improved health outcomes.

Figure and ground in physician misdiagnosis: metacognition and diagnostic norms

Meta-cognitive awareness, or self reflection informed by the “heuristics and biases” theory of how experts make cognitive errors, has been offered as a partial solution for diagnostic errors in medicine. I argue that this approach is not as easy nor as effective as one might hope. We should also promote mastery of the basic principles of diagnosis in medical school, continuing medical education, and routine reflection and review. While it may seem difficult to attend to both levels simultaneously, there is more to be gained from attending to both than from focusing only on one.

The critical step to reduce diagnostic errors in medicine: addressing the limitations of human information processing

Over the last 50 years diagnostic testing has improved dramatically and we are now able to diagnose patients faster and more precisely than ever before. However, the incidence of diagnostic errors, particularly of common diseases, has remained relatively stable over time. In this paper, I argue that the intrinsic limitations of human information processing are crucial. The way people process information has not changed over the years and is the main cause of diagnostic error. To take a decisive step forward and substantially reduce the number of diagnostic errors in medicine, we need to create an environment which takes the intrinsic limitations of in human information processing into account.