BackgroundErrors in reasoning are a common cause of diagnostic error. However, it is difficult to improve performance partly because providers receive little feedback on diagnostic performance. ...Examining means of providing consistent feedback and enabling continuous improvement may provide novel insights for diagnostic performance.MethodsWe developed a model for improving diagnostic performance through feedback using a six-step qualitative research process, including a review of existing models from within and outside of medicine, a survey, semistructured interviews with individuals working in and outside of medicine, the development of the new model, an interdisciplinary consensus meeting, and a refinement of the model.ResultsWe applied theory and knowledge from other fields to help us conceptualise learning and comparison and translate that knowledge into an applied diagnostic context. This helped us develop a model, the Diagnosis Learning Cycle, which illustrates the need for clinicians to be given feedback about both their confidence and reasoning in a diagnosis and to be able to seamlessly compare diagnostic hypotheses and outcomes. This information would be stored in a repository to allow accessibility. Such a process would standardise diagnostic feedback and help providers learn from their practice and improve diagnostic performance. This model adds to existing models in diagnosis by including a detailed picture of diagnostic reasoning and the elements required to improve outcomes and calibration.ConclusionA consistent, standard programme of feedback that includes representations of clinicians’ confidence and reasoning is a common element in non-medical fields that could be applied to medicine. Adapting this approach to diagnosis in healthcare is a promising next step. This information must be stored reliably and accessed consistently. The next steps include testing the Diagnosis Learning Cycle in clinical settings.
Abstract Background We examined outcomes of patient-initiated second opinions provided by a national second-opinion program. Methods We independently examined data collected from January 1, 2011 to ...December 31, 2012 from a second-opinion program (Best Doctors, Inc.) that allows employee-beneficiaries to request free second opinions. Clinical intake included ascertaining why patients sought second opinions and acquiring patients' complete medical records. Trained physicians summarized the cases; identified key, unresolved clinical questions; and forwarded the cases to expert specialists who provided independent assessments and recommendations. Second opinions were discussed with and returned to patients for review with their physicians. Nurses determined whether second opinions confirmed, clarified, or changed initial diagnoses and treatments, and physicians estimated their clinical impact. Patient satisfaction also was surveyed. Results A total of 6791 patient-initiated second opinions were completed across medical specialties. Patients primarily sought second opinions for help choosing treatment options (41.3%) and for diagnostic concerns (34.8%). Second opinions often resulted in changes in diagnosis (14.8%), treatment (37.4%), or changes in both (10.6%). Clinical impact was estimated as moderate/major in 20.9% of cases for diagnosis and 30.7% of cases for treatment. Changes in diagnoses and/or treatments and clinical impact varied across medical specialties. In patients surveyed (n = 2683), most (94.7%) were satisfied with the experience, but fewer (61.2%) planned to follow the recommendations. Conclusions Patient-initiated second opinions led to recommended changes in diagnosis for about 15% and in treatment for about 37% of participants. Further evaluation is needed to determine whether this impacts clinical outcomes, such as the reduction of diagnosis and treatment errors.
Diagnosis is the cornerstone of providing safe and effective medical care. Still, diagnostic errors are all too common. A key to improving diagnosis in practice is improving diagnosis education, yet ...formal education about diagnosis is often lacking, idiosyncratic, and not evidence based. In this Invited Commentary, the authors describe the outcomes of a national consensus project to identify key competencies for diagnosis and the themes that emerged as part of this work. The 12 competencies the authors describe span 3 categories—individual, teamwork, and system related—and address ideal diagnostic practice for all health professionals. In addition, the authors identify strategies for improving diagnosis education, including the use of theory-based pedagogy and interprofessional approaches, the recognition of the role of the health care system to enhance or inhibit the diagnostic process, and the need to focus on the individual attributes necessary for high-quality diagnosis, such as humility and curiosity. The authors conclude by advocating for increasing and improving the assessment of individual and team-based diagnostic performance in health professions education programs.
Diagnostic error is a prevalent, harmful, and costly phenomenon. Multiple national health care and governmental organizations have recently identified the need to improve diagnostic safety as a high ...priority. A major barrier, however, is the lack of standardized, reliable methods for measuring diagnostic safety. Given the absence of reliable and valid measures for diagnostic errors, we need methods to help establish some type of baseline diagnostic performance across health systems, as well as to enable researchers and health systems to determine the impact of interventions for improving the diagnostic process. Multiple approaches have been suggested but none widely adopted. We propose a new framework for identifying “undesirable diagnostic events” (UDEs) that health systems, professional organizations, and researchers could further define and develop to enable standardized measurement and reporting related to diagnostic safety. We propose an outline for UDEs that identifies both conditions prone to diagnostic error and the contexts of care in which these errors are likely to occur. Refinement and adoption of this framework across health systems can facilitate standardized measurement and reporting of diagnostic safety.
Diagnostic error typically involves both system-related and cognitive root causes. Educational interventions are proposed to address both of these dimensions: In regard to system-related origins, ...education should focus on communication skills, including handoffs. In regard to cognitive shortcomings, educators need to consider both normative approaches to decision making, as well as the ‘flesh and blood’ processes used by experienced clinicians. In the long term, the goal of education should be to promote expertise, based on the assumption that experts make the fewest mistakes. In the short term, education should emphasize the importance of reflective practice, and consider use of a checklist for diagnosis to improve reliability.
Background Given an unacceptably high incidence of diagnostic errors, we sought to identify the key competencies that should be considered for inclusion in health professions education programs to ...improve the quality and safety of diagnosis in clinical practice. Methods An interprofessional group reviewed existing competency expectations for multiple health professions, and conducted a search that explored quality, safety, and competency in diagnosis. An iterative series of group discussions and concept prioritization was used to derive a final set of competencies. Results Twelve competencies were identified: Six of these are individual competencies: The first four (#1-#4) focus on acquiring the key information needed for diagnosis and formulating an appropriate, prioritized differential diagnosis; individual competency #5 is taking advantage of second opinions, decision support, and checklists; and #6 is using reflection and critical thinking to improve diagnostic performance. Three competencies focus on teamwork: Involving the patient and family (#1) and all relevant health professionals (#2) in the diagnostic process; and (#3) ensuring safe transitions of care and handoffs, and "closing the loop" on test result communication. The final three competencies emphasize system-related aspects of care: (#1) Understanding how human-factor elements influence the diagnostic process; (#2) developing a supportive culture; and (#3) reporting and disclosing diagnostic errors that are recognized, and learning from both successful diagnosis and from diagnostic errors. Conclusions These newly defined competencies are relevant to all health professions education programs and should be incorporated into educational programs.
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