The variability in how physicians think: a casebased diagnostic simulation exercise

Diagnosis ◽  
2020 ◽  
Vol 0 (0) ◽  
Author(s):  
Ashwin Gupta ◽  
Martha Quinn ◽  
Sanjay Saint ◽  
Richard Lewis ◽  
Karen E. Fowler ◽  
...  
Keyword(s):  
Correct Diagnosis ◽  
Hospital Medicine ◽  
Final Diagnosis ◽  
Differential Diagnoses ◽  
Diagnostic Process ◽  
Academic Medical ◽  
Interview Format ◽  
Life Threatening ◽  
Diagnostic Simulation ◽  
Diagnostic Thinking

AbstractObjectivesLittle is known about how physician diagnostic thinking unfolds over time when evaluating patients. We designed a case-based simulation to understand how physicians reason, create differential diagnoses, and employ strategies to achieve a correct diagnosis.MethodsBetween June 2017 and August 2018, hospital medicine physicians at two academic medical centers were presented a standardized case of a patient presenting with chest pain who was ultimately diagnosed with herpes zoster using an interview format. Case information was presented in predetermined aliquots where participants were then asked to think-aloud, describing their thoughts and differential diagnoses given the data available. At the conclusion of the interview, participants were asked questions about their diagnostic process. Interviews were recorded, transcribed, and content analysis was conducted to identify key themes related to the diagnostic thinking process.ResultsSixteen hospital medicine physicians (nine men, seven women) participated in interviews and four obtained the correct final diagnosis (one man, three women). Participants had an average of nine years of experience. Overall, substantial heterogeneity in both the differential diagnoses and clinical reasoning among participants was observed. Those achieving the correct diagnosis utilized systems-based or anatomic approaches when forming their initial differential diagnoses, rather than focusing on life-threatening diagnoses alone. Evidence of cognitive bias was common; those with the correct diagnosis more often applied debiasing strategies than those with the incorrect final diagnosis.ConclusionsHeterogeneity in diagnostic evaluation appears to be common and may indicate faulty data processing. Structured approaches and debiasing strategies appear helpful in promoting diagnostic accuracy.

scholarly journals Aurea diagnosis of pneumomediastinum. A case report

2020 ◽  
Vol 14 (3) ◽  
pp. 179-183
Author(s):  
Lucio Brugioni ◽  
Francesca De Niederhausern ◽  
Chiara Gozzi ◽  
Pietro Martella ◽  
Elisa Romagnoli ◽  
...  
Keyword(s):  
Emergency Department ◽  
Case Report ◽  
Chest Pain ◽  
Correct Diagnosis ◽  
Young Male ◽  
Differential Diagnoses ◽  
Diagnostic Process ◽  
Acute Aortic Syndrome ◽  
X Ray ◽  
Chest X Ray

Pericarditis and spontaneous pneumomediastinum are among the pathologies that are in differential diagnoses when a patient describes dorsal irradiated chest pain: if the patient is young, male, and long-limbed, it is necessary to exclude an acute aortic syndrome firstly. We present the case of a young man who arrived at the Emergency Department for chest pain: an echocardiogram performed an immediate diagnosis of pericarditis. However, if the patient had performed a chest X-ray, this would have enabled the observation of pneumomediastinum, allowing a correct diagnosis of pneumomediastinum and treatment. The purpose of this report is to highlight the importance of the diagnostic process.

scholarly journals The histological patterns of inflammation in erythroderma

2016 ◽  
pp. 65-73
Author(s):  
D. Zaslavsky ◽  
I. Chuprov ◽  
R. Nasyrov ◽  
A. Sidikov ◽  
M. Maksimova ◽  
...  
Keyword(s):  
Clinical Diagnosis ◽  
Medical Condition ◽  
Correct Diagnosis ◽  
Molecular Genetic ◽  
Clinical Information ◽  
Final Diagnosis ◽  
The Body ◽  
Diagnostic Process ◽  
Correct Judgment ◽  
Histopathology Examination

Background: Erythroderma is a serious medical condition characterized by inflamed red skin, involving over 90% of the body. It can be a common presentation of different diseases, therefore clinical diagnosis can be problematic. Controversial data are reported regarding the diagnostic value of histological examination in erythroderma subjects. Methods: A retrospective study on histological skin specimens of patients admitted with a clinical diagnosis of erythroderma at the Department of Pathological anatomy with course of department of forensic medicine of State Pediatric Medical University, Saint-Petersburg, and derpatment of dermatolopathology of University clinic of Bonn from 2001 to 2014, was performed. Histopathology examination was performed in each case by a pathologist with a special interest in the skin disease who was blind to any clinical information as well as to final diagnosis. Results: Blinded histopathology examination alone was able to give the correct diagnosis in 61% (n=50/82) of cases when compared to final diagnosis. A diagnosis of psoriasis was made in 23.2% (n=19/82) of subjects, spongiotic dermatitis/eczema in 20.7% (n=17/82), mycosis fungoides in 8.5% (n=7/82) and drug eruption in 8.5%; histological diagnosis was inconclusive or not matching the final diagnosis when available in the remaining 39.1% of cases (n=32/82). Conclusion: Erythroderma remains a condition difficult to study and treat. We showed that a correct judgment about its cause can be based on objective histopathological criteria in up to 60% of cases. More studies are needed to try to find out further histological and/or immunohistochemical and molecular-genetic markers which could help the clinician in erythroderma aetiololgy diagnostic process.

scholarly journals A Perspective from a Case Conference on Comparing the Diagnostic Process: Human Diagnostic Thinking vs. Artificial Intelligence (AI) Decision Support Tools

2020 ◽  
Vol 17 (17) ◽  
pp. 6110
Author(s):  
Taku Harada ◽  
Taro Shimizu ◽  
Yuki Kaji ◽  
Yasuhiro Suyama ◽  
Tomohiro Matsumoto ◽  
...  
Keyword(s):  
Artificial Intelligence ◽  
Final Diagnosis ◽  
Future Perspective ◽  
Diagnostic Process ◽  
Case Conference ◽  
Input Information ◽  
Support Tools ◽  
Thinking Process ◽  
Diagnostic Thinking ◽  
Diagnostic Support

Artificial intelligence (AI) has made great contributions to the healthcare industry. However, its effect on medical diagnosis has not been well explored. Here, we examined a trial comparing the thinking process between a computer and a master in diagnosis at a clinical conference in Japan, with a focus on general diagnosis. Consequently, not only was AI unable to exhibit its thinking process, it also failed to include the final diagnosis. The following issues were highlighted: (1) input information to AI could not be weighted in order of importance for diagnosis; (2) AI could not deal with comorbidities (see Hickam’s dictum); (3) AI was unable to consider the timeline of the illness (depending on the tool); (4) AI was unable to consider patient context; (5) AI could not obtain input information by themselves. This comparison of the thinking process uncovered a future perspective on the use of diagnostic support tools.

scholarly journals Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions: a retrospective cohort study

2020 ◽  
Vol 29 (12) ◽  
pp. 971-979 ◽  
Author(s):  
Katie E Raffel ◽  
Molly A Kantor ◽  
Peter Barish ◽  
Armond Esmaili ◽  
Hana Lim ◽  
...  
Keyword(s):  
Cohort Study ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Correct Diagnosis ◽  
Diagnostic Errors ◽  
Hospital Medicine ◽  
Diagnostic Error ◽  
Diagnostic Reasoning ◽  
Diagnostic Process ◽  
Patient Morbidity

BackgroundThe prevalence and aetiology of diagnostic error among hospitalised adults is unknown, though likely contributes to patient morbidity and mortality. We aim to identify and characterise the prevalence and types of diagnostic error among patients readmitted within 7 days of hospital discharge.MethodsRetrospective cohort study at a single urban academic hospital examining adult patients discharged from the medical service and readmitted to the same hospital within 7 days between January and December 2018. The primary outcome was diagnostic error presence, identified through two-physician adjudication using validated tools. Secondary outcomes included severity of error impact and characterisation of diagnostic process failures contributing to error.ResultsThere were 391 cases of unplanned 7-day readmission (5.2% of 7507 discharges), of which 376 (96.2%) were reviewed. Twenty-one (5.6%) admissions were found to contain at least one diagnostic error during the index admission. The most common problem areas in the diagnostic process included failure to order needed test(s) (n=11, 52.4%), erroneous clinician interpretation of test(s) (n=10, 47.6%) and failure to consider the correct diagnosis (n=8, 38.1%). Nineteen (90.5%) of the diagnostic errors resulted in moderate clinical impact, primarily due to short-term morbidity or contribution to the readmission.ConclusionThe prevalence of diagnostic error among 7-day medical readmissions was 5.6%. The most common drivers of diagnostic error were related to clinician diagnostic reasoning. Efforts to reduce diagnostic error should include strategies to augment diagnostic reasoning and improve clinician decision-making around diagnostic studies.

scholarly journals Brain Abscess of Dental Origin: A Case Report and Literature Review

2021 ◽  
pp. 1-5
Author(s):  
Selmi wissal ◽  
Keyword(s):  
Case Report ◽  
Antibiotic Therapy ◽  
Brain Abscess ◽  
Correct Diagnosis ◽  
Final Diagnosis ◽  
Oral Infections ◽  
Pubmed Database ◽  
Dental Origin ◽  
Life Threatening ◽  
The Right

Introduction: Brain abscess (BA)of dental origin is a rare but potentially life-threatening complication of odontogenic infection that requires immediate neurosurgical attention. It is defined as an encapsulated collection of pus in various areas of the brain. The infectious process spreads from the dental site and occurs in 2 ways: haematogenous route or by contiguity. Treatment should ideally be based on the etiological factor excision, combined with drainage and adjuvant antibiotic therapy. The aim of this article was to report a case of frontal brain abscess of dental origin and to review the literature. Case report: We present the case of a 36-year-old man diagnosed with a brain abscess located in the frontal lobe and caused by a periodontal lesion of the right upper first molar. The final diagnosis was established due to the availability of computed tomography and magnetic resonance imaging. Drainage of the pus combined with extraction of the tooth and antibiotic therapy was followed by an excellent recovery. Clinical and radiological features, treatment and follow-up data were documented. A review of the literature using the PubMed database was performed Conclusion: Oral infections can lead to life-threatening infections, such as brain abscesses. Early detection of this condition through correct diagnosis is essential to give the patient the best treatment; in addition, improving of the oral environment and treating oral infections is highly recommended to limit this serious condition.

scholarly journals A large retroperitoneal lipoblastoma as an incidental finding: a case report

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Elena Gerhard-Hartmann ◽  
Verena Wiegering ◽  
Clemens Benoit ◽  
Thomas Meyer ◽  
Andreas Rosenwald ◽  
...  
Keyword(s):  
Incidental Finding ◽  
Correct Diagnosis ◽  
Clear Cell Sarcoma ◽  
Final Diagnosis ◽  
The Body ◽  
Differential Diagnoses ◽  
Molecular Diagnostic ◽  
Mesenchymal Neoplasm ◽  
Retroperitoneal Tumors ◽  
The Right

Abstract Background Lipoblastoma is a rare benign mesenchymal neoplasm of infancy that most commonly occurs on the extremities and trunk but can arise at variable sites of the body. Retroperitoneal lipoblastomas are particularly rare but can grow to enormous size, and preoperative diagnosis is difficult with diverse, mostly malignant differential diagnoses that would lead to aggressive therapy. Since lipoblastoma is a benign tumor that has an excellent prognosis after resection, correct diagnosis is crucial. Case presentation A case of a large retroperitoneal tumor of a 24-month old infant that was clinically suspicious of a malignant tumor is presented. Due to proximity to the right kidney, clinically most probably a nephroblastoma or clear cell sarcoma of the kidney was suspected. Radiological findings were ambiguous. Therefore, the mass was biopsied, and histology revealed an adipocytic lesion. Although mostly composed of mature adipocytes, in view of the age of the patient, the differential diagnosis of a (maturing) lipoblastoma was raised, which was supported by molecular analysis demonstrating a HAS2-PLAG1 fusion. The tumor was completely resected, and further histopathological workup led to the final diagnosis of a 13 cm large retroperitoneal maturing lipoblastoma. The child recovered promptly from surgery and showed no evidence of recurrence so far. Conclusion Although rare, lipoblastoma should be included in the differential diagnoses of retroperitoneal tumors in infants and children, and molecular diagnostic approaches could be a helpful diagnostic adjunct in challenging cases.

A case of splenomegaly with RK-39 positivity: A diagnostic pitfall

2021 ◽  
pp. 004947552110206
Author(s):  
Prasad Dange ◽  
Ankesh Gupta ◽  
Richa Juneja ◽  
Renu Saxena
Keyword(s):  
Hereditary Spherocytosis ◽  
Correct Diagnosis ◽  
Young Male ◽  
Differential Diagnoses ◽  
Patient Evaluation ◽  
Serological Testing ◽  
Endemic Region ◽  
Careful Patient ◽  
Diagnostic Pitfall ◽  
Marked Splenomegaly

Long-standing moderate to marked splenomegaly suggests several differential diagnoses, both haematological and infectious, particularly leishmaniasis and malaria in endemic areas. Non-infectious causes may be missed in these regions, especially if pitfalls of serological testing are not considered. Careful patient evaluation is necessary to arrive at the correct diagnosis. We report a case of a young male whose hereditary spherocytosis was initially missed because of RK-39 positivity, splenomegaly and the fact that he hailed from an endemic region.

Ultrasound diagnosis of dissecting thoracic aortic aneurysms: procedure with a handheld device and a video-illustrated case

2021 ◽  
Vol 51 (1) ◽  
pp. 10-15
Author(s):  
Kenneth V Iserson ◽  
Sri Devi Jagjit ◽  
Balram Doodnauth
Keyword(s):  
Aortic Dissection ◽  
Correct Diagnosis ◽  
Signs And Symptoms ◽  
Aortic Aneurysms ◽  
Thoracic Aortic Aneurysms ◽  
Handheld Device ◽  
Thoracic Aortic Dissection ◽  
Threatening Condition ◽  
Life Threatening ◽  
Handheld Ultrasound

Acute thoracic aortic dissection is an uncommon, although not rare, life-threatening condition. With protean signs and symptoms that often suggest more common cardiac or pulmonary conditions, it can be difficult to diagnose. Ultrasound has proven useful in making the correct diagnosis. This case demonstrates that training gained using standard ultrasound machines can be easily and successfully adapted to newer handheld ultrasound devices. The examination technique using the handheld device is illustrated with photos and a video.

scholarly journals Congenital Craniofacial Plexiform Neurofibroma in Neurofibromatosis Type 1

Diagnostics ◽  
2021 ◽  
Vol 11 (2) ◽  
pp. 218
Author(s):  
Antonella Cacchione ◽  
Alessia Carboni ◽  
Mariachiara Lodi ◽  
Rita De Vito ◽  
Andrea Carai ◽  
...  
Keyword(s):  
Neurofibromatosis Type 1 ◽  
Correct Diagnosis ◽  
Plexiform Neurofibroma ◽  
Neurofibromatosis Type ◽  
Detection Techniques ◽  
Life Threatening ◽  
Magnetic Resonance Imaging Mri ◽  
Diagnostic Work ◽  
Radiological Methods

We present a case demonstrating the performance of different radiographical imaging modalities in the diagnostic work-up of a patient with neurofibromatosis type 1 (NF1) and plexiform neurofibroma (PN). The newborn boy showed an expansive-infiltrative cervical and facial mass presented with macrocrania, craniofacial disfigurement, exophthalmos and glaucoma. A computer tomography (CT) and a magnetic resonance imaging (MRI) were performed. The CT was fundamental to evaluate the bone dysmorphisms and the MRI was crucial to estimate the mass extension. The biopsy of the lesion confirmed the suspicion of PN, thus allowing the diagnosis of NF1. PN is a variant of neurofibromas, a peripheral nerves sheath tumor typically associated with NF1. Even through currently available improved detection techniques, NF1 diagnosis at birth remains a challenge due to a lack of pathognomonic signs; therefore congenital PN are recognized in 20% of cases. This case highlights the importance of using different radiological methods both for the correct diagnosis and the follow-up of the patient with PN. Thanks to MRI evaluation, it was possible to identify earlier the progressive increasing size of the PN and the possible life threatening evolution in order to perform a tracheostomy to avoid airways compression.

Business intelligence tools to optimize the appropriateness of the diagnostic process for clinical and epidemiologic purposes in a multicenter veterinary pathology service

2021 ◽  
pp. 104063872110031
Author(s):  
Nicola Pozzato ◽  
Laura D’Este ◽  
Laura Gagliazzo ◽  
Marta Vascellari ◽  
Monia Cocchi ◽  
...  
Keyword(s):  
Business Intelligence ◽  
Reporting System ◽  
Animal Health ◽  
Final Diagnosis ◽  
Information Management System ◽  
Daily Basis ◽  
Diagnostic Process ◽  
Multifactorial Diseases ◽  
Specific Syndrome ◽  
Veterinary Pathology

Laboratory tests provide essential support to the veterinary practitioner, and their use has grown exponentially. This growth is the result of several factors, such as the eradication of historical diseases, the occurrence of multifactorial diseases, and the obligation to control endemic and epidemic diseases. However, the introduction of novel techniques is counterbalanced by economic constraints, and the establishment of evidence- and consensus-based guidelines is essential to support the pathologist. Therefore, we developed standardized protocols, categorized by species, type of production, age, and syndrome at the Istituto Zooprofilattico Sperimentale delle Venezie (IZSVe), a multicenter institution for animal health and food safety. We have 72 protocols in use for livestock, poultry, and pets, categorized as, for example, “bovine enteric calf”, “rabbit respiratory”, “broiler articular”. Each protocol consists of a panel of tests, divided into ‘mandatory’ and ‘ancillary’, to be selected by the pathologist in order to reach the final diagnosis. After autopsy, the case is categorized into a specific syndrome, subsequently referred to as a syndrome-specific panel of analyses. The activity of the laboratories is monitored through a web-based dynamic reporting system developed using a business intelligence product (QlikView) connected to the laboratory information management system (IZILAB). On a daily basis, reports become available at general, laboratory, and case levels, and are updated as needed. The reporting system highlights epidemiologic variations in the field and allows verification of compliance with the protocols within the organization. The diagnostic protocols are revised annually to increase system efficiency and to address stakeholder requests.

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