A clinical reasoning curriculum for medical students: an interim analysis

Diagnosis ◽  
2022 ◽  
Vol 0 (0) ◽  
Author(s):  
Denise M. Connor ◽  
Sirisha Narayana ◽  
Gurpreet Dhaliwal
Keyword(s):  
San Francisco ◽  
Clinical Reasoning ◽  
Self Efficacy ◽  
Safety Issue ◽  
Diagnostic Error ◽  
Diagnostic Process ◽  
First Year ◽  
Clinical Encounters ◽  
Individual Cognition ◽  
Patient Safety Issue

Abstract Objectives Diagnostic error is a critical patient safety issue that can be addressed in part through teaching clinical reasoning. Medical schools with clinical reasoning curricula tend to emphasize general reasoning concepts (e.g., differential diagnosis generation). Few published curricula go beyond teaching the steps in the diagnostic process to address how students should structure their knowledge to optimize diagnostic performance in future clinical encounters or to discuss elements outside of individual cognition that are essential to diagnosis. Methods In 2016, the University of California, San Francisco School of Medicine launched a clinical reasoning curriculum that simultaneously emphasizes reasoning concepts and intentional knowledge construction; the roles of patients, families, interprofessional colleagues; and communication in diagnosis. The curriculum features a longitudinal thread beginning in first year, with an immersive three week diagnostic reasoning (DR) course in the second year. Students evaluated the DR course. Additionally, we conducted an audit of the multiyear clinical reasoning curriculum using the Society to Improve Diagnosis in Medicine-Macy Foundation interprofessional diagnostic education competencies. Results Students rated DR highly (range 4.13–4.18/5 between 2018 and 2020) and reported high self-efficacy with applying clinical reasoning concepts and communicating reasoning to supervisors. A course audit demonstrated a disproportionate emphasis on individual (cognitive) competencies with inadequate attention to systems and team factors in diagnosis. Conclusions Our clinical reasoning curriculum led to high student self-efficacy. However, we stressed cognitive aspects of reasoning with limited instruction on teams and systems. Diagnosis education should expand beyond the cognitive- and physician-centric focus of most published reasoning courses.

Situativity: a family of social cognitive theories for understanding clinical reasoning and diagnostic error

Diagnosis ◽  
2020 ◽  
Vol 7 (3) ◽  
pp. 169-176 ◽  
Author(s):  
Jerusalem Merkebu ◽  
Michael Battistone ◽  
Kevin McMains ◽  
Kathrine McOwen ◽  
Catherine Witkop ◽  
...  
Keyword(s):  
Clinical Reasoning ◽  
Distributed Cognition ◽  
Social Cognitive ◽  
Diagnostic Error ◽  
Dynamic Interactions ◽  
Clinical Encounters ◽  
Cognitive Theories ◽  
Context Specific ◽  
Social Cognitive Theories ◽  
Physician Patient

AbstractThe diagnostic error crisis suggests a shift in how we view clinical reasoning and may be vital for transforming how we view clinical encounters. Building upon the literature, we propose clinical reasoning and error are context-specific and proceed to advance a family of theories that represent a model outlining the complex interplay of physician, patient, and environmental factors driving clinical reasoning and error. These contemporary social cognitive theories (i.e. embedded cognition, ecological psychology, situated cognition, and distributed cognition) can emphasize the dynamic interactions occurring amongst participants in particular settings. The situational determinants that contribute to diagnostic error are also explored.

Lessons in clinical reasoning – pitfalls, myths, and pearls: the contribution of faulty data gathering and synthesis to diagnostic error

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Martin A. Schaller-Paule ◽  
Helmuth Steinmetz ◽  
Friederike S. Vollmer ◽  
Melissa Plesac ◽  
Felix Wicke ◽  
...  
Keyword(s):  
Patient Safety ◽  
Clinical Reasoning ◽  
Data Gathering ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
Care Physician ◽  
Diagnostic Process ◽  
Myasthenic Crisis ◽  
Hospital Organization ◽  
Substantial Impact

Abstract Objectives Errors in clinical reasoning are a major factor for delayed or flawed diagnoses and put patient safety at risk. The diagnostic process is highly dependent on dynamic team factors, local hospital organization structure and culture, and cognitive factors. In everyday decision-making, physicians engage that challenge partly by relying on heuristics – subconscious mental short-cuts that are based on intuition and experience. Without structural corrective mechanisms, clinical judgement under time pressure creates space for harms resulting from systems and cognitive errors. Based on a case-example, we outline different pitfalls and provide strategies aimed at reducing diagnostic errors in health care. Case presentation A 67-year-old male patient was referred to the neurology department by his primary-care physician with the diagnosis of exacerbation of known myasthenia gravis. He reported shortness of breath and generalized weakness, but no other symptoms. Diagnosis of respiratory distress due to a myasthenic crisis was made and immunosuppressive therapy and pyridostigmine were given and plasmapheresis was performed without clinical improvement. Two weeks into the hospital stay, the patient’s dyspnea worsened. A CT scan revealed extensive segmental and subsegmental pulmonary emboli. Conclusions Faulty data gathering and flawed data synthesis are major drivers of diagnostic errors. While there is limited evidence for individual debiasing strategies, improving team factors and structural conditions can have substantial impact on the extent of diagnostic errors. Healthcare organizations should provide the structural supports to address errors and promote a constructive culture of patient safety.

Improving diagnosis by improving education: a policy brief on education in healthcare professions

Diagnosis ◽  
2018 ◽  
Vol 5 (3) ◽  
pp. 107-118 ◽  
Author(s):  
Mark L. Graber ◽  
Joseph Rencic ◽  
Diana Rusz ◽  
Frank Papa ◽  
Pat Croskerry ◽  
...  
Keyword(s):  
Health Care ◽  
Clinical Reasoning ◽  
Health Care Professionals ◽  
Interprofessional Education ◽  
Safety Concern ◽  
Diagnostic Error ◽  
Education And Training ◽  
Diagnostic Process ◽  
Specific Content ◽  
And Training

Abstract Diagnostic error is increasingly recognized as a major patient safety concern. Efforts to improve diagnosis have largely focused on safety and quality improvement initiatives that patients, providers, and health care organizations can take to improve the diagnostic process and its outcomes. This educational policy brief presents an alternative strategy for improving diagnosis, centered on future healthcare providers, to improve the education and training of clinicians in every health care profession. The hypothesis is that we can improve diagnosis by improving education. A literature search was first conducted to understand the relationship of education and training to diagnosis and diagnostic error in different health care professions. Based on the findings from this search we present the justification for focusing on education and training, recommendations for specific content that should be incorporated to improve diagnosis, and recommendations on educational approaches that should be used. Using an iterative, consensus-based process, we then developed a driver diagram that categorizes the key content into five areas. Learners should: 1) Acquire and effectively use a relevant knowledge base, 2) Optimize clinical reasoning to reduce cognitive error, 3) Understand system-related aspects of care, 4) Effectively engage patients and the diagnostic team, and 5) Acquire appropriate perspectives and attitudes about diagnosis. These domains echo recommendations in the National Academy of Medicine’s report Improving Diagnosis in Health Care. The National Academy report suggests that true interprofessional education and training, incorporating recent advances in understanding diagnostic error, and improving clinical reasoning and other aspects of education, can ultimately improve diagnosis by improving the knowledge, skills, and attitudes of all health care professionals.

scholarly journals Five things to know about diagnostic error

Diagnosis ◽  
2017 ◽  
Vol 4 (1) ◽  
pp. 13-15 ◽  
Author(s):  
Darya Yermak ◽  
Peter Cram ◽  
Janice L. Kwan
Keyword(s):  
Patient Safety ◽  
Information Technologies ◽  
Safety Issue ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
Cognitive Errors ◽  
Health Information Technologies ◽  
Education And Health ◽  
Patient Safety Issue ◽  
Missed Diagnoses

AbstractDiagnostic error represents an important patient safety issue. Herein, we summarize five important things to know about this topic. (1) At least 1 in 20 adults are affected by diagnostic errors annually. (2) The root causes for diagnostic errors are typically multifactorial. (3) Cognitive errors are found in the majority of cases. (4) Most missed diagnoses involve common conditions. (5) Advancements in policy, education, and health information technologies hold promise for improving diagnostic safety.

A Longitudinal Investigation of First-Generation College Students’ Mentoring Relationships During Their Transition to Higher Education

2021 ◽  
pp. 152102512110227
Author(s):  
Matthew A. Hagler ◽  
Kirsten M. Christensen ◽  
Jean E. Rhodes
Keyword(s):  
College Students ◽  
Self Efficacy ◽  
Help Seeking ◽  
First Generation ◽  
First Generation College Students ◽  
Mentoring Relationships ◽  
First Year ◽  
School Membership ◽  
Longitudinal Investigation ◽  
First Generation College

Non-parent mentoring relationships are important protective factors for first-generation college students. Previous research has focused on singular mentoring relationships measured at one time point, failing to capture the breadth and dynamic nature of social networks. The current study is a longitudinal investigation of first-generation students’ mentoring networks during their transition to college at a four-year, predominantly minority-serving commuter university. At the beginning and end of their first year, students (N = 176) responded to online surveys on their mentoring relationship(s), attitudes toward help-seeking, and college experiences. Cumulative support from pre-college mentoring relationships retained across the first year was positively associated with self-efficacy. Support from newly acquired mentoring relationships was positively associated with psychological sense of school membership. Network orientation was positively associated with self-efficacy and sense of school membership. These findings highlight the importance of diverse mentoring networks and demonstrate the utility of collecting longitudinal data on multiple mentoring relationships.

scholarly journals Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation

2021 ◽  
pp. bmjqs-2020-011593
Author(s):  
Traber D Giardina ◽  
Saritha Korukonda ◽  
Umber Shahid ◽  
Viralkumar Vaghani ◽  
Divvy K Upadhyay ◽  
...  
Keyword(s):  
Medical Record ◽  
Clinical Care ◽  
Diagnostic Testing ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
Diagnostic Process ◽  
Healthcare Organisation ◽  
Safety Concerns ◽  
Patient Complaints ◽  
Malpractice Claims

BackgroundPatient complaints are associated with adverse events and malpractice claims but underused in patient safety improvement.ObjectiveTo systematically evaluate the use of patient complaint data to identify safety concerns related to diagnosis as an initial step to using this information to facilitate learning and improvement.MethodsWe reviewed patient complaints submitted to Geisinger, a large healthcare organisation in the USA, from August to December 2017 (cohort 1) and January to June 2018 (cohort 2). We selected complaints more likely to be associated with diagnostic concerns in Geisinger’s existing complaint taxonomy. Investigators reviewed all complaint summaries and identified cases as ‘concerning’ for diagnostic error using the National Academy of Medicine’s definition of diagnostic error. For all ‘concerning’ cases, a clinician-reviewer evaluated the associated investigation report and the patient’s medical record to identify any missed opportunities in making a correct or timely diagnosis. In cohort 2, we selected a 10% sample of ‘concerning’ cases to test this smaller pragmatic sample as a proof of concept for future organisational monitoring.ResultsIn cohort 1, we reviewed 1865 complaint summaries and identified 177 (9.5%) concerning reports. Review and analysis identified 39 diagnostic errors. Most were categorised as ‘Clinical Care issues’ (27, 69.2%), defined as concerns/questions related to the care that is provided by clinicians in any setting. In cohort 2, we reviewed 2423 patient complaint summaries and identified 310 (12.8%) concerning reports. The 10% sample (n=31 cases) contained five diagnostic errors. Qualitative analysis of cohort 1 cases identified concerns about return visits for persistent and/or worsening symptoms, interpersonal issues and diagnostic testing.ConclusionsAnalysis of patient complaint data and corresponding medical record review identifies patterns of failures in the diagnostic process reported by patients and families. Health systems could systematically analyse available data on patient complaints to monitor diagnostic safety concerns and identify opportunities for learning and improvement.

scholarly journals Use of Continuous Infusion Pumps During Radiation Treatment

2013 ◽  
Vol 9 (2) ◽  
pp. 107-111 ◽  
Author(s):  
Kate Bak ◽  
Eric Gutierrez ◽  
Elizabeth Lockhart ◽  
Michael Sharpe ◽  
Esther Green ◽  
...  
Keyword(s):  
Patient Safety ◽  
Radiation Exposure ◽  
Continuous Infusion ◽  
Radiation Treatment ◽  
Safety Issue ◽  
Infusion Pumps ◽  
Additional Testing ◽  
Infusion Devices ◽  
Patient Safety Issue

The varied results of radiation exposure on infusion devices suggest that additional testing should be carried out to determine the limits of dose exposure, and to raise awareness around this patient safety issue.

Overconfidence of vocational education students when entering higher education

2015 ◽  
Vol 57 (4) ◽  
pp. 429-447 ◽  
Author(s):  
Mark P. Bowden ◽  
Subhash Abhayawansa ◽  
John Bahtsevanoglou
Keyword(s):  
Higher Education ◽  
Self Efficacy ◽  
Further Education ◽  
Small Sample ◽  
First Year ◽  
Education Students ◽  
Content Type ◽  
The Relationship ◽  
Practical Implications

Purpose – There is evidence that students who attend Technical and Further Education (TAFE) prior to entering higher education underperform in their first year of study. The purpose of this paper is to examine the role of self-efficacy in understanding the performance of students who completed TAFE in the previous year in a first year subject of microeconomics in a dual sector university in Melbourne, Australia. Design/methodology/approach – The study utilises data collected by surveys of 151 students. Findings – A student’s self-efficacy is positively associated with their marks in a first year subject of microeconomics. However, the relationship between final marks and self-efficacy is negative for those students who attended TAFE in the previous year suggesting that they suffer from the problem of overconfidence. When holding self-efficacy constant, using econometric techniques, TAFE attendance is found to be positively related to final marks. Research limitations/implications – The findings are exploratory (based on a small sample) and lead to a need to conduct cross institutional studies. Practical implications – The research points to the need for early interventions so that TAFE students perform well in their first year of higher education. It also points to potential issues in the development of Victorian Certificate of Applied Learning (VCAL) programs. Originality/value – To the best of the authors’ knowledge, this is the first paper to examine the inter-related impact of attendance at TAFE in the previous year and self-efficacy on the subsequent academic performance of TAFE students.

The impact of electronic health records on diagnosis

Diagnosis ◽  
2017 ◽  
Vol 4 (4) ◽  
pp. 211-223 ◽  
Author(s):  
Mark L. Graber ◽  
Colene Byrne ◽  
Doug Johnston
Keyword(s):  
Safety Concern ◽  
Diagnostic Error ◽  
The United States ◽  
Unintended Consequences ◽  
Diagnostic Process ◽  
Health It ◽  
Health Care Information ◽  
Health Care Information Technology ◽  
Electronic Health ◽  
The Impact

AbstractDiagnostic error may be the largest unaddressed patient safety concern in the United States, responsible for an estimated 40,000–80,000 deaths annually. With the electronic health record (EHR) now in near universal use, the goal of this narrative review is to synthesize evidence and opinion regarding the impact of the EHR and health care information technology (health IT) on the diagnostic process and its outcomes. We consider the many ways in which the EHR and health IT facilitate diagnosis and improve the diagnostic process, and conversely the major ways in which it is problematic, including the unintended consequences that contribute to diagnostic error and sometimes patient deaths. We conclude with a summary of suggestions for improving the safety and safe use of these resources for diagnosis in the future.

scholarly journals Renal recipients’ knowledge and self-efficacy during first year after implementing an evidence based educational intervention as routine care at the transplantation clinic

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Kristin Hjorthaug Urstad ◽  
Astrid Klopstad Wahl ◽  
Torbjørn Moum ◽  
Eivind Engebretsen ◽  
Marit Helen Andersen
Keyword(s):  
Outcome Measures ◽  
Educational Intervention ◽  
Education Program ◽  
Self Efficacy ◽  
Longitudinal Design ◽  
Routine Care ◽  
First Year ◽  
Evidence Based ◽  
Post Transplantation ◽  
Post Transplant

Abstract Background Following an implementation plan based on dynamic dialogue between researchers and clinicians, this study implemented an evidence-based patient education program (tested in an RCT) into routine care at a clinical transplant center. The aim of this study was to investigate renal recipients’ knowledge and self-efficacy during first year the after the intervention was provided in an everyday life setting. Methods The study has a longitudinal design. The sample consisted of 196 renal recipients. Measurement points were 5 days (baseline), 2 months (T1), 6 months (T2), and one-year post transplantation (T3). Outcome measures were post-transplant knowledge, self-efficacy, and self-perceived general health. Results No statistically significant changes were found from baseline to T1, T2, and T3. Participants’ levels of knowledge and self-efficacy were high prior to the education program and did not change throughout the first year post transplantation. Conclusion Renal recipients self-efficacy and insight in post-transplant aspects seem to be more robust when admitted to the hospital for transplantation compared to baseline observations in the RCT study. This may explain why the implemented educational intervention did not lead to the same positive increase in outcome measures as in the RCT. This study supports that replicating clinical interventions in real-life settings may provide different results compared to results from RCT’s. In order to gain a complete picture of the impacts of an implemented intervention, it is vital also to evaluate results after implementing findings from RCT-studies into everyday practice.

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