ABSTRACT
OBJECTIVES: The quest to measure and improve diagnosis has proven challenging; new approaches are needed to better understand and measure key elements of the diagnostic process in clinical encounters. The aim of this study was to develop a tool assessing key elements of the diagnostic assessment process and apply it to a series of diagnostic encounters examining clinical notes and encounters' recorded transcripts. Additionally, we aimed to correlate and contextualise these findings with measures of encounter time and physician burnout. DESIGN: We audio-recorded encounters, reviewed their transcripts and associated them with their clinical notes and findings were correlated with concurrent Mini Z Worklife measures and physician burnout. SETTING: Three primary urgent-care settings. PARTICIPANTS: We conducted in-depth evaluations of 28 clinical encounters delivered by seven physicians. RESULTS: Comparing encounter transcripts with clinical notes, in 24 of 28 (86%) there was high note/transcript concordance for the diagnostic elements on our tool. Reliably included elements were red flags (92% of notes/encounters), aetiologies (88%), likelihood/uncertainties (71%) and follow-up contingencies (71%), whereas psychosocial/contextual information (35%) and mentioning common pitfalls (7%) were often missing. In 22% of encounters, follow-up contingencies were in the note, but absent from the recorded encounter. There was a trend for higher burnout scores being associated with physicians less likely to address key diagnosis items, such as psychosocial history/context. CONCLUSIONS: A new tool shows promise as a means of assessing key elements of diagnostic quality in clinical encounters. Work conditions and physician reactions appear to correlate with diagnostic behaviours. Future research should continue to assess relationships between time pressure and diagnostic quality.
Subject(s)
Physicians , Working Conditions , Humans , Prospective Studies , Forecasting , Primary Health CareSubject(s)
Betacoronavirus , Chronic Disease/epidemiology , Chronic Disease/trends , Coronavirus Infections/epidemiology , Disease Management , Epidemics , Pneumonia, Viral/epidemiology , COVID-19 , Chronic Disease/therapy , Coronavirus Infections/therapy , Diagnostic Tests, Routine/trends , Drug Prescriptions , Humans , Pandemics , Pneumonia, Viral/therapy , SARS-CoV-2ABSTRACT
The commentary below was written by Dr. Gordon Schiff and Maria Mirica for the PRIDE (Primary Care Research in Diagnostic Errors) project, an initiative of the Betsy Lehman Center for Patient Safety and Brigham and Women's Hospital Center for Patient Safety Research and Practice with support from the Gordon and Betty Moore Foundation. It highlights some of the key issues related to diagnostic accuracy issues for COVID-19 and beyond.