Clinical Reasoning and Diagnostic Error: A Call to Merge Two Worlds to Improve Patient Care.

Numerous and substantial challenges exist in the provision of safe, cost-effective, and efficient health care. The prevalence and consequences of diagnostic error, one of these challenges, have been established by the literature; however, these errors persist, and the pace of improvement has been slow. One potential reason for the lack of needed progress is that addressing delayed and wrong diagnoses will require contributions from 2 currently distinct worlds: clinical reasoning and diagnostic error. In this Invited Commentary, the authors argue for merging the diagnostic error and clinical reasoning fields as the perspectives, frameworks, and methodologies of these 2 fields could be leveraged to yield a more aligned approach to understanding and subsequently to mitigating diagnostic error. The authors focus on the problem of diagnostic labeling (a categorization task where one has to choose the correct label or diagnosis). The authors elaborate on why this alignment could help guide health care improvement efforts, using the vexing problem of context specificity that leads to unwanted variance in health care as an example.

Low-dose compared to manufacturer-recommended dose four-factor prothrombin complex concentrate for acute warfarin reversal.

BACKGROUND: Four-factor PCC is the recommended standard of care for acute warfarin reversal but optimal dosing is unknown. We aim to show that a low-dose strategy is often adequate and may reduce the risk of thromboembolic events when compared to manufacturer-recommended dosing. METHODS: A weight-based dosing strategy of 15-25 units/kg was established as the institutional standard of care in May 2015. This retrospective, before-and-after cohort analysis included patients receiving 4F-PCC according to a manufacturer-recommended (n = 122) or a low-dose (n = 83) strategy. The primary efficacy outcome was a combination of INR reversal on first check and hemostatic efficacy at 24 h. RESULTS: Demographics, indications for warfarin, and presenting INR values were similar between the two groups. Patients in the manufacturer-recommended dose group received significantly more 4F-PCC than the low dose group (2110 units vs. 1530 units). More patients in the manufacturer-recommended dose group achieved the primary endpoint (75.4% vs. 61.4%), with more patients achieving the target INR on recheck in the manufacturer-recommended dose group (95.9% vs. 84.3%) and no difference in hemostatic efficacy between groups (79.5% vs. 74.7%). There was no difference in thromboembolic events at 72 h (4.1% vs. 1.2%) or at 30 days (8.2% vs. 4.8%). Significantly more patients in the manufacturer-recommended dose group died or were transferred to hospice care during hospitalization (21.3% vs. 9.6%). CONCLUSION: Utilization of a low-dose 4F-PCC strategy resulted in fewer patients achieving target INR reversal, but no difference in hemostatic efficacy, thromboembolic events, or survival.

A mixed-methods exploration of cognitive dispositions to respond and clinical reasoning errors with multiple choice questions.

BACKGROUND: Cognitive dispositions to respond (i.e., cognitive biases and heuristics) are well-established clinical reasoning phenomena. While thought by many to be error-prone, some scholars contest that these cognitive dispositions to respond are pragmatic solutions for reasoning through clinical complexity that are associated with errors largely due to hindsight bias and flawed experimental design. The purpose of this study was to prospectively identify cognitive dispositions to respond occurring during clinical reasoning to determine whether they are actually associated with increased odds of an incorrect answer (i.e., error). METHODS: Using the cognitive disposition to respond framework, this mixed-methods study applied a constant comparative qualitative thematic analysis to transcripts of think alouds performed during completion of clinical-vignette multiple-choice questions. The number and type of cognitive dispositions to respond associated with both correct and incorrect answers were identified. Participants included medical students, residents, and attending physicians recruited using maximum variation strategies. Data were analyzed using generalized estimating equations binary logistic model for repeated, within-subjects measures. RESULTS: Among 14 participants, there were 3 cognitive disposition to respond categories - Cognitive Bias, Flaws in Conceptual Understanding, and Other Vulnerabilities - with 13 themes identified from the think aloud transcripts. The odds of error increased to a statistically significant degree with a greater per-item number of distinct Cognitive Bias themes (OR = 1.729, 95% CI [1.226, 2.437], p = 0.002) and Other Vulnerabilities themes (OR = 2.014, 95% CI [1.280, 2.941], p < 0.001), but not with Flaws in Conceptual Understanding themes (OR = 1.617, 95% CI [0.961, 2.720], p = 0.070). CONCLUSION: This study supports the theoretical understanding of cognitive dispositions to respond as phenomena associated with errors in a new prospective manner. With further research, these findings may inform teaching, learning, and assessment of clinical reasoning toward a reduction in patient harm due to clinical reasoning errors.

The Assessment of Reasoning Tool (ART): structuring the conversation between teachers and learners.

Background Excellence in clinical reasoning is one of the most important outcomes of medical education programs, but assessing learners' reasoning to inform corrective feedback is challenging and unstandardized. Methods The Society to Improve Diagnosis in Medicine formed a multi-specialty team of medical educators to develop the Assessment of Reasoning Tool (ART). This paper describes the tool development process. The tool was designed to facilitate clinical teachers' assessment of learners' oral presentation for competence in clinical reasoning and facilitate formative feedback. Reasoning frameworks (e.g. script theory), contemporary practice goals (e.g. high-value care [HVC]) and proposed error reduction strategies (e.g. metacognition) were used to guide the development of the tool. Results The ART is a behaviorally anchored, three-point scale assessing five domains of reasoning: (1) hypothesis-directed data gathering, (2) articulation of a problem representation, (3) formulation of a prioritized differential diagnosis, (4) diagnostic testing aligned with HVC principles and (5) metacognition. Instructional videos were created for faculty development for each domain, guided by principles of multimedia learning. Conclusions The ART is a theory-informed assessment tool that allows teachers to assess clinical reasoning and structure feedback conversations.

Teaching about diagnostic errors through virtual patient cases: a pilot exploration.

BACKGROUND: Diagnostic error is a major problem in health care, yet there are few medical school curricula focused on improving the diagnostic process and decreasing diagnostic errors. Effective strategies to teach medical students about diagnostic error and diagnostic safety have not been established. METHODS: We designed, implemented and evaluated a virtual patient module featuring two linked cases involving diagnostic errors. Learning objectives developed by a consensus process among medical educators in the Society to Improve Diagnosis in Medicine (SIDM) were utilized. The module was piloted with internal medicine clerkship students at three institutions and with clerkship faculty members recruited from listservs. Participants completed surveys on their experience using the case and a qualitative analysis was performed. RESULTS: Thirty-five medical students and 25 faculty members completed the survey. Most students found the module to be relevant and instructive. Faculty also found the module valuable for students but identified insufficient curricular time as a barrier to implementation. CONCLUSIONS: Medical students and faculty found a prototype virtual patient module about the diagnostic process and diagnostic error to be educational.

Using computerized virtual cases to explore diagnostic error in practicing physicians.

Background Diagnostic errors are a significant cause of patient harm. Cognitive processes often contribute to diagnostic errors but studying and mitigating the effects of these errors is challenging. Computerized virtual patients may provide insight into the diagnostic process without the potential for patient harm, but the feasibility and utility of using such cases in practicing physicians has not been well described. Methods We developed a series of computerized virtual cases depicting common presentations of disease that included contextual factors that could result in diagnostic error. Cases were piloted by practicing physicians in two phases and participant impressions of the case platform and cases were recorded, as was outcome data on physician performance. Results Participants noted significant challenges in using the case platform. Participants specifically struggled with becoming familiar with the platform and adjusting to the non-adaptive and constraining processes of the model. Although participants found the cases to be typical presentations of problems commonly encountered in practice, the correct diagnosis was identified in less than 33% of cases. Conclusions The development of virtual patient cases for use by practicing physicians requires substantial resources and platforms that account for the non-linear and adaptive nature of reasoning in experienced clinicians. Platforms that are without such characteristics may negatively affect diagnostic performance. The novelty of such platforms may also have the potential to increase cognitive load. Nonetheless, virtual cases may have the potential to be a safe and robust means of studying clinical reasoning performance.

Becoming a teacher of clinical reasoning.

Diagnostic reasoning is one of the most challenging and rewarding aspects of clinical practice. As a result, facility in teaching diagnostic reasoning is a core necessity for all medical educators. Clinician educators' limited understanding of the diagnostic process and how expertise is developed may result in lost opportunities in nurturing the diagnostic abilities of themselves and their learners. In this perspective, the authors describe their journeys as clinician educators searching for a coherent means of teaching diagnostic reasoning. They discuss the initial appeal and immediate applicability of dual process theory and cognitive biases to their own clinical experiences and those of their trainees, followed by the eventual and somewhat belated recognition of the importance of context specificity. They conclude that there are no quick fixes in guiding learners to expertise of diagnostic reasoning, but rather the development of these abilities is best viewed as a long, somewhat frustrating, but always interesting journey. The role of the teacher of clinical reasoning is to guide the learners on this journey, recognizing true mastery may not be attained, but should remain a goal for teacher and learner alike.

Teachers as Learners: Developing Professionalism Feedback Skills via Observed Structured Teaching Encounters.

This Conversations Starter article presents a selected research abstract from the 2017 Association of American Medical Colleges Southern Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of 4 experts who shared their thoughts stimulated by the study. These thoughts explore the value of the Observed Structured Teaching Encounter in providing structured opportunities for medical students to engage with the complexities of providing peer feedback on professionalism.

Clinical Reasoning Education at US Medical Schools: Results from a National Survey of Internal Medicine Clerkship Directors.

BACKGROUND: Recent reports, including the Institute of Medicine's Improving Diagnosis in Health Care, highlight the pervasiveness and underappreciated harm of diagnostic error, and recommend enhancing health care professional education in diagnostic reasoning. However, little is known about clinical reasoning curricula at US medical schools. OBJECTIVE: To describe clinical reasoning curricula at US medical schools and to determine the attitudes of internal medicine clerkship directors toward teaching of clinical reasoning. DESIGN: Cross-sectional multicenter study. PARTICIPANTS: US institutional members of the Clerkship Directors in Internal Medicine (CDIM). MAIN MEASURES: Examined responses to a survey that was emailed in May 2015 to CDIM institutional representatives, who reported on their medical school's clinical reasoning curriculum. KEY RESULTS: The response rate was 74% (91/123). Most respondents reported that a structured curriculum in clinical reasoning should be taught in all phases of medical education, including the preclinical years (64/85; 75%), clinical clerkships (76/87; 87%), and the fourth year (75/88; 85%), and that more curricular time should be devoted to the topic. Respondents indicated that most students enter the clerkship with only poor (25/85; 29%) to fair (47/85; 55%) knowledge of key clinical reasoning concepts. Most institutions (52/91; 57%) surveyed lacked sessions dedicated to these topics. Lack of curricular time (59/67, 88%) and faculty expertise in teaching these concepts (53/76, 69%) were identified as barriers. CONCLUSIONS: Internal medicine clerkship directors believe that clinical reasoning should be taught throughout the 4 years of medical school, with the greatest emphasis in the clinical years. However, only a minority reported having teaching sessions devoted to clinical reasoning, citing a lack of curricular time and faculty expertise as the largest barriers. Our findings suggest that additional institutional and national resources should be dedicated to developing clinical reasoning curricula to improve diagnostic accuracy and reduce diagnostic error.

Low-dose Prothrombin Complex Concentrate for Warfarin-Associated Intracranial Hemorrhage with INR Less Than 2.0.

BACKGROUND: Prothrombin complex concentrates (PCCs) have become the first-line therapy for warfarin reversal in the setting of central nervous system (CNS) hemorrhage. Randomized, controlled studies comparing agents for warfarin reversal excluded patients with international normalized ratio (INR) <2, yet INR values of 1.6-1.9 are also associated with poor outcomes. METHODS: We retrospectively reviewed our use of a low-dose (15 units/kg) strategy of 4-factor PCC (4F-PCC) on warfarin reversal (INR 1.6-1.9) in the setting of both traumatic and spontaneous intracranial bleeding. RESULTS: A total of 21/134 (15.7%) patients with either spontaneous or traumatic intracranial hemorrhage presented with an INR value of 1.6-1.9. Nine patients (43%) presented with traumatic bleeding and 12 (57%) with spontaneous bleeding. The median (IQR) presenting INR was 1.8 (1.7, 1.9) which decreased to 1.3 (1.2, 1.3) following the administration of low-dose 4F-PCC (median dose = 1062 units; 15.2 units/kg). A total of 19/20 (95%) patients achieved a goal INR value of ≤1.5 on the first check following dosing and 17/20 (85%) achieved an INR value ≤1.3. One patient did not have follow-up INR testing due to withdrawal of life support. No patient experienced hematoma expansion within 48 h of 4F-PCC, and there were no thromboembolic events within 72 h of administration. CONCLUSIONS: The administration of low dose (15 units/kg) of 4F-PCC for urgent warfarin reversal in the setting of CNS hemorrhage was effective in correcting the INR in patients presenting with INR values of 1.6-1.9. Further assessment of low-dose PCC for urgent reversal of modest INR elevation is warranted.

Unfreezing the Flexnerian Model: introducing longitudinal integrated clerkships in rural communities.

INTRODUCTION: Physician shortages in rural areas remain severe but may be ameliorated by recent expansions in medical school class sizes. Expanding student exposure to rural medicine by increasing the amount of prolonged clinical experiences in rural areas may increase the likelihood of students pursuing a career in rural medicine. This research sought to investigate the perspective of rural physicians on the introduction of a rurally based nine-month Longitudinal Integrated Clerkship (LIC). METHODS: In this mixed-methods study, nine physician leaders were interviewed from five Maine, USA, rural hospitals participating in an LIC. Semi-structured interviews were audiotaped and transcribed. Qualitative analysis techniques were used to code the transcripts and develop themes. Forty-seven participating rural LIC preceptors were also surveyed through an online survey. RESULTS: Four major themes related to implementing the LIC model emerged: (1) melting old ways, (2) overcoming fears, (3) synergy of energy, and (4) benefits all-around. The faculty were very positive about the LIC, with increased job satisfaction, practice morale, and ongoing learning, but concerned about the financial impact on productivity. CONCLUSIONS: The importance of these themes and perceptions are discussed within the three-stage model of change by Lewin. These results describe how the innovative LIC model can conceptually unfreeze the traditional Flexnerian construct for rural physicians. Highlighting the many stakeholder benefits and addressing the anxieties and fears of rural faculty may facilitate the implementation of a rural LIC. Given the net favorable perception of rural faculty of the LIC, this educational model has the potential to play a major role in increasing the rural workforce.

Use of a novel, modified fishbone diagram to analyze diagnostic errors.

Diagnostic errors comprise a critical subset of medical errors and often stem from errors in individual cognition. While traditional patient safety methods for dissecting medical errors focus on faulty systems, such methods are often less useful in cases of diagnostic error, and a broader cognitive framework is needed to ensure a comprehensive analysis of these complex events. The fishbone diagram is a widely utilized patient safety tool that helps to facilitate root cause analysis discussions. This tool was expanded by the authors to reflect the contributions of both systems and individual cognitive errors to diagnostic errors. We describe how two medical centers have applied this modified fishbone diagram to approach diagnostic errors in a way that better meets the patient safety and educational needs of their respective institutions.

Educational agenda for diagnostic error reduction.

Diagnostic errors are a major patient safety concern. Although the majority of diagnostic errors are partially attributable to cognitive mistakes, the most effective means of improving clinician cognition in order to achieve gains in diagnostic reliability are unclear. We propose a tripartite educational agenda for improving diagnostic performance among students, residents and practising physicians. This agenda includes strengthening the metacognitive abilities of clinicians, fostering intuitive reasoning and increasing awareness of the role of systems in the diagnostic process. The evidence supporting initiatives in each of these realms is reviewed and a course of future implementation and study is proposed. The barriers to designing and implementing this agenda are substantial and include limited evidence supporting these initiatives and the challenges of changing the practice patterns of practising physicians. Implementation will need to be accompanied by rigorous evaluation.