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To understand the relationship between stressful work environments and patient care by assessing work conditions, burnout, and elements of the diagnostic process. Notes and transcripts of audiotaped encounters were assessed for verbal and written documentation related to psychosocial data, differential diagnosis, acknowledgement of uncertainty, and other diagnosis-relevant contextual elements using 5-point Likert scales in seven primary care physicians (PCPs) and 28 patients in urgent care settings. Encounter time spent vs time needed (time pressure) was collected from time stamps and clinician surveys. Study physicians completed surveys on stress, burnout, and work conditions using the Mini-Z survey. Physicians with high stress or burnout were less likely to record psychosocial information in transcripts and notes (psychosocial information noted in 0% of encounters in 4 high stress/burned-out physicians), whereas low stress physicians (n=3) recorded psychosocial information consistently in 67% of encounters. Burned-out physicians discussed a differential diagnosis in only 31% of encounters (low counts concentrated in two physicians) vs. in 73% of non-burned-out doctors' encounters. Burned-out and non-burned-out doctors spent comparable amounts of time with patients (about 25 min). Key diagnostic elements were seen less often in encounter transcripts and notes in burned-out urgent care physicians. [ABSTRACT FROM AUTHOR]

Diagnostic performance is uniquely challenging to measure, and providing feedback on diagnostic performance to catalyze diagnostic recalibration remains the exception to the rule in healthcare. Diagnostic accuracy, timeliness, and explanation to the patient are essential dimensions of diagnostic performance that each intersect with a variety of technical, contextual, cultural, and policy barriers. Setting aside assumptions about current constraints, we explore the future of diagnostic performance feedback by describing the "minimum viable products" and the "ideal state" solutions that can be envisioned for each of several important barriers. Only through deliberate and iterative approaches to breaking down these barriers can we improve recalibration and continuously drive the healthcare ecosystem towards diagnostic excellence. [ABSTRACT FROM AUTHOR]

The environment in which clinicians provide care and think about their patients is a crucial and undervalued component of the diagnostic process. In this paper, we propose a new conceptual model that links work conditions to clinician responses such as stress and burnout, which in turn impacts the quality of the diagnostic process and finally patient diagnostic outcomes. The mechanism for these interactions critically depends on the relationship between working memory (WM) and long-term memory (LTM), and ways WM and LTM interactions are affected by working conditions. We propose a conceptual model to guide interventions to improve work conditions, clinician reactions and ultimately diagnostic process, accuracy and outcomes. Improving diagnosis can be accomplished if we are able to understand, measure and increase our knowledge of the context of care. [ABSTRACT FROM AUTHOR]

Pharmacy Several publications have made the case for improving diagnosis-related education in schools of pharmacy; and courses on clinical reasoning, physical examination, and other aspects of diagnosis are now appearing (see Supplementary Appendix B) [[25]], [[26]], [[27]]. Current diagnosis education is inadequate Achieving competency in diagnosis is a primary focus in many health professions; however, the focus is relatively narrow, aimed primarily at conveying facts to students without ensuring expertise in the diagnostic process itself. Keywords: competence; competency; diagnosis; diagnostic error; health professions education; medical education; nursing education; pharmacy education EN competence competency diagnosis diagnostic error health professions education medical education nursing education pharmacy education 166 175 10 05/12/22 20220501 NES 220501 Introduction "Education is the most powerful weapon which you can use to change the world."-Nelson Mandela Improving diagnosis education represents a critically important approach to reduce harm related to diagnostic error in practice [[1]]. [Extracted from the article]

The future of diagnosis - where are we going? The field of diagnosis and our understanding of the diagnostic process have significantly evolved over the last several decades. Building on the use of technology in diagnosis feedback, Schmidt and colleagues propose a novel use for digital decision support (DDS) modeled on deliberate practice and aligned with our understanding of the diagnostic process [[14]]. [Extracted from the article]

We describe the case of Jessica Barnett, an adolescent girl whose repeated episodes of syncope and near-syncope were ascribed to a seizure or anxiety disorder. The correct diagnoses (congenital long QT syndrome; arrythmogenic right ventricular cardiomyopathy) were established by autopsy and genetic studies only after her death at age 17. The perspective of the family is presented, along with an analysis of what went right and what went wrong in Jessica’s diagnostic journey. Key lessons in this case include the value of family as engaged members of the diagnostic team, that a ‘hyperventilation test’ should not be used to exclude cardiac origins of syncope or pre-syncope, and the inherent challenges in the diagnosis of the long QT syndrome. [ABSTRACT FROM AUTHOR]

Diagnostic excellence underscores the patient-centered diagnosis and patient engagement in the diagnostic process. In contrast to a patient-centered diagnosis, a doctor-centered diagnosis with a lack of patient engagement may inhibit the diagnostic process due to the lack of responsibility, disrupted information, and increased effect of cognitive biases, particularly in a situation where multiple physicians are involved. In this paper, we suggest a promising idea to enhance patient engagement in the diagnostic process by using written information by a patient about their perspective and experience, which can fill the gaps needed for diagnosis that doctors cannot find alone.A 38-year-old woman developed chest pain, which gradually worsened during the following two years. For two years, she was evaluated in multiple departments; however, no definitive diagnosis was made, and her condition did not improve. During this evaluation, she searched her symptoms and image findings online. She reached a possible diagnosis of ‘esophageal achalasia.’ Still, she could not tell her concerns to any physicians because she felt that her concerns were not correctly recognized, although she showed her notes that her symptoms were recorded. She finally consulted the department of internal medicine, where her notes and previous test results were thoroughly reviewed. The final diagnosis of esophageal achalasia was confirmed.Doctors must organize an environment where patients can freely express their thoughts, emotions, and ideas regarding their diagnosis. Cogenerating visit notes using patient input through written communication can be a promising idea to facilitate patient engagement in the diagnostic process. [ABSTRACT FROM AUTHOR]

Teamwork is fundamental for high-quality clinical reasoning and diagnosis, and many different individuals are involved in the diagnostic process. However, there are substantial gaps in how these individuals work as members of teams and, often, work is done in parallel, rather than in an integrated, collaborative fashion. In order to understand how individuals work together to create knowledge in the clinical context, it is important to consider social cognitive theories, including situated cognition and distributed cognition. In this article, the authors describe existing gaps and then describe these theories as well as common structures of teams in health care and then provide ideas for future study and improvement. [ABSTRACT FROM AUTHOR]

Background: Miscommunication amongst providers is a major factor contributing to diagnostic errors. There is a need to explore the current state of communications between clinicians and diagnostic radiologists. We compare and contrast the perceptions, experiences, and other factors that influence communication behaviors about diagnostic errors between clinicians and radiologists. Methods: A survey with questions addressing (1) communication around diagnostic error, (2) types of feedback observed, (3) the manner by which the feedback is reported, and (4) length of time between the discovery of the diagnostic error and disclosing it was created and distributed through two large academic health centers and through listservs of professional societies of radiologists and clinicians. Results: A total of 240 individuals responded, of whom 58% were clinicians and 42% diagnostic radiologists. Both groups of providers frequently discover diagnostic errors, although radiologists encounter them more frequently. From the qualitative analysis, feedback around diagnostic error included (1) timeliness of error, (2) specificity in description or terminology, (3) collegial in delivery, and (4) of educational value through means such as quality improvement. Conclusions: Clinicians and radiologists discover diagnostic errors surrounding the interpretation of radiology images, although radiologists discover them more frequently. There is significant opportunity for improvement in education and practice regarding how radiologists and clinicians communicate as a team and, importantly, how feedback is given when an error is discovered. Educators and clinical leaders should consider designing, implementing, and evaluating strategies for improvement. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

This is a case report involving diagnostic errors that resulted in the death of a 15-year-old girl, and commentaries on the case from her parents and involved providers. Julia Berg presented with fatigue, fevers, sore throat and right sided flank pain. Based on a computed tomography (CT) scan that identified an abnormal-appearing gall bladder, and markedly elevated bilirubin and "liver function tests", she was hospitalized and ultimately underwent surgery for suspected cholecystitis and/or cholangitis. Julia died of unexplained post-operative complications. Her autopsy, and additional testing, suggested that the correct diagnosis was Epstein-Barr virus infection with acalculous cholecystitis. The correct diagnosis might have been considered had more attention been paid to her presenting symptoms, and a striking degree of lymphocytosis that was repeatedly demonstrated. The case illustrates how cognitive "biases" can contribute to harm from diagnostic error. The case has profoundly impacted the involved healthcare organization, and Julia's parents have become leaders in helping advance awareness and education about diagnostic error and its prevention. [ABSTRACT FROM AUTHOR]

Background: Uncertainty is ubiquitous in medical practice. The Pediatrics Milestones from the Accreditation Council on Graduate Medical Education state that advanced learners should acknowledge and communicate about clinical uncertainty. If uncertainty is not acknowledged, patient care may suffer. There are no described curricula specifically aimed to improve learners' ability to acknowledge and discuss clinical uncertainty. We describe an educational intervention designed to fill this gap. Methods: Second-year pediatric residents engaged in a two-phase simulation-based educational intervention designed to improve their ability to communicate about diagnostic uncertainty with patients and caregivers. In each phase, residents engaged in two simulated cases and debriefs. Performance was assessed after each simulated patient encounter using standardized metrics, along with learner perceptions of the experience. Results: Residents' skills in communicating with patients and families about diagnostic uncertainty improved after this intervention (mean score post 3.84 vs. 3.28 pre on a five-point Likert scale, p < 0.001). Residents rated the experience as relevant, challenging and positive. Conclusions: This prospective study suggests that a simulation- based intervention was effective in improving resident physicians' skills in communicating about diagnostic uncertainty with patients and families. Further study is needed to determine how learners perform in real clinical environments. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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) hypothesisdirected 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Eczema coxsackium (EC) can manifest in patients with underlying atopic dermatitis (AD) as a diffuse vesicular rash in a febrile child. The presentation overlaps clinically with the feared diagnosis of eczema herpeticum (EH), which makes differentiating between the conditions very important. Case presentation: A 6-month-old girl with known AD presented with fever and rapidly spreading vesicular rash. The patient had multiple exposures including a new antibiotic prescription, introduction of new foods, 6-month vaccinations and a sick contact. She was treated empirically with acyclovir for EH until herpes simplex virus (HSV) polymerase chain reaction (PCR) returned negative and enterovirus PCR returned positive. Once the diagnosis of EC was confirmed, antiviral therapy was discontinued and she was treated successfully with supportive measures without sequelae. Conclusions: Differentiating EC from EH is important clinically as EC is self-limiting and resolves spontaneously whereas EH may cause severe complications if not treated early. While morphology alone cannot reliably distinguish between the conditions, clinical suspicion based on history can prompt proper testing and improve patient outcomes. [ABSTRACT FROM AUTHOR]

We report a novel syndrome of aseptic myonecrosis in a child occurring after intramuscular (IM) benzathine penicillin G injection for the treatment of streptococcal pharyngitis. Common side effects of IM injection, including transient injection site pain and inflammation, are common and well described. However, isolated myonecrosis following IM injection in the pediatric patient has not been previously reported. Only one similar case, following IM diclofenac injection, has been discussed in the adult literature. [ABSTRACT FROM AUTHOR]

Osmotic demyelination syndrome (ODS), previously known as central pontine myelinolysis, is a rare neurological condition characterized by demyelination of the pons or extrapontine areas including the midbrain, thalamus, basal nuclei, and cerebellum, resulting in upper motor neuron dysfunction and pseudobulbar palsy. We report a case of a 45-year-old woman with a history of alcohol dependence and end stage liver disease complicated by hepatic encephalopathy who developed symptoms suspicious of recurrent hepatic encephalopathy and experienced a generalized seizure during an inpatient stay. After 10 days of treatment with no improvement, it was noted that the patient had locked-in syndrome and that her sodium levels had rapidly risen 2 days prior. This led to a clinical suspicion of ODS, which was confirmed on T2-weighted MRI and subsequently on autopsy. In this clinical vignette, we review the clinical presentation, prognosis, and diagnostic considerations of ODS. [ABSTRACT FROM AUTHOR]

Ovarian torsion is often a diagnosis of exclusion, and while less common in pre-pubertal females, it is on the differential for a pelvic mass. Tumor markers can be used to characterize a pelvic mass, with varying sensitivity and specificity. This is a case of a 10-year-old pre-pubertal female presenting with abdominal pain and found to have an ovarian mass. Her tumor markers demonstrated an elevated CA-125, increasing concern for neoplasm. This led to a delayed operative course and she was ultimately found to have an ovarian torsion. There is unclear utility of CA-125 in pediatrics and reliance on tumor markers during the work-up of an ovarian mass should be limited to avoid diagnostic error. [ABSTRACT FROM AUTHOR]