Competencies & Learning Objectives

• Accurately and efficiently collect key clinical findings needed to inform diagnostic hypotheses. Use these tools appropriately and efficiently in the diagnostic process: Effective interpersonal communication skills, history-taking, the physical examination, and record review; diagnostic testing; and the electronic health record and health IT resources.

• Formulate, or contribute to, an accurate problem representation expressed in a concise summary statement that includes essential epidemiological, clinical, and psychosocial information.

• Produce, or contribute to, a correctly prioritized, relevant differential diagnosis, including can’t-miss diagnoses.

• Explain and justify the prioritization of the differential diagnosis by comparing and contrasting the patient’s findings and test results with accurate knowledge about prototypical or characteristic disease manifestations and atypical presentations, and considering pathophysiology, disease likelihood, and clinical experience.

• Use decision support tools, including point-of-care resources, checklists, consultation, and second opinions to improve diagnostic accuracy and timeliness.

• Use reflection, surveillance, and critical thinking to improve diagnostic performance and mitigate detrimental cognitive bias throughout the clinical encounter. Discuss and reflect on the strengths and weaknesses of cognition, the impact of contextual factors on diagnosis, and the challenges of uncertainty. Demonstrate awareness of atypical presentations, information that is missing, and key findings that don’t "fit."

I-1. Accurately, efficiently, and comprehensively collect key clinical findings needed to inform diagnostic hypotheses.

• Verifies important data firsthand and ensure sufficient unpacking has occurred.
• Performs comprehensive and accurate patient assessments.
  • Obtains the patient’s history first hand and incorporates historical information obtained from the family and medical record.
  • Obtains relevant information from the physical exam skillfully.
  • Uses and supports/aids others’ use of new, advanced technologies in complementing information derived from the physical exam.

I-2. Formulate, or contribute to, an accurate problem representation expressed in a concise summary statement that includes essential epidemiological, clinical, and psychosocial information.

• Distinguishes more relevant from less relevant information
• Recognizes that problem representation is a key step in establishing the diagnosis, but predisposes to premature closure and a focus that may be too narrow

I-3. Produce, or contribute to, a correctly prioritized, relevant differential diagnosis, including can’t miss diagnoses.
From the ACGME milestones:

• Acquires accurate histories from patients in an efficient, prioritized, and hypothesis driven fashion that informs the differential diagnosis
• Synthesizes data to generate a prioritized differential diagnosis and problem list
• Revises the differential diagnosis appropriately when new information becomes available
• Able to appropriately utilize pragmatic, probable, and possible differential diagnoses paradigms and transition between them as appropriate to the clinical situation.

AND\OR …

• Recognizes factors that influence a patient’s ability or willingness to seek healthcare in a timely way, including healthcare literacy, socioeconomic status and financial concerns, denial of illness, physical disability, and lack of a healthcare advocate.
• Knows the primary goal of medicine—to care for the patient—may take precedence over establishing the diagnosis.
• Triages patients in different categories of urgency; distinguishes situations where the diagnosis has to be made immediately (e.g., aortic dissection), or can be paced out over time, approached through a trial of watchful waiting, or transferred to another provider
• Understands that a diagnosis may label or stereotype a patient and mask their individuality, may be stigmatizing, and may inhibit further diagnostic thinking about the patient and their problem.
• Takes into account unintended consequences of making a diagnosis, including its impact on the patient physically, emotionally, and financially.
• Describes the dual process model of decision-making and can discuss essential properties of both System 1 and 2 processes.
• Is willing to attempt metacognition and can reflect on reasoning as a learning opportunity, with partial success.
• Recognizes biases in self and others.
• Appreciates the impact that context has on cognition.
• Recognizes uncertainty and seeks help appropriately, though the advancing learner may still have discomfort in doing so (i.e., uncertainty may still be viewed as failure).

I-4. Explain and justify the prioritization of the differential diagnosis by comparing and contrasting the patient’s findings and test results with accurate knowledge about prototypical or characteristic disease manifestations and atypical presentations, and considering pathophysiology, disease likelihood, and clinical experience.

• Documents the thinking behind why certain diagnoses were considered or excluded. Documents how thinking evolves in view of new information, new input, or reflection.
• Explains the type of knowledge used to produce their differential diagnosis. Such knowledge is likely to be in the form of:
  • Their understanding of the prototypical/characteristic signs and symptoms associated with their two to three leading disease differential (System 1 knowledge of disease prototypes in conjunction with pattern recognition-based reasoning processes), and/or
  • Their biomedical understanding of how the organ system(s)/organ(s) associated with their top two to three differentials function under normal and abnormal conditions (System 2 knowledge of biomedical mechanisms in conjunction with causal reasoning-oriented mechanisms), and/or
  • Their experience with specific, previously experienced cases that presented in a manner similar to the signs/symptoms associated with the patient at hand (System 1 knowledge (case exemplars) in conjunction with pattern recognition-based reasoning processes), and/or
  • Their understanding of how to apply probabilistic reasoning via knowledge of the frequency with which the top two to three differentials are associated with signs/symptoms present in the case at hand) (System 2 knowledge of disease/feature frequencies in conjunction with reasoning via quasi-probabilistic analysis)

I-5. Use decision support tools, including point-of-care resources, checklists, consultation, and second opinions to improve diagnostic accuracy and timeliness.

• Knows how to access decision support tools and checklists in real time to assist in formulating an appropriate differential diagnosis
• Appreciates the value of different perspectives, especially on difficult cases. Seeks out consultation from specialists, and second opinions from peers when the diagnosis is unclear.
• Takes advantage of crowd-source opportunities, such as tumor boards, morning report, and case conferences, to obtain other opinions.
• Knows how to request second opinions and consultation and incorporates new input into clinical decision making.

1-6. Use reflection, surveillance, and critical thinking to improve diagnostic performance and mitigate detrimental cognitive bias throughout the clinical encounter. Discuss and reflect on the strengths and weaknesses of cognition, the impact of contextual factors on diagnosis, and the challenges of uncertainty. Demonstrate awareness of atypical presentations, information that is missing, and key findings that don’t ‘fit’.

• Describes the dual process model of decision-making and qualities and potential drawbacks of both System 1 and 2 processes.
• Reflects on their reasoning as a cornerstone of improving diagnosis, and as a learning opportunity
• Recognizes biases in self and others, usually with prompting.
• Thinks about what information is missing and what doesn’t fit.
• Is well calibrated: has a sense of their own knowledge and when to slow down and when to ask for help.

Context:

• Appreciates the impact that context has on cognition: Physician context factors: fatigue, sleep deprivation, distractions, workload, etc. Patient factors: Psychosocial issues, personal goals, priorities, and beliefs, etc.

Uncertainty:

• Tolerates and acknowledges uncertainty. Avoids attaching a diagnosis to a patient before sufficient information has been unpacked. Avoids excess testing in the quest for certainty.
• Accepts that uncertainty and ambiguity are inevitable aspects of clinical care. Understands that there is always some degree of uncertainty about any assigned diagnosis, and that other diagnoses are always possible.
• Understands that medical knowledge is constantly advancing, and that the evidence base for recommended practices is constantly changing.
• Understands that the symptoms and signs of disease are highly variable among patients and evolve over time in any given patient.
• Understands that clinical “facts” in the EMR may be incorrect and that diagnostic tests are not infallible.
• Is constantly vigilant to evidence that could change the diagnosis, including additional patient history not yet provided.

Clinical Reasoning

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2. Trowbridge R, Rencic J, Durning S. Teaching Clinical Reasoning: American College of Physicians; 2015.
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History and Physical Exam

1. Verghese A. In praise of the physical examination. BMJ. 2009;339:1385-87.
2. Juahar S. The demise of the physical exam. N Engl J Med. 2006;354:548-51.
3. Hampton JR, Harrison MJ, Mitchell JR, Prichard JS, Seymour C. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J. 1975;2:489.
4. Joshua AM, Celermajer DS, Stockler MR. Beauty is in the eye of the examiner: reaching agreement about physical signs and their value 364. Internal Med J. 2005;35:178-87.
5. Martin L, Howell E, Ziegelstein R, Martire C, Whiting-O'Keefe Q, Shapiro E, et al. Hand-carried ultrasound performed by hospitalists: does it improve the cardiac physical examination? Am J Med. 2009;122:35-41.
6. Tarique U, Tang B, Singh M, Kulasegaram K, Ailon J. Ultrasound curricula in undergraduate medical education: A scoping review. J Ultrasound Med. 2018;37(1):69-82.
7. Galusko V, Khanji M, Bodger O, Weston C, Chambers J, Ionescu A. Hand-held ultrasound scanners in medical education: A systematic review. J Cardiovasc Ultrasound. 2017;25(3):75-83.
8. Kassirer JP, Wong J, Kopelman R. Learning clinical reasoning. 2nd ed. Baltimore, MD: Lippincott Williams and Wilkins; 2010.

Differential Diagnosis

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3. Jaeschke R, Guyatt GH, Sackett DL. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? Evidence Based Medicine Working Group. JAMA. 1994; 271:59-63.

Second Opinions

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Cognitive errors and metacognition

1. Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Educ Theory Pract. 2009;14 Suppl 1:27-35.
2. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-80.
3. Croskerry P. A universal model of diagnostic reasoning. Acad Med. 2009;84(8):1022-8.
4. Croskerry P. From mindliess to mindful practice - Cognitive bias and clinical decision making. N Engl J Med. 2013;368(26):2445-7.
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8. Institute of Medicine. Improving Diagnosis in Health Care. National Academies Press, Washington, DC. 2015.
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10. Mamede S, Schmidt HG, Rikers R. Diagnostic errors and reflective practice in medicine. J Eval Clin Pract. 2007;13(1):138-45.
11. Mamede S, van Gog T, van den Berge K, Rikers RM, van Saase JL, van Guldener C, et al. Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. JAMA. 2010;304(11):1198-203.

Uncertainty

1. Hall KH. Reviewing intuitive decision-making and uncertainty: the implications for medical education. Med Educ. 2002;36(3):216-24.
2. Ofri D. Medical Humanities: The Rx for Uncertainty? Acad Med. 2017.
3. Kassirer J. Our stubborn quest for diagnostic certainty. N Engl J Med. 1989;320(22):1489-91.
4. Guenter D, Fowler N, Lee L. Clinical uncertainty; helping our learners. Canadian Family Physician. 2011;57:120-3.
5. Simpkin A, Schwartzstein R. Tolerating uncertainty - the next medical revolution? N Engl J Med.375(18):1713-5.