Diagnosis Education – A Pathway to Improving Diagnosis
There’s a breath of fresh air in healthcare education – and it’s all about improving diagnosis.
The oft-quoted wisdom from Paul Batalden that “Every system is perfectly designed to get the results it gets” can be applied to health professions education as well. As summarized in the landmark report from the National Academy of Medicine (NAM), Improving Diagnosis in Health Care, our current education system generates clinicians who get the diagnosis right roughly 90% of the time. It is reasonable to ask, “Can we improve diagnosis by improving education?”
The NAM report concluded that the answer is “yes.” One of its most important recommendations was to improve health professions education, based on the hope that the next generation of clinicians could reach higher levels of diagnostic quality and safety if they received more effective training. The report and its recommendation to improve education, along with the growing interest in diagnosis and diagnostic error more generally, provide the impetus for renewed attention to what is taught today and how it can be improved.
Goal 2: Enhance health care professional education and training in the diagnostic process
Recommendation 2a: Educators should ensure that curricula and training programs across the career trajectory:
- Address performance in the diagnostic process, including areas such as clinical reasoning, teamwork, communication with patients, their families, and other health
care professionals, appropriate use of diagnostic tests and the application of these
results on subsequent decision-making, and use of health IT.
- Employ educational approaches that are aligned with evidence from the learning
Improving Diagnosis in Health Care, pg. 9-10
Problems with educational programs in use today are many and varied, including:
- Training is idiosyncratic; the quality of teachers varies dramatically, and the number and types of cases a trainee may see also vary greatly.
- There is not enough content on how diagnostic errors arise and how they can be avoided, nor how to work in teams, partner with the patient, or work more effectively in one’s healthcare system.
- There is little or no exposure to using decision-support resources to improve diagnosis.
- Training doesn’t take advantage of the most up-to-date advice on pedagogy.
- Case studies and simulation are underutilized as ways to standardize training and improve recognition of disease variants.
Special Issue of Diagnosis Focuses on Education
The good news is that there is growing consensus that education needs to and can improve. As evidence, the latest special issue of Diagnosis focuses specifically on diagnosis education and on early experience with pilot programs working to improve diagnosis-related training. Andrew Olson, Geeta Singhal, and Gurpreet Dhaliwal—representing the SIDM Education Committee—served as guest editors, highlighting in their opening editorial many recently implemented or ongoing SIDM initiatives:
- Virtual patient cases illustrating and discussing diagnostic error for senior medical students
- Education resources for the SIDM website, such as the Clinical Reasoning Toolkit and the Assessment of Reasoning Tool
- Monthly #TeachDx Twitter chats
- SIDM’s Fellowship in Diagnostic Excellence – New fellows are selected each year for this competitive fellowship and are paired with SIDM mentors
- A consensus curriculum that identifies 12 key competencies for the education and training of all health professionals
The special issue of Diagnosis includes 15 articles that illustrate the breadth of work now in progress relating to “diagnosis education,” the new term that refers to this growing area. Several articles focus on using technology to enhance case-based learning, including simulation, point-of-care ultrasound, and smartphone apps. Articles examine using simulation to familiarize trainees with heuristics in clinical reasoning is one such application, and remind us that “serious games” have been used successfully to teach “debiasing” skills in decision-making. Another looks at a new app that facilitates the use of Bayes theorem to help clinical decision-making by taking into account the characteristics of diagnostic tests. Other projects focus specifically on improving diagnostic reasoning. For example, using checklists at the point of care allows trainees to recognize information that “doesn’t fit” in time to revise incorrect diagnoses.
These early research efforts are interesting and important, both in terms of preventing harm from diagnostic errors and in promoting high value health care. Another study examines how many training programs have little or no content on diagnostic error or quality assurance more generally. Research at a basic level is needed to understand the different subtasks that make up the diagnostic process and how to incorporate this knowledge to improve education. Several articles report early experience in this regard, presenting clinical reasoning curricula for clerkships and residents and advice on how to understand and communicate uncertainty in diagnosis.
Articles in the special issue also focus on faculty development, one of the key unmet needs for moving diagnosis education forward. Faculty today aren’t comfortable discussing diagnostic error with trainees and aren’t generally familiar with the common biases that lead to diagnostic errors.
These articles are a starting point for moving diagnosis education from the drawing board to classrooms, clinics, and wards. This work will continue for years to come. It is exciting to see that work has started and interest is growing, especially among trainees, to address diagnostic quality and safety.
In this Issue:
Health Professions Education Special Issue
The Health Professions Education Special Issue of Diagnosis is available open access online. Check out the wide range of articles - from basic clinical reasoning research to educational interventions to understanding diagnostic education in the clinical environment.