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.

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.

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.

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.

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.

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.

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.

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.

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.

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).

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.

A systematic review of the use and effectiveness of the Objective Structured Teaching Encounter.

Background: The Objective Structured Teaching Encounter (OSTE) has been proposed as a means of promoting and assessing the teaching skills of medical faculty.

Aims: To describe the uses of the OSTE and the evidence supporting its effectiveness.

Method: MEDLINE (January 1966 through February 2010) was searched for English-language studies detailing the use of an OSTE for any educational purpose.

The effect of overnight in-house attending coverage on perceptions of care and education on a general medical service.

Background: An increased emphasis on patient safety has led to calls for closer supervision of medical trainees. It is unclear what effect an increased degree of faculty presence will have on educational and clinical outcomes. The aim of this study was to evaluate resident and attending attitudes and preferences regarding overnight attending supervision.

Twelve tips for teaching avoidance of diagnostic errors.

Background: Despite an increasing emphasis on patient safety on the part of healthcare systems worldwide, diagnostic error remains common. Errors frequently result in significant clinical consequences and persist despite remarkable advances in diagnostic technology. Most medical students and physician trainees receive little instruction regarding both the root causes of diagnostic errors and how to avoid such errors.