Think Twice: Effects on Diagnostic Accuracy of Returning to the Case to Reflect Upon the Initial Diagnosis

doi:10.1097/ACM.0000000000003153

. 2020 Aug;95(8):1223-1229.

doi: 10.1097/ACM.0000000000003153.

Think Twice: Effects on Diagnostic Accuracy of Returning to the Case to Reflect Upon the Initial Diagnosis

Sílvia Mamede¹, Wolf E Hautz², Christoph Berendonk³, Stefanie C Hautz⁴, Thomas C Sauter⁵, Jerome Rotgans⁶, Laura Zwaan⁷, Henk G Schmidt⁸

Affiliations

¹ S. Mamede is associate professor, Institute of Medical Education Research Rotterdam, Erasmus MC, and Department of Psychology, Education & Child Studies, Erasmus University Rotterdam, Rotterdam, the Netherlands; ORCID: https://orcid.org/0000-0003-1187-2392.
² W.E. Hautz is assistant professor of medical education and chief of service, Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland; ORCID: https://orcid.org/0000-0002-2445-984X.
³ C. Berendonk is deputy head, Department for Assessment and Evaluation, Institute for Medical Education, University of Bern, Bern, Switzerland; ORCID: https://orcid.org/0000-0002-3740-9358.
⁴ S.C. Hautz is educational consultant, Department of Emergency Medicine, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland; ORCID: https://orcid.org/0000-0003-4715-8465.
⁵ T.C. Sauter is senior consultant, Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland; ORCID: https://orcid.org/0000-0002-6646-5789.
⁶ J. Rotgans is assistant professor, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
⁷ L. Zwaan is assistant professor, Institute of Medical Education Research Rotterdam, Erasmus MC, Rotterdam, the Netherlands.
⁸ H.G. Schmidt is professor, Institute of Medical Education Research Rotterdam, Erasmus MC, and Department of Psychology, Education & Child Studies, Erasmus University Rotterdam, the Netherlands.

PMID: 31972673
DOI: 10.1097/ACM.0000000000003153

Free article

Think Twice: Effects on Diagnostic Accuracy of Returning to the Case to Reflect Upon the Initial Diagnosis

Sílvia Mamede et al. Acad Med. 2020 Aug.

Free article

. 2020 Aug;95(8):1223-1229.

doi: 10.1097/ACM.0000000000003153.

Authors

Sílvia Mamede¹, Wolf E Hautz², Christoph Berendonk³, Stefanie C Hautz⁴, Thomas C Sauter⁵, Jerome Rotgans⁶, Laura Zwaan⁷, Henk G Schmidt⁸

Affiliations

¹ S. Mamede is associate professor, Institute of Medical Education Research Rotterdam, Erasmus MC, and Department of Psychology, Education & Child Studies, Erasmus University Rotterdam, Rotterdam, the Netherlands; ORCID: https://orcid.org/0000-0003-1187-2392.
² W.E. Hautz is assistant professor of medical education and chief of service, Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland; ORCID: https://orcid.org/0000-0002-2445-984X.
³ C. Berendonk is deputy head, Department for Assessment and Evaluation, Institute for Medical Education, University of Bern, Bern, Switzerland; ORCID: https://orcid.org/0000-0002-3740-9358.
⁴ S.C. Hautz is educational consultant, Department of Emergency Medicine, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland; ORCID: https://orcid.org/0000-0003-4715-8465.
⁵ T.C. Sauter is senior consultant, Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland; ORCID: https://orcid.org/0000-0002-6646-5789.
⁶ J. Rotgans is assistant professor, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
⁷ L. Zwaan is assistant professor, Institute of Medical Education Research Rotterdam, Erasmus MC, Rotterdam, the Netherlands.
⁸ H.G. Schmidt is professor, Institute of Medical Education Research Rotterdam, Erasmus MC, and Department of Psychology, Education & Child Studies, Erasmus University Rotterdam, the Netherlands.

PMID: 31972673
DOI: 10.1097/ACM.0000000000003153

Abstract

Purpose: Diagnostic errors have been attributed to failure to sufficiently reflect on initial diagnoses. However, evidence of the benefits of reflection is conflicting. This study examined whether reflection upon initial diagnoses on difficult cases improved diagnostic accuracy and whether reflection triggered by confrontation with case evidence was more beneficial than simply revising initial diagnoses.

Method: Participants were physicians in Bern, Switzerland, registered for the 2018 Swiss internal medicine certification exam. They diagnosed written clinical cases, providing an initial diagnosis by following the same instructions and returning to the case to provide a final diagnosis. The latter required different types of reflection depending on the physician's experimental condition: return without instructions, identify confirmatory evidence, identify contradictory evidence, or identify both confirmatory and contradictory evidence. The authors examined diagnostic accuracy scores (range 0-1) as a function of diagnostic phase and reflection type.

Results: One hundred and sixty-seven physicians participated. Diagnostic accuracy scores did not significantly differ between the 4 groups of physicians in the initial (I) or the final (F) diagnostic phase (mean [95% CI]: return without instructions, I: 0.21 [0.17, 0.26], F: 0.23 [0.18, 0.28]; confirmatory evidence, I: 0.24 [0.19, 0.29], F: 0.31 [0.25, 0.37]; contradictory evidence, I: 0.22 [0.17, 0.26], F: 0.26 [0.22, 0.30]; confirmatory and contradictory evidence, I: 0.19 [0.15, 0.23], F: 0.25 [0.20, 0.31]). Regardless of type of reflection employed while revising the case, accuracy increased significantly between initial and final diagnosis, I: 0.22 (0.19, 0.24) vs F: 0.26 (0.24, 0.29); P < .001.

Conclusions: Physicians' diagnostic accuracy improved after reflecting upon initial diagnoses provided for difficult cases, independently of the evidence searched for while reflecting. The findings support the importance attributed to reflection in clinical teaching. Future research should investigate whether revising the case can become more beneficial by triggering additional reflection.

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References

1. Kohn LT, Corrigan J, Donaldson MS. To Err Is Human: Building a Safer Health System. 2000.Washington, DC: National Academies Press;
1. Balogh E, Miller BT, Ball J; Institute of Medicine (U.S.). Committee on Diagnostic Error in Health Care. Improving Diagnosis in Health Care. 2015.Washington, DC: National Academies Press;
1. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: A systematic review. JAMA. 2003;289:2849–2856.
1. Hautz WE, Kämmer JE, Hautz SC, et al. Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room. Scand J Trauma Resusc Emerg Med. 2019;27:54.
1. Sauter TC, Capaldo G, Hoffmann M, et al. Non-specific complaints at emergency department presentation result in unclear diagnoses and lengthened hospitalization: A prospective observational study. Scand J Trauma Resusc Emerg Med. 2018;26:60.

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[1] Kohn LT, Corrigan J, Donaldson MS. To Err Is Human: Building a Safer Health System. 2000.Washington, DC: National Academies Press;

[2] Kohn LT, Corrigan J, Donaldson MS. To Err Is Human: Building a Safer Health System. 2000.Washington, DC: National Academies Press;

[3] Balogh E, Miller BT, Ball J; Institute of Medicine (U.S.). Committee on Diagnostic Error in Health Care. Improving Diagnosis in Health Care. 2015.Washington, DC: National Academies Press;

[4] Balogh E, Miller BT, Ball J; Institute of Medicine (U.S.). Committee on Diagnostic Error in Health Care. Improving Diagnosis in Health Care. 2015.Washington, DC: National Academies Press;

[5] Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: A systematic review. JAMA. 2003;289:2849–2856.

[6] Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: A systematic review. JAMA. 2003;289:2849–2856.

[7] Hautz WE, Kämmer JE, Hautz SC, et al. Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room. Scand J Trauma Resusc Emerg Med. 2019;27:54.

[8] Hautz WE, Kämmer JE, Hautz SC, et al. Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room. Scand J Trauma Resusc Emerg Med. 2019;27:54.

[9] Sauter TC, Capaldo G, Hoffmann M, et al. Non-specific complaints at emergency department presentation result in unclear diagnoses and lengthened hospitalization: A prospective observational study. Scand J Trauma Resusc Emerg Med. 2018;26:60.

[10] Sauter TC, Capaldo G, Hoffmann M, et al. Non-specific complaints at emergency department presentation result in unclear diagnoses and lengthened hospitalization: A prospective observational study. Scand J Trauma Resusc Emerg Med. 2018;26:60.

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Think Twice: Effects on Diagnostic Accuracy of Returning to the Case to Reflect Upon the Initial Diagnosis

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Think Twice: Effects on Diagnostic Accuracy of Returning to the Case to Reflect Upon the Initial Diagnosis

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