Tips for Hospitalists on Improving Diagnostic Skills

Deliberate practice. To improve diagnostic skills, trainees must engage in deliberate practice, defined as intentional, repetitious practice aimed at improving performance.⁸ To facilitate this, a trainee should evaluate as many patients as possible and present to an experienced clinician with subsequent feedback. Trainees are likely to miss subtle historical or examination points (e.g. the history of sheepherding) because their illness scripts are limited or incompletely developed. Teachers should emphasize the importance of developing broad and deep illness scripts, so learners will, hopefully, become more aware of their limitations and recognize what they do not know.

Key Takeaways

Clinicians solve diagnostic problems using both nonanalytic and analytic reasoning processes. Although evidence is inconclusive, some clinical reasoning experts suggest the use of reflective strategies to enhance diagnostic accuracy, especially in complicated cases.⁹ To prevent premature closure, we encourage hospitalists to perform an analytic “double-check” before determining their final diagnosis.

Furthermore, the clinical reasoning literature suggests that knowledge and its organization are key to expert performance.¹⁰ In diagnostic reasoning, this key knowledge has been termed “illness scripts.” Thus, the task of the aspiring expert diagnostician is to learn the key features of diseases and focus on discriminating features, starting with typical presentations of common diseases and working up to atypical presentations of uncommon diseases.

Engaging in deliberate practice, seeking feedback on diagnostic accuracy, and reflecting upon your own reasoning process can provide valuable information for improving future diagnostic reasoning. The ultimate goal of these practices is to enhance diagnostic skills in order to avoid errors and improve patient care.

Bottom Line

Diagnosis is a challenging task. Diagnostic accuracy may be enhanced by expanding the learner’s knowledge of illness scripts and using an analytic double-check to confirm initial diagnoses determined by nonanalytic reasoning.

Drs. Rendon, Roesch, and Rao are hospitalists in the department of internal medicine at the University of New Mexico School of Medicine in Albuquerque. Dr. Rencic is a hospitalist in the department of internal medicine at Tufts University School of Medicine in Boston.

References

1. Eva KW. What every teacher needs to know about clinical reasoning. Med Educ. 2005;39(1):98-106.
2. Bowen JL. Educational strategies to promote clinical diagnostic reasoning. N Engl J Med. 2006;355(21):2217-2225.
3. Nendaz MR, Bordage G. Promoting diagnostic problem representation. Med Educ. 2002;36(8):760-766.
4. Norman GR, Eva KW. Diagnostic error and clinical reasoning. Med Educ. 2010;44(1):94-100.
5. Schön DA. The Reflective Practitioner: How Professionals Think in Action. London: Temple Smith; 1983.
6. Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002;9(11):1184-1204.
7. Van Someren MW, Burnard YF, Sandberg JAC. The Think Aloud Method: A Practical Guide to Modelling Cognitive Processes. London: Academic Press; 1994.
8. Ericsson KA, Krampe RT, Tesch-Romer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev. 1993;100(3):363-406.
9. Mamede S, Schmidt HG, Penaforte JC. Effects of reflective practice on the accuracy of medical diagnoses. Med Educ. 2008;42(5):468-475.
10. Elstein, AS, Shulman LS, Sprafka SA. Medical Problem Solving: An Analysis of Clinical Reasoning. Cambridge, Mass.: Harvard University Press; 1978.
11. Kassirer JP. Teaching clinical reasoning: case-based and coached. Acad Med. 2010;85(7):1118-1124.
12. Rencic J. Twelve tips for teaching expertise in clinical reasoning. Med Teach. 2011;33(11):887-892.