Identification of facilitators and barriers to residents’ use of a clinical reasoning tool
-
Deborah DiNardo
,
Sarah Tilstra
Abstract
Background:
While there is some experimental evidence to support the use of cognitive forcing strategies to reduce diagnostic error in residents, the potential usability of such strategies in the clinical setting has not been explored. We sought to test the effect of a clinical reasoning tool on diagnostic accuracy and to obtain feedback on its usability and acceptability.
Methods:
We conducted a randomized behavioral experiment testing the effect of this tool on diagnostic accuracy on written cases among post-graduate 3 (PGY-3) residents at a single internal medical residency program in 2014. Residents completed written clinical cases in a proctored setting with and without prompts to use the tool. The tool encouraged reflection on concordant and discordant aspects of each case. We used random effects regression to assess the effect of the tool on diagnostic accuracy of the independent case sets, controlling for case complexity. We then conducted audiotaped structured focus group debriefing sessions and reviewed the tapes for facilitators and barriers to use of the tool.
Results:
Of 51 eligible PGY-3 residents, 34 (67%) participated in the study. The average diagnostic accuracy increased from 52% to 60% with the tool, a difference that just met the test for statistical significance in adjusted analyses (p=0.05). Residents reported that the tool was generally acceptable and understandable but did not recognize its utility for use with simple cases, suggesting the presence of overconfidence bias.
Conclusions:
A clinical reasoning tool improved residents’ diagnostic accuracy on written cases. Overconfidence bias is a potential barrier to its use in the clinical setting.
Acknowledgments
The authors thank Silvia Mamede, MD, PhD, and Henk Schmidt, PhD, at Erasmus University, Rotterdam Netherlands for sharing clinical cases, consulting on the design of the experimental test booklets and providing constructive feedback on the manuscript.
Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.
Research funding: This project was funded by a grant from the Hearst Foundations awarded to Dr. William Follansbee.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
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Article note:
Prior presentations: This work was presented previously in the following venues
Society for General Internal Medicine, Oral Abstract Presentation, April 2015.
Society to Improve Diagnosis in Medicine, Poster Presentation, September 2015.
©2018 Walter de Gruyter GmbH, Berlin/Boston
Artikel in diesem Heft
- Frontmatter
- Editorial
- Diagnosis is now indexed in PubMed
- Review
- Sepsis as a model for improving diagnosis
- Opinion Paper
- Becoming a teacher of clinical reasoning
- Original Articles
- Laboratory error reporting rates can change significantly with year-over-year examination
- Identification of facilitators and barriers to residents’ use of a clinical reasoning tool
- Improved contrast microscopy: modification of bright field for urine sediment visualisation
Artikel in diesem Heft
- Frontmatter
- Editorial
- Diagnosis is now indexed in PubMed
- Review
- Sepsis as a model for improving diagnosis
- Opinion Paper
- Becoming a teacher of clinical reasoning
- Original Articles
- Laboratory error reporting rates can change significantly with year-over-year examination
- Identification of facilitators and barriers to residents’ use of a clinical reasoning tool
- Improved contrast microscopy: modification of bright field for urine sediment visualisation
