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The effect of a provisional diagnosis on intern diagnostic reasoning: a mixed methods study

  • Cody Clary EMAIL logo , Adam Cohen ORCID logo , Shelley Kumar , Moushumi Sur , Brian Rissmiller , Geeta Singhal and Satid Thammasitboon
Published/Copyright: January 1, 2025
Diagnosis
From the journal Diagnosis Volume 12 Issue 2

Abstract

Objectives

Competency in diagnostic reasoning is integral to medical training and patient safety. Situativity theory highlights the importance of contextual factors on learning and performance, such as being informed of a provisional diagnosis prior to a patient encounter. This study aims to determine how being informed of a provisional diagnosis affects an intern’s approach to diagnostic reasoning.

Methods

This mixed methods study was conducted in a real-time workplace learning environment at a large teaching hospital. Interns were randomized to the Chief Complaint (CC) only or chief complaint with Provisional Diagnosis (PD) group. One blinded researcher assessed intern diagnostic reasoning using a validated tool. Mean group scores were compared using the two-sample t-test. The researcher was unblinded for think aloud interviews analyzed via thematic analysis.

Results

There was no difference in performance between the CC and PD groups (mean ± SD): 47.8 ± 8.1 vs. 43.9 ± 10.9, p=0.24. Thematic analysis identified that interns aware of the provisional diagnosis 1) invested less effort in diagnostic reasoning, 2) formulated a differential through a narrowly focused frame, 3) accepted a provisional diagnosis as definitive, and 4) sought to confirm rather than refute the provisional diagnosis.

Conclusions

Our discordant results highlight the complex interplay between a provisional diagnosis and diagnostic reasoning performance in early learners. Though an accurate provisional diagnosis may enhance diagnostic reasoning outcomes, our qualitative results suggest that it may pose certain risks to the diagnostic reasoning process. Metacognitive strategies may be a ripe field for exploration to optimize this complex interplay.

Keywords: diagnostic reasoning; medical education; cognitive tendencies; diagnostic error
Corresponding author: Cody Clary, MD, Assistant Professor of Pediatrics, Division of Pediatric Hospital Medicine, Baylor College of Medicine-Texas Children’s Hospital, 9835 N Lake Creek Pkwy Austin, 78717, TX, USA, E-mail:

Acknowledgments

Thanks to Gal Barak, MD MEd for editorial support.

  1. Research ethics: The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013) and approved by the Baylor College of Medicine IRB.

  2. Informed consent: Informed consent was obtained from all individuals included in this study, or their legal guardians or wards. Study was exempt from written, informed consent by local IRB.

  3. Author contributions: The authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  4. Use of Large Language Models, AI and Machine Learning Tools: None declared.

  5. Conflict of interests: The authors state no conflict of interest.

  6. Research funding: None declared.

  7. Data availability: The raw data can be obtained on request from the corresponding author.

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Supplementary Material

This article contains supplementary material (https://doi.org/10.1515/dx-2024-0097).

Received: 2024-05-30
Accepted: 2024-11-11
Published Online: 2025-01-01

© 2024 Walter de Gruyter GmbH, Berlin/Boston

Articles in the same Issue

  1. Frontmatter
  2. Editorial
  3. Pioneering diagnosis in Asia: advancing clinical reasoning expertise through the lens of 3M
  4. Short Communication
  5. The foundations of the diagnostic error movement: a tribute to Eta Berner, PhD
  6. Reviews
  7. Interventions to improve timely cancer diagnosis: an integrative review
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  9. Mini Review
  10. Challenges and barriers for the adoption of personalized medicine in Europe: the case of Oncotype DX Breast Recurrence Score® test
  11. Opinion Papers
  12. Beyond thinking fast and slow: a Bayesian intuitionist model of clinical reasoning in real-world practice
  13. Diagnostic scope: the AI can’t see what the mind doesn’t know
  14. Guidelines and Recommendations
  15. CDC’s Core Elements to promote diagnostic excellence
  16. Original Articles
  17. Trends of diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective record review studies
  18. The effect of a provisional diagnosis on intern diagnostic reasoning: a mixed methods study
  19. On context specificity and management reasoning: moving beyond diagnosis
  20. Diagnostic errors in patients admitted directly from new outpatient visits
  21. Breaking the guidelines: how financial unawareness fuels guideline deviations and inefficient DVT diagnostics
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https://doi.org/10.1515/dx-2024-0097
Keywords for this article
diagnostic reasoning; medical education; cognitive tendencies; diagnostic error

Articles in the same Issue

  1. Frontmatter
  2. Editorial
  3. Pioneering diagnosis in Asia: advancing clinical reasoning expertise through the lens of 3M
  4. Short Communication
  5. The foundations of the diagnostic error movement: a tribute to Eta Berner, PhD
  6. Reviews
  7. Interventions to improve timely cancer diagnosis: an integrative review
  8. Technical aspects and clinical applications of synthetic MRI: a scoping review
  9. Mini Review
  10. Challenges and barriers for the adoption of personalized medicine in Europe: the case of Oncotype DX Breast Recurrence Score® test
  11. Opinion Papers
  12. Beyond thinking fast and slow: a Bayesian intuitionist model of clinical reasoning in real-world practice
  13. Diagnostic scope: the AI can’t see what the mind doesn’t know
  14. Guidelines and Recommendations
  15. CDC’s Core Elements to promote diagnostic excellence
  16. Original Articles
  17. Trends of diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective record review studies
  18. The effect of a provisional diagnosis on intern diagnostic reasoning: a mixed methods study
  19. On context specificity and management reasoning: moving beyond diagnosis
  20. Diagnostic errors in patients admitted directly from new outpatient visits
  21. Breaking the guidelines: how financial unawareness fuels guideline deviations and inefficient DVT diagnostics
  22. Harbingers of sepsis misdiagnosis among pediatric emergency department patients
  23. Factors affecting diagnostic difficulties in aseptic meningitis: a retrospective observational study
  24. Prenatal diagnostic errors in hemoglobin Bart’s hydrops fetalis caused by rare genetic interactions of α-thalassemia
  25. Screening fasting glucose before the OGTT: near-patient glucometer- or laboratory-based measurement?
  26. Three-way comparison of different ESR measurement methods and analytical performance assessment of TEST1 automated ESR analyzer
  27. Short Communications
  28. Medical language matters: impact of clinical summary composition on a generative artificial intelligence’s diagnostic accuracy
  29. Impact of meta-memory techniques in generating effective differential diagnoses in a pediatric core clerkship
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