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Diagnostic decision-making refers to the process of evaluating a patient complaint to develop a differential diagnosis, design a diagnostic evaluation, and arrive at a final diagnosis. Hospitalists frequently care for acutely ill patients with undifferentiated symptoms such as shortness of breath or chest pain. Establishing a correct diagnosis in these situations allows for timely therapeutic interventions and eliminates unnecessary diagnostic evaluation. Diagnostic errors account for more than 15% of all adverse events, and cognitive errors—resulting from faulty data gathering, flawed reasoning, or faulty verification—have a large role in most of these cases.1-3 Hospitalists assess disease prevalence, pretest probability, and posttest probability to make a diagnostic decision while avoiding cognitive bias. By engaging in efficient and timely diagnostic decision-making, hospitalists can positively influence the quality and cost of medical care.
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KNOWLEDGE
Hospitalists should be able to:
Describe the prevalence of common disease states in the local patient population.
Define and differentiate problem-solving strategies, including hypothesis testing and pattern recognition.
Define and differentiate prevalence, pretest probability, test characteristics (including sensitivity, specificity, negative predictive value, positive predictive value, likelihood ratios), and posttest probability.
Describe the relevance of sensitivity and specificity in interpreting diagnostic findings.
Describe the sensitivity and specificity of key clinical features and diagnostic findings for common clinical syndromes.
Describe the concepts that underlie Bayes’ theorem and explain how it is used in diagnostic decision-making.
Describe the factors that account for excessive or indiscriminate testing.
Describe types of cognitive biases that can influence decision-making.
SKILLS
Hospitalists should be able to:
Elicit a targeted medical history and perform a physical examination to detect symptoms and data that help refine the diagnostic hypothesis.
Access resources that contain relevant information such as prevalence and incidence rates of disease states.
Analyze the value of each diagnostic test, especially testing procedures that carry clinically significant patient discomfort or risk.
Formulate a pretest probability using initial history, physical examination, and preliminary diagnostic information when available.
Calculate posttest probabilities of disease using pretest probabilities and likelihood ratios.
Communicate with patients and families to explain the differential diagnosis and evaluation of the patient’s presenting symptoms.
Communicate with patients and families to explain how testing will change the scope of diagnostic possibilities.
Communicate with other physicians, trainees, and healthcare providers to explain the rationale for use of diagnostic tests.
Anticipate, identify, and avoid cognitive biases when making diagnostic decisions.
Incorporate the principles of evidence-based medicine, healthcare costs, and individual patient characteristics and preferences into each patient’s diagnostic evaluation.
Determine when sufficient evaluation has occurred in the absence of diagnostic certainty.
Lead, coordinate, and/or participate in the development of clinical care pathways designed to simplify and/or improve the diagnostic process for a particular clinical condition.
ATTITUDES
Hospitalists should be able to:
Recognize that each test should be preceded by a conscious decision to change or maintain the clinical care or initiate further diagnostic evaluation as indicated on the basis of test results.
Appreciate that all tests have false-positive and false-negative results and rigorously scrutinize or repeat the test when the result is in question.
1. Croskerry P. From mindless to mindful practice—cognitive bias and clinical decision making. N Engl J Med. 2013;268(26):2445-2448.
2. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):377-384.
3. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA. 2003;289(21):2849-2856.
Diagnostic decision-making refers to the process of evaluating a patient complaint to develop a differential diagnosis, design a diagnostic evaluation, and arrive at a final diagnosis. Hospitalists frequently care for acutely ill patients with undifferentiated symptoms such as shortness of breath or chest pain. Establishing a correct diagnosis in these situations allows for timely therapeutic interventions and eliminates unnecessary diagnostic evaluation. Diagnostic errors account for more than 15% of all adverse events, and cognitive errors—resulting from faulty data gathering, flawed reasoning, or faulty verification—have a large role in most of these cases.1-3 Hospitalists assess disease prevalence, pretest probability, and posttest probability to make a diagnostic decision while avoiding cognitive bias. By engaging in efficient and timely diagnostic decision-making, hospitalists can positively influence the quality and cost of medical care.
Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.
KNOWLEDGE
Hospitalists should be able to:
Describe the prevalence of common disease states in the local patient population.
Define and differentiate problem-solving strategies, including hypothesis testing and pattern recognition.
Define and differentiate prevalence, pretest probability, test characteristics (including sensitivity, specificity, negative predictive value, positive predictive value, likelihood ratios), and posttest probability.
Describe the relevance of sensitivity and specificity in interpreting diagnostic findings.
Describe the sensitivity and specificity of key clinical features and diagnostic findings for common clinical syndromes.
Describe the concepts that underlie Bayes’ theorem and explain how it is used in diagnostic decision-making.
Describe the factors that account for excessive or indiscriminate testing.
Describe types of cognitive biases that can influence decision-making.
SKILLS
Hospitalists should be able to:
Elicit a targeted medical history and perform a physical examination to detect symptoms and data that help refine the diagnostic hypothesis.
Access resources that contain relevant information such as prevalence and incidence rates of disease states.
Analyze the value of each diagnostic test, especially testing procedures that carry clinically significant patient discomfort or risk.
Formulate a pretest probability using initial history, physical examination, and preliminary diagnostic information when available.
Calculate posttest probabilities of disease using pretest probabilities and likelihood ratios.
Communicate with patients and families to explain the differential diagnosis and evaluation of the patient’s presenting symptoms.
Communicate with patients and families to explain how testing will change the scope of diagnostic possibilities.
Communicate with other physicians, trainees, and healthcare providers to explain the rationale for use of diagnostic tests.
Anticipate, identify, and avoid cognitive biases when making diagnostic decisions.
Incorporate the principles of evidence-based medicine, healthcare costs, and individual patient characteristics and preferences into each patient’s diagnostic evaluation.
Determine when sufficient evaluation has occurred in the absence of diagnostic certainty.
Lead, coordinate, and/or participate in the development of clinical care pathways designed to simplify and/or improve the diagnostic process for a particular clinical condition.
ATTITUDES
Hospitalists should be able to:
Recognize that each test should be preceded by a conscious decision to change or maintain the clinical care or initiate further diagnostic evaluation as indicated on the basis of test results.
Appreciate that all tests have false-positive and false-negative results and rigorously scrutinize or repeat the test when the result is in question.
Diagnostic decision-making refers to the process of evaluating a patient complaint to develop a differential diagnosis, design a diagnostic evaluation, and arrive at a final diagnosis. Hospitalists frequently care for acutely ill patients with undifferentiated symptoms such as shortness of breath or chest pain. Establishing a correct diagnosis in these situations allows for timely therapeutic interventions and eliminates unnecessary diagnostic evaluation. Diagnostic errors account for more than 15% of all adverse events, and cognitive errors—resulting from faulty data gathering, flawed reasoning, or faulty verification—have a large role in most of these cases.1-3 Hospitalists assess disease prevalence, pretest probability, and posttest probability to make a diagnostic decision while avoiding cognitive bias. By engaging in efficient and timely diagnostic decision-making, hospitalists can positively influence the quality and cost of medical care.
Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.
KNOWLEDGE
Hospitalists should be able to:
Describe the prevalence of common disease states in the local patient population.
Define and differentiate problem-solving strategies, including hypothesis testing and pattern recognition.
Define and differentiate prevalence, pretest probability, test characteristics (including sensitivity, specificity, negative predictive value, positive predictive value, likelihood ratios), and posttest probability.
Describe the relevance of sensitivity and specificity in interpreting diagnostic findings.
Describe the sensitivity and specificity of key clinical features and diagnostic findings for common clinical syndromes.
Describe the concepts that underlie Bayes’ theorem and explain how it is used in diagnostic decision-making.
Describe the factors that account for excessive or indiscriminate testing.
Describe types of cognitive biases that can influence decision-making.
SKILLS
Hospitalists should be able to:
Elicit a targeted medical history and perform a physical examination to detect symptoms and data that help refine the diagnostic hypothesis.
Access resources that contain relevant information such as prevalence and incidence rates of disease states.
Analyze the value of each diagnostic test, especially testing procedures that carry clinically significant patient discomfort or risk.
Formulate a pretest probability using initial history, physical examination, and preliminary diagnostic information when available.
Calculate posttest probabilities of disease using pretest probabilities and likelihood ratios.
Communicate with patients and families to explain the differential diagnosis and evaluation of the patient’s presenting symptoms.
Communicate with patients and families to explain how testing will change the scope of diagnostic possibilities.
Communicate with other physicians, trainees, and healthcare providers to explain the rationale for use of diagnostic tests.
Anticipate, identify, and avoid cognitive biases when making diagnostic decisions.
Incorporate the principles of evidence-based medicine, healthcare costs, and individual patient characteristics and preferences into each patient’s diagnostic evaluation.
Determine when sufficient evaluation has occurred in the absence of diagnostic certainty.
Lead, coordinate, and/or participate in the development of clinical care pathways designed to simplify and/or improve the diagnostic process for a particular clinical condition.
ATTITUDES
Hospitalists should be able to:
Recognize that each test should be preceded by a conscious decision to change or maintain the clinical care or initiate further diagnostic evaluation as indicated on the basis of test results.
Appreciate that all tests have false-positive and false-negative results and rigorously scrutinize or repeat the test when the result is in question.
1. Croskerry P. From mindless to mindful practice—cognitive bias and clinical decision making. N Engl J Med. 2013;268(26):2445-2448.
2. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):377-384.
3. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA. 2003;289(21):2849-2856.
1. Croskerry P. From mindless to mindful practice—cognitive bias and clinical decision making. N Engl J Med. 2013;268(26):2445-2448.
2. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):377-384.
3. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA. 2003;289(21):2849-2856.
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