Diagnostic Reasoning: An Endangered Competency in Internal Medicine Training

Ideas and Opinions3 October 2017Diagnostic Reasoning: An Endangered Competency in Internal Medicine TrainingArabella L. Simpkin, MD, MMSc, Jatin M. Vyas, MD, PhD, and Katrina A. Armstrong, MD, MSCEArabella L. Simpkin, MD, MMScFrom Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts., Jatin M. Vyas, MD, PhDFrom Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts., and Katrina A. Armstrong, MD, MSCEFrom Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M17-0163 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Diagnosis is one of the most important tasks performed by internal medicine physicians, and diagnostic reasoning is perhaps the most critical of an internist's skills. The foundation of the diagnostic process is the patient's medical history and the physical examination, which lead to an initial differential diagnosis that is adjudicated through an ever-increasing array of diagnostic tests and data points as well as the patient's course over time. Historically, diagnostic reasoning and expertise have been highly valued in residency training, figuring prominently in curricula, conferences, and teaching rounds. However, despite growing recognition of the importance of diagnostic error with regard ...References1. Balogh EP, Miller BT, Ball JR, eds. Committee on Diagnostic Error in Health Care; Board on Health Care Services. Improving Diagnosis in Health Care. Washington, DC: National Academies Pr; 2015. Google Scholar2. Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ. 2016;353:i2139. [PMID: 27143499] doi:10.1136/bmj.i2139 CrossrefMedlineGoogle Scholar3. Internal Medicine Milestone Group. The Internal Medicine Milestone Project. Accreditation Council for Graduate Medical Education; American Board of Internal Medicine. July 2015. Accessed at www.acgme.org/Portals/0/PDFs/Milestones/InternalMedicineMilestones.pdf on 22 June 2017. Google Scholar4. Schmidt HG, Mamede S. How to improve the teaching of clinical reasoning: a narrative review and a proposal. Med Educ. 2015;49:961-73. [PMID: 26383068] doi:10.1111/medu.12775 CrossrefMedlineGoogle Scholar5. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165:1493-9. [PMID: 16009864] CrossrefMedlineGoogle Scholar6. Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking. Acad Med. 2017;92:23-30. [PMID: 27782919] doi:10.1097/ACM.0000000000001421 CrossrefMedlineGoogle Scholar7. Simpkin AL, Schwartzstein RM. Tolerating uncertainty—the next medical revolution? N Engl J Med. 2016;375:1713-5. [PMID: 27806221] CrossrefMedlineGoogle Scholar8. Cooke S, Lemay JF. Transforming medical assessment: integrating uncertainty into the evaluation of clinical reasoning in medical education. Acad Med. 2017;92:746-51. [PMID: 28557933] doi:10.1097/ACM.0000000000001559 CrossrefMedlineGoogle Scholar9. Newman-Toker DE, Pronovost PJ. Diagnostic errors—the next frontier for patient safety. JAMA. 2009;301:1060-2. [PMID: 19278949] doi:10.1001/jama.2009.249 CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-0163.Corresponding Author: Arabella L. Simpkin, MD, MMSc, Department of Medicine, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA, 02114; e-mail, [email protected]org.Current Author Addresses: Dr. Simpkin: Department of Medicine, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA 02114.Drs. Vyas and Armstrong: Department of Medicine, Massachusetts General Hospital, Grey/Bigelow 7th Floor, 55 Fruit Street, Boston, MA 02114.Author Contributions: Conception and design: A.L. Simpkin, K.A. Armstrong, J.M. Vyas.Drafting of the article: A.L. Simpkin, K.A. Armstrong, J.M. Vyas.Critical revision for important intellectual content: A.L. Simpkin, K.A. Armstrong, J.M. Vyas.Final approval of the article: A.L. Simpkin, K.A. Armstrong, J.M. Vyas.Administrative, technical, or logistic support: K.A. Armstrong.This article was published at Annals.org on 12 September 2017. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoDiagnostic Reasoning Arabella L. 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Mitchell, MD, PhDDiagnostic ReasoningPaul F. Griner, MDThe gaps in specialists' diagnoses 3 October 2017Volume 167, Issue 7Page: 507-508KeywordsDecision makingDiagnostic medicineHospital medicineInpatientsMedical educationMedical servicesPathology and laboratory medicineReasoningResidencySafety ePublished: 12 September 2017 Issue Published: 3 October 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...