Misdiagnosis teaching and assessment tool

Graber, Mark Mark.Graber at VA.GOV
Mon Jul 29 18:38:04 UTC 2013

Bob's comments are perfect:  Ehud's project meets all of the key elements of effective feedback: timely, relevant, non-judgmental and actionable.

Ehud's experiment seems like an ideal model that other training programs could follow.  The most powerful teaching tool is to see your own mistakes.  With autopsies now a historical relic in most countries, this kind of real-time experience seems like an ideal replacement.

Just wondering though, if students who DIDN'T make the diagnostic error go on to be overconfident about their abilities (or less reflective) than the ones who did.


Mark L Graber, MD FACP
Senior Fellow, RTI International
Professor Emeritus, SUNY Stony Brook School of Medicine
Founder and President, Society to Improve Diagnosis in Medicine
Phone:   919 990-8497

From: Bob Swerlick <rswerli at GMAIL.COM>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Bob Swerlick <rswerli at GMAIL.COM>
Date: Sun, 28 Jul 2013 12:05:38 -0400
Subject: Re: [IMPROVEDX] Misdiagnosis teaching and assessment tool

Yes, it is all about providing feedback in a time frame that is relevant. The challenge in medicine is that this does not happen in any meaningful way in the outpatient setting. The feedback physicians and trainees often receive is simply about money and clinical volume, with a few "quality" metrics salted in. At this point in time they are generally selected because they can be measured as opposed to have have real meaning.

We may be able to identify specific exercises within a training environment where trainees can receive important feedback, and Dr. Zamir needs to be lauded for his insight and clever approach. Perhaps as trainees are enlightened as to the power of real time feedback a cultural change may come about with similar inroads being made in the world of every day practice. We can hope but at this point our cutting age feedback tools are Press Ganey surveys which tell us whether our patients are happy or unhappy.

On Sat, Jul 27, 2013 at 9:27 PM, Ehud Zamir <ezamir at unimelb.edu.au> wrote:
I have recently conducted an experiment where real patients volunteered to be examined by senior ophthalmology residents in a mock clinical exam. Several cases were chosen because they had a history of (usually harmless) misdiagnosis, but were presented to the trainees just as they had presented to the doctor, with (erroneous) presumptive diagnoses from previous doctors or with other contextual/cognitive biases. In the vast majority of cases, trainees misdiagnosed them exactly in the same way it had been done by the original doctors, namely stumbled on the cognitive biases or contextual misleading information inherently present in the cases.  I found this a good way to teach about diagnostic error, as it is not just a list of theoretical biases. It is a very authentic simulation. Trainees are in fact led towards making a diagnostic error (similar to the original doctor) and made the error in a controlled environment, then received feedback and "learned the lesson". In addition to a good teaching model about diagnostic errors, I also believe it is a very useful method for assessment of diagnostic skills. A bit difficult logistically (finding patients with a history of misdiagnosis who still have the findings) but certainly feasible. If we value the skill of diagnosis, we have to test it in authentic conditions, and in the presence of proven misleading factors. Lessons learnt from misdiagnosis should be used for training and assessment in a concrete manner.

Ehud Zamir
Centre for Eye Research Australia
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