Diagnostic skill assessment at a pre-specialist level

Ehud Zamir ezamir at UNIMELB.EDU.AU
Tue Aug 20 23:43:55 UTC 2013

Whether the skill of jumping over diagnostic hurdles is innate or learnt is a fascinating question. So is the question of to what extent we can teach it to our trainees and how is it best done. One big elephant in this room, from a patient-centered perspective, is whether we actually assess our trainees reliably for that skill. I believe that prior to becoming independent specialists, doctors should be assessed not only on their knowledge, as happens too often, but also on their diagnostic skills in real life situations (where there are often confounders, distracting factors, misleading previous information and inherent cognitive biases). While most "educationalists" would view this as unfair to the candidates, and while it is not so simple logistically, I believe it is our duty to patients to do so.

Specialists should be able to demonstrate the skill of questioning a previous diagnosis when appropriate, rather than assume it is correct, the skill of confidently stating nothing is seriously wrong with a patient they examine (rather than refer to unnecessary tests), and the skill of keeping an open mind and not just focusing on the first and most obvious finding they find (search satisfaction). All of the above may be tested by clinical simulations, either with real patients in an exam or in a well-constructed (ideally incognito patient based) workplace assessment. While we should continue to try and understand what's in the diagnostic black box (intuition/ a well balanced Type 1 thinking and Type 2 thinking/ experience/ innate or acquired properties), we should also remember that whatever it is made of, specialists should be assessed and prove they have it, or at least an acceptable level of it. As Pat Croskerry says, experience is a necessary but not sufficient condition for expertise. Some doctors can be very experienced but never reach expertise.

Just like some doctors can, in their exams, quote the latest studies better than others (and get credit for it), some doctors can make the right diagnosis in difficult or misleading situations more often than others. While the former is routinely tested, exams are not usually deliberately constructed to test the latter.


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