SIDM's priority: Translating ideas into action

Papa, Frank Frank.Papa at UNTHSC.EDU
Thu Nov 5 23:11:14 UTC 2015


All of us dedicated to improving diagnostic performance, and therefore diagnostic outcomes, are excited to hear Mark Graber's recent announcements regarding SIDM mediated initiatives. However, we have to disagree with advocacy of critical thinking interventions in UGME and PGME as the main means of improving reasoning, problem solving skills, diagnostic performance and thereby diagnostic outcomes.

Certainly, learning sciences researchers would assume that three core constructs, knowledge, intellectual skills and cognitive strategies (with metacognition included with the latter), are all factors enabling humans to perform categorization tasks such as differential diagnosis (DDX). However, given at least four decades of research into the roles these three factors play in categorization in general and DDX in particular, the data are pretty clear. The most important cognitive factor underlying DDX is whether the student/clinician has knowledge (knowledge structures) relevant to each of the specific diseases associated with the problem at hand. It is not known whether that knowledge is structured as Dual Processing Theory (DPT) suggests, that is as "System 1" exemplars or prototypes, or "System 2" rule-based knowledge structures (IF ..., THEN ... propositions), or, as probabilistically associated structures enabling Bayesian-like reasoning, or neuro/cognitive models of memory (e.g., abstracted, semantically stored and/or experientially-derived memory structures encoded in terms of the relative strength of associative links between clinical signs and symptoms and disease categories). And it is not clear that it matters, as long as the knowledge is there.

In the 1980's Barrows convinced medical educators across the world to institute Problem-Based Learning (with explicit teaching to general problem solving skills) as one means of improving medical education, practice and patient care. There remains little evidence that PBL achieved the desired outcome, as was evidenced by studies conducted at schools promulgating its use, and as is now witnessed by current outcomes data indicating that the DDX performance of contemporary practitioners leaves much to be desired.

Certainly, the development of robust problem- and disease-specific knowledge bases, with whatever structure one chooses to theorize, along with  the development of intellectual skills and cognitive strategies, will all benefit from education techniques involving multiple and varied practice opportunities. However, before we leap to the position that training in critical thinking will enhance DDX capabilities, performance and outcomes, and, make a deep resource commitment to this approach, it would seem appropriate to design studies enabling medical educators to compare and contrast the impact of various DDX training approaches (e.g., increasing general critical thinking skill, versus knowledge-oriented training approaches) upon the DDX performance of subjects in UGME and PGME programs.

Furthermore, the development of SIDM sponsored presentations by which medical educators might better understand these various theoretical frameworks, and the evidence resulting from their applications in medical education, would provide them an opportunity to more deeply consider whether they would be willing to participate in such studies.


Frank J Papa, DO, PhD
Associate Dean, Curricular Design and Faculty Development
Director, Academy of Medical Educators
Professor, Medical Education
University of North Texas Health Science Center

Robert Hamm, PhD
Professor, Department of Family and Preventive Medicine
Director, Clinical Decision Making Program
University of Oklahoma Health Science Center

From: Marius Laurent [mailto:marius.laurent at SKYNET.BE]
Sent: Thursday, November 05, 2015 9:35 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] SIDM's priority: Translating ideas into action

Pat,
I like your proposition, but I must confess my surprise seeing your affirmation about numerous studies proving the role of thinking failure in diagnosis errors, and about meta-analytic studies demonstrating the efficacy of critical thinking training. I desperately look for such evidences, maybe you can help me?
Marius

De : Pat Croskerry [mailto:croskerry at EASTLINK.CA]
Envoyé : mercredi 4 novembre 2015 21:52
À : IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Objet : Re: [IMPROVEDX] SIDM's priority: Translating ideas into action


Mark: these all look worthwhile initiatives.

I'd like to add a further one: given that a number of studies now point to a significant proportion of diagnostic failure being due to thinking failures, and given that meta-analytic studies demonstrate conclusively that by far the most effective way of improving reasoning and problem solving skills is through critical thinking interventions, I advocate for the introduction of critical thinking interventions at UGME and PGME. Others have already designated critical thinking as a meta-competency and some programs have embarked on this in separate initiatives. Others in the ethics domain have strongly proposed that this be done as an 'ethical imperative', and, given the unacceptably high estimates of preventable deaths from diagnostic failure it's hard to argue with that.

Rather than each inventing our own wheels, how about developing a generic Critical Thinking Module that would be available off the shelf that medical educators could use? The content could be approved by a consensus committee. This would be an inexpensive project with potentially high returns.

Pat


On 11/04/15 12:43 PM, Mark Graber <mark.graber at IMPROVEDIAGNOSIS.ORG<mailto:mark.graber at IMPROVEDIAGNOSIS.ORG>> wrote:
With the IOM report now officially out on the street, SIDM is now focused on how to change practice to improve diagnosis.  The "Coalition to Improve Diagnosis" will be our first priority; the Coalition steering committee has had several meetings already, and the next steps are for each organization to identify at least one action they can take, and for all the members to agree on a common action. The Coalition will also be growing very soon to include another set of key national organizations.

We are also urging federal agencies to step up to the plate.  Founding Board member David Newman-Toker represented SIDM at a meeting yesterday of the AHRQ National Advisory Committee, and publicly thanked AHRQ for being a key supporter of our efforts through funding of our Diagnostic Error Conferences, the IOM report itself, and through the new R01 and R18 grant funding to study diagnostic error they have recently made available. We asked the NAC to support 3 initiatives deriving from the IOM report:  1) Developing a Common Format for organizations to report diagnostic errors to their Patient Safety Organizations; 2) Working with DOD, HHS, VA and others to develop the national research priorities for diagnosis, and to develop a public-private partnership to promote research; and 3) Providing dedicated funding for AHRQ to support research on diagnostic error in proportion to the harm associated with diagnostic error.

Later this month I'll be addressing a group at the CDC to emphasize the actions we'd like to see them take: 1) Resurrect the clinical pathologist position by providing funding for this type of consultation; 2) Resuscitate autopsies at key designated centers as a way to learn about errors; 3) Help develop and use failsafe procedures for test reporting; and 4) Use second opinions in anatomic pathology.

We'll provide updates on these activities as they come up, and would love to hear about initiatives that the listserv readership might also know about, or be involved with.

  Mark

Mark L Graber MD FACP
President, SIDM  www.improvediagnosis.org<http://www.improvediagnosis.org>
919 990-8497
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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