Diagnostic Reasoning: An Endangered Competency in Internal Medicine Training

Powell, Melanie A Melanie.A.Powell at MEDSTAR.NET
Tue Sep 12 17:10:29 UTC 2017


One curriculum journey I like is that of palliative care. In the late 80s and early 90s it was a struggle to include palliative care teaching in residency programs, now it is a required rotation of many and it's own specialty, with certification and board questions included on other specialty certification exams. Medical schools regularly teach palliative and hospice care through clinical rotations.

There are many innovative ways to augment curricula. Most medical schools provide 2-4 hours of didactics a day in the first two years with additional introductions to clinical medicine that may take 5 hours per week. If not added as didactic education in the first two years of medical school, there could certainly be "Quality and Safety Tracks", weekly forums guided by institution leaders in quality and safety, or electives during clinical years (some medical schools already do this).

As a fellow primary care physician, I would argue that learning about diagnostic error, quality metrics and safety science has only increased my clinical curiosity by constantly pushing me to wonder: "Is this the right diagnosis? Is this the best test to confirm my diagnosis? If not, what is? What are the potential hazards with this treatment plan? How can I get better control among my hypertensive patients - I thought what I was doing was effective, but metrics show otherwise, are there innovative strategies the clinic can use?" etc., etc. I think these things can be taught.

To me, it feels like there is a growing movement to integrate quality and safety themes into medical school and residency curricula. It does take faith and a paradigm shift on the part of medical school deans and residency program directors that these concepts are best taught early in one's career.

Quality and Safety fellows (of which I am one) are growing in numbers across the country and adding fuel to the debate that this is a necessary part of provider education and key to ensuring safe and effective care.

Melanie Powell, MD/MPH
MedStar Institute Quality and Safety Fellow
(c) 410-688-5216

________________________________
From: Tommaso, Laura [ltommaso at NCH.ORG]
Sent: Tuesday, September 12, 2017 11:33 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Diagnostic Reasoning: An Endangered Competency in Internal Medicine Training


Another side of the coin: There is a lot of curriculum that many argue should be included in medical school curriculum including practice management, billing, ethics.. Unfortunately, there is just not room, the science content is much more important, and there are only 2 years for classroom study. As a primary care physician, I find that my favorite part of the job is being a “detective”, and I see the same enthusiasm in the medical students I teach. In fact, some have even chosen to go into primary care because there is much more opportunity to use the diagnostic process. I don’t think the intellectual curiosity that a master diagnostician has is something that can be taught, either. There are many PCPs that just want to refer, refer, refer..

From: HM Epstein [mailto:hmepstein at GMAIL.COM]
Sent: Monday, September 11, 2017 11:37 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [IMPROVEDX] Diagnostic Reasoning: An Endangered Competency in Internal Medicine Training

This may be a terrific article...if only I could read it. I don't have access to the Annals of Internal Medicine. I've requested Media credentials but in the meantime, for those of you who do have access, here's an abstract. And the link: http://annals.org/aim/article/2653703/diagnostic-reasoning-endangered-competency-internal-medicine-training<https://urldefense.proofpoint.com/v2/url?u=http-3A__annals.org_aim_article_2653703_diagnostic-2Dreasoning-2Dendangered-2Dcompetency-2Dinternal-2Dmedicine-2Dtraining&d=DwMGaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=3dT8qskNXwt9dVcbDWhmqJloLmy7wemgET-LOSYnQeY&s=eVHWSOt_dBvooHsCskO0zy9A1v-h50u9YoUJ5gEFnWk&e=>

Best,
Helene

Diagnostic Reasoning: An Endangered Competency in Internal Medicine Training

Arabella L. Simpkin, MD, MMSc; Jatin M. Vyas, MD, PhD; Katrina A. Armstrong, MD, MSCE
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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 to patient safety and the need to “enhance healthcare professional education and training in the diagnostic process” (1), several signs indicate that the focus on diagnostic reasoning in internal medicine training may be threatened (2). Indeed, only 2 of the 22 Internal Medicine Milestones of the Accreditation Council for Graduate Medical Education and American Board of Internal Medicine—milestones 1 and 7—explicitly include diagnostic skills (3). Although this disconnect between the importance of diagnostic reasoning skills and the current approach to medical education has not gone unnoticed, responses largely have focused on adding clinical reasoning courses to medical school curricula and incorporating clinical reasoning into certification assessments (1, 4).


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