Diagnostic errors (missed, delayed, incorrect diagnoses) are increasingly being recognized as a prevalent cause of harm to patients. At the same time, physicians are simultaneously under pressure to deliver high-quality, low-cost health care. How do physicians come to a balance between the competing demands of addressing underuse versus overuse, and consequently a balance between under-diagnosis from inadequate investigations versus over-diagnosis and resource waste? Can physicians learn from hearing about their diagnostic errors and improve their diagnostic performance? Could this lead to reducing error and improving safety?
In a recent JAMA paper, we suggest strategies to help answer some of these questions and move forward. We suggest ways to better align physicians’ diagnostic accuracy with their confidence — or better calibrate physicians in their diagnostic thinking. Why? Because low confidence may lead to over-testing and high confidence to under-testing. In fact, we suggest that the best diagnostician may be the physician who makes the correct diagnosis using the least resources, while maximizing patient experience.
This is no small feat.
Psychology literature suggests a solution: improve physicians’ calibration by providing them with feedback about their diagnoses.
Why do we not do this already?
The answer is complicated. While there are too many reasons to list here, one is that currently, when a physician gives a patient an incorrect diagnosis, that physician may never learn about the mistake. Given an incorrect diagnosis, the patient might go elsewhere (either by seeking emergency care unbeknownst to their original physician or by seeking a second opinion from another physician).
Another, perhaps thornier, reason why physicians do not receive feedback about their diagnostic performance is that conversations involving feedback pose several challenges. For one, physicians may be uncomfortable receiving feedback about their thinking skills and competencies. They might find it threatening to their professional image. It has also been difficult to figure out what type of feedback would be most helpful. …
We think a combination of quantitative and qualitative feedback will enable physicians to recalibrate their thinking by providing a helpful overview of their diagnostic processes, while also providing an informative, in-depth analysis into the reasons behind their thinking and the context surrounding their decisions. We don’t need to always focus on outcomes (e.g., mistakes). Instead, we think focusing on what processes went right — and wrong — could be most useful.
How could this feedback occur? We suggest the following to deliver diagnostic performance feedback.
Ideally, diagnostic performance feedback should:
- Occur within a receptive learning environment. For example, tell physicians that the feedback is meant for learning and deliver all feedback in a positive, constructive, nonjudgmental, non-punitive way.
- Involve quantitative summaries of performance that are meaningful, but revolve around processes that can be improved by the physician (e.g., identifying test results that were not acted upon, or patients that were not timely notified)
- Involve in-depth, qualitative deep dives of specific cases to enable self-assessment and accountability. It’s important to highlight the cognitive, systems, and patient factors to paint a rich context.
- Involve teams. Diagnosing is often a team sport; capturing a larger picture of the diagnostic process by soliciting team feedback can help with processes related to team dynamics.
Generating this type of feedback within a health care system can produce better calibrated clinicians who prevent harm from missed diagnostic opportunities as well as from over-diagnosis, over-testing, and over-treatment.
Even if the tips suggested above are implemented, there are still many unknowns. What are the unintended consequences of such feedback, i.e., could this lead to hyper-vigilance? What specific diagnostic processes and outcomes should be tracked and provided to physicians in various specialties? How do we maintain clinician accountability? How do we develop peer-to-peer collaborative learning networks for practicing physicians who have no real means of getting feedback from, let’s say, a supervisor?
These unknowns, however, can be worked out and examined once feedback part of the practice routine. Who will take the first steps?
Ashley N.D. Meyer, PhD is a cognitive psychologist and Hardeep Singh, MD, MPH is a physician specializing in Internal Medicine. They can be contacted, respectively, on Twitter at @AshleyNDMeyer and @HardeepSinghMD.
The findings and conclusions in this post are those of the authors and do not necessarily represent the official position of the Department of Veterans Affairs or the U.S. government.
This piece has also been accepted for publication at KevinMD and is based on the publication The Path to Diagnostic Excellence Includes Feedback to Calibrate How Clinicians Think in JAMA, published online February 8, 2019.