Multiple themes have informed the development and refinement of emerging diagnosis education curricula and programs. Just as knowledge in many other areas of biomedical science continues to greatly expand, the expanding knowledge base regarding the diagnostic process and causes of diagnostic errors provides important insight into what should be taught, learned, and assessed in diagnosis education.
This expanding knowledge is anchored, perhaps most importantly, in increased recognition that diagnosis is a "team sport." Everyone involved—patients, families, nurses, pharmacists, physicians, physical therapists, and others—should be encouraged to bring their experience and expertise to bear on the incredibly complex and complicated task of diagnosis.
Team-based diagnosis in practice is not necessarily new, but neither is it the standard. The emerging formal analysis and education regarding team-based education has focused new attention and energy on it. The report Improving Diagnosis in Health Care identified improving teamwork as the most important strategy for decreasing diagnostic errors, followed by improving education.2 Thus, diagnosis education curricula must be part of all health professions education programs. More importantly, these curricula must not be siloed within educational programs. Instead, diagnosis education curricula must be intentionally designed to be truly interprofessional, aiming to educate learners the way they will ideally practice in the future.
Improving teamwork and collaboration in diagnosis requires a deep understanding of how people interact with one another and within the health system. Social cognitive theories (such as ecological psychology and distributed cognition) are thus particularly valuable in research, curriculum development, and assessment of diagnostic reasoning.14,15
Many believe that focusing on diagnostic teams, rather than an individual, may ultimately have major positive impact on diagnostic outcomes.16 Teams benefit from the different skill sets and perspectives of their members. It is imperative that the diagnostic team acknowledge the patient as the core team member, aiming to fully engage the patient, along with clinical and ancillary members of the care team, as coequal coproducers of diagnosis and health.
Substantial improvement has also been realized in understanding how diagnostic reasoning occurs within individuals. Diagnosis relies heavily on clinicians' cognitive processes: the depth and breadth of their knowledge, their skill in eliciting the appropriate history and physical exam findings, and their ability to synthesize all the available information into a prioritized differential diagnosis and communicate it effectively to the patient and the team..
Although cognitive processes are clearly an appropriate target for addressing diagnostic error, few intervention trials have been conducted to date, and fewer still have proven effective.17,18 Contemporary studies focus on the role of feedback in improving diagnostic performance, especially given the overconfidence and miscalibration that results from open-loop decision making and inadequate awareness of patient outcomes.19-22 Future studies will need to examine the potential impact of efforts to improve clinical reasoning and encourage clinicians to use decision-support tools and engage second opinions. All these interventions have promise and some of the requisite tools exist, but changing provider behavior is challenging.
Finally, the healthcare system has a defining influence on clinical reasoning and diagnosis. Both the accuracy and the timeliness of diagnosis depend greatly on the context of care in the health system. For example:
- How easy is it to get an appointment or see a specialist?
- How chaotic is the care delivery environment?
- How many minutes are allocated to a new patient visit?
- How mature is the electronic health record (EHR)?
Thus, it is imperative that health systems science be taught in parallel with traditional diagnosis-related topics and that those completing health professions education programs can easily navigate the healthcare system. This means, especially, that they learn to use the EHR and other resources to their maximal potential as powerful enablers of diagnostic quality and safety.23,24 Much education regarding EHR use is informal and teachers may not be facile or competent themselves, leaving an important gap to address.
The corollary is true as well: educational programs that focus on health systems science and as detailed below, healthcare administration programs, must include specific content regarding the impact of health systems, processes, and operations on clinical reasoning and diagnostic performance. Improved awareness of such impact would better equip healthcare administrators and system leaders to effectively mitigate harmful effects of system factors on diagnostic performance and ensure these leaders can engage as partners in building highly reliable diagnostic systems.
