A primary goal of health professions education is to achieve competency in the clinical skills required for diagnosis, but the adequacy of this preparation is increasingly being called into question. Diagnosis begins with obtaining an appropriate history from the patient and performing a hypothesis-driven physical examination, but evidence suggests that even these most basic elements are often deficient.25,26 Diagnosis then depends on clinical reasoning to apply the clinician’s depth of knowledge in an effort to make sense of the patient findings in the appropriate context. Clinical reasoning is challenging and represents the dominant issue in diagnostic error, as repeated studies have shown.6,27,28
Some of the origins of this problem trace back to health professions training programs. For example, clinical reasoning is a fundamental competency for physicians, yet it is not addressed explicitly in many medical schools; learners are expected, instead, to acquire clinical reasoning competence organically. Surveys of medicine clerkship directors have found that most students enter the clerkship years with only a poor (29%) or fair (55%) knowledge of clinical reasoning concepts, and that most schools (57%) lacked curricular time dedicated to these topics.29
A survey that focused specifically on the preclerkship years found that only a quarter of programs offered content on Bayesian reasoning, the use and limitations of heuristics, or dual-process theory, although most program directors deemed these topics important.30 The major barriers cited in why this content was lacking included inadequate time in the curriculum (81%) and lack of qualified faculty instructors on these topics (66%). This lack of curricular focus on diagnosis is present in nursing and pharmacy education programs as well, although important progress has been made in improving diagnosis curricula in nursing, pharmacy, and other fields.12,31-34
Health professions education (a broad definition including education of all individuals entering or advancing healthcare careers) has important gaps in many other areas relevant to diagnosis and diagnostic error. Student exposure to content regarding diagnostic testing is limited and inconsistent across the health professions, even though medical imaging and laboratory testing are commonly used in diagnostic evaluation.35
Second, clinical reasoning is taught by each profession from its narrow lens, usually without deliberate efforts to support team-based diagnostic practice. Even the language used in describing diagnosis varies from one health profession to the next. Thus, health professional team members may not be equipped with a common language that would garner trust and establish the psychological safety needed to contribute fully to the diagnostic process.
Breakdowns in collaboration and teamwork are leading system-related issues in cases of diagnostic error,27 yet historically education has not been interprofessional, and students (or their teachers) have essentially no experience in team-based diagnosis. The tacit lessons they learn in the chaos of the modern clinical environment likely teach students much more about how healthcare teams do not work than how they do.
In addition, health professions education programs have been slow to adopt evidence-based methods to improve clinical reasoning education. It is clear that learners must interact with a significant number of cases across contexts and clinical conditions while receiving feedback for improvement. Yet, many learners leave their educational programs neither exposed to common conditions nor ready to care for them.36,37
In summary, substantial evidence shows that healthcare professionals are not optimally prepared for excellence in diagnostic practice. This was one of the major conclusions from the report Improving Diagnosis in Health Care, and a major recommendation from the report was to improve education as one of the most promising avenues for improving diagnosis in practice 16 (Exhibit 1).
Exhibit 1. Recommendations from the National Academy of Medicine to improve diagnosis education
Goal 2: Enhance health care professional education and training in the diagnostic process
Recommendation 2a: Educators should ensure that curricula and training programs across the career trajectory:
- Address performance in the diagnostic process, including areas such as clinical reasoning, teamwork, communication with patients, their families, and other health care professionals, appropriate use of diagnostic tests and the application of these results on subsequent decision making, and use of health IT.
- Employ educational approaches that are aligned with evidence from the learning sciences.
Recommendation 2b: Health care professional certification and accreditation organizations should ensure that health care professionals have and maintain the competencies needed for effective performance in the diagnostic process, including the areas listed above.
Other individuals and groups have similarly concluded that improving diagnostic education is mandatory. The Millennium Conference in 2011 specifically focused on the importance of improved training on clinical reasoning and critical thinking.38 Stark and Fins made the case that improving diagnosis education was an "ethical imperative," given the aggregate harm from diagnostic error and the evidence that current education and training in this area are lacking.39
