Although the potential for education to improve diagnosis is real, so are the barriers to achieving successful implementation in this domain.31 Outside of the clinical reasoning realm, much of the content related to the desired competencies has yet to be developed or tested. The newly recommended competencies provide a useful framework for a new curriculum, but the content, experiences, and relevant assessment tools have yet to be built. Educators and health professional organizations will need to help fill these gaps.
Many curricular elements will be developed at the local institutional level, but there is a growing need to have widely available, easily implementable curricular elements focused on diagnosis education at a national level. TeamSTEPPS for Diagnosis is such an example, as are recent faculty development efforts put forth by the Society to Improve Diagnosis in Medicine. Because the time and resources needed for a completely new curriculum or even curricular elements are substantially more than those needed to implement an existing curriculum that has been implemented elsewhere, national collaborative efforts are needed.
A second large concern is: who will teach this? As was the case in holding back patient safety education generally, faculty development around diagnostic education is greatly needed.29,30,87 Faculty must be equipped to teach these diagnostic competencies. Since today's faculty are a product of yesterday's educational programs, it is quite likely that many, if not most, are lacking many of the key competencies espoused above. Thus, schools and programs will need to engage in "train the trainer" efforts to equip faculty to develop learner diagnostic competence. Adoption also will hinge on the endorsement and enthusiasm of the many professional organizations responsible for health professions education in the United States.
One of the most important next steps in diagnosis education is developing team-based diagnosis assessment tools. There are important early approaches to assessing the diagnostic functioning of teams in simulation,88 as well as in the clinical setting.89 However, no validated, widely available tools are available to assess the diagnostic performance of teams. What makes a good diagnostic team? What differentiates a highly effective diagnostic team from one that is less effective? It is quite clear that diagnostic teams are more than a sum of their parts; thus, combining traditional assessment methods of individuals would be inadequate in assessing the diagnostic performance of teams. Thus, we should aim to develop robust tools for team-based diagnostic performance and use these for assessment of diagnosis education programs.
Pharmacy, nursing, and medicine have all made important progress in diagnosis education by contributing to the development of the key diagnostic competencies48 and through actions taken by their leading education-focused organizations.
Pharmacy Education
The case for incorporating diagnosis-related competencies has been made,90,91 and curricula have been initiated.92-94 In addition, the responsible professional organization, the American Association of Colleges of Pharmacy, has formally endorsed "supporting education on the pharmacist's responsibility for contributing to the diagnostic process to help minimize errors, maximize patient safety, and optimize health outcomes."95 These organizational endorsements are important and calls to action are key but must be translated into widely adopted, robust curricula.
Pharmacists have engaged in diagnosis despite a lack of formal recognition. For example, community pharmacists assess patients for self-care and triage for further evaluation everyday, helping patients identify when further care should be sought based on a patient's concerns and context.96,97 When trained appropriately, pharmacists can help the team diagnose in an accessible, trusted context often outside traditional care settings.
Pharmacy students are taught physical exam skills in many schools,98 and pharmacy students are more likely to put these skills into practice when trained by well-prepared faculty to whom they relate.99 Pharmacists are often in the position of being at the frontline of healthcare and must be equipped to help patients engage in the diagnostic process, ensure diagnostic safety, and avoid diagnostic and management errors.
Nursing Education
The American Association of Colleges of Nursing has incorporated the competencies for diagnosis into the recently-approved 2021 Essentials, which sets the educational framework for professional nurse education at all U.S. 4-year colleges and universities.100 The Essentials represents consensus recommendations from academia, practice partners, and other nursing organizations and establishes a new, competency-based model for entry into professional nursing practice and advanced nursing practice. Sample language from the Essentials that outlines the roles nurses can play in diagnosis100 is illustrated in Exhibit 2, emphasizing how professional nurses contribute to diagnosis.
Nurses have always played a role in diagnosis, and the case has been made that this role needs to be recognized explicitly and encouraged.16,101 Nurse engagement in diagnosis improves timeliness and accuracy of diagnosis and reduces the risk of diagnostic error.32,102-104 Recommendations for removing scope-of-practice barriers for nurses’ full participation in diagnosis will be the next key step in advancing this role.33
Nurses are key members of the diagnostic team and this recognition must happen at a policy level and at the frontline care delivery and educational levels so that nurses are empowered to improve diagnosis. This recognition has important content and cultural elements and speaks much to the interprofessional nature of practice and education.
Exhibit 2. Excerpts from The Essentials: Core Competencies for Professional Nursing Education relevant to the nurse's role in diagnosis100
Domain 2: Person Centered Care
Contributing to or making diagnoses is one essential aspect of nursing practice and critical to an informed plan of care and improving outcomes of care (p. 29)… Diagnoses at the system-level are equally as relevant, affecting operations that impact care for individuals. Person-centered care results in shared meaning with the healthcare team, recipient of care, and the healthcare system, thus creating humanization of wellness and healing from birth to death (p. 29).
2.3: Integrate assessment skills in practice.
2.4: Diagnose actual or potential health problems and needs.
Domain 6: Interprofessional Partnerships
…Nursing knowledge and expertise uniquely contributes to the intentional work within teams and in concert with patient, family, and community preferences and goals. Interprofessional partnerships require a coordinated, integrated, and collaborative implementation of the unique knowledge, beliefs, and skills of the full team for the end purpose of optimized care delivery. Effective collaboration requires an understanding of team dynamics and an ability to work effectively in care-oriented teams…(p. 42).
6.1: Communicate in a manner that facilitates a partnership approach to quality care delivery.
6.4: Work with other professions to maintain a climate of mutual learning, respect, and shared values.
Medical Education
The American Association of Medical Colleges has incorporated many of the competency elements in their Quality in Patient Safety (QIPS) set.105 Such national-level competencies drive educational content at the institutional and national levels, and recognition that diagnostic quality and safety are fundamental to overall quality and safety is an important step forward. Many new courses on clinical reasoning and critical thinking have been published.106 Both undergraduate and graduate medical education have seen renewed interest in promoting diagnostic quality, many through case discussion and analysis, discussion of uncertainty, and discussion on other leading topics in diagnosis.107-109
