Context (e.g., patient characteristics, setting) can influence clinical reasoning and increase the risk for diagnostic errors. This article explores the ways in which individual-, team-, and system-level contextual factors impact reasoning, clinician performance and risk of error. The authors propose a multilevel framework to better understand how contextual factors impact clinical reasoning.

Cognitive biases, such as heuristics, help clinicians make rapid decisions, but these biases can result in errors. This review sought to explore biases in internal medicine, the impact of biases on patient outcomes, and the effect of debiasing strategies. Forty-one biases were studied, and debiasing strategies showed little to no effect on reducing bias.

Clinical decision-making is a complex process often involving interactions with multiple team members, processes, and systems. Using distributed cognition theory and qualitative synthesis, this scoping review including 37 articles identified seven themes addressing how distribution of tasks influences clinical decision-making in acute care settings The themes included information flow, task coordination, team communication, situational awareness, electronic health record (EHR) design, systems-level error, and distributed decision-making.

This study explored the influence of contextual factors (i.e., factors beyond the case content potentially influencing reasoning) on context specificity and clinical reasoning. Internal medicine residents and attending physicians viewed outpatient clinic videos involving unstable angina and diabetes mellitus – one video with distracting contextual factors and one without. The results provide insight into factors influencing diagnostic reasoning during outpatient visits for common medical conditions.

In this Letter to the Editor, the authors suggest that the COVID-19 pandemic presents a unique opportunity to consider how situational factors impact clinical reasoning performance and lead to errors. The authors discuss the potential implications through a clinical story involving a redeployed resident working in a COVID-19 assessment and treatment unit and an older man with respiratory symptoms. 

… J Patient Saf … In this survey of clerkship directors in …

Enhancing clinical reasoning skill, particularly among trainees, is emerging as a strategy to reduce diagnostic error. The authors of this commentary suggests that the Accreditation Council for Graduate Medical Education’s (ACGME) consider revising their core competencies to include clinical reasoning to provide trainees with the tools necessary to monitor and prevent diagnostic errors. 

Mitigating diagnostic error has become a critical patient safety concern. As a result, medical education and training programs are increasingly focused on teaching students and residents about diagnostic safety. This article describes the development of a novel interprofessional framework to improve diagnostic competency across health professions education programs. A consensus committee identified 12 key competencies that focus on individual performance (e.g., prioritizing differential diagnosis; utilizing second opinions, decision support, and checklists), teamwork (e.g., engaging patients and families; collaborating with other health professionals), and system-related aspects of clinical care (e.g., developing a culture of diagnostic safety; disclosing and learning from errors). The authors emphasize the innovative aspects of their recommendations and suggest that education programs develop curriculum incorporating these competencies to improve diagnosis. A previous WebM&M commentary discussed an incident involving a diagnostic error.

… evaluate clinical reasoning assessment tools. … Daniel M, Rencic J, Durning SJ, et al. Acad Med. 2019;94:902-912. …

Metacognition is an approach to enhance diagnostic thinking. This study used focus groups to assess physicians' and medical students' impressions of a metacognitive diagnostic checklist. Participants found the checklist to be applicable and usable, and the authors conclude that it should be tested in a clinical setting.

Prior research has shown that educational interventions can be developed to teach trainees about cognitive biases that contribute to diagnostic errors. The authors describe the development and implementation of a virtual patient module to teach medical students about the diagnostic process.

This simulation study presented virtual patient cases to practicing physicians with the aim of improving diagnostic accuracy. Physician participants reported challenges using the computerized platform, and overall diagnostic performance was poor, with less than a third of respondents identifying the correct diagnosis. This study highlights the challenge of developing interventions to enhance diagnostic performance.

Efforts to reduce diagnostic error have mainly focused on safety and quality improvement initiatives. This commentary describes an educational strategy for improving diagnosis. The authors suggest that learners should demonstrate effective use of knowledge, clinical reasoning, system orientation, patient and team engagement, and appropriate attitudes regarding diagnosis to achieve lasting success.

Enhancing clinical reasoning skill is emerging as a strategy to reduce diagnostic error. This review spotlights the need for a uniform definition of clinical reasoning and a robust literature base to augment efforts to improve reasoning and decision making. The authors suggest these refinements will identify cognitive biases and other contextual influences on clinical reasoning and improve education and professional development.

This commentary reviews five differences between diagnostic reasoning and patient management reasoning, such as the changing nature of management over time and the team-based nature of the activity. The authors recommend areas of research needed to further understand patient management reasoning.

… perspective provides an update on diagnostic error. … Rencic J, Trowbridge RL Jr, Fagan M, Szauter K, Durning S. Clinical Reasoning Education …

This commentary discusses how two medical centers utilized the fishbone diagram as a tool to analyze diagnostic errors. A health care facility in Maine developed a root cause analysis model to determine common factors, and a residency program in Pennsylvania introduced a modified fishbone diagram to educate trainees about cognitive biases and systems issues.

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … Although diagnostic errors cause …

This review outlines an educational approach to enhance clinical and diagnostic reasoning skills for trainees and physicians.