Minimizing Diagnostic Error: The Importance of Follow-up and Feedback
Section snippets
The need for systematic feedback
In this commentary, I consider the issues raised in the review by Drs. Berner and Graber3 and take the discussion further in contemplating the need for systematic feedback to improve diagnosis. Whereas their emphasis centers around the question of physician overconfidence regarding their own cognitive abilities and diagnostic decisions, I suspect many physicians feel more beleaguered and distracted than overconfident and complacent. There simply is not enough time in their rushed outpatient
Expanded paradigms in diagnosis
The true concern in routine clinical diagnosis is not whether unsuspected new diagnoses are made or missed as much as it is the complexities of weighing and pursuing diagnostic considerations that are either obvious, may have been previously considered, or simply represent “dropped balls” (e.g., failed follow-up on an abnormal test result).9 Furthermore, other paradigms often turn out to be more important than simply affixing a label on a patient naming a specific diagnosis (Table 2). Central
Response over time: The ultimate test?
Although the traditional “test of time” is frequently invoked, it is rarely applied in a standardized or evidence-based fashion, and never in a way that involves systematic tracking and calculating of accuracy rates or formal use of data that evolves over time for recalibration. One key unanswered question is, To what extent can we judge the accuracy of diagnoses based on how patients do over time or respond to treatment? In other words, if a patient gets better and responds to recommended
Viewing diagnosis as a relationship rather than a label
Feedback on how patients are doing embodies an important corollary to the entire paradigm of diagnosis tracking and feedback. To a certain extent, diagnosis has been “reified,” i.e., taken as an abstraction—an artificially constructed label—and misconceived as a “fact of nature.”10, 11 By turning complex dynamic relationships between patients and their social environments, and even relationships between physicians and their patients, into “things” that boil down to neat categories, we risk
Avoidance of tampering
Carefully refined signals from downstream feedback represent an important antidote to a well-known cognitive bias, anchoring, i.e., fixing on a particular diagnosis despite cues and clues that such persistence is unwarranted. However, feedback can exacerbate another bias—availability bias,15 i.e., overreacting to a recent or vividly recalled event. For example, upon learning that a patient with a headache that was initially dismissed as benign was found to have a brain tumor, the physician
Conclusion
Learning and feedback are inseparable. The old tools—ad hoc fortuitous feedback, individual idiosyncratic systems to track patients, reliance on human memory, and patient adherence to or initiating of follow-up appointments—are too unreliable to be depended upon to ensure high quality in modern diagnosis. Individual efforts to become wiser from cumulative clinical experience, an uphill battle at best, lack the power to provide the intelligence needed to inform learning organizations. What is
Author disclosures
The author reports the following conflicts of interest with the sponsor of this supplement article or products discussed in this article:
Gordon D. Schiff, MD, has no financial arrangement or affiliation with a corporate organization or a manufacturer of a product discussed in this article.
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2021, Joint Commission Journal on Quality and Patient SafetyA Program to Provide Clinicians with Feedback on Their Diagnostic Performance in a Learning Health System
2021, Joint Commission Journal on Quality and Patient SafetyCitation Excerpt :Indeed, feedback has been highlighted as important for both clinical practice7 and medical education.8,9 Although feedback can improve diagnostic performance, very little of this occurs after clinicians enter practice.4,10–12 Feedback should be integral to a learning health system that focuses on measuring and improving diagnostic performance.
Do patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests and referrals in primary care? A retrospective cohort study
2024, Journal of the American Medical Informatics Association
Statement of Author Disclosure: Please see the Author Disclosures section at the end of this article.