Blog | Friday, October 20, 2017

Where did diagnosis education go, and why?


As I wrote recently, “We must once again make the term diagnostician the most prestigious term in medicine. We should celebrate the great diagnosticians for they truly help patients.”

While we were not looking, diagnosis became a second-class citizen. This article in the Annals of Internal Medicine echoes many blog posts, “Diagnostic Reasoning: An Endangered Competency in Internal Medicine Training“. The article ends with this paragraph:

“As we strive to ensure that the diagnostic process receives the attention it deserves in our internal medicine training programs, we must look to the challenges that have resulted in our shift of focus and work to provide solutions that return this art form to the forefront of our training models. We need to build time for trainees to develop curiosity without constraint, rewarding the diagnostic reasoning process and looking to compensate for imperfect systems that hinder optimal decision making. We also need to amalgamate the great strides being made in diagnostic technologies, with a focus on the cognitive psychology underpinning our decision-making process. In this way, we hope to begin turning the tide on diagnostic errors—a major patient safety concern—and to ensure that great internist remains synonymous with great diagnostician.

Diagnosis education clearly had primacy in the 1970s when I went through medical school and residency. I have always considered diagnosis as our first and most important responsibility. Sometime, when I was not really paying attention, that focus shifted.

This morning I did a quick Google search on “add to medical school curriculum”. I quickly found articles imploring us to add nutrition & diet, opioids, health care policy, diversity, management 101, cultural competency and exercise. You can probably add to this list.

These “add ons” are all important. They all address important issues. But, whenever you expand the medical school curriculum you dilute the core. Our students have much to learn, and limited time. Do these important issues diminish the focus on diagnosis?

At the residency level (which the Annals article addresses), we have also diluted resident education. We now spend time doing multi-disciplinary rounds. We focus on performance metrics. We often have patients seen initially by the night float team and then taken over by a floor team. We run the risk of diagnostic inertia.

Too few attending physicians are considered diagnosticians. Attending physicians are busy making certain that treatment is correct, charts are completed, and patients are discharged appropriately.

We still have wonderful cadres of diagnosticians at most medical schools. Our ward attending round research suggests that learning how to think (and we believe this refers at least in part to the diagnostic process) is the most important goal of successful attending rounds.

Given that diagnostic errors are probably the most important problem in medicine today, we must focus on the primacy of teaching diagnostic reasoning. The authors of the Annals article write about their diagnostic curriculum at the Massachusetts General Hospital. While I love that the Annals published this article and that the authors are working to address this most important problem, I am saddened that we need a curriculum.

Diagnostic expertise should be the curriculum. Our clinician educators should role model diagnostic expertise every day, on the wards, in the clinic and on consult rounds. If we do not do that, no curriculum will help.

Perhaps we can blame the lack of diagnostic education on residency reform, or performance measurement, or multidisciplinary rounds. But the real culprit may be the assumption that almost any internist can function adequately as a ward attending, or clinic supervisor or subspecialty consult attending. Teaching internal medicine is a skill with great complexity.

Our medical schools have not focused sufficiently on developing great clinician educators. Perhaps that should become the curricular fix. We should actually train our clinicians how to educate and what great clinician educators do. If we could do that, then our curriculum for both medical students and residents would be on target.

Too often we have a signal to noise problem. We need to tighten our focus on the signal. We cannot deliver high quality care unless we work diligently to diagnose patients correctly.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.