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Ways to enhance diagnostic reasoning in trainees

Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. Lambe KA, O’Reilly G, Kelly BD, Curristan S.  BMJ Qual Saf 2016;25:808-20

Reviewed by Craig DeWolfe

Tags: clinical reasoning, teaching, systematic review

What was the study question?

What is the effectiveness of interventions used to enhance analytical (deliberate, rational and controlled) and non-analytical (unconscious, intuitive, and automatic) diagnostic reasoning among medical trainees and doctors?


How was the study done?

Guided by the PRISMA guidelines, the authors performed a literature search of medical, psychological, and educational databases, bibliographies and relevant journals looking for studies that reported results of interventions designed to enhance analytical or non-analytical reasoning among medical trainees and doctors at the individual clinician level. They narrowed the list of articles to 28 studies under six categories:  educational interventions, checklists, cognitive forcing strategies, guided reflection, instructions at test, and other. 

What were the results?

Although many studies in each of the categories found some effect on learners, there was significant heterogeneity in the type of effect measured (Kirkpatrick hierarchy) and consistency of the effect.  While accounting for these limitations, guided reflection interventions were found to be the most consistently successful and cognitive forcing strategies improved accuracy and confidence judgments among learners.

What are the implications? 

Although diagnostic error is a leading cause of adverse events in patient care, the study concludes that the optimal approach to enhance diagnostic reasoning remains unclear.  In the meantime, a multi-faceted approach may be best.  Educators may benefit by examining how the categories of diagnostic reasoning interventions described in the study are represented in their own curriculum.    Finally, for researchers interested in studying the effects of diagnostic error interventions, this article provides an excellent summary of study design and gaps in the literature.  

Editor's note: Excellent review of literature from diverse disciplines to help medical educators guide trainees (and experienced physicians) to improve diagnostic reasoning. (RR)

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