The relationship between time to diagnose and diagnostic accuracy among internal medicine residents: a randomized experiment.
Ontology highlight
ABSTRACT: Background
Diagnostic errors have been attributed to cognitive biases (reasoning shortcuts), which are thought to result from fast reasoning. Suggested solutions include slowing down the reasoning process. However, slower reasoning is not necessarily more accurate than faster reasoning. In this study, we studied the relationship between time to diagnose and diagnostic accuracy.Methods
We conducted a multi-center within-subjects experiment where we prospectively induced availability bias (using Mamede et al.'s methodology) in 117 internal medicine residents. Subsequently, residents diagnosed cases that resembled those bias cases but had another correct diagnosis. We determined whether residents were correct, incorrect due to bias (i.e. they provided the diagnosis induced by availability bias) or due to other causes (i.e. they provided another incorrect diagnosis) and compared time to diagnose.Results
We did not successfully induce bias: no significant effect of availability bias was found. Therefore, we compared correct diagnoses to all incorrect diagnoses. Residents reached correct diagnoses faster than incorrect diagnoses (115 s vs. 129 s, p < .001). Exploratory analyses of cases where bias was induced showed a trend of time to diagnose for bias diagnoses to be more similar to correct diagnoses (115 s vs 115 s, p = .971) than to other errors (115 s vs 136 s, p = .082).Conclusions
We showed that correct diagnoses were made faster than incorrect diagnoses, even within subjects. Errors due to availability bias may be different: exploratory analyses suggest a trend that biased cases were diagnosed faster than incorrect diagnoses. The hypothesis that fast reasoning leads to diagnostic errors should be revisited, but more research into the characteristics of cognitive biases is important because they may be different from other causes of diagnostic errors.
SUBMITTER: Staal J
PROVIDER: S-EPMC8061054 | biostudies-literature |
REPOSITORIES: biostudies-literature
Similar Datasets
Project description:BACKGROUND: Physicians in specialties other than dermatology care for the majority of patients with skin diseases, yet most physicians receive little training in dermatology. OBJECTIVES: The primary objective of this study was to determine whether there would be a sizable (20%) improvement in posttraining scores for internal medicine residents after completing 1 of 3 assigned curricula. A secondary objective was to determine whether there were significant differences in improvement among the 3 resident cohorts after completing their curriculum. Finally, we explored the residents' change in perceived clinical knowledge postcurriculum. METHODS: Thirty-six postgraduate year 2 internal medicine residents were randomized to complete 1 of 3 one-month dermatology curricula (didactic, clinical, or combined). The main outcome measure was performance on different sets of Medical Knowledge Self-Assessment Program (MKSAP)-15 questions at study entry and completion. A secondary outcome was self-rated performance in 3 clinical domains. RESULTS: All participants completed the study. All curricula led to an improvement in MKSAP-15 scores, but only students who completed the didactic curriculum demonstrated a 20% improvement in posttraining scores. A larger number of residents completing the clinical and didactic curricula rated their clinical performance as improved compared to those who completed the combined curriculum. CONCLUSIONS: While all 3 curricula led to improvement, as measured by a standardized assessment, a didactic curriculum in dermatology resulted in the largest improvement in knowledge as measured by a multiple-choice test.
| S-EPMC4054730 | biostudies-other
Project description:BACKGROUND: Multiple factors affect residency education, including duty-hour restrictions and documentation requirements for regulatory compliance. We designed a work sampling study to determine the proportion of time residents spend in structured education, direct patient care, indirect patient care that must be completed by a physician, indirect patient care that 5 be delegated to other health care workers, and personal activities while on an inpatient general practice unit. METHODS: The 3-month study in 2009 involved 14 categorical internal medicine residents who volunteered to use personal digital assistants to self-report their location and primary tasks while on an inpatient general practice unit. RESULTS: Residents reported spending most of their time at workstations (43%) and less time in patient rooms (20%). By task, residents spent 39% of time on indirect patient care that must be completed by a physician, 31% on structured education, 17% on direct patient care, 9% on indirect patient care that 5 be delegated to other health care workers, and 4% on personal activities. From these data we estimated that residents spend 34 minutes per patient per day completing indirect patient care tasks compared with 15 minutes per patient per day in direct patient care. CONCLUSIONS: This single-institution time study objectively quantified a current state of how and where internal medicine residents spend their time while on a general practice unit, showing that residents overall spend less time on direct patient care compared with other activities.
| S-EPMC3244324 | biostudies-other
Project description:ImportanceThe United States spends more than $12 billion annually on graduate medical education. Understanding how residents balance patient care and educational activities may provide insights into how the modern physician workforce is being trained.ObjectiveTo describe how first-year internal medicine residents (interns) allocate time while working on general medicine inpatient services.Design, setting, and participantsDirect observational secondary analysis, including 6 US university-affiliated and community-based internal medicine programs in the mid-Atlantic region, of the Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial, a cluster-randomized trial comparing different duty-hour policies. A total of 194 weekday shifts were observed and time motion data were collected, sampled by daytime, nighttime, and call shifts in proportion to the distribution of shifts within each program from March 10 through May 31, 2016. Data were analyzed from June 1, 2016, through January 5, 2019.Main outcomes and measuresMean time spent in direct and indirect patient care, education, rounds, handoffs, and miscellaneous activities within a 24-hour period and in each of four 6-hour periods (morning, afternoon, evening, and night). Time spent multitasking, simultaneously engaged in combinations of direct patient care, indirect patient care, or education, and in subcategories of indirect patient care were tracked.ResultsA total of 80 interns (55% men; mean [SD] age, 28.7 [2.3] years) were observed across 194 shifts, totaling 2173 hours. A mean (SD) of 15.9 (0.7) hours of a 24-hour period (66%) was spent in indirect patient care, mostly interactions with the patient's medical record or documentation (mean [SD], 10.3 [0.7] hours; 43%). A mean (SD) of 3.0 (0.1) hours was spent in direct patient care (13%) and 1.8 (0.3) hours in education (7%). This pattern was consistent across the 4 periods of the day. Direct patient care and education frequently occurred when interns were performing indirect patient care. Multitasking with 2 or more indirect patient care activities occurred for a mean (SD) of 3.8 (0.4) hours (16%) of the day.Conclusions and relevanceThis study's findings suggest that within these US teaching programs, interns spend more time participating in indirect patient care than interacting with patients or in dedicated educational activities. These findings provide an essential baseline measure for future efforts designed to improve the workday structure and experience of internal medicine trainees, without making a judgment on the current allocation of time.Trial registrationClinicalTrials.gov identifier: NCT02274818.
| S-EPMC8462976 | biostudies-literature
Project description:BackgroundResidents graduate from medical school with increasing levels of debt and also may possess poor financial knowledge and practices. Prior studies have assessed resident financial knowledge and interest in financial education, yet additional information regarding their attitudes about personal finance and financial planning could be essential for the development of relevant curricula.ObjectiveWe assessed baseline financial attitudes and planning behaviors of internal medicine and internal medicine-pediatrics residents in 3 geographically diverse academic programs.MethodsA modified version of the Financial Industry Regulatory Authority National Financial Capability survey was administered anonymously to residents in 3 programs in spring 2017. Outcomes included levels of educational debt, positive financial planning behaviors, perception of finances and debt, and education about personal finance.ResultsResponse rate was 62% (184 of 298). Rates of educational debt were high, with 81% (149 of 184) of respondents reporting educational debt, and the majority owing more than $100,000. Residents' financial practices were variable, and residents could be grouped into 1 of 3 categories-concerned-engaged, concerned-unengaged, and unconcerned-unengaged-based on their engagement with debt and financial management. Residents with high debt (>?$250,000) had a bimodal distribution of respondents who strongly agreed and those who strongly disagreed they were concerned about debt.ConclusionsResident financial attitudes and practices are variable, ranging from highly engaged residents actively managing their financial wellness to unengaged residents who have low concern, despite high educational debt.
| S-EPMC6314372 | biostudies-literature
Project description:BackgroundMany residents experience burnout, prompting national attention to well-being; however, well-being is not merely the absence of burnout. A recently developed measure of flourishing may provide insight on this important topic.ObjectiveWe investigated flourishing in a sample of medical residents.MethodsInternal medicine residents and psychiatry residents at 2 residency programs responded to a cross-sectional online survey (December 2017-February 2018), which focused on the Flourish Index (FI) and Secure Flourish Index (SFI). Both measures generate scores ranging from a low of 0 to a high of 10. Participants were queried about quality of life, burnout, work-life balance, empathic concern, and sociodemographic characteristics. Simple and multiple linear regressions were performed to examine the relationship between FI/SFI and other variables.ResultsThe response rate was 92% (92 of 101). Participants were found to have a mean FI score of 6.8 (SD = 1.6) and mean SFI score of 6.9 (SD = 1.6). Low quality of life, low work-life balance satisfaction, high emotional exhaustion, lower empathic concern, and having a pet were all significantly associated with lower FI scores (R2 = 0.59; F[14, 69] = 7.10; P < .0001), indicating lesser flourishing, controlling for other variables. Similarly, low quality of life, high emotional exhaustion, lower empathic concern, and having a pet were all significantly associated with lower SFI scores (R2 = 0.55; F[14, 69] = 6.06; P < .0001), controlling for other variables.ConclusionsIn this sample, the flourishing indices were associated with well-being and burnout metrics.
| S-EPMC7301920 | biostudies-literature
Project description:ObjectivesThe vast majority of residents' working time is spent away from patients. In hospital practice, many factors may influence the resident's working day structure.Using an innovative method, we aimed to compare working time allocation among internal medicine residents using time-motion observations. The first study goal was to describe how the method could be used for inter-hospital comparison. The secondary goal was to learn about specific differences in the resident's working day structure in university and non-university hospital settings.DesignTwo separate time-motion studies. Trained peer-observers followed the residents during weekday day shifts with a tablet, able to record 22 different activities and corresponding context (with patient, phone, colleague or computer).SettingInternal medicine residencies at a university (May-July 2015) and a non-university (September-October 2016) community hospital.Participants28 residents (mean age: 29 years, average postgraduate training: 30 months) at university hospital, 21 residents (mean age: 30 years, average postgraduate training: 17 months) at non-university hospital.OutcomesTime spent with patients and time dedicated to activities directly related to patients; description of main differences of time allocation between hospitals.ResultsCumulatively 1051 hours of observation (566 (university hospital)+486 (non-university hospital)) and 92 day shifts (49+43) were evaluated. Daily working time was 11.5 versus 11.3 hours. A median daily period of 195 min (IQR 179-211, 27.9%) and 116 min (IQR 98-134, 17.2%) (p<0.001) was dedicated to direct patient care, respectively.ConclusionsWe successfully identified differences potentially related to each hospital structure and organisation. Inter-hospital comparisons could help set up interventions aiming to improve workday structure and experience of residents.
| S-EPMC7044966 | biostudies-literature
Project description:BACKGROUND: Increasing complexity of medical care, coupled with limits on resident work hours, has prompted consideration of extending Internal Medicine training. It is unclear whether further hour reductions and extension of training beyond the current duration of 3 years would be accepted by trainees. OBJECTIVE: We aimed to determine if further work-hour reductions and extension of training would be accepted by trainees and whether resident burnout affects their opinions. DESIGN: A postal survey was sent to all 143 Internal Medicine residents at the University of Colorado School of Medicine in May 2004. MEASUREMENTS: The survey contained questions related to opinions on work-hour limits using a 5-point Likert scale ranging from strongly agree to strongly disagree. Burnout was measured using the Maslach Burnout Inventory, organized into three subscales: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment, with burnout defined as high EE or DP. RESULTS: Seventy-four percent (106/143) of residents returned the survey. The vast majority (84%) of residents disagreed or strongly disagreed with extending training to 4 or 5 years. Burnout residents were less averse to extending training (strongly agree or agree, 18.9% vs 4.3%, P = .04). The majority of residents (68.9%) disagreed or strongly disagreed with establishing a 60-hour/week limit. Residents who met the criteria for burnout were more likely to agree that a 60-hour limit would be better than an 80-hour limit (strongly agree or agree, 22% vs 8%, P = .02). CONCLUSIONS: In this program, most Internal Medicine residents are strongly opposed to extending their training to 4 or 5 years and would prefer the current 80 hours/week cap. A longer, less intense pace of Internal Medicine training seems to be less attractive in the eyes of current trainees.
| S-EPMC1824782 | biostudies-other
Project description:Proficiency and self-confidence in the physical examination is poor among internal medicine residents and interest in ultrasound technology has expanded.We aimed to determine whether a pocket-sized ultrasound improves the diagnostic accuracy and confidence of residents after a 3-h training session and 1 month of independent practice.This was a randomized parallel group controlled trial.Forty internal medicine residents in a single program at an academic medical center participated in the study.Three hours of training on use of pocket-sized ultrasound was followed by 1 month of independent practice.The primary outcome was a comparison of the diagnostic accuracy of a physical exam alone versus a physical examination augmented with a pocket-sized ultrasound. Other outcomes included confidence in exam findings and a survey of attitudes towards the physical exam and the role of ultrasound.Residents in the intervention group using a pocket-sized ultrasound correctly identified an average of 7.6 of the 17 abnormal findings (accuracy rate of 44.9 %). Those in the control group correctly identified an average of 6.4 abnormal findings (accuracy rate of 37.6 %, p?=?0.11). Residents in the intervention group identified on average 15.9 findings as abnormal when no abnormality existed (false positive rate of 16.8 %). Those in the control group incorrectly identified an average of 15.5 positive findings (false positive rate of 16.3 %). There was no difference between groups regarding self-assessed confidence in physical examination. Residents in the intervention group identified 6.1 of 13 abnormal cardiac findings versus the control group's 4.5 of 13, an accuracy rate of 47.0 % versus 34.6 % (p?=?0.023).The diagnostic ability of internal medicine residents did not significantly improve with use of a pocket-sized ultrasound device after a 3-h training session and 1 month of independent practice.clinicaltrials.gov: number NCT01948076; URL http://clinicaltrials.gov/ct2/show/study/NCT01948076?term=ultrasound+physical+exam&rank=2.
| S-EPMC4314490 | biostudies-literature
Project description:BackgroundLittle is known about whether and how medical knowledge relates to interest in subspecialty fellowship training. The purpose of this study was to examine the relationships between residents' interest in subspecialty fellowship training and their knowledge of internal medicine (IM).MethodsA questionnaire was emailed to 48 categorical postgraduate-year (PGY) two and three residents at a New York university-affiliated IM residency program in 2007 using the Survey Monkey online survey instrument. Overall and content area-specific percentile scores from the IM in-training examination (IM-ITE) for the same year was used to determine objective knowledge.ResultsForty-five of 48 residents (response rate was 93.8%) completed the survey. Twenty-two (49%) were PG2 residents and 23(51%) were PGY3 residents. Sixty percent of respondents were male. Six (13%) residents were graduates of U.S. medical schools. Eight (18%) reported formal clinical training prior to starting internal medicine residency in the U.S. Of this latter group, 6 (75%) had training in IM and 6 (75) % reported a training length of 3 years or less. Thirty-seven of 45 (82%) residents had a subspecialty fellowship interest. Residents with a fellowship interest had a greater mean overall objective knowledge percentile score (56.44 vs. 31.67; p = 0.04) as well as greater mean percentile scores in all content areas of IM. The adjusted mean difference was statistically significant (p < 0.02) across three content areas.ConclusionsMore than half of surveyed residents indicated interest in pursuing a subspecialty fellowship. Fellowship interest appears positively associated with general medical knowledge in this study population. Further work is needed to explore motivation and study patterns among internal medicine residents.
| S-EPMC3038163 | biostudies-literature
Project description:BackgroundFew internal medicine residency programs provide formal ultrasound training. This study sought to assess the feasibility of simulation based ultrasound training among first year internal medicine residents and measure their comfort at effectively using ultrasound to perform invasive procedures before and after this innovative model of ultrasound training.MethodsA simulation based ultrasound training module was implemented during intern orientation that incorporated didactic and practical experiences in a simulation and cadaver laboratory. Participants completed anonymous pre and post surveys in which they reported their level of confidence in the use of ultrasound technology and their comfort in identifying anatomic structures including: lung, pleural effusion, bowel, peritoneal cavity, ascites, thyroid, and internal jugular vein. Survey items were structured on a 5-point Likert scales (1 = extremely unconfident, 5 = extremely confident).ResultsSeventy-five out of seventy-six interns completed the pre-intervention survey and 55 completed the post-survey. The mean confidence score (SD) increased to 4.00 (0.47) (p < 0.0001). The mean (SD) comfort ranged from 3.61 (0.84) for peritoneal cavity to 4.48 (0.62) for internal jugular vein. Confidence in identifying all anatomic structures showed an increase over the pre-intervention means (p < 0.002).ConclusionA simulation based ultrasound learning module can improve the self-reported confidence with which residents identify structures important in performing invasive ultrasound guided procedures. Incorporating an ultrasound module into residents' education may address perceived need for ultrasound training, improve procedural skills, and enhance patient safety.
| S-EPMC3196730 | biostudies-literature