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Schmidt HG, Norman GR, Mamede S, Magzoub M. The influence of context on diagnostic reasoning: A narrative synthesis of experimental findings. J Eval Clin Pract 2024. [PMID: 38818694 DOI: 10.1111/jep.14023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 05/03/2024] [Accepted: 05/13/2024] [Indexed: 06/01/2024]
Abstract
AIMS AND OBJECTIVES Contextual information which is implicitly available to physicians during clinical encounters has been shown to influence diagnostic reasoning. To better understand the psychological mechanisms underlying the influence of context on diagnostic accuracy, we conducted a review of experimental research on this topic. METHOD We searched Web of Science, PubMed, and Scopus for relevant articles and looked for additional records by reading the references and approaching experts. We limited the review to true experiments involving physicians in which the outcome variable was the accuracy of the diagnosis. RESULTS The 43 studies reviewed examined two categories of contextual variables: (a) case-intrinsic contextual information and (b) case-extrinsic contextual information. Case-intrinsic information includes implicit misleading diagnostic suggestions in the disease history of the patient, or emotional volatility of the patient. Case-extrinsic or situational information includes a similar (but different) case seen previously, perceived case difficulty, or external digital diagnostic support. Time pressure and interruptions are other extrinsic influences that may affect the accuracy of a diagnosis but have produced conflicting findings. CONCLUSION We propose two tentative hypotheses explaining the role of context in diagnostic accuracy. According to the negative-affect hypothesis, diagnostic errors emerge when the physician's attention shifts from the relevant clinical findings to the (irrelevant) source of negative affect (for instance patient aggression) raised in a clinical encounter. The early-diagnosis-primacy hypothesis attributes errors to the extraordinary influence of the initial hypothesis that comes to the physician's mind on the subsequent collecting and interpretation of case information. Future research should test these mechanisms explicitly. Possible alternative mechanisms such as premature closure or increased production of (irrelevant) rival diagnoses in response to context deserve further scrutiny. Implications for medical education and practice are discussed.
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Affiliation(s)
- Henk G Schmidt
- Institute of Medical Education Research, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Geoffrey R Norman
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Silvia Mamede
- Institute of Medical Education Research, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Mohi Magzoub
- Department of Medical Education, United Arab Emirates University, Al Ain, United Arab Emirates
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Bradford A, Meyer AND, Khan S, Giardina TD, Singh H. Diagnostic error in mental health: a review. BMJ Qual Saf 2024:bmjqs-2023-016996. [PMID: 38575311 DOI: 10.1136/bmjqs-2023-016996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/04/2024] [Indexed: 04/06/2024]
Abstract
Diagnostic errors are associated with patient harm and suboptimal outcomes. Despite national scientific efforts to advance definition, measurement and interventions for diagnostic error, diagnosis in mental health is not well represented in this ongoing work. We aimed to summarise the current state of research on diagnostic errors in mental health and identify opportunities to align future research with the emerging science of diagnostic safety. We review conceptual considerations for defining and measuring diagnostic error, the application of these concepts to mental health settings, and the methods and subject matter focus of recent studies of diagnostic error in mental health. We found that diagnostic error is well understood to be a problem in mental healthcare. Although few studies used clear definitions or frameworks for understanding diagnostic error in mental health, several studies of missed, wrong, delayed and disparate diagnosis of common mental disorders have identified various avenues for future research and development. Nevertheless, a lack of clear consensus on how to conceptualise, define and measure errors in diagnosis will pose a barrier to advancement. Further research should focus on identifying preventable missed opportunities in the diagnosis of mental disorders, which may uncover generalisable opportunities for improvement.
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Affiliation(s)
- Andrea Bradford
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Ashley N D Meyer
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Sundas Khan
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Traber D Giardina
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Hardeep Singh
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
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Tamura H, Shikino K, Sogai D, Yokokawa D, Uchida S, Li Y, Yanagita Y, Yamauchi Y, Kojima J, Ishizuka K, Tsukamoto T, Noda K, Uehara T, Imaizumi T, Kataoka H, Ikusaka M. Association Between Physician Empathy and Difficult Patient Encounters: a Cross-Sectional Study. J Gen Intern Med 2023; 38:1843-1847. [PMID: 36385409 PMCID: PMC10271945 DOI: 10.1007/s11606-022-07936-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/02/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Physicians frequently experience patients as difficult. Our study explores whether more empathetic physicians experience fewer patient encounters as difficult. OBJECTIVE To investigate the association between physician empathy and difficult patient encounters (DPEs). DESIGN Cross-sectional study. PARTICIPANTS Participants were 18 generalist physicians with 3-8 years of experience. The investigation was conducted from August-September 2018 and April-May 2019 at six healthcare facilities. MAIN MEASURES Based on the Jefferson Scale of Empathy (JSE) scores, we classified physicians into low and high empathy groups. The physicians completed the Difficult Doctor-Patient Relationship Questionnaire-10 (DDPRQ-10) after each patient visit. Scores ≥ 31 on the DDPRQ-10 indicated DPEs. We implemented multilevel mixed-effects logistic regression models to examine the association between physicians' empathy and DPE, adjusting for patient-level covariates (age, sex, history of mental disorders) and with physician-level clustering. KEY RESULTS The median JSE score was 114 (range: 96-126), and physicians with JSE scores 96-113 and 114-126 were assigned to low and high empathy groups, respectively (n = 8 and 10 each); 240 and 344 patients were examined by physicians in the low and high empathy groups, respectively. Among low empathy physicians, 23% of encounters were considered difficulty, compared to 11% among high empathy groups (OR: 0.37; 95% CI = 0.19-0.72, p = 0.004). JSE scores and DDPRQ-10 scores were negatively correlated (r = -0.22, p < 0.01). CONCLUSION Empathetic physicians were less likely to experience encounters as difficult. Empathy appears to be an important component of physician perception of encounter difficulty.
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Affiliation(s)
- Hiroki Tamura
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan.
| | - Kiyoshi Shikino
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Daichi Sogai
- Department of General Medicine, Sanmu Medical Center, Chiba, Japan
| | - Daiki Yokokawa
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Shun Uchida
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Yu Li
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Yasutaka Yanagita
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Yosuke Yamauchi
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Jumpei Kojima
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Kosuke Ishizuka
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Tomoko Tsukamoto
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Kazukata Noda
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Takanori Uehara
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Takahiro Imaizumi
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Hitomi Kataoka
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masatomi Ikusaka
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, Japan
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Shikino K, Mito T, Ohira Y, Yokokawa D, Katsuyama Y, Ota T, Sato E, Hirose Y, Yamashita S, Suzuki S, Noda K, Uehara T, Ikusaka M. Frequency of Difficult Patient Encounters in a Japanese University Hospital and Community Hospitals: A Cross-sectional Study. Intern Med 2023; 62:533-537. [PMID: 35793958 PMCID: PMC10017258 DOI: 10.2169/internalmedicine.0085-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective Difficult patient encounters (DPEs) are defined as encounters with patients causing strong negative feelings in physicians. In primary care settings, DPEs account for approximately 15% of visits among outpatients. To our knowledge, this is the first epidemiological study of DPEs in Japan. Methods We conducted a survey of 8 physicians (5.0±2 years of clinical experience) who examined first-visit patients ≥15 years old with clinical symptoms at the Department of General Medicine in Chiba University Hospital and 4 community hospitals over a 2-month period since December 2015. Materials We evaluated 10-Item Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10) scores (DPE ≥31 points; non-DPE ≤30 points) and patient age, sex, and presence of psychological or social problems. Results The valid response rate was 98.9% (94/95) and 98.4% (189/192) in the university and community hospitals, respectively. The percentage of DPEs was 39.8% (37/93) and 15.0% (26/173) in the university and community hospitals, respectively; the percentage of DPEs was significantly higher at the university hospital than at the community hospitals (p<0.001). The proportion of patients with psychosocial problems was significantly higher in the DPE group than in the non-DPE group (93.7% vs. 40.4%, p<0.001). Conclusion Our findings were similar to those reported in primary care settings in other countries in community hospital outpatient and general internal medicine departments, where patients are mostly non-referrals, although the values were higher in university hospital general medicine departments, where patients were mostly referrals. Patients involved in DPEs have a high rate of psychological and social problems.
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Affiliation(s)
- Kiyoshi Shikino
- Department of General Medicine, Chiba University Hospital, Japan
- Department of Community-based Medical Education, Graduate School of Medicine, Chiba University, Japan
| | - Tsutomu Mito
- Department of General Medicine, Chiba University Hospital, Japan
| | - Yoshiyuki Ohira
- Department of General Medicine, Chiba University Hospital, Japan
- Department of General Medicine, International University of Health and Welfare Narita Hospital, Japan
| | - Daiki Yokokawa
- Department of General Medicine, Chiba University Hospital, Japan
| | - Yota Katsuyama
- Department of General Medicine, Chiba University Hospital, Japan
- Department of Community-based Medical Education, Graduate School of Medicine, Chiba University, Japan
- Department of General Medicine, Sanmu Medical Center, Japan
| | - Takahiro Ota
- Department of General Medicine, Chiba University Hospital, Japan
| | - Eri Sato
- Department of General Medicine, Chiba University Hospital, Japan
| | - Yuta Hirose
- Department of General Medicine, Chiba University Hospital, Japan
| | - Shiho Yamashita
- Department of General Medicine, Chiba University Hospital, Japan
| | - Shingo Suzuki
- Department of General Medicine, Chiba University Hospital, Japan
- Department of Internal Medicine, Chiba Central Medical Center, Japan
| | - Kazutaka Noda
- Department of General Medicine, Chiba University Hospital, Japan
| | - Takanori Uehara
- Department of General Medicine, Chiba University Hospital, Japan
| | - Masatomi Ikusaka
- Department of General Medicine, Chiba University Hospital, Japan
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So S, Brennan FP, Brown MA. Cognitive Biases in Medicine: The Potential Impact on the Diagnosis of Restless Legs Syndrome in Chronic Kidney Disease. J Pain Symptom Manage 2021; 61:870-877. [PMID: 33035652 DOI: 10.1016/j.jpainsymman.2020.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 09/26/2020] [Accepted: 09/30/2020] [Indexed: 11/12/2022]
Affiliation(s)
- Sarah So
- Department of Palliative Care, St George Hospital, Kogarah, Sydney, Australia; St George & Sutherland Clinical Schools, University of NSW, Sydney, New South Wales, Australia.
| | - Frank P Brennan
- Department of Palliative Care, St George Hospital, Kogarah, Sydney, Australia; Department of Renal Medicine, St George Hospital, Kogarah, Sydney, Australia; St George & Sutherland Clinical Schools, University of NSW, Sydney, New South Wales, Australia
| | - Mark A Brown
- Department of Renal Medicine, St George Hospital, Kogarah, Sydney, Australia; St George & Sutherland Clinical Schools, University of NSW, Sydney, New South Wales, Australia
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