Where did diagnosis education go, and why?


Category : Medical Rants

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.


Comments (7)

And then we have the money! More test, more office visits etc. generate more money, and this becomes the main focus and driver of many medical practices.

Steve Lucas

I am glad to see this comment coming from an academician. For years, I have bemoaned this loss (close to 15 years now). In my region, we have five major institutions of medical education and training. Yet, not one has ever approached me to participate in the training of their Residents. While hospital-based training is important, most diagnostic work occurs in the community. We have some great diagnosticians remaining in private practice (unfortunately many have retired). Yet these institutional leaders fail to recognize this problem.

For now their focus is producing a crop of doctors that is great at following guidelines to the T, dutiful at checking boxes to compete charting requirements, and practicing population medicine. Another observation is the total loss of camaraderie (and communication that goes along with that). This is a trend that has already gone too far. All you need to do is simply follow the money, and you will get your answer. Truly sad that the profession is dying. The solution, in my mind, is to completely exit the current financing system and rebuild…I know its a dream.

As I’m about to start my medicine sub-I this somewhat resonated. While I agree that the medical school curriculum is already overcrowded and in need of streamlining, some focus on human aspects is important. Likewise, I’m a strong believer that this is a team sport. Multidisciplinary rounds allow us to better arrange care for our patients. They probably save time or at least extra pages from social work. Same thing for having a pharmacist present while rounding.
I totally agree we need clinician role models who embody what a good diagnostician is, and a curriculum, or at least an outline for how to teach this to students might help.

Please reread my post. All of these “add ons” seem reasonable, but they can detract from job #1.

We learn best from our patients. The best attendings teach diagnostic reasoning every day without having a specific curriculum. Sometimes developing a curriculum looks good on paper, but unless we live the topic every day, our learners will not really learn the topic.

I would agree that being a diagnostician is a key part of being an internist and I would extend that to being a key part of medical education as well.

The idea of being a diagnostician is best experienced and embodied. The joy and passion of discovering what ails someone goes beyond a curriculum. A written curriculum, although helpful, is only a start.

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I have thought about this quite a lot since you posted this piece. I think one of the problems is that physicians get distracted with all the recommended tests and guidelines. That and the short appointment times make practicing quality medicine very difficult.

Another problem is requiring healthy people to come in at least once a year regardless of their health status. Since they come in, doctors feel pressured to “do” stuff like tests and inevitably, write prescriptions. Then we get into the issue of possible side effects. Do you stop an Rx to see if it is the problem or treat the symptoms of the side effects?

Finally, we get to the issue of the truly sick patient. What is the issue (or issues)? Is it possibly being caused by side effects of medication? Is the problem caused by life style choices? How does the doctor help this person. Here is where we really need a skilled diagnostician. Being able to discover the actual problem is the mark of a great doctor!

Just a few thoughts….

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