Interventions to improve diagnostic decision making: A systematic review and meta-analysis on reflective strategies

Abstract

Aims: To identify, appraise and describe studies of cognitive interventions to improve diagnostic decision making (DDM) amongst medical professionals, assess their effectiveness and identify methodological limitations in existing studies.

Methods: We systematically searched for studies (publication date 2000–2016) in multiple databases including Cochrane Controlled Trials, EMBASE, ERIC, Medline, PubMed and PsycINFO, and used additional strategies such as hand searching and snowballing. Included studies evaluated cognitive interventions to enhance DDM amongst medical professionals, using defined outcomes such as diagnostic accuracy. A meta-analysis assessed the impact of “reflection”.

Results: Forty-four studies out of 10,114 screened citations, involving 4380 medical professionals, were included. Studies evaluated reasoning workshops/curricula, de-biasing workshops, checklists, reflection, feedback, and instructions to induce analytical thinking. Guided reflection was demonstrated to improve DDM [effect size 0.38(95%CI 0.23–0.52), p < 0.001]. Immediate feedback and modeling reflection using contrasting examples also appeared to improve diagnostic accuracy, however underlying methodological issues prevented a quantitative assessment of any strategies other than reflection.

Conclusions: Educational interventions incorporating practising deliberate reflection on a formulated diagnosis, modeled reflection on contrasting examples and immediate feedback are promising strategies for improving DDM. The effectiveness of other strategies is unknown, with more methodological refinements required in future research.

Acknowledgments

The authors acknowledge literature search support provided by Raechel Damarell, Senior Liaison Librarian for Medicine, Flinders University, and peer review provided by Prideaux Centre for Research in Health Professions Education, Flinders University.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Glossary

Diagnostic decision making: Is the process of summarizing the whole of patient information – emanating from history taking, physical examination and any applicable additional diagnostic procedure – into a single or short list of diagnoses. Cognitively it can be seen as a convergent classification task. Typically there is a clear boundary between correct and incorrect outcomes.

Additional information

Notes on contributors

Shivesh Prakash

Shivesh Prakash, MD, MPH, FCICM, is an intensive care specialist and research fellow, with research interests in diagnostic decision making and cognitive biases.

Ruth M. Sladek

Ruth M. Sladek, MPH, PhD, is a senior lecturer in medical education with published research relating to dual processing models of reasoning and current interests in student selection and professionalism.

Lambert Schuwirth

Lambert Schuwirth, MD, PhD, has wide ranging research interests including assessment of medical competence and performance, both in undergraduate and postgraduate training settings.