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Licensed Unlicensed Requires Authentication Published by De Gruyter September 6, 2018

Using computerized virtual cases to explore diagnostic error in practicing physicians

  • Robert L. Trowbridge ORCID logo EMAIL logo , James B. Reilly , Jerome C. Clauser and Steven J. Durning
From the journal Diagnosis



Diagnostic errors are a significant cause of patient harm. Cognitive processes often contribute to diagnostic errors but studying and mitigating the effects of these errors is challenging. Computerized virtual patients may provide insight into the diagnostic process without the potential for patient harm, but the feasibility and utility of using such cases in practicing physicians has not been well described.


We developed a series of computerized virtual cases depicting common presentations of disease that included contextual factors that could result in diagnostic error. Cases were piloted by practicing physicians in two phases and participant impressions of the case platform and cases were recorded, as was outcome data on physician performance.


Participants noted significant challenges in using the case platform. Participants specifically struggled with becoming familiar with the platform and adjusting to the non-adaptive and constraining processes of the model. Although participants found the cases to be typical presentations of problems commonly encountered in practice, the correct diagnosis was identified in less than 33% of cases.


The development of virtual patient cases for use by practicing physicians requires substantial resources and platforms that account for the non-linear and adaptive nature of reasoning in experienced clinicians. Platforms that are without such characteristics may negatively affect diagnostic performance. The novelty of such platforms may also have the potential to increase cognitive load. Nonetheless, virtual cases may have the potential to be a safe and robust means of studying clinical reasoning performance.

Corresponding author: Robert L. Trowbridge, MD, Department of Medicine, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA, Phone: +(207) 662-4618; and Department of Medicine, Tufts University School of Medicine, Boston, MA, USA

  1. Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission. The views expressed herein are those of the authors and not necessarily those of the Department of Defense or other federal agencies.

  2. Research funding: None declared.

  3. Employment or leadership: Dr. Durning and Dr. Clauser are employed by the American Board of Internal Medicine.

  4. Honorarium: None declared.

  5. Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.


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Supplementary Material

The online version of this article offers supplementary material (

Received: 2017-12-18
Accepted: 2018-07-25
Published Online: 2018-09-06
Published in Print: 2018-11-27

©2018 Walter de Gruyter GmbH, Berlin/Boston

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