Competencies for improving diagnosis: an interprofessional framework for education and training in health care

Introduction

Diagnostic errors represent one of the most pressing patient safety and quality concerns in health care today. In a landmark report, the National Academy of Medicine (National Academy) reviewed the epidemiology and etiology of diagnostic errors, concluding that they are common and harmful. In view of estimates that diagnostic error contributes to 40,000–80,000 deaths annually in the US, the National Academy designated the need to address diagnostic error as an urgent national priority [1]. A reasonable conclusion drawn from these statistics is that the outcomes of our current education programs with respect to diagnosis are not enough; that is, the products of our current education programs – health care professionals in practice – are not achieving desirable levels of diagnostic performance.

The National Academy report outlined a number of possible interventions to reduce the likelihood of diagnostic error. While these interventions are wide-ranging, the top two recommendations of the report were to facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families; and enhance health care professional education and training in the diagnostic process. These recommendations aligned with those previously made by the Lucien Leape Institute [2], the Millenium Report [3], the Macy Foundation [4], and others [5]. While these two recommendations at first may seem unrelated, there are important connections between them and the diagnostic process. Diagnosis in modern health care is a team-based social activity, and education programs in the health professions have a moral obligation to equip tomorrow’s health care professionals to be effective members of diagnostic teams. Improving the education and training of health care professionals concerning diagnosis could have both an immediate effect, as well as a sustained impact on reducing harm from diagnostic error for future generations of patients.

There are substantial gaps in health professions education with respect to explicit education about the diagnostic process as well as the team-based and system-related aspects of care. We have previously identified five primary drivers through which education could ultimately improve the practice of diagnosis by addressing these gaps [6]. The five action items identify the need to (1) acquire and effectively use a relevant knowledge base; (2) optimize clinical reasoning to reduce cognitive error; (3) understand system-related aspects of care; (4) effectively engage patients and the diagnostic team; and (5) acquire the appropriate perspectives and attitudes relating to diagnostic quality and safety.

An important contemporary trend that must inform any curricular recommendation or innovation in health professions education is the shift toward competency-based education [7], [8]. This shift reflects the need to define the outcomes (competencies) that education programs must ensure their learners meet before graduation and measure attainment of those outcomes. This model is in stark contrast to the traditional time-based framework of health professions education, in which learners are generally assumed to have attained competence if they complete the requisite number of years allocated for their education and satisfactorily pass requisite knowledge-based examinations. By better defining these competencies, educators and educational leaders can design curricula to achieve them and assessments to measure this attainment. While diagnosis is implicit – or marginally explicit – in many competency sets, there generally remains a gap in defining competencies for diagnosis and diagnostic teamwork. Defining these competencies is the first step in the curricular change necessary to improve both the quality and safety of diagnosis in health care.

Methods

Results

The major work product developed through the consensus-building process is a set of 12 recommended competencies. We propose that, if met broadly by health care professionals, these competencies would promote and improve diagnostic quality and safety (Table 2).

The literature review conducted in the early phases of the project highlighted several key findings. First, the dual process paradigm (composed of intuitive and rational components) provides a useful and now well-accepted general framework for understanding the cognitive processes that underlie and enable clinical reasoning [11]. Second, the practice environment and health care system both have a dramatic impact on individual and team performance, and ultimately on the diagnostic process itself [12], [13]. An additional important theme is that improving the safety and quality of diagnosis could be aided by engaging patients more effectively in the diagnostic process [14]. In this concept, diagnosis is co-produced by patients and health professionals. Each of these themes is reflected in one or more of the 12 competencies.

The 12 key competencies ultimately accepted are listed in Table 2, divided into three domains:

1. Individual competencies relate to the knowledge, skills, and attitudes that a health care professional must demonstrate on an individual level in order to contribute in their specific role to the diagnostic process.

2. Team-based competencies relate to the knowledge, skills, and attitudes that a health care professional must demonstrate in collaboration as a member of the diagnostic team.

3. Systems-based competencies relate to the knowledge, skills, and attitudes that a health care professional must demonstrate in relation to how the diagnostic process operates within a particular health care system.

An extensively referenced set of learning objectives was created for each competency (Appendix E). These include specific learning objectives for diagnostic testing (both laboratory and imaging), and using health information technology. The specificity of these learning objectives facilitates curricular development and innovation in each competency domain.

In order to inform assessment of competence, we developed a prototype milestone for Competency I-1 for the profession of medicine (Table 3). Milestones for the remaining competencies and professions can be constructed using this prototype, with the understanding that these may differ, or be less relevant, across the various health care professions.

Discussion

We believe that one of the most promising and sustainable ways to improve diagnosis is to improve education and training in the health professions. The first step in this process is to define the outcomes that trainees in each profession must achieve in order to be effective members of a diagnostic team in the modern health care setting, and in this paper we define these competencies for the first time.

The consensus committee endorsed the primacy of content-specific knowledge as a fundamental requirement for effective diagnostic reasoning. Factual knowledge alone, however, is necessary but not sufficient. Transmitting this knowledge base and incorporating it into practice is the current focus of education and training in every health care profession. What is novel in our set of competency recommendations is the expectation that education and training need to impart additional knowledge, skills, and attitudes that are not typically covered. In the domain of individual competencies, this includes, for example, knowing how and when to effectively get help with diagnosis (Competency I-5) through second opinions or taking advantage of decision-support tools for differential diagnosis. Similarly, Competency I-6 conveys the expectation to employ critical thinking and reflection in the diagnostic process.

While the recommended competencies for individual diagnostic performance reflect and refine much of what has been written in recent decades about the development of decision-making in health professions education, the new competency set also specifies team-based and system-related competencies that are novel, and not typically included in current curricular objectives. Working in teams was the top recommendation for reducing diagnostic errors in the National Academy report. This area is markedly underdeveloped from a curricular standpoint. It must be noted that we define the health care team very broadly and believe firmly that this team always involves the patient. Achieving effective communication is a key attribute of high-functioning teams, and breakdowns in communication are the most commonly encountered problems contributing to diagnostic error [15].

It is also increasingly apparent that education programs in the health professions must equip their trainees to practice within the modern health care system. Health systems science is an emerging area of emphasis, and our system-related competencies define three key aspects that relate to diagnostic performance. These include calls for transparency in disclosing diagnostic error and promoting a culture of diagnostic safety. Obtaining feedback on diagnostic performance is essential to improvement, and this feedback must consistently occur at the level of the individual, teams, and health care systems.

In this spirit, we believe that these new competencies are appropriate for the education and training of every health care professional involved in diagnosis. This includes professionals in fields that traditionally have been viewed as peripheral to diagnosis, such as pharmacists, social workers, physical therapists, and a wide range of additional health professionals. These professionals contribute to the diagnostic process through their own unique observations, and to the safety of diagnosis by participating in communication, health care coordination, patient monitoring, and helping to detect diagnostic errors.

There are limitations to our methodology and competencies. First, the competency recommendations are generally based on expert opinion and not empirical studies. As an example, while it seems likely that team-based strategies will improve the outcome of the diagnostic process, this has not been studied on a large scale. In addition, it is possible that, despite our inclusive approach, there are voices and opinions of other stakeholders that are not represented in our final project. A final issue concerns how priorities were assigned; a different group might have chosen other competencies to include, for example items that we classified as “learning objectives”.

There are three major limitations that, if not addressed, will limit the impact of this project:

First, the curricula in health professions education programs are already “full.” Most educational programs are extremely limited in what new concepts and activities can be added to their existing programming. Thus, these competencies must be mapped to existing activities whenever possible.

Second, much of the content of educational programs in health professions education programs is driven by accreditors and other stakeholder organizations. Thus, we must engage with these organizations to gain their endorsement. A “top-down” approach will encourage curricular innovation and give innovative faculty members more impetus for their drive to improve diagnosis through education.

The final limitation is that there are significant gaps with respect to valid and pragmatic assessment tools to measure attainment of these competencies. This will be a focus of much work for many in the coming years, and we believe that this assessment gap may now be filled once the outcomes (competencies) have been better defined. In particular, there is a dearth of instructional and assessment tools focused on team-based diagnosis, a novel concept for most health care professions [16], [17], [18]. Although there are many well-described instructional activities and programs aimed at improving teamwork, these generally do not address the final outcome that the team achieves, particularly as this relates to diagnostic performance. Although there are some exciting early demonstrations in the literature [19], [20], there are currently no widely adopted, validated means to assess the diagnostic performance of a team.

Conclusions

Diagnosis is the foundation of medical practice. It is remarkable that in the training of most health professionals, there is no specific course on diagnosis. Diagnosis education mirrors diagnostic practice: both are often idiosyncratic and not standardized. The past two decades have seen important growth in understanding the mechanisms that contribute to the harm associated with diagnostic error. The diagnostic process is complex, plays out over time and space, and uncertainty is the norm. Various cognitive and system-related contributions to diagnostic error have now been identified. We believe that incorporating this new knowledge into health professions education and training has the potential to substantially improve the diagnostic process and reduce the harm associated with diagnostic errors.