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Use of a structured approach and virtual simulation practice to improve diagnostic reasoning

  • Michael Dekhtyar ORCID logo , Yoon Soo Park , Judy Kalinyak , Saumil M. Chudgar , Kelly Bossenbroek Fedoriw , Khadeja J. Johnson , Craig F. Knoche , Lisa Martinez , Nina Mingioni , Amber T. Pincavage , Rachel Salas , Fred Sanfilippo , Stephen M. Sozio , Nancy Weigle , Sarah Wood , Jillian Zavodnick and Scott Stern EMAIL logo
From the journal Diagnosis



In 2015, the National Academy of Medicine IOM estimated that 12 million patients were misdiagnosed annually. This suggests that despite prolonged training in medical school and residency there remains a need to improve diagnostic reasoning education. This study evaluates a new approach.


A total of 285 medical students were enrolled in this 8 center, IRB approved trial. Students were randomized to receive training in either abdominal pain (AP) or loss of consciousness (LOC). Baseline diagnostic accuracy of the two different symptoms was assessed by completing a multiple-choice question (MCQ) examination and virtual patient encounters. Following a structured educational intervention, including a lecture on the diagnostic approach to that symptom and three virtual patient practice cases, each student was re-assessed.


The change in diagnostic accuracy on virtual patient encounters was compared between (1) baseline and post intervention and (2) post intervention students trained in the prescribed symptom vs. the alternate symptom (controls). The completeness of the student’s differential diagnosis was also compared. Comparison of proportions were conducted using χ 2-tests. Mixed-effects regressions were used to examine differences accounting for case and repeated measures. Compared with baseline, both the AP and LOC groups had marked post-intervention improvements in obtaining a correct final diagnosis; a 27% absolute improvement in the AP group (p<0.001) and a 32% absolute improvement in the LOC group (p<0.001). Compared with controls (the groups trained in the alternate symptoms), the rate of correct diagnoses increased by 13% but was not statistically significant (p=0.132). The completeness and efficiency of the differential diagnoses increased by 16% (β=0.37, p<0.001) and 17% respectively (β=0.45, p<0.001).


The study showed that a virtual patient platform combined with a diagnostic reasoning framework could be used for education and diagnostic assessment and improved correct diagnosis compared with baseline performance in a simulated platform.

Corresponding author: Dr. Scott Stern, University of Chicago, Pritzker School of Medicine, 5756 S Dorchester Ave, Chicago, IL, 60637, USA, Phone: +1 773 702 4082, E-mail:

Award Identifier / Grant number: NA


The authors would like to thank Lisa Ksandr, project administrator at the American Medical Association, for her expert logistical assistance with coordinating study activities. Additionally, we would like to thank Drs. Susan Skochelak, Richard Hawkins, and Sally Santen for their thoughtful contributions throughout the development of the protocol and analysis of the data. The authors would also like to thank the faculty and staff who worked on the study from Duke University School of Medicine, Charles E. Schmidt College of Medicine at Florida Atlantic University, The Johns Hopkins University School of Medicine, Morehouse School of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, The University of Chicago Pritzker School of Medicine, University of North Carolina School of Medicine, and Vanderbilt University School of Medicine.

  1. Research funding: This study has been made possible with the generous support of The Marcus Foundation.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: Mr. Dekhtyar was a paid employee of the American Medical Association. Dr. Sanfilippo is a paid consultant of The Marcus Foundation. Mr. Knoche is the retired co-founder of i-Human Patients, a Kaplan Healthcare company. Dr. Kalinyak is VP and Chief Medical Officer for i-Human Patients by Kaplan. Dr. Stern is co-editor of the book Symptom-to-Diagnosis: An Evidence-Based Guide, and was a consultant and contributor of educational cases and lecture videos distributed by IHP by Kaplan.

  4. Informed consent: Not applicable.

  5. Ethical approval: The University of Illinois at Chicago, the central review board for the AMA, and each participating site’s Review Board designated this study as exempt.


AP cases: abdominal aortic aneurysm, appendicitis, biliary colic, choledocholithiasis, chronic mesenteric ischemia, diverticulitis, ectopic pregnancy, irritable bowel syndrome, large and small bowel obstruction, pancreatitis, and peptic ulcer disease with and without perforation.

LOC cases; aortic stenosis, AV heart block, hypertrophic cardiomyopathy, hypoglycemia, orthostatic syncope, retroperitoneal hemorrhage, seizure, vasovagal syncope, ventricular tachycardia, and the Wolff Parkinson White syndrome.


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Received: 2020-12-14
Accepted: 2021-05-25
Published Online: 2021-07-12

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