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Official Journal of the Society to Improve Diagnosis in Medicine (SIDM)

Editor-in-Chief: Graber, Mark L. / Plebani, Mario

Ed. by Argy, Nicolas / Epner, Paul L. / Lippi, Giuseppe / McDonald, Kathryn / Singh, Hardeep

Editorial Board: Basso , Daniela / Crock, Carmel / Croskerry, Pat / Dhaliwal, Gurpreet / Ely, John / Giannitsis, Evangelos / Katus, Hugo A. / Laposata, Michael / Lyratzopoulos, Yoryos / Maude, Jason / Newman-Toker, David / Singhal, Geeta / Sittig, Dean F. / Sonntag, Oswald / Zwaan, Laura

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Identification of facilitators and barriers to residents’ use of a clinical reasoning tool

Deborah DiNardo / Sarah Tilstra / Melissa McNeil / William Follansbee / Shanta Zimmer / Coreen Farris / Amber E. Barnato
Published Online: 2018-02-09 | DOI: https://doi.org/10.1515/dx-2017-0037



While there is some experimental evidence to support the use of cognitive forcing strategies to reduce diagnostic error in residents, the potential usability of such strategies in the clinical setting has not been explored. We sought to test the effect of a clinical reasoning tool on diagnostic accuracy and to obtain feedback on its usability and acceptability.


We conducted a randomized behavioral experiment testing the effect of this tool on diagnostic accuracy on written cases among post-graduate 3 (PGY-3) residents at a single internal medical residency program in 2014. Residents completed written clinical cases in a proctored setting with and without prompts to use the tool. The tool encouraged reflection on concordant and discordant aspects of each case. We used random effects regression to assess the effect of the tool on diagnostic accuracy of the independent case sets, controlling for case complexity. We then conducted audiotaped structured focus group debriefing sessions and reviewed the tapes for facilitators and barriers to use of the tool.


Of 51 eligible PGY-3 residents, 34 (67%) participated in the study. The average diagnostic accuracy increased from 52% to 60% with the tool, a difference that just met the test for statistical significance in adjusted analyses (p=0.05). Residents reported that the tool was generally acceptable and understandable but did not recognize its utility for use with simple cases, suggesting the presence of overconfidence bias.


A clinical reasoning tool improved residents’ diagnostic accuracy on written cases. Overconfidence bias is a potential barrier to its use in the clinical setting.

Keywords: clinical reasoning tool; diagnostic error; graduate medical education; overconfidence bias


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About the article

Corresponding author: Deborah DiNardo, MD, MS, Department of Medicine, VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240, USA, Phone: +412-360-1709

Received: 2017-10-16

Accepted: 2018-01-11

Published Online: 2018-02-09

Published in Print: 2018-03-28

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

Research funding: This project was funded by a grant from the Hearst Foundations awarded to Dr. William Follansbee.

Employment or leadership: None declared.

Honorarium: None declared.

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.

Citation Information: Diagnosis, Volume 5, Issue 1, Pages 21–28, ISSN (Online) 2194-802X, ISSN (Print) 2194-8011, DOI: https://doi.org/10.1515/dx-2017-0037.

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