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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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Using computerized virtual cases to explore diagnostic error in practicing physicians

Robert L. TrowbridgeORCID iD: https://orcid.org/0000-0002-0460-2733 / James B. Reilly
  • Allegheny Health Network Medical Education Consortium, Vice Chair for Education, Department of Medicine, Allegheny Health Network, Pittsburgh, PA, USA
  • Temple University School of Medicine, Philadelphia, PA, USA
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/ Jerome C. Clauser / Steven J. Durning
  • Department of Medicine, Division of Graduate Programs in Health Professions Education, Uniformed Services University of Health Sciences School of Medicine, Bethesda, MD, USA
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Published Online: 2018-09-06 | DOI: https://doi.org/10.1515/dx-2017-0044



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.

This article offers supplementary material which is provided at the end of the article.

Keywords: cognitive bias; diagnostic error; virtual cases


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About the article

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

Received: 2017-12-18

Accepted: 2018-07-25

Published Online: 2018-09-06

Published in Print: 2018-11-27

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.

Research funding: None declared.

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

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 4, Pages 229–233, ISSN (Online) 2194-802X, ISSN (Print) 2194-8011, DOI: https://doi.org/10.1515/dx-2017-0044.

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