Quantitative evaluation of the diagnostic thinking process of physicians

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BackgroundIn previous study, we analyzed diagnostic abilities of medical students in terms of three elements of the hypothetico-deductive method, i.e., knowledge of test characteristics (sensitivity and specificity), ability to estimate pre-test disease probability from clinical history, and ability to estimate post-test probability from pre-test probability and test characteristic (1,2).PurposeWe planned this research to clarify whether or not clinical experience improves above-mentioned abilities.MethodsWe surveyed junior residents (Post Graduate Year (PGY) 1 and 2), senior residents (PGY3 or more) in 11 educational hospitals in Japan. We presented hypothetical scenarios of chest pain patients to the residents and asked them to answer questions. Clinical scenarios of typical anginal pain, atypical anginal pain, and non-anginal chest pain were provided. Each resident was asked to provide answers independently to the best of ****r her ability, based on the scenarios along with their ow … More n knowledge and experience.ResultsTwo hundred and sixty two residents answered the questionnaire. Following findings were obtained:1)Residents could rule in diseases in high pre-test probability scenario.2)Residents could not rule out disease in low pre-test probability scenario, mainly because of poor pre-test estimates of disease probability.3)Residents could not change the post-test probability in intermediate pre-test probability scenario.4)They were also easily confused by the test results against their anticipation, which is likely to be due to their inaptitude in applying Bayes' theorem to real clinical situations.5)The estimates in high pre-test probability scenario improved with increase in PGY. The estimates in low pretest probability scenario showed some improvements but not enough to improve practical diagnostic ability.6)The capacity in applying Bayes' theorem to clinical scenarios did not improve with increase in PGY.ConclusionNovice physicians could not rule out disease in low pre-test probability setting and could not utilize information from history due to inaptitude in applying Bayes' theorem to real clinical situations. These diagnostic thinking patterns account for why medical students or novice physicians end up repeating unnecessary examinations. These faults in diagnostic performance were not corrected by clinical "experience" spontaneously. Less