Jain Michael D, Tomlinson George A, Lam Danica, Liu Jessica, Damaraju Deepti, Detsky Allan S, Devine Luke A
J Grad Med Educ. 2014 Sep;6(3):532-5. doi: 10.4300/JGME-D-13-00431.1.
Making an accurate diagnosis is a core skill residents must develop. Assessments of this skill and decisions to grant residents clinical independence often are based on global impressions. A workplace-based assessment of diagnostic accuracy could be a useful part of a competency-based assessment program and could inform decisions about granting residents independence.
We developed a method for measuring diagnostic accuracy that was integrated into the workflow of internal medicine residents and attending physicians.
Four senior medical residents and 6 attending physicians working in the internal medicine clinical teaching unit of a tertiary hospital participated in this study. To determine their diagnostic accuracy, residents documented a leading diagnosis for each patient they evaluated in the emergency department. After reviewing each case with the resident and after examining the patient, the resident's attending physician documented the diagnosis. Discharge diagnosis was determined by retrospective chart review to allow determination of resident and attending physician diagnostic accuracy. Data were collected for 240 consecutive patients referred for a medicine consultation.
Resident diagnostic accuracy was 66% (95% CI 60-72), whereas attending physician accuracy was significantly higher at 79% (95% CI 74-84, P < .001). By logistic regression, the accuracy of the attending physician was found to be influenced by the accuracy of the resident. Participants felt this process motivated them to improve their clinical reasoning.
Measuring resident diagnostic accuracy provides information that could be used in a competency-based assessment program to provide feedback and motivation to stimulate performance improvement.
做出准确诊断是住院医师必须培养的核心技能。对这项技能的评估以及给予住院医师临床独立权的决策通常基于整体印象。基于工作场所的诊断准确性评估可能是基于能力的评估计划的一个有用部分，并且可以为给予住院医师独立权的决策提供依据。
我们开发了一种测量诊断准确性的方法，该方法被整合到内科住院医师和主治医师的工作流程中。
一家三级医院内科临床教学单元的4名高级住院医师和6名主治医师参与了本研究。为了确定他们的诊断准确性，住院医师记录了他们在急诊科评估的每个患者的主要诊断。在与住院医师回顾每个病例并检查患者后，住院医师的主治医师记录诊断。出院诊断通过回顾病历确定，以确定住院医师和主治医师的诊断准确性。收集了连续240例转诊进行内科会诊的患者的数据。
住院医师的诊断准确性为66%（95%可信区间60 - 72），而主治医师的准确性显著更高，为79%（95%可信区间74 - 84，P <.001）。通过逻辑回归分析，发现主治医师的准确性受住院医师准确性的影响。参与者认为这个过程激励他们提高临床推理能力。
测量住院医师的诊断准确性可提供信息，可用于基于能力的评估计划，以提供反馈和激励，促进绩效改进。
