Anthony E. Voytovich

Premature Conclusions in the Diagnosis of Iron-deficiency Anemia: Cause and Effect

Case records of patients with iron-deficiency anemia were audited using a computer-based algorithm. In 24 of 35 cases, the diagnostic conclusion seemed unjustified and characteristic of premature closure, one of four recurring errors in diagnostic reasoning described previ ously. Premature closure appeared to originate from subjects at all levels of training, to be easily and unquestioningly accepted by other physicians, and to inappropriately condition diagnostic and therapeutic decisions. Heuristics and biases described by Tversky and Kahne man are considered as contributory factors and patient care and teaching implications are discussed.

Knowledge, realism, and diagnostic reasoning in a physical diagnosis course

Two 20-item tests and a case problem were administered to 83 students in a physical diagnosis course. One test contained items related to the content of the case problem, and the other items related to the balance of the course content. Confidence scoring procedures yielded scores of both knowledge and realism on the two tests. The case problem determined the subjects ability to integrate clinical data into an accurate list of diagnoses and yielded scores reflecting incomplete assembly of clues into diagnoses (incomplete synthesis) and unjustified conclusions (premature closure). Reliability of the confidence-scored tests was significantly greater than the reliability on the same items scored as a single correct answer. Knowledge improvement scores on both tests (relevant and nonrelevant knowledge) were significantly correlated with errors of incomplete synthesis. The realism score correlated significantly with premature closures but only on the test where the item content was relevant to the case problem.

Diagnostic Reasoning in the Multiproblem Patient An Interactive, Microcomputer-Based Audit

This article describes an interactive computerprogram that allows students to enter a completely free-form problem list at the keyboard and receive immediate analysis of the accuracy and thoroughness of their diagnostic impressions. This type of exercise is a departure from traditional instruments because it focuses on patients with multiple interacting issues offering greater realism in approximating the elderly or primary care interaction. The program is briefly described and correlations with traditional audit techniques are shown. More important, development of the program had a profound effect in evolving our understanding of the teaching of diagnostic reasoning in multiproblem patients. This process is described.

Focused versus screening CT scans for evaluation of nontraumatic abdominal pain in the emergency department

Objective To evaluate the utility of computed tomography (CT) scans in patients with abdominal pain in the emergency department. We compared focused scans (having a single diagnosis in mind) and screening scans (having no diagnosis or more than one diagnosis in mind) with the hypothesis that focused scans will reveal pathology more often than screening scans. Treatment plans and patient outcomes were also compared between the two populations. Methods This is a prospective study in which 100 patients who presented to an academic medical center with abdominal pain and underwent an abdominal CT were enrolled in the study. A chart review was later completed to gather ultimate outcome data for each of the enrolled subjects. Results Of the 61 patients having a focused CT, pathology was identified on 63.9% of the scans, which did not differ significantly from the 65.4% of scans that revealed pathology in the screening group. In the focused group, anticipated admissions were reduced, but the reduction was not significant. The screening group did show a significant difference, with eight fewer patients being admitted than initially planned. The total number of patients deemed to require admission was significantly reduced by 15% following all CT scans. Conclusion While there was no difference between the focused and screening groups in the rate of identifying pathology, there was a significant decline in number of patients requiring admission to the hospital in the “screening” CT group (when comparing emergency physicians’ pre- and post-CT treatment plans).