While most medical researchers are focusing their attention
on diseases, drugs, and their effects on patients, Dr
Charles Friedman, at the University of Pittsburgh School,
has turned his microscope on the clinician. His study
examining doctors' confidence in diagnosis will be published
in the April issue of the Journal of General Internal
Medicine.
"An overconfident physician will
not seek help or may ignore help that is offered; someone
underconfident may, in extreme cases, be talked out
of what was an accurate assessment," Dr Friedman explains
in the article. But how many docs are buoyed by either
too much or too little confidence? To find out, 216
volunteers, one-third of whom were senior med school
students, one- third of whom were senior residents and
one-third of whom were faculty internists, were put
to the test.
OVERCONFIDENT
COLLEAGUES?
The medicos were given detailed, diagnostically challenging,
medical cases with definitive diagnoses. The cases were
drawn from three different universities and experienced
academic internists created synopses of each case, omitting
the definitive correct diagnosis. The volunteers were
then asked to read through the synopses of nine different
cases and come up with their own diagnoses, each time
rating the "likelihood of seeking assistance in reaching
a diagnosis at the time they generated the differential."
Each volunteer went through their nine cases twice:
once without computer-generated assistance and again
using a decision support system designed to generate
diagnostic advice.
When the results were analyzed,
12% of faculty internists and 15% of residents were
in fact overconfident, placing credence in an incorrect
diagnosis. Overall, said Dr Friedman, "Focusing on the
residents and faculty physicians, what we found was
that correctness and confidence were not aligned in
about one-third of the cases."
When asked to put the findings
in context, however, Dr Friedman acknowledged that the
results were not necessarily representative of what
happens in a clinical setting. "I believe that if we
did the study in a real clinical setting and included
all patients physicians encountered, the data would
be very highly skewed toward knowing the correct diagnosis."
PSYCHO-BLUNDERS
There were also a number of other variables that this
study did not investigate. For instance, according to
Dr Friedman "for better or for worse, the analysis we
did was gender blind." Moreover, he admits that he can
only conjecture as to how including doctors from other
fields would have impacted the results. "I would guess
that psychiatrists, in clinical practice, are 'wrong'
about diagnosis more often than the internists, but
at the same time, in many psychiatric patients definitive
diagnoses are difficult to establish."
Nonetheless, the bottom line of
this study according to the paper is that "designers
of clinical decisions support systems cannot assume
clinicians to be accurate in their own assessments of
when they do and do not require assistance from external
knowledge resources." But in the end, "physicians' perceptions
of their need for help will be the biggest determinant
of whether they seek it," adds Dr Friedman. This could
have serious consequences for how such support systems
are set up.
JGIM published online Mar
17, 2005
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