Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Battling The System in Defense of Diagnosis


Healthcare delivery is at odds with a fundamental aspect of being a physician—strategic curriculum interventions are necessary to preserve the art of diagnosis.

A fundamental belief by physicians, particularly internists, is that diagnosis is foundational to the practice of medicine. However, most of us are not extrinsically incentivized in our healthcare systems to diagnose accurately and thoughtfully. The system of healthcare is focused more on clarity of documentation, maximization of resources and minimization of cost; fundamental principles in business, not medicine.

Internal medicine trainees persistently and repeatedly hear more about “dispo planning” rather than “diagnostic reasoning” in their daily workflow. In this setting coupled with work hour regulations, pushes to minimize length of stay, often tedious electronic documentation requirements, and admitting diagnoses anchored by other providers, our trainees are forced to spend less time ‘thinking’ and more time ‘doing.’

In an attempt to combat the system pressures limiting diagnostic reasoning, the Massachusetts General Hospital Department of Medicine implemented several modifications to their Internal Medicine Training Program Curriculum. Their interventions included:

  • Promoting the discussion of diagnostic reasoning in a clinically relevant and case-based format
  • Decreasing the size of inpatient teams
  • The creation of an education innovation center to advance medical education research on clinical reasoning.

This focus on diagnostic reasoning is commendable, but, as the authors note, there is a lot more that will need to be done.

One wonders if the sacrifice inherent in a smaller team and more thorough discussion of a fewer number of patients, comes at the cost of seeing more patients and building the illness scripts that are a hallmark of the expert clinician. The best strategies for teaching diagnostic reasoning are yet to be worked out, but it does require attention and dedicated time in residency education. Unfortunately, education strategies as described in the article are resource and time intensive.

The multitude of factors that contribute to the shrinking time to ‘think’ in medicine, derive not just from the hospital business model, but our society as a whole. With the pervasiveness of the internet, social media, and smart phones, our patience is rarely challenged and we spend more time “multi-tasking” than engaged in focused critical thinking.

While setting aside time for diagnostic reasoning may feel like a low-tech and simple intervention, it perhaps provides exactly what we all need, a little time and space to think.