The diagnostic process must be inferred from performance.
Diagnostic reasoning is a complex process, with elements of both System 1 and System 2 thinking. Assessment of these processes must be inferred from behavior because it is not a discrete, measurable quality, nor is it independent of context and content. No single strategy can be used to assess the accuracy of a clinician’s diagnostic decisions. Rather, multiple strategies must be used if an accurate assessment is to be gained. Many questions remain regarding how these reasoning processes can be most accurately measured, offering a multitude of avenues for future research that offer great potential to ultimately improve patient care.
The "answer-centric" conceptualization:
Untangling which cues are predictive or non predictive would require reliable assessment of whether learners ‘got it right’ in real time, which is unlikely to be feasible in settings in which even two experts may not agree, such as when patients have undifferentiated complaints or when there has been insufficient evolution of patients’ problems.
Cues in more traditional instructional settings such as those described by de Bruin et al. are deemed ‘predictive’ when their influences lead learners towards ‘the right answer’. Yet if educators emphasise the same approach to reasoning in settings in which answers are less clear, such as in simulated or authentic clinical cases, we may unintentionally reinforce maladaptive behaviours in our learners. For example, if learners perceive that ‘accuracy’ amounts to ‘labelling’ clinical syndromes with a diagnosis (e.g. ‘This patient’s lower back pain is caused by a herniated disc’), we will reinforce cues that lead them towards a diagnosis-centric judgement (e.g. ordering a magnetic resonance imaging scan to identify a herniated disc), which may persist even if they consciously understand that their decision is unlikely to benefit the patient. Reinforcing cues that drive such an ‘answer-centric’ conceptualisation of clinical reasoning may promote judgements that run counter to other values we espouse, such as cost-conscious, patient-centred decision making.
Having competence without comprehension:
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One of the big themes in my book is how up until recently, the world and nature were governed by competence without comprehension. Serious comprehension of anything is very recent, only millennia old, not even a million years old. But we’re now on the verge of moving into the age of post-intelligent design and we don’t bother comprehending any more. That’s one of the most threatening thoughts to me. Because for better or for worse, I put comprehension as one of my highest ideals. I want to understand everything. I want people to understand things. I love understanding things. I love explaining things to myself and to others. We’ve always had plenty of people who, for good reason, said, “Oh, don’t bother explaining to me how the car engine works, I don’t care. I just push the ignition and off I go.” What happens when we take that attitude towards everything?