Improving Resident Feedback on Diagnostic Reasoning after Handovers: The LOOP Project

Abstract

Appropriate calibration of clinical reasoning is critical to becoming a competent physician. Lack of follow-up after transitions of care can present a barrier to calibration. This study aimed to implement structured feedback about clinical reasoning for residents performing overnight admissions, measure the frequency of diagnostic changes, and determine how feedback impacts learners’ self-efficacy. Trainees shared feedback via a structured form within their electronic health record’s secure messaging system. Forms were analyzed for diagnostic changes. Surveys evaluated comfort with sharing feedback, self-efficacy in identifying and mitigating cognitive biases’ negative effects, and perceived educational value of night admissions—all of which improved after implementation. Analysis of 544 forms revealed a 43.7% diagnostic change rate spanning the transition from night-shift to day-shift providers; of the changes made, 29% (12.7% of cases overall) were major changes. This study suggests that structured feedback on clinical reasoning for overnight admissions is a promising approach to improve residents’ diagnostic calibration, particularly given how often diagnostic changes occur.

Bridging the feedback gap: a sociotechnical approach to informing clinicians of patients’ subsequent clinical course and outcomes

“…Viewpoint in diagnosis after care transitions was viewed positively and noted to contribute to improving clinical practice and identifying system vulnerabilities. 20 Among German primary care physicians, patient outcome feedback resulted in self-reflection and resolve to improve analytical reasoning and change clinical practice. 21 Consistently relaying patient outcomes to upstream clinicians also eliminates reliance on individual motivations to seek feedback.…”

“…One study used an EHR-generated templated feedback form delivered via the EHR's messaging function to determine the effect of structured feedback to resident trainees who admitted patients overnight. 20 After the intervention, residents indicated improved comfort with sharing feedback and self-efficacy in identifying cognitive biases.…”

When Measuring Is More Important than Measurement: The Importance of Measuring Diagnostic Errors in Health Care

“…Studies have suggested that the diagnostic process is one from which much rich learning can be gleaned, but this must be intentional and does not happen without significant institutional investment and individual commitment. 19 These 3 components are related to one another: a just culture is a prerequisite for a reporting culture, which in turn is needed to create learning opportunities for a learning culture. The DEI addresses all 3 of the cultural aspects.…”

Operational measurement of diagnostic safety: state of the science

“…Providers and HCOs, often unaware of their patients' ultimate diagnosis-related outcomes, could benefit from measurement of diagnostic performance, which can then contribute to better system-level understanding of the problem and enable improvement through feedback and learning [27][28][29]. Developing and implementing measurement methods that focus on what matters is consistent with LHS approaches [30].…”