By Tim Webster
An Assistant Professor at Rosalind Franklin University of Medicine and Science (RFUMS) has gathered some interesting information regarding the effectiveness of conferring with one’s colleagues as compared to the use of electronic diagnostic reasoning tools during the diagnosis process. According to Jim Carlson, Director of Interprofessional Simulation for the Physician Assistant Department at RFUMS, “more than 15% of diagnoses are unnecessarily delayed, flat-out wrong, or missed.”
Carlson’s findings were a result of his dissertation for a newly-minted Interprofessional Studies PhD Program created by the RFUMS College of Health Professions (CHP), a program which Carlson himself helped to pilot. Uniquely positioned because of the number of health professions they have under one roof, RFUMS has for years focused on behaviors of providers and how those behaviors impact patient health and safety, specifically communication errors in team work. “This was not an independent study but a program built with interprofessional studies in mind based on rigorous study of editorial literature,” Carlson said.
One of the difficulties this new PhD program faced was the fact that there was little prior rigorous research regarding interprofessional studies from which to build. As a PA himself, Carlson’s scope of practice and license necessitates that he work with a physician but he found that there was not a lot of research on team communication. With few programs established from which to model, Carlson and his mentors had to build a curriculum and methods largely from scratch. “I had good mentors, but none of the mentors had the same degree I was going for.” He explained that having a strong group of people with whom to work and a wonderful cohort with whom to learn made the process easier and more meaningful. “I leaned on them and they leaned on me and we were able to set our own path.”
Knowing that Interprofessional education (IPE) and practice (IPP) are central to the mission of RFUMS, Carlson was supported in the research path he chose which looked at strategies around diagnostic accuracy at the bedside. “We are trying to encourage learners to stop a moment to reconsider diagnoses, based on diagnostic accuracy and clinical reasoning theory.”
Knowing the margin for error, he speculated why that rate was so high and what could be done in team training to lower it. He perceived a gap in teaching learners to be metacognitively aware of the challenges in considering other diagnosis. The obvious solutions? 1) Get a second opinion by collaborating with other professions, and / or 2) use support tools.
Before even considering these two options, Carlson realized that he needed to continue to explore and ask more questions. The research study used student resident teams – primarily Physician Assistants – and looked at how they worked in a series of a 4-case OSCE, asking them to give initial rank order diagnoses which were then scored for accuracy.
The group was then split into two groups and asked to re-do the OSCE: one was given the tool Isabel Pro,™ a kind of “smart Google” for health professionals. The other group had interprofessional and resident discussions post-encounter and had to update their care plans based on these discussions.
Once the study assessed which intervention helped diagnostic reasoning, and which “tool” had more significant impact on accurate diagnosis, “the group using Isabel Pro™ won hands down every time.” Interprofessional collaboration in its existing form did not make an objective difference in diagnostic accuracy. Carlson discovered that teams may be more fallible as a result of peer influence; clinicians have individual cognitive bias when making decisions that can spill over into an interprofessional team.
Carlson’s goal was to contribute to his profession and help in identifying the behavioral sets that clinicians need to meaningfully work together well. He now maintains that “deliberate mechanisms should be taught and diagnoses should be challenged. There are specific mechanisms we can teach to overcome that bias in team collaboration.”
Carlon’s findings from the dissertation and what he learned during the degree have shaped how he and now RFUMS’ simulation/SP educators view learning and assessment experiences involving diagnostic accuracy and the interprofessional team. They’ve incorporated much of what was learned into activities run with current students, since now there’s evidence as to the effectiveness of the methods they’ve been advocating when teaching interprofessionalism.
“When we design our SP simulations we are trying more and more to weave in interprofesional teamwork theories in addition to the clinician and patient communications.” RFUMS now allows learners to use tools like Isabel Pro™ during simulations, not replacing clinical judgment, but allowing learners to work with tools and giving them practice in using those tools effectively.
Carlson’s dissertation may have answered his primary research questions, but it led to many, many more. “Specifically, I think I have identified a set of questions about interprofessional collaboration around diagnostic decision making that will provide a framework for research and teaching for much of my future career.” Intending to use simulation/SP methods for both training IP behavior and studying it, he now seeks publication of these final results in multiple Journals and academic medicine publications