The effect of a provisional diagnosis on intern diagnostic reasoning: a mixed methods study

Objectives: Competency in diagnostic reasoning is integral to medical training and patient safety. Situativity theory highlights the importance of contextual factors on learning and performance, such as being informed of a provisional diagnosis prior to a patient encounter. This study aims to determine how being informed of a provisional diagnosis affects an intern's approach to diagnostic reasoning.

Methods: This mixed methods study was conducted in a real-time workplace learning environment at a large teaching hospital. Interns were randomized to the Chief Complaint (CC) only or chief complaint with Provisional Diagnosis (PD) group. One blinded researcher assessed intern diagnostic reasoning using a validated tool. Mean group scores were compared using the two-sample t-test. The researcher was unblinded for think aloud interviews analyzed via thematic analysis.

Results: There was no difference in performance between the CC and PD groups (mean ± SD): 47.8 ± 8.1 vs. 43.9 ± 10.9, p=0.24. Thematic analysis identified that interns aware of the provisional diagnosis 1) invested less effort in diagnostic reasoning, 2) formulated a differential through a narrowly focused frame, 3) accepted a provisional diagnosis as definitive, and 4) sought to confirm rather than refute the provisional diagnosis.

Conclusions: Our discordant results highlight the complex interplay between a provisional diagnosis and diagnostic reasoning performance in early learners. Though an accurate provisional diagnosis may enhance diagnostic reasoning outcomes, our qualitative results suggest that it may pose certain risks to the diagnostic reasoning process. Metacognitive strategies may be a ripe field for exploration to optimize this complex interplay.