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Do you have to re-examine to reconsider your diagnosis? Checklists and cardiac exam
Matthew Sibbald1, Anique B H de Bruin, Rodrigo B Cavalcanti
1Faculty of Health Professions Education, Maastricht University, Maastricht, The Netherlands. mattsibbald@gmail.com
Insights
Checklists improve diagnostic accuracy for clinicians, but only when they can gather more information. This study found no increase in cognitive load when using checklists during cardiac exams.
Area of Science:
- Medical Education
- Clinical Decision Support
- Diagnostic Accuracy
Background:
- Limited research exists on clinicians using checklists for diagnostic verification.
- Checklists may enhance accuracy by prompting review but could increase cognitive load.
- This study investigates checklist impact on cardiac exam diagnostic accuracy and information gathering.
Purpose of the Study:
- To assess if checklists improve diagnostic accuracy in internal medicine residents.
- To determine if the benefit of checklists depends on the ability to collect additional information.
- To evaluate the impact of checklist use on cognitive load.
Main Methods:
- 191 internal medicine residents used a cardiopulmonary simulator, providing diagnoses before and after checklist use.
- Residents were randomized to have or not have simulator access while using the checklist.
- Cognitive load was rated during pre-diagnosis, checklist use, and post-diagnosis phases.
Main Results:
- Diagnostic accuracy improved with checklist use (46% to 51%, p=0.04).
- Benefits were significant only for residents with simulator access (p=0.03).
- Checklist use had the lowest cognitive load compared to other steps.
Conclusions:
- Checklist verification enhances diagnostic accuracy.
- The positive impact of checklists is contingent on the ability to gather more information.
- Checklist implementation does not increase cognitive load.
Background:
Few studies have investigated whether clinicians can use checklists to verify their diagnostic decisions. Checklists may improve accuracy by prompting clinicians to reconsider or recollect information but might impair decision making by adding to clinicians' cognitive load. This study assessed whether checklists improve cardiac exam diagnostic accuracy, and whether this benefit is dependent on collecting additional information.
Methods:
191 internal medicine residents examined a cardiopulmonary simulator. They provided a diagnosis, subjective rating of certainty, and key findings before and after using a checklist. Residents were randomised; half were allowed access to the simulator and half were prohibited access to the simulator while using the checklist. Residents rated their cognitive load in each step: prechecklist diagnosis, checklist use and postchecklist diagnosis.
Result:
Verifying with a checklist resulted in improved diagnostic accuracy; 88 residents (46%) made the correct diagnosis before using the checklist compared with 97 (51%) afterwards, p=0.04. The benefit of checklist use was restricted to residents allowed to re-examine the simulator (10 changed to correct diagnosis and one to an incorrect diagnosis) whereas no net benefit was seen among residents unable to re-examine the simulator (two changed to a correct diagnosis and two to an incorrect diagnosis, p=0.03). Those able to re-examine the simulator were slightly more confident after checklist use, whereas those unable to re-examine were slightly less confident after checklist use (p=0.01). The opportunity to re-examine the simulator had no effect on the accuracy of key findings reported. Of the three steps, checklist use was associated with the lowest cognitive load (F1,189=68 p<0.001).
Conclusions:
Verifying diagnostic decisions with a checklist improved diagnostic accuracy. This benefit was only seen when more information could be collected. Checklist use was not associated with increased cognitive load.
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