Differential diagnosis checklists reduce diagnostic error differentially: A randomised experiment

Wrong and missed diagnoses contribute substantially to medical error. Can a prompt to generate alternative diagnoses (prompt) or a differential diagnosis checklist (DDXC) increase diagnostic accuracy? How do these interventions affect the diagnostic process and self-monitoring?

Advanced medical students (N = 90) were randomly assigned to one of four conditions to complete six computer-based patient cases: group 1 (prompt) was instructed to write down all diagnoses they considered while acquiring diagnostic test results and to finally rank them. Groups 2 and 3 received the same instruction plus a list of 17 differential diagnoses for the chief complaint of the patient. For half of the cases, the DDXC contained the correct diagnosis (DDXC+), and for the other half, it did not (DDXC-; counterbalanced). Group 4 (control) was only instructed to indicate their final diagnosis. Mixed-effects models were used to analyse results.

Students using a DDXC that contained the correct diagnosis had better diagnostic accuracy, mean (standard deviation), 0.75 (0.44), compared to controls without a checklist, 0.49 (0.50), P < 0.001, but those using a DDXC that did not contain the correct diagnosis did slightly worse, 0.43 (0.50), P = 0.602. The number and relevance of diagnostic tests acquired were not affected by condition, nor was self-monitoring. However, participants spent more time on a case in the DDXC-, 4:20 min (2:36), P ≤ 0.001, and DDXC+ condition, 3:52 min (2:09), than in the control condition, 2:59 min (1:44), P ≤ 0.001.

Being provided a list of possible diagnoses improves diagnostic accuracy compared with a prompt to create a differential diagnosis list, if the provided list contains the correct diagnosis. However, being provided a diagnosis list without the correct diagnosis did not improve and might have slightly reduced diagnostic accuracy. Interventions neither affected information gathering nor self-monitoring.