Deborah Dinardo, MD, MS
PITTSBURGH – A clinician’s mind leaps to a diagnosis. It matches the symptoms; it wouldn’t be that unusual for a patient of that age; it seems the most likely solution to the answers that both veteran and physician are seeking.
But what are the other possible diagnoses? Are there any possibilities that would be more immediate or more dangerous for the veteran? What happens if the clinician takes a moment and looks back over their full time with the veteran–all of the visits, all of the tests, all of the symptoms? Is there anything that was missed?
These are the questions Deborah Dinardo, MD, MS, and her colleagues work to teach VA clinicians to ask themselves. Those questions might lead to the same answer–that first diagnosis the clinician thought of–but the process provides a stop-gap that allows VA doctors to catch mistakes before they happen.
“We don’t teach people that you should never trust your gut instinct or, if you see a patient and identify a diagnosis that seems very likely very early, that you should assume you’re wrong,” Dinardo explained. “It’s more about making sure that, at least in your mind, you’re considering alternatives and being open to information that would make you think twice about what you thought yesterday.”
Dinardo is the women’s health medical director at the VA Pittsburgh Healthcare System. She arrived at the Pittsburgh VA as a resident in the women’s health track of the internal medicine residency program, was hired as a physician in general internal medicine in 2013 and has been there ever since.
VA Pittsburgh has a very strong presence in women’s health in the VA, and a number of leaders in the field have emerged out of their training programs.
“I started out my clinical experience here, even as a resident appreciating the importance of women’s healthcare at the VA, seeing it as important, seeing it propagated by the people I was working with,” Dinardo said. “As the years went on, I got more involved in the women’s health educational side, … educating providers about all of the aspects of care that are unique to and important for women veterans.”
It was her passion for teaching that led her to discover how clinical reasoning can be used as a tool to counteract diagnostic error. During her early years at VA, Dinardo was working on completing a Masters in Medical Education. That program required a medical education project. She was connected with a group of faculty who were already interested in clinical reasoning education. Dinardo quickly found that the topic was something she enjoyed thinking about.
Avoiding Diagnostic Errors
“Clinical reasoning is basically how clinicians think through a case. How they approach the diagnostic process when they are evaluating a process and trying to understand what may be creating the symptoms and come to a treatment plan,” Dinardo explained. “There’s a pretty direct relationship between clinical reasoning and diagnostic error.”
In 2015, the National Academy of Medicine released a report that emphasized the importance clinical reasoning in understanding diagnostic errors and called for a number of things to address the situation. One of those was to improve education in the diagnostic process across all disciplines.
Over the last decade, Dinardo has worked with a group of committed faculty at VA who are focused on how they can improve clinical reasoning education from the medical student level, through residency training, up to already-practicing faculty.
One of the strategies that they teach is cognitive forcing. This strategy asks a clinician to build time into their process to ask some basic questions about a diagnosis and makes them not act on a first response without reflection.
“Every time I’m thinking about a new diagnosis, I’m always going to force myself to … think about what are the can’t-miss diagnoses. What are the diagnoses that could threaten this person’s life or livelihood,” Dinardo said.
This works hand in hand with reflective reasoning, which is a process of scrutinizing the initial impression of a medical problem to see if there were diagnostic paths discarded early on that, if taken, might have led to a different answer.
While it’s easy for students and doctors to understand intellectually that these strategies are useful and that it’s correct to regularly question their diagnoses, making the leap actually practicing these strategies can be difficult.
“What we talk a lot about in these educational settings is [the difference between knowing it intellectually] and practicing that in the context of a very busy day where you’re doing a lot of things, taking care of patients, getting paged, answering emails. Practicing some of these strategies needs to be more deliberate,” Dinardo explained.
In 2020, Dinardo was awarded VA’s Worthen Rising Star Award, recognizing her work in clinical reasoning and specifically noting her work in creating a series of conferences that introduce the concept along with an online curriculum and an elective on enhancing reasoning skills in preparation for residency training.
One of the most unique educational experiences Dinardo has had a hand in creating is the clinical reasoning case conference, where she and her colleagues will present a physician volunteer with a case they have never seen and ask them to work through their thought process out loud for a roomful of students.
“We’ll deliver the case to that person piecemeal, and they’ll describe what they would be thinking. What else would they want to know?” Dinardo said. “It’s an explicit role-modeling of their clinical reasoning; getting to step inside their head.”
It also provides a concrete demonstration to young physicians-in-training that even attending physicians don’t know everything. That they have doubts. It shows students what physicians think about when they hit an unexpected problem. And in doing that, trainees invariably think about their own reasoning process. What questions do they ask? How could their thought process improve?
“We feel pretty strongly that educating our trainees and clinicians in how a clinician thinks is really important. [It’s about] learning how it can help you converse with your trainees, mentors, role models and colleagues in ways that might foster things like reflection when things aren’t going the way you expect,” Dinardo explained. “Saying ‘I don’t know’ is an important part of being a physician.”