Predictors of diagnostic accuracy and safe management in difficult diagnostic problems in family medicine

Objective. To investigate the role of information gathering and clinical experience on the diagnosis and management of difficult diagnostic problems in family medicine. Method. Seven diagnostic scenarios including 1 to 4 predetermined features of difficulty were constructed and presented on a computer to 84 physicians: 21 residents in family medicine, 21 family physicians with 1 to 3 y in practice, and 42 family physicians with >= 10 y in practice. Following the Active Information Search process tracing approach, participants were initially presented with a patient description and presenting complaint and were subsequently able to request further information to diagnose and manage the patient. Evidence-based scoring criteria for information gathering, diagnosis, and management were derived from the literature and a separate study of expert opinion. Results. Rates of misdiagnosis were in accordance with the number of features of difficulty. Seventy-eight percent of incorrect diagnoses were followed by inappropriate management and 92% of correct diagnoses by appropriate management. Number of critical cues requested (cues diagnostic of any relevant differential diagnoses in a scenario) was a significant predictor of accuracy in 6 scenarios: 1 additional critical cue increased the odds of obtaining the correct diagnosis by between 1.3 (95% confidence interval [CI], 1.0-1.8) and 7.5 (95% CI, 3.2-17.7), depending on the scenario. No effect of experience was detected on either diagnostic accuracy or management. Residents requested significantly more cues than experienced family physicians did. Conclusions. Supporting the gathering of critical information has the potential to improve the diagnosis and management of difficult problems in family medicine.