What was known Developing diagnostic skill is a critical aim of resident education.;What is new Residents' diagnoses were accurate in two-thirds of cases, and faculty diagnostic accuracy was lower when the residents' initial diagnoses were wrong.;Limitations A single-site study limits generalizability; residents' diagnoses were not independent due to prior diagnosis by emergency department.;Bottom line Although the metrics used to assess diagnostic accuracy are not perfect, their use in everyday practice will enhance the quality and safety of care.;Introduction A successful internist possesses many attributes, but the ability to make an accurate diagnosis is paramount. Diagnostic acumen emerges as a major theme when master clinicians are interviewed about clinical practice,1 and the public expects that physicians make accurate diagnoses.2 Currently, most measures of diagnostic excellence are anecdotal; masterful clinicians are identified not by any metric but by peer recognition and reputation. A practical means of measuring diagnostic accuracy in clinical practice is lacking. In the conventional clinical apprenticeship model, a trainee is granted progressive independence in patient care responsibilities over time, rather than after achieving a prespecified level of competence.3,4 Independence for residents is often significantly increased during on-call shifts, when they receive less direct supervision. The degree of independence afforded is determined by clinical supervisors and by the trainees themselves. This can be problematic because supervisors are often insufficiently critical of trainees they know well and therefore trust more than they should,4,5 and trainees may not ask for help when necessary because of inaccurate self-assessment of their diagnostic accuracy6 or a desire to maintain independence and reputation.3 Measurement of trainees' diagnostic accuracy could be a valuable tool in the assessment of competence. As part of the competency-based education movement, there has been a focus on developing methods to assess what physicians do in actual clinical practice.7 Arriving at an accurate diagnosis requires integration of several of the Accreditation Council for Graduate Medical Education competencies, including medical knowledge, patient care, and interpersonal and communication skills,8 whereas the exercise of measuring, reflecting, and improving on patient care practices embodies practice-based learning and improvement.9 A workplace-based assessment of diagnostic accuracy could be a helpful component of a competency-based assessment program and could inform decisions about progressive independence. We sought to develop a method to determine senior on-call internal medicine (IM) residents' diagnostic accuracy that could easily be incorporated into the regular workflow.;Methods Setting and Participants This study was conducted between July 2010 and April 2011 at Mount Sinai Hospital, a tertiary care hospital affiliated with the University of Toronto. The study was embedded in the existing on-call system, where a single senior IM resident evaluated patients referred by the emergency department (ED) physician during 24 consecutive hours (8 am to 8 am). These referrals were formally reviewed by the attending physician between 6:30 am and 10 am on the day following the start of the on-call shift. Infrequently, in the interests of expediency or patient safety, a referred patient's case might have been reviewed prior to that time. The attending physician supervised the same resident for a consecutive 1-month period, during which time the resident would be on call 6 to 8 times. During the study period, 4 senior (postgraduate year–2) residents and 6 attending physicians volunteered to participate. All attending physicians and 2 residents participated for 1?month, and 2 residents participated for 2?months. The study was approved by the Mount Sinai Hospital Research Ethics Board.;Results Over the study period, we collected
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