Diagnostic Reasoning: An Endangered Competency in Internal Medicine Training

Diagnosis is one of the most important tasks performed by internal medicine physicians, and diagnostic reasoning is perhaps the most critical of an internist's skills. The foundation of the diagnostic process is the patient's medical history and the physical examination, which lead to an initial differential diagnosis that is adjudicated through an ever-increasing array of diagnostic tests and data points as well as the patient's course over time. Historically, diagnostic reasoning and expertise have been highly valued in residency training, figuring prominently in curricula, conferences, and teaching rounds. However, despite growing recognition of the importance of diagnostic error with regard to patient safety and the need to “enhance healthcare professional education and training in the diagnostic process” (1), several signs indicate that the focus on diagnostic reasoning in internal medicine training may be threatened (2). Indeed, only 2 of the 22 Internal Medicine Milestones of the Accreditation Council for Graduate Medical Education and American Board of Internal Medicine—milestones 1 and 7—explicitly include diagnostic skills (3). Although this disconnect between the importance of diagnostic reasoning skills and the current approach to medical education has not gone unnoticed, responses largely have focused on adding clinical reasoning courses to medical school curricula and incorporating clinical reasoning into certification assessments (1, 4).