P4A218: The Effect of a Provisional Diagnosis on Pediatric Resident Clinical Reasoning: A Mixed Methods Study

Background: Developing competency in clinical reasoning is a distinctive and integral part of medical training and is crucial to patient safety in teaching hospitals. Situativity theory challenges the traditional view of learning as an individualistic, cognitive process and highlights the importance of understanding the social and contextual factors that influence learning and performance, such as being informed of a provisional diagnosis prior to a patient encounter. This study aims to determine how being informed of a provisional diagnosis, as opposed to a chief complaint alone, affects a first-year pediatric resident’s approach to clinical reasoning.

Methods: This mixed methods study was conducted in situ at a university-based teaching hospital. Participating residents were randomized into two groups: Chief Compliant (CC) only vs. chief complaint with Provisional Diagnosis (PD). For 36 new admissions to pediatric hospital medicine from the emergency department (ED), the CC group was told only the chief complaint and asked not to review the ED note prior to seeing a patient; whereas, the PD group was told the diagnosis and had access to the ED note. A single, blinded researcher assessed residents’ clinical reasoning using a validated, 15-item, 5-point Likert scale tool with five clinical reasoning domains. Mean group scores were compared using the two-sample t-test. The researcher was subsequently unblinded for think aloud interviews to gain insights to residents’ clinical reasoning process via thematic analysis.

Results: There was no significant difference in clinical reasoning performance between the CC and PD groups (Mean ± SD): 47.8 ± 8.1 vs. 43.9 ± 10.9, p = 0.24. Thematic analysis identified that residents aware of the provisional diagnosis 1) invested less effort in diagnostic reasoning, 2) formulated a differential diagnosis through a narrowly focused frame, 3) accepted a provisional diagnosis as a definitive diagnosis, and 4) sought to confirm the provisional diagnosis rather than refute it.

Conclusion: Although we found no quantitative difference between groups, our themes suggests that awareness of the provisional diagnosis may place early trainees at risk for multiple cognitive biases, including premature closure, framing bias, diagnostic momentum, and confirmation bias. Further research needs to define educational interventions that optimize clinical reasoning without disrupting resident workflow.