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Rationale

Physicians are responsible for directing and conducting the diagnostic evaluation of a broad range of patients, including acutely and chronically ill patients. In a time of rapidly proliferating tests, internists must design safe, expeditious, and cost-effective diagnostic evaluations. This requires well-developed diagnostic decision-making skills that incorporate probability-based thinking.

Prerequisite

Courses in clinical epidemiology and physical diagnosis.

Specific Learning Objectives

  1. Knowledge: Each student should be able to describe:
    1. key history and physical examination findings pertinent to the differential diagnosis.
    2. information resources for determining diagnostic options for patients with common and uncommon medical problems.
    3. key factors to consider when selecting from among diagnostic tests, including pretest probabilities, performance characteristics of tests (sensitivity, specificity, likelihood ratios), cost, risk, and patient preferences.
    4. the relative cost of diagnostic tests.
    5. how critical pathways or practice guidelines can be used to guide diagnostic test ordering.
    6. the method of deductive reasoning.
  2. Skills: Each student should be able to:
    1. formulate a differential diagnosis based on the findings from the history and physical examination.
    2. use probability-based thinking to identify the most likely diagnoses.
    3. use the differential diagnosis to help guide diagnostic test ordering and sequence.
    4. use pretest probabilities and scientific evidence about performance characteristics of tests (sensitivity, specificity, likelihood ratios) to determine post-test probabilities according to the predictive value paradigm.
    5. participate in selecting the diagnostic studies with the greatest likelihood of providing useful results at a reasonable cost.
  3. Attitudes: Each student should:
    1. incorporate the patient’s perspective into diagnostic decision-making.
    2. limit the chances of false positive/false negative results by demonstrating thoughtful test selection.