To the Editor: In their Commentary on diagnostic errors and patient safety, Drs Newman-Toker and Pronovost1 underemphasized the importance of physicians' diagnostic competencies—and the potential role of board certification in assessing and promoting them—in decreasing harm from diagnostic errors. While we share the authors' enthusiasm for new systems such as checklists and computerized clinical decision support, for the foreseeable future (at least until computers replace clinicians' brains as the primary engines of diagnostic reasoning) diagnostic accuracy will continue to hinge, in large part, on individual physicians' knowledge and skills.
To minimize the probability of diagnostic error, physicians must be competent in areas such as medical interviewing, physical examination, data analysis, and clinical judgment. Although computers can enhance human performance in these areas (such as by suggesting lists of possible diagnoses or providing test characteristics such as positive predictive value), they cannot substitute for substantial gaps in foundational knowledge and clinical reasoning.2 - 3 It is likely that most patients would prefer being diagnosed by a physician highly skilled in the art and science of diagnosis rather than one with mediocre skills working in a health care system with strong computerized decision support.
For now, the process of board certification remains the most robust measure of physicians' competence in these critical areas.4 Enhancing the system of board certification can include creating more realistic scenarios through simulation and other modern gaming techniques, building assessment tools that permit the use of online data gathering and decision support, providing more frequent assessments (under maintenance of certification programs) coupled with meaningful feedback, and ensuring that all physicians participate in the certification process. Promoting and improving the process of board certification should be high on the agenda of those arguing for “systems solutions” to the long-neglected problem of diagnostic errors.
Financial Disclosures: Dr Wachter reported being a member of the board of directors of the American Board of Internal Medicine; being on the health care advisory board of Google, for which he receives compensation, and the advisory board of Doctor Evidence, for which he receives stock options; giving lectures on patient safety, for which he receives compensation; and receiving royalties for 2 books on patient safety. Dr Holmboe reported being a paid employee of the American Board of Internal Medicine and receiving royalties as an author and editor for a textbook on assessment of physician competence.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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