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Do physicians know when their diagnoses are correct?: Implications for decision support and error reduction
Open accessAbstract
Objective This study explores the alignment between physicians' confidence in their diagnoses and the "correctness" of these diagnoses, as a function of clinical experience, and whether subjects were prone to over-or underconfidence.Design Prospective, counterbalanced experimental design.Setting Laboratory study conducted under controlled conditions at three academic medical centers.Participants Seventy-two senior medical students, 72 senior medical residents, and 72 faculty internists.Intervention We created highly detailed, 2-to 4-page synopses of 36 diagnostically challenging medical cases, each with a definitive correct diagnosis. Subjects generated a differential diagnosis for each of 9 assigned cases, and indicated their level of confidence in each diagnosis.Measurements and main results A differential was considered "correct" if the clinically true diagnosis was listed in that subject's hypothesis list. To assess confidence, subjects rated the likelihood that they would, at the time they generated the differential, seek assistance in reaching a diagnosis. Subjects' confidence and correctness were "mildly" aligned (kappa=.314 for all subjects, .285 for faculty, .227 for residents, and .349 for students). Residents were overconfident in 41% of cases where their confidence and correctness were not aligned, whereas faculty were overconfident in 36% of such cases and students in 25%.Conclusions Even experienced clinicians may be unaware of the correctness of their diagnoses at the time they make them. Medical decision support systems, and other interventions designed to reduce medical errors, cannot rely exclusively on clinicians' perceptions of their needs for such support.
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“underconfident clinicians are likely to seek external information to validate and ensure their diagnostic accuracy [106,107], resulting in over testing and delays in decision making [108].”
From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [106]
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“and diagnostic difficulties persist despite practitioner experience and advances in diagnostic tests.23,24”
From Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology (2008) · cites this paper as [24]
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Metadata
- Authors
- Friedman, C. P., Gatti, G. G., Franz, T. M., Murphy, G. C., Wolf, F. M., Heckerling, P. S., Fine, P. L., Miller, T. M., & Elstein, A. S.
- Affiliations
- University of Pittsburgh (US)
- St. John Fisher University (US)
- Duke University (US)
- University of Washington (US)
- University of Illinois Chicago (US)
- University of Michigan (US)
- University of North Carolina at Chapel Hill (US)
- Corresponding author
- Friedman, Charles P.
- Venue
- Journal of General Internal Medicine
- Published
- 2005-04
- Volume
- 20
- Issue
- 4
- Pages
- 334-339
- ISSN
- 0884-8734 (ISSN-L)
- 1525-1497
- PMC
- PMC1490097
- OpenAlex
- W2044202249
- Cited by
- 187
- References
- 36
- Citations by year
- 2026: 5 · 2025: 8 · 2024: 8 · 2023: 7 · 2022: 11 · 2021: 7 · 2020: 6 · 2019: 10 · 2018: 14 · 2017: 13 · 2016: 8 · 2015: 4 · 2014: 15 · 2013: 18 · 2012: 9
- FWCI
- 5.90
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- Journal of General Internal Medicine (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Deep Blue (University of Michigan) (submittedVersion)
- Funders
- National Institutes of Health (5r01lm005630-06)
- U.S. National Library of Medicine (R01-LM-05630)
- Topics
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Patient Safety and Medication Errors
- Social Sciences › Education › Innovations in Medical Education
- Keywords
- diagnostic confidence, overconfidence, diagnostic accuracy, differential diagnosis, clinical experience, medical students, medical residents, faculty physicians, clinical decision support, medical errors, physician self-assessment
- MeSH terms
- Clinical Competence, Decision Support Techniques, Humans, Internal Medicine, Internship and Residency, Judgment, Prospective Studies, Students, Medical, Linear Models, Medical Errors, Decision Support Systems, Clinical
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