Sidestepping superstitious learning, ambiguity, and other roadblocks: a feedback model of diagnostic problem solving.

A central argument of Drs. Eta S. Berner and Mark L. Graber’s review is that feedback processes are crucial to enhancing or inhibiting the quality of diagnostic problem solving over time. Our goal is to enrich the conversation about diagnostic problem solving by presenting an explicit model of the feedback processes inherent in improving diagnostic problem solving. We present a simple, generic model of the fundamental feedback processes at play in calibrating or improving diagnostic problem-solving skill over time. To amplify these key processes, this commentary draws on a 50-year evidence and theory base from the discipline of system dynamics. Using Berner and Graber’s analysis of the challenges of feedback and calibration as a starting point, we depict how feedback loops can operate in a robust or benign manner to support and improve immediate and long-term diagnostic problem solving. Drawing on insights from research on how people manage problem solving that involves dynamic feedback, we then describe how this process is likely to break down. Finally, leverage points for improving diagnostic problem solving and avoiding error are provided. To improve diagnostic problem solving, practitioners and researchers need to move away from viewing diagnosis as a “one-shot deal.” When diagnosis is perceived as a stand-alone, discrete episode of judgment, the solutions suggested to resolve error focus on reducing cognitive biases and increasing expertise and vigilance at the individual clinician level. It is not that such recommendations have no merit, but simply that they are only a small piece of a much larger repertoire of possible solutions that come into sight when we regard diagnostic problem solving as a recursive, feedback-driven process. Put differently, rather than viewing diagnosis as an event or episode, we suggest emphasizing it as an active, ongoing practice in which clinicians revise and redraft their conclusions over time.