How Well Do Neurology Residents Recognize Neurological Illness? An Analysis of the Close the Loop Resident Clinical Acumen Assessment Project (P4.204)

OBJECTIVE/BACKGROUND: To characterize the types of diagnostic errors made by neurology residents with the aim of improving clinical acumen. DESIGN/METHODS: From July 2010 to June 2013 all patients assessed and presented by on-call junior residents during daily morning report were captured in a caselog. We recorded residents’ initial diagnostic impressions and “closed the loop” by later revisiting each case after reviewing the final diagnosis. Cases were categorized as having a final diagnosis of a primary neurological condition or as non-neurological (medical, psychiatric, ophthalmologic, other). We then determined if the initial impression was accurate, partially accurate, or inaccurate. We have previously shown residents were 68[percnt] accurate; in this study, inaccurate cases were analyzed to determine the types of errors made. RESULTS: 834 cases were presented with a total of 198 diagnostic errors. 77 (38.8[percnt]) were erroneously deemed neurological when the final diagnosis proved to be non-neurological. Of this subset, 41 were medical, 15 were psychiatric, 1 was ophthalmological and 20 were categorized as “other.” The 15 cases of psychiatric illness were mistakenly thought to be seizure, ischemic stroke, demyelinating disease, and movement disorder, though most often were given no specific neurologic diagnosis. Conversely, 25 cases that proved to be neurological were incorrectly diagnosed as having medical (20), psychiatric (4) and ophthalmological (1) conditions. The 4 cases wrongly considered psychiatric included 3 cases of seizure and 1 case of ischemic stroke. The remaining 48[percnt] of total errors were correctly judged to be neurological presentations, but were etiologically inaccurate. CONCLUSIONS: This educational initiative further examines diagnostic errors made by neurology residents. When inaccurate, residents tended to over-interpret cases as neurological, and a large percentage of total errors were within the sub-categories of neurological disease. Psychiatric illness presented a particular diagnostic challenge and was misclassified as a wide range of neurological disorders. Disclosure: Dr. Brandstadter has nothing to disclose. Dr. Hannigan has nothing to disclose. Dr. Zubkov has nothing to disclose. Dr. Krieger has received personal compensation for activities with Acorda Therapeutics, Bayer HealthCare, Biogen Idec, EMD Serono, Genzyme, Questcor Pharmaceuticals, and Teva Neuroscience as a consultant and/or advisory board member.