Diagnostic pause: stop before closing the case

The patient has been in the hospital for two days with a diagnosis that everyone repeats on rounds. The prescription is adjusted, discharge is planned for tomorrow. During handoff, the resident asks a question no one had asked: "if it's not this, what else could it be?". The conversation lasts three minutes. At the end, the team orders a test that changes the story.

NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.

This question, asked on purpose and at a set moment, has a name: diagnostic pause, or diagnostic time-out. This guide explains what it is, where the idea came from, what studies show so far, and how to put together a short script to use in the internship and residency.

Key points

• The diagnostic pause is a planned moment to review the working diagnosis before proceeding with it.
• The idea comes from cognitive forcing strategies, which take the physician out of automatic mode at predictable points.
• In a pilot in hospital pediatrics, the pause failed to confirm the initial diagnosis more than half the times it was used.
• The results are still modest and variable, and evidence that teaching these strategies reduces error is limited.
• The main obstacle reported is lack of time, and short scripts help to work around it.

What a diagnostic pause is

A set moment to review

The diagnostic pause is a deliberate interruption of reasoning, at a defined moment, to check whether the working diagnosis still holds. A review describes the pause as a cognitive forcing function capable of reducing the risk of diagnostic error (Yale et al., 2022).

The difference from spontaneous reflection is in the "set moment". The pause is scheduled in advance: on admission, on transfer, during handoff, when a test contradicts the hypothesis. That way it happens even on days when no one is suspicious.

Inspired by the surgical pause

The name recalls the safety pause in the operating room, where the team checks patient, side and procedure before the incision. The diagnostic pause applies the same logic to reasoning: a short check, at a predictable point, that protects against the error of those who are too sure.

What the pause tries to avoid

The main target is premature closure, when reasoning stops at the first plausible explanation. The mechanism is described in the differential diagnosis guide, along with anchoring. The pause is the procedural response to these biases. The influence of the physician's emotion, affective bias, and of stereotypes, implicit bias, can also be reviewed in the pause, but each has its own guide.

Where the idea comes from

Cognitive forcing strategies

In 2003, Pat Croskerry proposed that, through metacognition, physicians can develop cognitive forcing strategies to interrupt latent errors (Croskerry, 2003). The article describes three levels of these strategies, universal, generic and specific, and argues that the approach can be taught to practicing and trainee physicians (Croskerry, 2003).

The diagnostic pause is a universal strategy: it applies to any case and any specialty. The metacognition in medicine guide explains the basis of this thinking about one's own thinking.

Efficiency and thoroughness

A pilot in hospital pediatrics started from the principle that trading thoroughness for efficiency is normal and frequent in medicine (Yale et al., 2022). The goal of the pause, according to the authors, was to offer a concrete model for the moment when the professional shifts from intuitive to analytical mode (Yale et al., 2022). The pause accepts that the shortcut is the rule and creates a fixed point to check it.

What studies show

A pilot in hospital pediatrics

In the pilot, eight hospital pediatrics professionals used the pause over 12 months (Yale et al., 2022). Patients were chosen for the pause mainly by the clinician's intuition; more than half the time, the pause failed to confirm the initial diagnosis, and new actions were taken in every use (Yale et al., 2022). Students and residents took part in all pauses, and only once was the time spent considered a burden (Yale et al., 2022).

A quality project with a modest result

A quality improvement project in a pediatric hospital applied a pause to the admission of children with abdominal pain and reviewed 165 charts, 64 before and 101 after the intervention (Kasick et al., 2021). The residents' differential diagnosis quality score rose only slightly, from 2.41 to 2.47, without significance, and the preceptors' score stayed the same (Kasick et al., 2021).

The proportion of progress notes with a complete differential diagnosis actually fell in the same project, from 67% to 58% among residents and from 77% to 68% among preceptors (Kasick et al., 2021). The authors described the improvement as marginal (Kasick et al., 2021). The result shows that putting the pause on paper is different from making it happen.

Checklists

A pilot trial randomized 14 primary care physicians, in an emergency department and in a walk-in clinic, to usual care or to reading a checklist of differential diagnoses aloud after the history and examination (Ely and Graber, 2015). The diagnostic error rate was 11.2% with the checklist and 17.8% without it, a difference without significance, but the physicians with the checklist considered on average 6.5 diagnoses, against 3.4 (Ely and Graber, 2015).

The evidence on teaching these strategies

A short review on emergency medicine found two relevant articles and concluded that there is little evidence that teaching cognitive forcing strategies reduces cognitive error in practice (Oliver et al., 2017). The pause is a plausible idea with still preliminary data, and it is worth presenting it that way to students.

Guided reflection in students

In an experimental study with 80 third-year and 62 sixth-year students, deliberate reflection with instructions improved diagnostic accuracy on the immediate test for all case types, whatever the year (Fernandes et al., 2021). The groups with guided reflection or with a worked example outperformed the free reflection group (Fernandes et al., 2021). For teaching, the lesson is that the pause works better with defined questions than with a vague "think again".

When to take the pause

At transitions

Transfer from intensive care to the ward is a high-risk period, with complexity, less monitoring and diagnostic uncertainty (Cornell et al., 2023). A handoff tool in the electronic record, called ICU-PAUSE, built a diagnostic pause into that moment; in interviews with intensivists from ten academic centers, the pause to address uncertainty was recognized as a central benefit (Cornell et al., 2023).

The barriers cited in the same study were workflow, institutional culture, people and evaluation (Cornell et al., 2023). Other transitions call for the same pause: admission, team change, discharge.

When something contradicts the hypothesis

A test that does not fit, a course different from the expected one, a patient who comes back: these are natural triggers. The guide on diagnostic uncertainty deals with how to act while the doubt remains open.

When intuition bothers you

In the pediatric pilot, the most common choice for the pause was the clinician's own intuition (Yale et al., 2022). The feeling that something is out of place is a piece of data, and the pause gives it a space.

The obstacle of time

In a survey with neonatal intensive care professionals, perceived lack of time was cited by all as a barrier, and experienced physicians perceived less risk of diagnostic error than residents (Yale et al., 2022). That is why the script needs to fit in a few minutes.

A five-question pause script

A short script, to be done aloud with the team or silently, alone:

1. What is the working diagnosis, and what supports it? List the findings in favor.
2. What does not fit? Every piece of data that contradicts or that went unexplained.
3. If it is not this, what else could it be? At least two alternatives, including a serious one.
4. What have I not asked or examined yet? The most obvious gap in the history.
5. What data would change my decision? The test or the information that separates the hypotheses.

The third question is the heart of the pause and connects to clinical reasoning in the internship, where prioritizing hypotheses has to fit into the routine. The fifth conversation involves pretest probability: a test only helps if it can change the probability of some hypothesis.

Record the pause

Writing the result of the pause in the progress note, with the alternatives considered, makes the reasoning visible to the next team. The guide on how to organize clinical reasoning in the medical record shows formats for this.

Teach with the script in hand

For preceptors, the pause becomes a teaching tool when the student leads the five questions on rounds and the preceptor only fills in. The study with students suggests that guided questions yield more than free reflection (Fernandes et al., 2021).

Practice reviewing hypotheses in NEXO

In NEXO, the case of the day arrives in up to six clues, and each new clue is a small pause: the player can keep the hypothesis or change it. With each guess, the ICD-10 proximity in five levels shows how far off the hypothesis was, and the distribution of correct answers by clue shows whether you tend to close early or late.

The cases are fictional with real clinical presentation, and the guide what NEXO is explains the whole game. How the modes are unlocked is on the NEXO economy page.

If you coordinate a medical school, a student league or a residency and want to practice the pause in a group, see NEXO Closer. Researchers in medical education can propose studies through NEXO Researcher. Physicians who review cases take part through NEXO Curator, and those who create health content on social media can take part through NEXO Creators.

Frequently asked questions

What is a diagnostic pause?

It is a planned moment to review the working diagnosis before proceeding with it, also called a diagnostic time-out.

Does the diagnostic pause work?

The data are still preliminary: a pilot showed a change in diagnosis and in management (Yale et al., 2022), and a quality project had a marginal improvement (Kasick et al., 2021).

What is the difference between a pause and a checklist?

The pause is the moment; the checklist is one of the tools that can be used in it. In a pilot trial, the checklist increased the number of diagnoses considered (Ely and Graber, 2015).

When should the pause be done?

At transitions of care, when a finding contradicts the hypothesis, and when intuition signals that something is out of place.

How long does it take?

A five-question script fits into a few minutes. In the pediatric pilot, time was considered a burden only once (Yale et al., 2022).

What is premature closure?

It is stopping the reasoning at the first plausible explanation. The guide on differential diagnosis covers the topic.

Diagnostic pause checklist

1. Mark the moment of the pause before you need it.
2. List what supports the working diagnosis.
3. List what does not fit.
4. Name two alternatives, including a serious one.
5. Find the gap in the history or the exam.
6. Define the finding that would change the decision.
7. Record the pause in the progress note.

Want to practice reviewing hypotheses with each clue? Play the case of the day in NEXO.

References

1. Yale S, Cohen S, Bordini BJ. Diagnostic Time-Outs to Improve Diagnosis. Crit Care Clin. 2022. https://pubmed.ncbi.nlm.nih.gov/35369942/
2. Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med. 2003. https://pubmed.ncbi.nlm.nih.gov/12514691/
3. Yale SC, Cohen SS, Kliegman RM, Bordini BJ. A pause in pediatrics: implementation of a pediatric diagnostic time-out. Diagnosis (Berl). 2022. https://pubmed.ncbi.nlm.nih.gov/35417931/
4. Kasick RT, Melvin JE, Perera ST, Perry MF, Black JD, Bode RS, et al. A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain. Diagnosis (Berl). 2021. https://pubmed.ncbi.nlm.nih.gov/31677376/
5. Ely JW, Graber MA. Checklists to prevent diagnostic errors: a pilot randomized controlled trial. Diagnosis (Berl). 2015. https://pubmed.ncbi.nlm.nih.gov/29540029/
6. Oliver G, Oliver G, Body R. BET 2: Poor evidence on whether teaching cognitive debiasing, or cognitive forcing strategies, lead to a reduction in errors attributable to cognition in emergency medicine students or doctors. Emerg Med J. 2017. https://pubmed.ncbi.nlm.nih.gov/28724568/
7. Fernandes RAF, Malloy-Diniz LF, de Vasconcellos MC, Camargos PAM, Ibiapina C. Adding guidance to deliberate reflection improves medical student's diagnostic accuracy. Med Educ. 2021. https://pubmed.ncbi.nlm.nih.gov/33978967/
8. Cornell EG, Harris E, McCune E, Fukui E, Lyons PG, Rojas JC, et al. Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitators to implementation of the ICU-PAUSE handoff tool. Diagnosis (Berl). 2023. https://pubmed.ncbi.nlm.nih.gov/37598362/