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May 17, 1985

Differential Diagnosis and the Competing-Hypotheses HeuristicA Practical Approach to Judgment Under Uncertainty and Bayesian Probability

Author Affiliations

From the Departments of Postgraduate Medicine and Health Professions Education (Dr Wolf and Mr Gruppen) and Internal Medicine (Dr Billi), University of Michigan Medical School, Ann Arbor.

JAMA. 1985;253(19):2858-2862. doi:10.1001/jama.1985.03350430070028

Evaluating the same diagnostic information across the plausible competing diagnoses is a practical strategy (ie, heuristic) to guide decision making in the face of uncertainty. The prevalence of use of this competing-hypotheses heuristic by 89 first-year house officers was examined in three simulated patient cases. Results indicated that only a minority (24%) of the house officers selected optimal diagnostic information consistent with this Bayesian heuristic across all three cases. Almost all (97%) of the house officers selecting optimal diagnostic information were able to identify the most probable diagnosis specified by Bayes' theorem, while only a chance number (53%) of house officers selecting nonoptimal information were able to identify the most probable diagnosis. The competing-hypotheses heuristic is discussed within the context of diagnostic problem-solving models derived from the literature on medical decision making and clinicopathological conference case records. It is suggested that the heuristic, which does not necessitate any mathematical calculations, may be useful as a complement to clinical judgment.

(JAMA 1985;253:2858-2862)