CODEX Digest 08.27.26

The convenience of telemedicine is changing how clinicians conduct examinations, communicate with patients, and organize diagnostic work. This interview study examines the impact of this evolution on improving and degrading diagnosis through the eyes of primary stakeholders. Its central implication is that diagnostic quality cannot be assumed to transfer unchanged from in-person care to virtual settings; new workflows, communication practices, and safeguards may be needed to maintain diagnostic accuracy and safety.

Unnecessary respiratory cultures can generate misleading results, inappropriate treatment, and diagnostic cascades. This multicenter cohort study evaluates a team-enabled clinical decision support approach designed to promote more appropriate culture ordering in pediatric intensive care. The work illustrates diagnostic stewardship as a practical component of diagnostic excellence: improving diagnosis may depend not only on detecting disease, but also on system enhancement to know when testing is unnecessary to prevent low-value information from driving care.

Diagnostic delays after emergency department (ED) presentation vary widely across gynecologic and breast cancers, revealing vulnerabilities in the transition from acute care to definitive diagnosis. This retrospective cohort study examines the timing of diagnosis after patient workup at the ED. The findings demonstrate that diagnostic timeliness depends on more than recognizing disease in the ED; follow-up, referral, testing, and system coordination also matter. Improving cancer diagnostic excellence therefore requires attention to the entire diagnostic pathway.

Clinicians are encouraged to discuss uncertainty with patients, but patients’ responses to it vary. This secondary analysis of a cluster randomized trial examines how older adults’ comfort with uncertainty shapes colorectal cancer screening decisions. Greater tolerance for ambiguity or complexity was linked to less concern about screening harms, though screening intentions were unchanged. The findings suggest tailoring shared decision-making to patients’ uncertainty styles may improve screening conversations.

This special issue highlights emerging directions in diagnostic research through a Japanese and international lens. Its contributions collectively emphasize diagnostic uncertainty, safety, innovation, and the need for stronger approaches to understanding and improving diagnosis. Rather than focusing narrowly on technological solutions, the articles provide a broader research agenda spanning clinical reasoning, systems, measurement, patient involvement, and the future infrastructure of diagnostic excellence.

Limited exposure to diverse skin tones can undermine clinicians’ confidence and ability to recognize clinical findings in black and brown skin. This British educational intervention improved students’ confidence in assessing darker skin tones. Although confidence does not establish improved diagnostic accuracy, this small study highlights an important and addressable contributor to diagnostic inequity: ensuring that clinical education adequately represents the diversity of patients encountered in practice.

Older adults admitted after seemingly minor trauma may harbor serious conditions that are initially overlooked. This single-center Dutch observational cohort study finds a substantial burden of missed diagnoses and linked missed diagnosis with adverse outcomes, including mortality. The findings illustrate how diagnostic risk can arise when clinical presentation, frailty, competing conditions, and the presumed reason for admission interact—and underscore the importance of systematic diagnostic reassessment in vulnerable patients.

Using national routinely collected data from England, this population-based study identifies patient and cancer characteristics linked to ovarian cancer diagnosis within 28 days of emergency admission. Two in five women were diagnosed after emergency admission, highlighting the need for targeted interventions to improve earlier diagnosis and outcomes. Emergency diagnosis was more common among younger and older women, those with greater frailty, and those from deprived neighborhoods. The national scope strengthens generalizability and shows how routine data can reveal populations and pathways where earlier recognition may be improved.

Older adults admitted after seemingly minor trauma may harbor serious conditions that are initially overlooked. This single-center Dutch observational cohort study finds a substantial burden of missed diagnoses and linked missed diagnosis with adverse outcomes, including mortality. The findings illustrate how diagnostic risk can arise when clinical presentation, frailty, competing conditions, and the presumed reason for admission interact—and underscore the importance of systematic diagnostic reassessment in vulnerable patients.

Conversational AI can offer accessible diagnostic guidance but are often evaluated with simulated patients. This preprint study analyzing 2,053 real patient–chatbot conversations to characterize communication styles and emotional expression. Based on this analysis, the authors developed a patient simulator with distinct patient personas, and tested the ability of LLMs to perform emergency triage with each different persona. They found that different communication styles affected triage reliability and timeliness of care, diminishing the safety of consumer-facing medical AI in real-world patient contexts.

Emergency clinicians make diagnostic decisions in environments characterized by uncertainty, time pressure, and emotional stress. This commentary introduces how threats to cognition can influence attention, reasoning, and clinical judgment. It reinforces a central diagnostic-safety principle: reducing error requires addressing the conditions in which clinicians work, not simply teaching individuals to reason better or adding technological decision support.

Wearable devices may support diagnostic excellence by continuously capturing vital signs, detecting potential clinical events, and sharing data with clinicians. This Technology Assessment report explores how the devices may expedite clinical decisions by integrating wearable-generated health data into clinical workflows. The report discusses the role that AI may play in driving improvement and provides policy options to strengthen the benefits of wearables while addressing known challenges.