Excellence in Clinical Reasoning

Adapted from Dhaliwal's 2011 article in JAMA & his 2012 article in Academic Medicine

1. Build rapport with your patient. For example, delve into the social history before getting into the clinical questions. E.g. occupation, family, home life, immigration history, travel history, etc. Have a positive demeanor. All this makes eliciting a complete history and performing a thorough physical exam much easier. Further, these social details might be the key to the diagnosis!

2. Allow the differential to guide investigations from the start. Develop a broad differential from the chief complaint and narrow the possibilities by asking pertinent questions and performing physical exam maneuvers that address these entities. This makes history taking and physical exam a more of an intellectual challenge, instead of just rote checklists. (Not to undermine checklists. Checklists support safety and quality. Checklists should serve as a back-up of "things not to forget" rather than the principle method of evaluating a case.)

3. Base of knowledge and experience guides evaluation. Without a large base of knowledge and experience, one cannot generate the "pertinents" of a case. Emphasize the importance of study of cases and clinical opportunities. This allows the clinician to develop "illness scripts" - pattern recognition of clinical entities - and the knowledge that allows accurate clinical reasoning when the presentation does not promptly lead to a clear diagnosis. You need to know the disease to detect the disease.

4. Problem representation. AKA the one-liner or the "Assessment". Synthesis of the pertinent details into a meaningful representation of the case that allows the clinician to connect the case to their database of illness scripts and clinical encounters, or appropriately reference their knowledge base to evaluate other possibilities.

5. Utilizing both pattern recognition and analytical reasoning. Familiarity with many different clinical presentations, illness scripts, frequently allows the clinician to steer their investigations to quickly confirm the most likely culprits, but when complex or unclear situations arise, the expert can use analytical reasoning supported by a broad knowledge of the field to guide the investigation.

6. Prioritize. A knowledgable and experienced clinician should be able to use the relevant details of the case to prioritize what conditions are most likely and what cannot-miss diagnoses must be considered.

7. Second opinion. Especially for complex cases, discuss the case and the clinical reasoning with others. One may find there are other ways to categorize the possibilities, other diagnostic algorithms  or new evidence that should be integrated into the work up.

8. Feedback. Follow up the case to its definitive conclusion. This follow up will provide feedback that allows the clinician to refine their clinical reasoning processes and build up their knowledge and experience base to help them in future encounters. Follow up outcomes, treatment responses, lab results, pathology, encounters with other providers, etc. This feedback will hone your judgement.

9. Progressive Problem Solving. Learn from every case, even the "easy" ones. Find a way to reformulate the case in such a way that you consider related challenges, such as potential complications, rare diagnoses, common mistakes, contingency planning, medication side-effects, treatment failures, etc.

10. Simulate. Advance your cognitive skills through case simulation. Review published cases, case-quizzes, and interactive/virtual cases.

11. Deliberate Practice. Select specific competencies that need improvement. Focus on the skill, seek out guidance, study the relevant literature, and repeatedly practice until habitual mastery is achieved.

12. Defend against Cognitive Errors. Of course you cannot defend against cognitive error if you are not aware of the types of cognitive errors that clinicians are susceptible to. This is a whole other topic that will be discussed in the future.

13. Model these behaviors for the benefit of other learners & yourself.

Expect to see more cases, differential building, illness scripts, analytical reasoning, and cognitive errors discussed on this blog.