Clinical reasoning: what do we know?

Dr Nicola Cooper

Consultant Physician & Hon Clinical Associate Professor

@Cooper00Nicola

Acute Medicine – Loughborough

September 2018

What is clinical reasoning?

There are several definitions of clinical reasoning in

the literature

In a nutshell: ‘clinical reasoning describes the

thinking and decision making processes associated

with clinical practice’.

Cooper N & Frain J. Clinical reasoning – an overview. In: Cooper N & Frain J [Eds]. ABC of Clinical

Reasoning. Wiley, 2016.

In definitions in the literature, several ‘components’ of clinical reasoning are described:

1. History

2. Physical examination

3. Use and interpretation of diagnostic tests

4. ‘Reasoning’

5. Shared decision making

The components of clinical reasoning

Environment, context and culture

Durning SJ & Artino AR. (2011). Situativity theory: A perspective on how participants and the environment can interact:

AMEE Guide no. 52. Medical teacher; 33(3): 188-199.

Why does clinical reasoning matter?

The scale of diagnostic error

• 10-15% of diagnoses are incorrect

• Diagnostic error causes significant harm

• Diagnostic error accounts for 40,000 – 80,000 deaths annually in the US, somewhere between breast cancer and diabetes

• Chances are, we will all experience a diagnostic error in our lifetime

US Institute of Medicine. (2013). 25-year summary of US malpractice claims for diagnostic errors 1986-2010: an

analysis from the National Practitioner Data Bank. BMJ Qual Saf; 22(8): 672-680

Results -

‘System-related factors contributed to diagnostic error

in 65% of the cases and cognitive factors in 74% …

the most common cognitive factors involved faulty synthesis.’

Arch Intern Med 2005; 165: 1493-1499

Sherbino J & Norman GR. (2014). Academic Emergency Medicine; 21(8): 931-933.

‘The prevailing opinion that diagnostic error is a cognitive

processing error … is incorrect. This perspective

presupposes that all of the available knowledge is present.

… In contrast, a diagnostic error may reflect not a

processing error, but an incomplete knowledge base or

inadequate experience.’

What do we know about clinical reasoning

ability , and how it develops?

Expertise = general problem-solving ability?

‘Two of the most important determinants of competence are information and experience; problem-solving skills without a rich supply of facts are insufficient for diagnostic acumen.’

Elstein AS, Shulman LS, Sprafka SA. Medical problem solving. An analysis of clinical reasoning. Harvard University Press, 1978.

Expertise = memory?

Norman GR, Eva K, Brooks L and Hamstra S. Expertise in medicine and surgery. In: Ericsson KA, Charness N, Feltovich PJ,

Hoffman RR [Eds]. The Cambridge handbook of expertise and expert performance. Cambridge University Press, 2011.

‘Reasoning’ as a dual process

System 1• Intuitive, heuristic (patterns)

• Automatic, subconscious

• Fast, effortless

• Low/variable reliability

• Vulnerable to error

• Highly affected by context

• High emotional involvement

• Low scientific rigour

System 2• Analytical, systematic

• Deliberate, conscious

• Slow, effortful

• High/consistent reliability

• Less prone to error

• Less affected by context

• Low emotional involvement

• High scientific rigour

A bat and ball cost £1.10

The bat costs £1 more than the ball

How much does the ball cost?

Reflection is fairly consistently beneficial

Stanovich KE. (2011). Rationality and the reflective mind. New York, NY: Oxford University Press.

Ericsson KA. (2004). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med; 79 (10): S70-S81.

Deliberate practice vs experience

The ‘components’ of clinical reasoning:

1. History

2. Physical examination

3. Use and interpretation of diagnostic tests

4. ‘Reasoning’

5. Shared decision making

WHAT to teach

‘Acute infection of the meninges presents with a characteristic combination of fever, headache and meningism.

Meningism consists of headache, photophobia and neck stiffness, often accompanied by other signs of meningeal irritation, including Kernig’s and Brudzinski’s sign.’

From Davidson’s Principles and Practice of Medicine, 22nd Ed: p1201

Does this adult patient have acute meningitis?

The ‘components’ of clinical reasoning:

1. History

2. Physical examination

WHAT to teach

� Evidence-based

history and physical

examination

Thomas KE, Hasbun R, Jekel J, Quagliarello VJ. (2002). The diagnostic accuracy of Kernig’s sign, Brudzinski’s

sign and nuchal rigidity in adults with suspected meningitis. Clin Infec Dis; 35(1): 46-52

Elieson SW, Papa FJ. (1994). The effects of various knowledge formats on diagnostic performance. Academic

Medicine; 69:S81–S83

The ‘components’ of clinical reasoning:

1. History

2. Physical examination

3. Use and interpretation of diagnostic tests

WHAT to teach

� Prevalence of disease

� Pre-test probability

� Sensitivity, specificity

� Post-test probability

� Predictive values

Use and interpretation of diagnostic tests

Conclusions: ‘Commonly used measures of test accuracy are poorly understood by health professionals.’

BMJ Open 2015; 5e:008155

HOW to teach: the evidence

Coderre S, Jenkins D & McLaughlin K. (2009). Qualitative differences in knowledge structure are associated with

diagnostic performance in medical students. Adv in Health Sci Educ; 14: 677-684

What teaching strategies are effective in developing

clinical reasoning ability?

• Strategies that build knowledge* and understanding

• Purposeful practice with as many ‘real’ cases as possible

in as many different contexts as possible, with guidance

and feedback

• Developing organised problem-specific knowledge

• Engaging the reflective mind

HOW to teach: summary of the evidence

Further resources

www.clinical-reasoning.org www.creme.org.uk