ABC of Clinical Reasoning
From an international team of authors, the ABC of Clinical Reasoning is essential reading for all students, medical professionals and other clinicians involved in diagnosis, in order to improve their decision-making skills and provide better patient care. Nicola Cooper is Consultant Physician and Honorary Clinical Associate Professor, Derby Teaching Hospitals NHS Foundation Trust, and Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, UK John Frain is General Practitioner and Director of Clinical Skills, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, UK
ABC of Clinical Reasoning
Clinical Reasoning : An Overview
Nicola Cooper1,2 and John Frain2
1 Derby Teaching Hospitals NHS Foundation Trust, UK
2 University of Nottingham, UK
Clinical reasoning describes the thinking and decision-making processes associated with clinical practice
The core elements of clinical reasoning include: evidence-based clinical skills, use and interpretation of diagnostic tests, understanding cognitive biases, human factors, metacognition (thinking about thinking), and patient-centred evidence-based medicine
Diagnostic error is common and causes significant harm to patients. Errors in reasoning play a significant role in diagnostic error
Sound clinical reasoning is directly linked to patient safety and quality of care Introduction
Fellow author, Pat Croskerry, argues that although there are several qualities we would look for in a good clinician, the two absolute basic requirements for someone who is going to give you the best chance of being correctly diagnosed and appropriately managed are these: someone who is both knowledgeable and a good decision-maker. At the time of writing, medical schools and postgraduate training programmes teach and assess the knowledge and skills required to practise as a doctor, but few offer a comprehensive curriculum in decision-making. This is a problem because how doctors think, reason and make decisions is arguably their most critical skill.
This book covers the core elements of clinical decision-making - or clinical reasoning. It is designed not only for individuals but also as an introductory text for a course or as part of a curriculum in clinical reasoning. Chapter 9 specifically covers teaching clinical reasoning in undergraduate and postgraduate settings. In this chapter we define clinical reasoning, explain why it is important, and provide an overview of the different elements involved.
What is clinical reasoning?
Clinical reasoning describes the thinking and decision-making processes associated with clinical practice. According to Schön, it involves the 'naming and framing of problems' based on a personal understanding of the patient or client's situation. It is a clinician's ability to make decisions, often with others, based on the available clinical information, which includes history (sometimes from multiple sources), clinical examination findings and test results - against a backdrop of clinical uncertainty. Clinical reasoning also includes choosing appropriate treatments (or no treatment at all) and decision-making with patients and/or their carers. Box 1.1 gives a definition of clinical reasoning.
Box 1.1 A definition of clinical reasoning
'Clinical reasoning comprises the set of reasoning strategies that permit us to combine and synthesise diverse data in to one or more diagnostic hypotheses, make the complex trade-offs between the benefits and risks of tests and treatments, and formulate plans for patient management. Tasks such as generating diagnostic hypotheses, gathering and assessing clinical data, deciding on the appropriateness of diagnostic tests, assessing test results, assembling a coherent working diagnosis, and weighing the value of therapeutic approaches are a few of the components. Teaching these cognitive skills is a difficult matter even for outstanding clinician-teachers.'
From Kassirer JP and Kopelman RI. Learning clinical reasoning , 1st edn. Williams & Wilkins, 1991.
Figure 1.1 shows the different elements involved in clinical reasoning covered in this book, underpinned by a knowledge of basic and clinical sciences. Good clinical skills - in particular communication skills - are vital because the heart of the clinical reasoning process is often the p