Raiders of lost clinical reasoning

In a previous post, "Against manual medicine," I analyzed the concern of two internal physicians at Brigham and Women's Hospital for the excesses of manual medicine in their book When doctors don’t listen. Avoid misdiagnoses and unnecessary tests. on this same subject I want to talk about Jerome Kassirer, John Wong and Richard Kopelman, three authors who in 1991 published Learning Clinical Reasoning, a reference work that laid the foundations of clinical reasoning through the inferential process of hypothesis generation diagnosis, its subsequent refinement with the elaboration of a diagnosis of work, the sustained request of complementary tests, the management of Bayes' theorem, the causal models, the diagnostic verification and the taking of therapeutic decisions. Twenty years later, the same authors published the second edition of the book, and in their presentation said they were forced to update it because in recent times, the practice of medicine had undergone very profound changes. According to them, rapid triage in emergencies and reduction of hospital stays are forcing doctors to be less contemplative and they are often seen short-circuiting the diagnostic process, or by cutting out minutes of time spent in interviewing or exploring where they try to compensate by quickly sending patients to perform diagnostic tests. This obsession with the performance of physicians is detrimental to the reflection on what has been learned in the observations made and the establishment of a qualified relationship with the patient. The authors state that the diagnostic process, as it was known, has been replaced by "take a look and ask for a CT".

Clinical reasoning had been highly valued in the training of the residents, but several signs indicate the existence of a serious decline in that aspect. Without going any further, a group of internists from the Massachusetts General Hospital claim that only 2 of the 22 milestones used by the "Accreditation Council for Graduate Medical Education" for the specialty of Internal Medicine include issues related to the diagnostic skills of residents. This impoverishment of clinical practice has several causes of which it should be noted, as one of the most outstanding, the model of guards and rotations of residents that prevent them from following the progress of patients that they had admitted themselves and therefore having the longitudinal perspective of the clinical processes. A second negative aspect that also needs to be emphasized during training in clinical reasoning would be the manner in which work is being done in the hospitals’ ER units, a place where residents spend many hours. There it’s valued, stabilized and treatments are prescribed quickly based on diagnoses that respond almost faithfully to the reason for consultation. The decisive capacity is prioritized, in the most mechanical sense of the concept, above the clinical effectiveness and the value contributed to the health of the people served.

Proposals of the Mass General for recovering the clinical reasoning

In the article linked above, Arabelle Simpkin and her colleagues make several proposals to improve the quality of the diagnostic process, of which I have highlighted the following 7:

1. Discussion of cases in clinical sessions with special emphasis on aspects of the diagnostic process, including the uncertainties of each step and the - probabilistic nature of clinical reasoning.
2. Analysis of the causes of readmissions.
3. Promotion of clinical-pathological sessions.
4. Sincere discussions about the diagnostic errors and the strategies that should be carried out to avoid repeating them.
5. In complex cases, learn to work with diagnostic hypotheses, since they better capture the uncertainties inherent in clinical reasoning.
6. The tutors should organize resident seminars where a favourable climate should be established to analyze the alternatives of the diagnostic process without the stiffness of the sessions.
7. Provide training plans to residents on the diagnostic process, strengths and weaknesses of evidence-based medicine, Bayes theorem, sensitivity, specificity, NNT and predictive value of tests, diagnostic errors, shared decisions and uncertainty management, among other topics of interest to enhance clinical reasoning.

The impoverishment of the diagnostic process is a powerful fact. According to a report by the National Academy of Medicine (formerly Institute of Medicine), diagnostic errors are responsible for 10% of deaths and 6-7% of adverse effects in hospitals, so recovering the clinical reasoning lost is essential, but it will not be easy.

Jordi Varela

Editor