Learning Clinical Reasoning

Tufts University School of Medicine, Boston, Massachusetts. Textbook of diagnosis for medical students; includes case presentations. DNLM: 1. Cognition.

Foreword

vii

Samuel O. Thier

Harry R. Kimball

Preface

ix

Acknowledgments

xi

A Note About the Book's Format

xiii

Part I. The Processes of Clinical Reasoning

Overview

2

(5)

Introduction

Diagnosis is an inferential process

Problem-solving strategies

The nature and function of diagnostic hypotheses

Toward a working diagnosis

Therapeutic principles

Linking diagnosis and treatment

Diagnostic Hypothesis Generation

7

(4)

Hypotheses and cues

The cognitive basis of hypothesis generation

Hypotheses as a context

Expertise and error

Refinement of Diagnostic Hypotheses

11

(6)

Where refinement begins and ends

Context and diagnostic classification

Hypothesis evolution

Sequence of data collection

Reducing diagnostic entropy

The differential diagnosis

Relation to formal probabilistic approach

Use and Interpretation of Diagnostic Tests

17

(11)

The function of tests

Quantifying testing decisions

Sensitivity and specificity

Bayes' rule

Testing principles

Bayesian revision for multiple diseases with multiple attributes

Pragmatic considerations in the probabilistic approach

Interpreting results

When to test

The threshold concept

The therapeutic threshold

Testing thresholds

Causal Reasoning

28

(4)

Definition

A detailed example

Using a causal model

Where in the diagnostic process does causal reasoning fit?

Explaining relations between variables

Diagnostic Verification

32

(2)

Definition

Criteria of validity

Premature closure

The penultimate result: a working diagnosis

Therapeutic Decision Making

34

(3)

Principles

Treatment under conditions of uncertainty

When the value of therapeutic choices is close

Incommensurate options

Quantitative therapeutic decision making

Cognitive Errors

37

(3)

Classification

Many errors are not strictly cognitive

The nature of cognitive errors

Cognitive biases in the laboratory

Consequences of cognitive biases

Some Cognitive Concepts

40

(3)

Cognitive science

Studying mental processes

The structure of memory

Search strategies

Characteristics of expertise

Learning Clinical Problem Solving

43

(5)

Facts vs. process

Pedagogic principles

A specific example

Learning by instantiation

Learning clinical problem solving vs. problem-based learning

Part II. Cognition at the Bedside: A Set of Examples

Introduction to the Cases

48

(1)

Diagnostic Hypothesis Generation

49

(22)

Generation of diagnostic hypotheses

Hypothesis triggering by an expert

A quick and accurate solution

A modern medical Descartes

A hit after a miss

Better late than never

Refinement of Diagnostic Hypotheses

71

(53)

The critical role of context in the diagnostic process

Strategies of information gathering

A fatal flaw in Sutton's law

Narrowing down the diagnostic options

An orderly, sequential approach

Red herrings in the history

A picture is worth a thousand words

Distinguishing among competing hypotheses

Separating the wheat from the chaff

What is a differential diagnosis?

Discrimination: The problem of look-alikes

Tolerating uncertainty

Use and Interpretation of Diagnostic Tests

124

(47)

Searching for a pony

It's what you believe that counts

Interpreting negative test results

All that glisters is not gold

Renal rescue by Reverend Bayes

An autopsy of the clinical reasoning process

Surprise!

Tripping over technology

Short-circuiting the diagnostic process

The bypass on the way to the bypass

A diagnostic fluke

The probability of a probability

Causal Reasoning

171

(16)

The case for causal reasoning

Judging causality

Post hoc, ergo propter hoc

The right answer for the wrong reason

Diagnostic Verification

187

(24)

Verification

Leaving no stone unturned

A meticulous approach

A diagnostic quandary

Diagnosis by fiat

Iron pyrite and diagnostic confirmation

Therapeutic Decision Making

211

(22)

The surgeon opts to operate: Why?

A seemingly simple decision

Treat or keep testing?

Watch and wait or operate?

An apple or an orange?

A test of clinical judgment

Cognitive Errors

233

(22)

Remedies for faulty hypothesis generation

A defective detective

Derailed by the availability heuristic

Wrong diagnosis, wrong tests, wrong treatment

Some Cognitive Concepts

255

(37)

A message about methods

Intuitive and inspirational, or inductive and incremental?

Searching for solutions

Memory: How we overcome its limitations

Diagnosis and the structure of memory

Disease polymorphism and mental models

Diagnosis and the structure of memory

Exemplars, scripts, and simulation

Knowledge and clinical expertise

Cognition and connectionism

Learning Clinical Problem Solving

292

(27)

The luxuriant language of diagnosis

Clinical cognition 101

Learning clinical reasoning from examples

Making a silk purse out of a sow's ear

Clinical problem solving at Grand Rounds

Glossary

319

(6)

Index

325

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Learning Clinical Reasoning

Summary

Table of Contents

Supplemental Materials