Diagnostic reasoning is an essential skill for all physicians. There are multiple tools to refine this skill in physicians and to teach diagnostic reasoning to learners.
The session “Strategies for Promoting Clinical Reasoning to Avoid Diagnostic Errors” sought to review these skills in depth. According to Mary Ottolini, MD, of Children’s National Medical Center, the fundamentals of diagnostic reasoning are 1) Co-selection, in which 2-3 hypotheses or diagnoses are actively considered, 2) looking at the “big picture”, and 3) analyzing the information.
Looking at the big picture includes using appropriate adjectives to describe the patient and the illness presentation in medical and efficient terms. A well worded “one-liner” can frame the patient well for the team and for the next steps in diagnosis. Careful problem representation promotes thoughtful case presentations.
Analyzing the information includes comparing and contrasting key findings. Discriminating features should be discussed and competing evidence should be acknowledged.
Illness scripts is a method of looking at an illness in its entirety as a diagnosis is approached. The four parts of an illness script are mechanism of disease, epidemiology, clinical presentation (signs and symptoms), and time course.
Presentations can include diagnostic reasoning. The PBEAR format consists of:
- P- Problem Presentation
- BE – Background Evidence
- A- Analysis (including differential diagnoses)
- R- Recommendations (including goals and plan)
- Diagnostic reasoning during case presentations is a valuable tool for patient care.
- Three fundamentals of diagnostic reasoning are 1) Co-selection of potential diagnoses, 2) looking at the “big picture”, and 3) analyzing the information.
- The PBEAR format (Problem Presentation, Background Evidence, Analysis , and Recommendations) can streamline presentations.
- Illness scripts (mechanism of disease, epidemiology, clinical presentation, and time course) are a helpful approach in diagnosis.
Dr. Hale is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston