There have been many papers describing the differences in clinical reasoning between young and more experienced professionals. However, there is not a definitive factor to define this theoretical assumption, and, in practical terms, it is recognized that experts are more prone to a “pattern recognition” strategy or system 1, while young doctors need more time and reflection to achieve a diagnosis, following a system 2 approach (1).
The measure of the diagnostic accuracy and the final outcome
The diagnostic process is not the same in the Emergency Department, in Primary Care or inside a Hospital, above all, the time factor can be very different, but the objective is the same, to achieve a correct diagnosis and to start a proper action or treatment. What is the main difference , in my opinion, between an expert or a young doctor? I have the feeling that expert clinicians have a more complete explanation of the clinical landscape, building a comprehensive mental model of the situation of the patient, defining at the same time a diagnosis and the possible outcome. Young doctors, in contrast, have an attitude of “problem resolution” or symptom driven behaviour, before obtaining a complete mental model of the clinical problem, in an attitude that I named as “the Chinese pharmacy syndrome”, where you can find a medicinal herb for every sign or symptom of the patient, leaving the Differential Diagnosis for a second step.
The reasoning for a complete Differential Diagnosis
When an intern or a less expert doctor approach a patient with an important problem, the attitude will be to go direct to resolve the clinical problem, many times an abnormal blood test, an electrolytic disturbance or a radiographic finding such as a pulmonary consolidation. On the other hand, a more expert clinician will be more interested in the general clinical landscape and the final prognosis, based on his or her experience. Of course, this is not a black and white situation, but in my opinion, this is something that must be taken into account during the clinical teaching of interns and young doctors.
When we ask an intern for a Differential Diagnosis, we have to teach them the real meaning of this task, a real safety net for the patient and the provider, and, at the same time we are forcing them to make a mental exercise about clinical decision and prognosis.
I am not saying that the urgent control of an analytic disbalance or the treatment of a symptom such as a dyspnea is not urgent, but, in some occasions, the attention is focused in the detail and not in the whole picture.
There is no an universal rule about how to teach clinical reasoning, no rules about how to retrieve a clinical pattern, but the important clue is to have an attitude of learning from practice and improve our expertise as a continuous task through our clinical practice.
Author: Dr. Lorenzo Alonso