Q J Med 2015; 108:435–442

doi:10.1093/qjmed/hcv022 Advance Access Publication 30 January 2015

Commentary

Teaching clinical medicine: the key principals

A. SCHATTNER1,2
From the 1Ethox Centre, Department of Public Health, University of Oxford, Oxford, UK and 2Faculty
of Medicine, Hebrew University Hadassah Medical School, Jerusalem, Israel

Address correspondence to A. Schattner, Ethox Centre, Department of Public Health, University of Oxford,
Rosemary Rue Building, Old Road Campus, Headington, Oxford OX3 7LF, UK. email: amischatt@gmail.com

Summary
Background: Many studies analyse the diagnostic Results: Twenty-four principles were identified
process, diagnostic errors and diagnostic excellence and each one is presented followed by a brief

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but few provide a broad, yet practical view of this
complex and highly context-dependent challenge.
Methods: A personal, experience- and research-
based selection of the principles of data collection,
processing and clinical reasoning found to be most
useful in achieving an efficient, timely and patient-
centered diagnosis.
commentary.
Conclusions: No single strategy can provide a solu-
tion for all diagnostic problems. However, the 24
principles have proven validity and can be applied
for solving diagnostic problems in varied settings
and as a scaffold in teaching diagnosis at all levels
of medical education.

Diagnosis is the vital engine that carries forward not
only the train of treatment but also health outcomes.
Acquiring the science and art of clinical diagnosis
is central to medical education, but there is no
consensus on how it should be taught. Diagnostic
problem solving is highly context dependent. The
absence of a single, universal problem-solving pro-
cess common to all cases and all physicians in-
creases the challenge facing practitioners and
educators.1 Diagnosis is often taught by clinician
educators demonstrating on current patients, but
this is usually done without attention to its general
principles. Moreover, role model clinicians teaching
diagnosis at the bedside2 have been pronounced
‘endangered species’ and are hard to come by.3
CPCs, clinical problem solving, clinical images
and other published ‘exercises’ in diagnosis provide
enlightening examples of clinical reasoning but are
often selective and present unusual patients.
Learning from diagnostic errors can be beneficial,
whether identified by autopsy studies,4 malpractice
claims,5 chart review,6 or self-reported.7 However,
these were studied in retrospect and apply to groups
only. Studies of the cognitive aspects of diagnostic
decisions based on actual8 or standardized9 patients
transformed our insight on mechanisms of bias and
diagnostic failure, but their practical implications
are uncertain. Other studies try to decipher the key
to being superior diagnosticians10,11 or the essence
of medical expertise.12 However, not many studies
address the diagnostic process as a whole, starting
from the patient encounter and data gathering,
through analysis and the basic principles of decision
making. Although some excellent books have been
devoted to diagnosis, these lengthy texts are not very
practical.13,14 For example, the advocated use of
Bayesian approach requires complex time-consum-
ing mathematics that most clinicians had rather
avoid.15 We present an experience- and research-
based overview of the major practical principles

! The Author 2015. Published by Oxford University Press on behalf of the Association of Physicians.
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436
covering all stages of the diagnostic process that can
be used as a framework in teaching as well as by
residents and clinicians in all settings.
Methods
The author has been serving as head of a large (400
admissions/month) academic department of medi-
cine for 24 years. Diagnostic principles were
derived from a long personal experience in practi-
cing, researching16 and teaching diagnostic meth-
ods to medical students, interns and residents.
Commitment to medical education has mandated
ongoing follow-up of the literature on decision
making, clinical reasoning and diagnostic
errors—an additional important influence on the
choice of principles. The author’s research in related
areas such as the intrinsic value of the history and
examination,16, 17 the non-biological aspects of dis-
ease,18 the patient–physician relationship,19 clinical
excellence20 and non-clinical influences on deci-
sion making21 have also been incorporated.
Several principles have been included after they
proved highly useful in deciphering some intriguing
problems in the past.22-28
Results
Twenty-four principles central to clinical reasoning
and diagnosis were identified. Each is briefly
described, followed by a comment.
I. The ABCD rule—Achieve the most from
the Basic Clinical Data
Methodical, personal, curiosity-driven gathering
of the patient’s narrative (all history elements, all
potential sources), followed by a systematic (yet
problem-directed) examination, often also incorpor-
ating electrocardiogram, chest X-ray and basic la-
boratory tests will likely diagnose correctly four of
five patients16,17 or suggest appropriate investiga-
tions. A sound base of knowledge and skills is a
prerequisite.10,29 Attention to the timeframe28 and
to detail, ‘the  rule’ (A. Schattner, submitted for
publication), and awareness of the operating char-
acteristics (strengths and limitations - sensitivity, spe-
cificity, likelihood ratio) of common history and
examination elements15,30 are particularly useful.
The history (and especially the reason for presenta-
tion) remains the most rewarding single source of
diagnostic information.23 Simple or recurrent prob-
lems are often amenable to a much shorter, focused
approach.
A. Schattner
*Thoroughness in data collection does not guaran-
tee accuracy in interpretation and diagnosis, but re-
mains a strong starting point.31 In addition, the more
patients are seen, the more ‘illness scripts’ are mas-
tered,32 and the more efficient would the next en-
counter be. Although shunned by some,14 the
technique can be applied after some experience
within a framework of minutes, retaining its inherent
power.
II. Record and arrange key findings using
a ‘problem list’
After recording the findings, review the data, iden-
tifying meaningful ‘clusters’ and ‘key phrases’ and
arranging them in a laconic (<100 words), com-
prehensive (all types of problems, biologic and
other), dynamic (constantly changing with new in-
formation or insight) problem list.33
*Although this step seems to slow you down, it has a
high yield for the provider ensuring a concise sum-
mary of all salient facts, a view of the whole picture
and an excellent departure for problem solving, test
selection, presentations and consultations.34 Here, a
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first attempt to grasp the gist of patient symptoms
and their meaningful connections can be made.35
III. Cherchez Les ‘red flags’
Screen your problem list giving early consideration
to potential ‘red flags’! Any high impact/high treat-
ability possible diagnoses identified, require urgent
intensive attention.26,27
* This is similar to the rule-out worst-case scenario
(‘ROWS’) principle.36
IV. Does ‘pattern recognition’ apply?—
if so, verify
Intuitive, ‘augenblick’ (‘at the blink of the eye’)
diagnosis suspected by its overall appearance
and ‘Gestalt’ based on reflexive recognition of
resemblance to previously seen cases, is often
rapid (seconds), efficient (effortless) and
accurate.37 However, it is also highly prone to bias
and errors.38
*Pattern recognition (PR) should be always be tried
first but mandates confirmation: a quick verification
stage is suggested wherein the provider mentally
compares the degree of match between disease
characteristics and mental model of the essentials
of the suspected diagnosis,32 as if written on two
overlapping transparencies. Any significant incon-
sistency may signify error and makes re-evaluation
necessary. Reliance on non-analytical reasoning
 Teaching clinical Diagnosis
tends to increase with experience but is not
limited to experts. Since even accomplished clin-
icians remain susceptible to bias,9 a further quick
‘conscious’ double-check is always essential.39
V. Identify & analyse specific features
germane to the case
Having failed PR, look for ‘specific’ features that are
both central to the case and unique. These idiosyn-
cratic clues often allow a shortlist of just a few dif-
ferential diagnoses.40 Conditions appearing under
two or more columns of ‘specific’ features are espe-
cially promising diagnostic possibilities and should
be critically evaluated by selecting appropriate
tests.24
*This variant of the usual analytical (‘hypothetico-
deductive’) (HD) method that names the main
etiologies for the patient’s presentation (usually,
4  1) following a conscious deliberate search and
slowly constructs a workup to rule out/rule in
hypotheses1 may be more effective.
VI. The rule of reflexive consultation
‘Look it up’ as a habit, as early and as often as
possible using PubMed (even Google), UpToDate,
Textbooks, as well as expert colleagues. Main con-
clusions had better be added to the patient’s chart.
Such attitude not only ensures a broad comprehen-
sive view but also informed test selection and inter-
pretation22; a learning opportunity17 and fostering
an attitude of humility and maximal care—as
opposed to overconfidence.41
*This habit also establishes the art of diagnosis as a
lifetime learning endeavor10 and is in line with
Graber’s ‘get help’ category of interventions likely
to reduce diagnostic errors.42
VII. ‘Milk’ the pretest probability
The diagnosis is often pathogenetically related to the
patient’s past predisposing factors and susceptibil-
ities (genetic, past illnesses, iatrogenic, occupa-
tional, lifestyle and other easily ascertainable risk
factors and exposures). These predispositions consti-
tute the ‘pretest probability,’ also defined as the
expected prevalence of the suspected condition in
similar patients.
*This relationship may be true even when it does not
initially seem so. Unfortunately, errors of omission
in obtaining these history elements prevail and they
may ‘surface’ only after a long circuitous and costly
detour. Thus, a quick but comprehensive survey of
predispositions (which may be unapparent at first)
437
had better be given priority and carefully con-
sidered23,28 before ‘unrelated’ conditions arising de
novo.
VIII. Could it be iatrogenic?
Take a moment to consider the possibility that the
patient’s medications (possibly ‘over the counter’ or
‘natural’ preparations) or past medical interventions
underlie the current symptoms, signs or abnormal
laboratory tests.
*This particular brand of ‘pretest probability’ is par-
ticularly common, comprising the main diagnosis in
up to 19% of hospital admissions43 and a similarly
significant proportion of primary care consultations.
IX. Try ‘Occam’s razor’—the law of
parsimony
Consider the possibility of a single unifying diagno-
sis that may account for all (or most) clinical find-
ings, before resorting to multiple concurrent
different explanations (so-called Saint’s triad).44
*Today’s elderly patients with multimorbidity and
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polypharmacy may easily have more than one
operative problem, but still, Occam’s law often
applies.25
X. The ‘law of imperfection’: prevalent
‘partial’ presentations
Do not expect to find a perfect set of symptoms,
signs and tests characterizing a given condition in
order to make a diagnosis. Any combination may
occur and sometimes even a single symptom and
sign may suggest the correct diagnosis.
*Complete presentations are most commonly found
in textbooks and are not necessary for diagnosis.
XI. Is there a tenable alternative?
Finding (or being unable to find) a tenable alterna-
tive diagnosis is of paramount importance in the
diagnostic considerations.
*Any ‘Key’ symptom or sign must be explainable by
the diagnosis. A potential alternative explanation
detracts, whereas its absence may strongly support
it even in the absence of a typical confirmatory test
(few tests are 100% sensitive).
XII. The dog that did not bark in the
night. . .
We are all tuned primarily toward positive findings
and preoccupied with their importance. However,
what is not found is often as important—useful in
438 A. Schattner
ruling out diagnoses (by absent key findings) or,
even more significant, in drawing attention to an
expected but absent feature as a potential specific
diagnostic clue.
*Do not look only at the half-full glass. The empty
half may be as revealing.
XIII. What is it?—Or what it is not!
Sometimes it is sufficient (and much more useful) to
determine that a given presentation is not one of
several significant and ominous possibilities. To be
able to state its exact cause is occasionally a hard
and not cost-effective task (e.g. syncope, headache,
low back pain, etc.).26,27
*Uncertainty is the ‘bread and butter’ of the diagnos-
tic process and a degree of tolerance had better be
adopted. This is true provided ‘red flags’ are effect-
ively excluded. Under such circumstances, time
may be a powerful, safe and frugal diagnostic tool
(strategy of ‘watchful waiting’ or the ‘test of time’):
patients may either get well spontaneously or the
diagnosis will become more obvious.45
XIV. Be aware of common biases leading
to diagnostic errors
Several common cognitive biases need recognition
and attention, since they precipitate pitfalls in diag-
nosis, especially when using the intuitive PR mode.
Dozens of biases have been identified, including:
considering recent, memorable, easily recalled diag-
noses or those in your field of expertise as more likely
(‘Availability bias’, ‘Recall bias’); preferring data
that support it, excluding contradictory material
(‘Confirmation Bias’; ‘Anchoring’); tendency to stop
considering alternatives and sticking to your diagno-
sis (‘Premature closure’); tendency to rule out a
common disease presenting without its prototypical
features (‘Representativeness bias’); pursuing rare but
more exotic diagnoses (‘Base rate neglect bias’); let-
ting emotion influence your reasoning (‘affective
bias’); and endless testing to exclude even highly un-
likely possibilities (‘Uncertainty angst’).
*Unfortunately, there is no good evidence that
awareness may prevent diagnostic mistakes due to
common biases.46 Nevertheless, until we know
more on strategies effective in cognitive debiasing,
enhanced reflection on our diagnostic reasoning37
and critical thinking need to be encouraged.
XV. Mind interfering context factors
Contextual factors (such as language barrier, emo-
tional volatility, bias vs. patient characteristics, effect
of the encounter setting) are common and may re-
quire additional attention so that diagnosis will not
be adversely affected.47
*Situation-related factors which tend to influence
and may skew clinical reasoning process must be
recognized and acknowledged.
XVI. Maintain fluidity in clinical reasoning
For complex problems, remember to examine, re-
construct and reformulate hypotheses as data are
obtained and the case evolves.
*’Premature closure’ remains one of the most
common and unyielding errors in diagnosis.6,34
XVII. Think of ‘robbins’
Once any past diagnosis is encountered, think in
terms of the renown pathology textbook:
Backwards—What caused it? Forward—What does
it cause? And Present—How is it being treated? Can
it be linked to the present illness?
Think of the complex patient in terms of which
anatomical systems are involved (e.g. gastrointes-
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tinal tract [GIT], peripheral nervous system [PNS],
myocard) and what pathogenetic mechanisms
might apply (e.g. infectious, inflammatory,
neoplastic).
*This type of evaluation is much better than erratic
‘name dropping’ of many different possible
diseases . . . Both anatomical systems and pathogen-
etic mechanisms can be further subclassified (e.g.
GIT—small bowel; PNS—autonomic; myocard—
diastolic dysfunction; or: Infectious—viral, bacterial,
protozoal, etc.). Maintain healthy skepticism: do not
take prior diagnoses for granted but take time to
briefly check their ‘solidity’ (validity).
XVIII. Invest time!
Some diagnostic problems require more effort and
are inherently time consuming. Unless urgent, slow
down, consult, reflect, schedule another appoint-
ment if necessary.36
*Discern as quickly as possible between the straight-
forward and the complex. The latter will not be de-
ciphered without appropriate time allocation.
Complex diagnostic problems are more likely to rep-
resent atypical presentation of the more common
diseases that should be considered before rare ones.
XIX. Consider using the ‘test of treatment’
Failure to respond to treatment as expected may be
a clue to diagnostic error. More often, a probable
but uncertain single diagnosis may be resolved by
 Teaching clinical Diagnosis
‘test of treatment’ (e.g. edrophonium in myasthenia;
low-dose corticosteroids in polymyalgia rheuma-
tica). Also, clinical deterioration after discontinu-
ation of an empiric treatment may suggest its
appropriateness.
*Provided it is used sparingly and interpreted vs. a
predetermined objective measurement, the ‘test of
treatment’ may be a useful adjunct to diagnosis in
selected cases.48
XX. Back to Step 1?
In case the diagnosis remains obscure despite pro-
longed and extensive workup, personally repeating
the complete patient’s history and examination may
point the clinician in the right direction and resolve
the difficulty.
*Rather than repeating sophisticated imaging studies
that have already proved non-contributory, going
back to the basics with a fresh mind may be more
rewarding.23–25
XXI. If unwell . . .
In a ‘bad’ day (of feeling unwell, fatigued, or burn-
out)—take extra care or preferably step aside (if you
can), for recreation and ‘recharge’.49
*Persisting despite temporary incapacity is a recipe
for mistakes.50
XXII. Ensure ‘tracking’ & feedback
Make a habit of regularly obtaining feedback on
your diagnostic performance by comparing your
findings and thoughts with test results and ‘tracking’
your patients’ subsequent course. Retain continuous
mindfulness and reflection on your performance.
*Providers often overrate their performance.41,51,52
A habit of tracking and feedback ensures that no
abnormal results are disregarded7 and that mistakes
are recognized, encouraging a continuous learning
curve, improvement of performance12 and decrease
in future diagnostic errors.53
XXIII. Avoid ‘tunnel vision’—be holistic
Commitment to diagnosis does not end with the
patient’s primary complaint: heed any potential
problem that may affect the patient’s health in the
future.16 Also, diagnosis does not end with biolo-
gical disease: attention to prevalent emotional fac-
tors (such as depression, anxiety, stress) may reveal
important risk factors and further active diagnoses.17
*Relating to one major condition at the expense
of others is a common form of neglect54–56 and so
439
is disregard of the patient’s psychological status, an
inseparable and influential feature of illness.17
XXIV. Respect, show empathy, share,
support
The diagnostic process may occasionally be pro-
longed and creates an ordeal for the patient too.
Throughout, be truthful to your patient, even when
in doubt or in need to consult a colleague or infor-
mation source. Once the diagnosis is established
and verified, communicate it to the patient/family
without delay, providing information, answering
questions—but stressing positive aspects and main-
taining hope.19
*Sharing and support are essential components
of the diagnostic journey and of patient-centered
care.57
Discussion
Accurate, comprehensive and timely diagnosis is
central to patient care and a major determinant
of health outcomes. However, cases of delayed,
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missed and erroneous diagnosis are common with
an incidence of 10–20%.4,37,58 This significant rate
of diagnostic failures is confirmed by surveys59 and
research60 and remains disappointingly persistent
despite all advances in medicine.
Many factors appear to be responsible, including
the complexity of the diagnostic process1; time con-
straints61; susceptibility of even the most sophisti-
cated tests to false (positive or negative) results62
that is underappreciated by physicians4; prevalent
bias and cognitive errors63; context variability and
shortcomings in teaching. Findings from research on
physicians’ diagnostic reasoning have not yet been
sufficient to determine how clinical diagnosis
should be taught.64
Most of the literature on diagnosis focuses on the
performance of the analytic (HD) method vs. the
intuitive, subconscious, non-analytic (PR) method
(‘‘dual processing’’) and the merits of their combined
use which is strongly advocated.37,39,65 Another
centrepiece is the cognitive aspects of clinical rea-
soning and contribution of bias to diagnostic errors.
Other texts provide a mathematical basis for the in-
formed use of history elements, physical findings
and test results.14 However, providers have paucity
of data and a limited capacity for detailed numerical
analysis.15 Few have addressed the diagnostic pro-
cess as a whole continuous process, providing
advice on its general, widely applicable principles.
We have made a personal, experience- and re-
search-based selection of 24 basic principles of the
440
Table 1. The 24 practical principles of clinical
diagnosisa
I. The ABCD rule—Achieve the most from the
Basic Clinical Data
II. Record and arrange key findings using a ‘prob-
lem list’
III. Cherchez Les ‘red flags’
IV. Does ‘pattern recognition’ apply?—if so, verify
V. Identify & analyse specific features germane to
the case
VI. The rule of reflexive consultation
VII. ‘Milk’ the pretest probability
VIII. Could it be iatrogenic?
IX. Try ‘Occam’s razor’—the law of parsimony
X. The ‘law of imperfection’: prevalent ‘partial’
presentations
XI. Is there a tenable alternative?
XII. The dog that did not bark in the night . . .
XIII. What is it? Or what it is not!
XIV. Be aware of common biases leading to diag-
nostic errors
XV. Mind interfering context factors
XVI. Maintain fluidity in clinical reasoning
XVII. Think of ‘robbins’
XVIII. Invest time!
XIX. Consider using the ‘test of treatment’
XX. Back to Step 1?
XXI. If unwell . . .
XXII. Ensure ‘tracking’ & feedback
XXIII. Avoid ‘tunnel vision’—be holistic
XXIV. Respect, show empathy, share, support
a in complex ones (I, XIII and XVIII). Quite a few of the
Principles IV and V refer to the two basic (reflexive vs.
analytical) methods of reasoning. Principles I, VI and XXIII
are of prime importance, whereas XXIII and XXIV highlight
an essential commitment toward the patient and family
that is inseparable from the diagnostic process.
diagnostic process (Table 1) that may be used in
teaching this science and art as well as in practice.
Only 2 of 24 principles cover the basic aforemen-
tioned methods (IV and V) but contain important
modifications. First, since PR is so vulnerable to a
myriad of biases and cognitive errors,37 a brief man-
datory verification step is suggested and added
for confirmation.46 It is intended as a cautionary
measure and unlikely to detract much from the
swiftness and elegance of PR. Second, the usual
HD method was preceded by an alternative analyt-
ical approach based on identification of a few spe-
cific features of the patient’s problem, working out
their short differential diagnosis and concentrating
on the few entities that may account for all. Only
if these fail, the usual HD method is recommended
(i.e. listing the differential of each major symptom or
sign and testing accordingly).
A. Schattner
Not all of the 24 principles discussed were
created equal. Except for the two basic methods,
the most crucial techniques in our experience are
ABCD—Achieving the most from the Basic Clinical
Data (I)16; Reflexive Consultation and learning
(VI)10; and assuming Holistic commitment for com-
prehensive patient care (XXII).57 These three quint-
essential principles ensure the numerous benefits of
a clinically based approach17; a whole, patient-cen-
tered view of the patient’s health57; and an attitude
of humility, optimal care and lifelong learning, as
opposed to overconfidence.41 Other principles re-
inforce the weight of the patient’s pre-existing risk
factors and susceptibilities in the pathogenesis of a
new diagnosis (VII and VIII) and underline the value
of more reflection and introspection (XIV, XV and
XX) and of regular follow-up and feedback (XXII).
Both approaches are essential not only for reducing
diagnostic error but also for continued improvement
and learning. Adopting a systematic, methodical
modus operandi is an additional theme with
myriad benefits that we believe and translate into
improved diagnostic skills (I, II and XVII). Further
principles stress the inherent values in diagnosis
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of selected practical logic laws (IX–XIII); consider
unique, personal patient-related factors (XV and
XXIV); as well as providers’ factors (XXI). Other prin-
ciples highlight the element of time as both a valu-
able diagnostic clue by itself, a diagnostic policy in
non-urgent problems and an obligatory investment
principles can be particularly useful for patients who
present a major diagnostic challenge (V, X, XIII and
XVII–XX).
Thus, the 24 principles have the potential to
become useful in teaching and as a reminder to
practicing clinicians in hospitals and primary care.
Interestingly, they conform to the SOAPS mnemonic
summarizing the essential ingredients of excellent
clinicians: being Systematic and orderly; using
Observation and listening as the basic skills;
Accessing databases; being ‘Personal’; and provid-
ing Shared decision making and patient-centered
care.20
The strength of the study is in the derivation of the
principles from both long-term personal experience,
research and the current literature. Their usefulness
for solving diagnostic problems has been repeatedly
demonstrated in bedside teaching rounds and con-
sultations, and has occasionally been published.22-28
They can be easily applied to daily patient care, pro-
viding practical guidance on information gathering,
processing and diagnostic decision making.
Limitations include the entirely subjective selection
process and lack of validation in controlled studies.
Diagnostic errors, although little discussed in the
 Teaching clinical Diagnosis
renown Institute of Medicine report,66, continue to
pose a significant danger to patient safety and the
quality of care.67 Teaching and practice of the 24
principles may facilitate timely, high-quality clinical
reasoning and diagnosis. Their potential to reduce
diagnostic error remains to be examined in future
research.
Conflict of interest: None declared.
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