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ABG
Clinical Reasoning
SECOND EDITION

Edited by Nicola Cooper and John Frain

WILEY Blackwell
Clinical Reasoning
Clinical
Reasoning
2nd Edition
EDITED BY

Nicola Cooper
Consultant Physician & Clinical Associate Professor in Medical Education
Medical Education Centre
University of Nottingham, UK

John Frain
General Practitioner & Clinical Associate Professor
Director of Clinical Skills
Division of Medical Sciences & Graduate Entry Medicine
University of Nottingham, UK
This edition first published 2023
© 2023 John Wiley & Sons Ltd

Edition History
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Names: Cooper, Nicola, editor. | Frain, John (John Patrick James), editor.
Title: ABC of clinical reasoning / edited by Nicola Cooper, Consultant Physician & Clinical Associate Professor in
Medical Education, Medical Education Centre, University of Nottingham, UK, John Frain, General Practitioner & Clinical Associate
Professor, Director of Clinical Skills, Division of Medical Sciences & Graduate Entry Medicine, University of Nottingham, UK.
Description: 2nd edition. | Hoboken, NJ, USA : John Wiley & Sons, Inc., 2023. | Includes bibliographical references and index.
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Subjects: LCSH: Medical care--Decision making. | Medical care--Quality control. | Diagnostic errors. | Evidence-based medicine.
Classification: LCC RA399.A1 A215 2023 (print) | LCC RA399.A1 (ebook) | DDC 362.1--dc23/eng/20221007
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Contents

Contributors, vi
Preface (Second Edition), vii
1 Introduction to Clinical Reasoning, 1
Nicola Cooper and John Frain
2 Evidence-based History and Examination, 7
John Frain
3 Choosing and Interpreting Diagnostic Tests, 17
Nicola Cooper
4 Problem Identification and Management, 23
Nicola Cooper and John Frain
5 Shared Decision-making, 29
Anna Hammond and Simon Gay
6 Models of Clinical Reasoning, 35
Nicola Cooper
7 Cognitive Biases, 41
Nicola Cooper
8 Situativity and Human Factors, 47
Nicola Cooper
9 Metacognition and Cognitive Strategies, 53
Pat Croskerry
10 Teaching Clinical Reasoning, 61
Nicola Cooper and Mini Singh
Index, 71
 Contributors

Nicola Cooper Simon Gay

MBChB MMedSci FRCPE FRACP FAcadMEd SFHEA MBBS MSc MMedEd FRCGP SFHEA
Consultant Physician and Clinical Associate Professor in Medical Education Professor of Medical Education (Primary Care)
Medical Education Centre, University of Nottingham, UK University of Leicester School of Medicine, UK

Pat Croskerry Anna Hammond

MD PhD FRCP(Edin) MBChB DRCOG FRCGP MClinEd SFHEA
Director, Critical Thinking Program General Practitioner and Academic Lead for Clinical Skills and Reasoning
Division of Medical Education, Dalhousie University, Canada Hull York Medical School, UK

John Frain Mini Singh

MBChB MSc FRCGP DGM DCH DRCOG PGDipCard SFHEA MBChB MMEd FRCP PFHEA
General Practitioner and Clinical Associate Professor Professor of Medical Education and Honorary Consultant Dermatologist
Director of Clinical Skills University of Manchester, UK
Division of Medical Sciences and Graduate Entry Medicine
University of Nottingham, UK

vi
 Preface (Second Edition)
Excellence in clinical practice is not just about good knowledge,
skills, and behaviours. As fellow author Pat Croskerry points out,
how doctors think, reason, and make decisions is arguably their
most critical skill. While medical schools and postgraduate
training programmes teach and assess the knowledge and skills
required to practice as a doctor, few currently offer comprehensive
training in clinical reasoning and decision making. This matters
because studies show that diagnostic error is common and results
in significant harm to patients, and the majority of the root causes
of diagnostic error involve errors in clinical reasoning.
Clinical reasoning is complex and takes years to learn. Most of
the time it is learned implicitly and in an ad hoc fashion. In this
book, we have made it explicit, broken down into its core compo-
nents. This book is designed to be an introduction for individuals
and also an up-to-date resource for teachers and curriculum plan-
ners. Each chapter describes a component of clinical reasoning
and its applications for clinical practice, teaching, and learning.
This second edition has been extensively re-written and updated,
and key references and further resources have been included for
readers who want to explore topics in more detail.
Clinical reasoning is relevant to every clinical specialty in every
setting, and it is not confined to medical students and doctors –
we have written this book with advanced clinical practitioners
and other clinicians in mind as well. We hope you enjoy reading it
as much as we enjoyed re-writing and editing it.
Nicola Cooper
John Frain
 CHAPTER 1
Introduction to Clinical Reasoning
Nicola Cooper and John Frain
OVERVIEW
• Clinical reasoning describes the application of knowledge to
collect and integrate information from various sources to arrive at
a diagnosis and/or management plan
• A lack of clinical reasoning ability has been shown to be a major
cause of diagnostic error
• Several components of clinical reasoning have been identified
• Expertise in clinical reasoning develops as a result of different
types of knowledge plus some other important factors
• Clinical reasoning can be viewed from different perspectives that
each give insights into how it can be taught and learned and why
it goes wrong
Introduction
Fellow author, Pat Croskerry, argues that although there are sev-
eral qualities we would look for in a good clinician, the two abso-
lute basic requirements for someone who is going to give you the
best chance of being correctly diagnosed and appropriately
managed are these: someone who is both knowledgeable and a
good decision maker. At the time of writing, medical schools and
postgraduate training programmes teach and assess the knowledge
and skills required to practice as a doctor, but few offer a compre-
hensive curriculum in decision-making. This is a problem because
how doctors think, reason, and make decisions is arguably their
most critical skill [1].
This book covers the core components of clinical decision-
making – or clinical reasoning. It is designed for individuals but
also for teachers and learners as part of a curriculum in clinical
reasoning. Chapter 10 specifically covers teaching clinical
reasoning in undergraduate and postgraduate settings. In this
chapter we define clinical reasoning, explain why it is important,
and introduce some of the different components of clinical
reasoning that are explored in this book. We will consider how
expertise in clinical reasoning develops, and also look at clinical
reasoning through different lenses.
ABC of Clinical Reasoning, Second Edition. Edited by Nicola Cooper and John Frain.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
Definitions
Clinical reasoning describes the application of knowledge to col-
lect and integrate information from various sources to arrive at a
diagnosis and/or management plan for patients [2]. It is a com-
plex cognitive process involving clinical skills, memory, problem-
solving, and decision-making. A definition of clinical reasoning is
given in Box 1.1.
As the definition in Box 1.1 states, clinical reasoning can be
defined as a skill, process, or outcome and multiple components
of clinical reasoning have been identified. However, for teachers
and learners, it can be useful to think of clinical reasoning as a
process made up of different components, each of which requires
specific knowledge, skills, and behaviours. The UK Clinical
Reasoning in Medical Education group has defined five broad
areas of clinical reasoning education [3]:
1. History and physical examination
2. Choosing and interpreting diagnostic tests
3. Problem identification and management
Box 1.1 A definition of clinical reasoning
‘Clinical reasoning can be defined as a skill, process, or outcome
wherein clinicians observe, collect, and interpret data to diagnose
and treat patients. Clinical reasoning entails both conscious and
unconscious cognitive operations interacting with contextual
factors. Contextual factors include, but are not limited to, the
patient’s unique circumstances and preferences and the characteris-
tics of the practice environment. Multiple components of clinical
reasoning can be identified: information gathering, hypothesis
generation, forming a problem representation, generating a
differential diagnosis, selecting a leading or working diagnosis,
providing a diagnostic justification, and developing a management
or treatment plan. A number of theories (e.g., script, dual process,
and cognitive load theories) from diverse fields (e.g., cognitive
psychology, sociology, education) inform research on clinical
reasoning.’
From Daniel et al. (2019). Acad Med; 94(6): 902–12.
2 ABC of Clinical Reasoning
Figure 1.1 Five broad areas of clinical reasoning education. Clinical
reasoning concepts include key theories (e.g., script, dual process), how
clinical reasoning ability develops, the problem of diagnostic error, the role of
clinical reasoning in safe and effective care for patients, cognitive errors, and
other factors that may impair the clinical reasoning process or outcome.
4. Shared decision-making
5. Clinical reasoning concepts
In this second edition, we have used this framework and explore
each of these areas (see Figure 1.1) in more detail.
Why Is Clinical Reasoning Important?
Diagnostic errors tend to occur in common diseases and are a
significant cause of preventable harm to patients worldwide [4]. It
has been estimated that diagnosis is wrong 10–15% of the time
[5]. Post-mortem studies consistently find undiagnosed disease
as the cause of death in 10–20% of patients, of which half could
have been successfully treated [6]. Diagnostic error is by far the
leading source of paid malpractice claims in the UK, and diag-
nostic error has been identified as a high-priority patient safety
problem by the World Health Organization.
A lack of clinical reasoning ability has been shown to be a
major cause of diagnostic errors which can result in unnecessary
pain, treatments, or procedures, and increase the costs of health-
care [2]. There are many reasons why diagnostic errors occur. A
comprehensive review of studies of misdiagnosis assigned three
main categories, shown in Box 1.2. However, faulty synthesis of the
available information was found to be the most common reason
for diagnostic errors leading to death and serious harm [7]. In
other words, the clinician had all the information to make the
right diagnosis but made the wrong diagnosis. There is a growing
consensus that medical schools and postgraduate training pro-
grammes need to do more to teach clinical reasoning in an explicit
and systematic way. The National Academy of Medicine’s report
Improving Diagnosis in Health Care [8] found that diagnosis and
diagnostic errors have been largely unappreciated in efforts to
improve the quality and safety of healthcare and called for cur-
ricula to explicitly address teaching the diagnostic process, using
educational approaches that are aligned with evidence from the
learning sciences.
Diagnostic error definitely causes harm, but increasing attention
is also being paid to another problem which can be caused by
faulty clinical reasoning – the harm caused by unnecessary tests
and overdiagnosis. A study of over one million Medicare patients
in the USA looked at how often people received one of 26 tests or
treatments deemed by scientific and professional organisations to
be of no benefit [9]. These included things like brain imaging in
syncope, screening for carotid artery disease in asymptomatic
patients, and imaging of the spine in low back pain with no red
flags. In one year, at least 25% of patients received at least one of
these tests or treatments. It has been estimated that at least 20% of
healthcare spending is waste [10]. This waste has a huge impact on
patients and the wider healthcare economy. Overdiagnosis occurs
when people without relevant symptoms are diagnosed with a dis-
ease that ultimately will not cause them to experience symptoms
or early death. There are many factors contributing to overdiagno-
sis (see Box 1.3), but one of them is the increasing availability of
increasingly sensitive tests.
The growing recognition of the problem of diagnostic error,
unnecessary tests, and overdiagnosis is why clinical reasoning is
Box 1.2 Categories of misdiagnosis
Error category Examples
No fault Unusual presentation of a disease
Missing information
System errors Technical, e.g. unavailable tests/results
Organisational, e.g. poor supervision of junior
staff, error-prone processes, impossible workload
Human Faulty data gathering
cognitive error Inadequate reasoning
Adapted from Graber ML et al., 2005 [7].
Box 1.3 Factors contributing to overdiagnosis
• Screening programmes that detect ‘pseudodisease’ – disease in a
person without symptoms in a form that will never cause
symptoms or early death
• Increasingly sensitive tests
• Greater access to scanning – diagnostic scanning of the head and
body reveals incidental findings in up to 40% of those being
scanned for other reasons, often leading to anxiety and further
testing for an abnormality that would never have caused harm
• Widening definitions of disease and lower treatment thresholds,
for example:
• Chronic kidney disease
• High cholesterol
• Attention-deficit hyperactivity disorder
• Cultural considerations – medicalisation, commission bias (better
to do something than nothing), fear of litigation
• Individual clinicians’ lack of understanding of statistics relevant to
the disease, diagnostic test, and intervention in question
Adapted from Moynihan R. Preventing overdiagnosis: how to stop
harming the healthy. BMJ 2012; 344: e3502.

of such interest to researchers, medical educators, and policy
makers. Improving clinical reasoning outcomes is a patient safety
and healthcare economy priority.
Components of Clinical Reasoning
Several components of clinical reasoning have been identified. A
fundamental one is the application of knowledge to gather and
interpret data in the patient’s history and physical examination.
The purpose is to establish the clinical probability of disease – a
judgement based on the clinician’s knowledge of epidemiology
and what we call evidence-based history and physical examination,
a topic which we explore in Chapter 2. The clinical probability of
disease is a prerequisite for choosing and interpreting diagnostic
tests. Interpreting diagnostic tests is something even qualified
health professionals find difficult [11]. This is because tests lie;
very often, tests give us test probabilities, not real probabilities,
which is why test results have to be interpreted by knowledgeable
clinicians, a topic which we explore in Chapter 3.
Problem representation is something that is neglected in tradi-
tional ‘history–examination–differential diagnosis’ teaching
methods, but studies show that being able to represent the problem
before attempting to solve it (i.e., think of a diagnosis) is a key step
in problem-solving, and dramatically increases diagnostic accu-
racy, especially in more complex cases [12]. This is a skill that can
be learned, and a topic which we explore in Chapter 4.
Clinical reasoning often takes place within teams. Clinicians
also make use of guidelines, scores and decision aids, and co-pro-
duce decisions with patients and carers. The important topic of
shared decision-making is explored further in Chapter 5.
Simply knowing about clinical reasoning concepts does not
help people reason better. But it is important for clinicians,
teachers, and learners to have a shared definition, vocabulary and
understanding of clinical reasoning in order to facilitate mean-
ingful discussion and learning. Models of clinical reasoning can
be useful to help us understand the processes underpinning our
decision-making – as clinicians, teachers, and learners. Chapter 6
explores dual process theories which are widely accepted as a
framework with which to understand diagnostic reasoning and
diagnostic error. Some common misunderstandings are identi-
fied, and we explore critical thinking, rationality, the different
types of knowledge used by Type 1 and Type 2 processing, and
thinking about one’s own thinking (metacognition).
The topic of cognitive biases in clinical reasoning is controver-
sial. This is partly because there are several key fallacies in the
received view of dual process theories. There is definitely
agreement that cognitive biases exist in medicine, but disagree-
ment as to whether they are a significant source of diagnostic
errors compared with knowledge deficits. Chapter 7 explores this
topic further using a case history and analysis.
Clinical reasoning does not exist solely inside a clinician’s
organised cognitive structures but is entangled in the activity of
providing care for the patient [13]. Chapter 8 explores ‘situativity’
and human factors (the science of the limitations of human
performance). ‘To err is human’, therefore in order to minimise
Introduction to Clinical Reasoning 3
errors, we need to focus on improving processes, systems, and
technology, as well as education and training in cognitive strat-
egies. Pat Croskerry explores metacognition and cognitive strat-
egies further in Chapter 9.
Finally, we look at teaching clinical reasoning in Chapter 10.
There is no evidence that teaching clinical reasoning concepts
alone, or short courses, improves clinical reasoning ability. The
most effective way to teach clinical reasoning is to use strategies
that build knowledge and understanding, and to practice with as
many different cases as possible in as many different contexts as
possible with coaching and feedback. We explore key concepts in
teaching clinical reasoning, specific evidence-based strategies
that teachers can use, and describe one approach to introducing a
clinical reasoning curriculum at undergraduate level.
How Does Expertise in Clinical Reasoning
Develop?
If how clinicians think, reason, and make decisions is arguably their
most critical skill, it is useful to consider how expertise in clinical
reasoning develops. In the 1970s, expertise in medicine was thought
to be related to superior general thinking skills. However, when
researchers observed experts and novices, they found there was no
difference in the processes or thinking strategies used – both
quickly came up with one or more diagnostic hypotheses which
guided the search for further information. Experts were more accu-
rate because they knew more, and because the knowledge of experts
varied from case to case, their performance varied from case to case
as well [14]. This led to researchers changing direction and exam-
ining the role of knowledge in medical expertise.
One of the next questions for researchers was, do experts have
bigger, better memories? The answer was no – given unlimited
time, novices can remember as much as experts about a clinical
case on paper. But experts appear to acquire information more
efficiently and pay attention to more critical information (you
have probably seen this in action). In a series of well-known
experiments, Chase and Simon showed chess players of varying
strength – from master to novice – chessboards set up as if in the
middle of a game for only 5 seconds and then asked them to
reconstruct the position of 28 pieces on a blank chessboard imme-
diately afterwards. What they found was the chess masters showed
a remarkable ability to reconstruct the board almost perfectly,
whereas the novices could only recall the position of four or five
pieces. However, when the experiment was repeated with the
chess pieces arranged randomly, chess masters performed no
better than anyone else [15]. Chase and Simon concluded that
chess masters had stored in memory a large number of recogni-
sable ‘chunks’, or meaningful patterns (see Box 1.4). Similar results
have been found in other fields – experts can reconstruct a briefly
examined scene provided it portrays a realistic (as opposed to
random or meaningless) pattern. But pattern recognition by itself
does not explain expertise. Non-chess players can be trained to
memorise chess patterns. Experts recognise patterns of high sig-
nificance because of their formal as well as experiential knowledge
of chess – in other words, they study [16].
4 ABC of Clinical Reasoning
We know that knowledge is fundamental to expertise in clinical
reasoning. (As we will see in Chapter 6, other things matter as
well.) But by knowledge, we do not mean only facts. That is like
saying the raw ingredients are the same as the cake. Figure 1.2
refers to different types of knowledge; all these types of knowledge
matter in clinical reasoning.
With learning, the process of chunking and automating, as
described in Box 1.4, frees up mental resources. The difference
Metacognitive
• Knowledge of cognition in general as well as
awareness of one’s own cognition
Procedural
• How to do something, methods of inquiry, and
criteria for using skills, algorithms, techniques, and
methods
Conceptual
• The inter-relationships among the basic elements
within a larger structure that enable them to
function together
Factual
• The basic elements learners must know to be
acquainted with a discipline or solve problems in it
Figure 1.2 Different types of knowledge. Adapted from: A model of
learning objectives–based on: a taxonomy for learning, teaching, and
assessing: a revision of Bloom’s Taxonomy of educational objectives by Rex
Heer, Center for Excellence in Learning and Teaching, Iowa State University.
https://www.celt.iastate.edu/teaching/effective-teaching-practices/
revised-blooms-taxonomy (accessed April 2022).
Box 1.4 Chunking and automating: how we can think more
complex thoughts
Human working memory can only process a limited number of
elements at a time. But not all elements are created equal. The
elements of information stored in our long-term memory increase in
complexity over time, with smaller elements combining to form
larger ones. This process is called ‘chunking’ and it is what allows us
to think more complex thoughts.
For example, a child who has not yet learned the alphabet will see
the letter ‘H’ as three straight lines. Reproducing these three straight
lines correctly could be a cognitively demanding task. Over time,
they will chunk and automate drawing the letter ‘H’ until it becomes
effortless. Once they have mastered individual letters, whole words
will still be new to them. The word ‘H, o, u, s, e’ will consist of five
separate elements. But over time, this will be chunked as the word
‘House’ in long-term memory which can then be read and written
effortlessly.
Chunking and automation is a result of learning. Experts store
knowledge in long-term memory as rich chunks called schemas
which allows them to overcome the limitations of working memory
when solving problems. (See Chapter 10 for information on how
teachers can facilitate the process of schema formation.)
Adapted from Lovell O. Sweller’s cognitive load theory in action. A
John Catt Publication, 2020. pp. 20.
between normal learning and expert learning is what people do
with those freed up resources. People who become experts rein-
vest their mental resources in further learning. They seek out
more difficult problems. They tackle more complex representa-
tions of common problems. They continue to work at the edge of
their competence [17].
In summary, we know that expertise in clinical reasoning is
highly dependent on knowledge, but that is not the whole story.
We will explore this further in Chapters 6 and 10.
Clinical Reasoning through Different
Lenses
At its most basic level, clinical reasoning is to do with knowledge,
how knowledge is organised in long-term memory as mental rep-
resentations, and the cognitive processes responsible for storing,
transforming, and retrieving these. This view of clinical reasoning
is important for learners, who must have a) a deep foundation of
factual knowledge, b) understand facts and ideas in a conceptual
framework, and c) organise their knowledge in a way that facili-
tates retrieval and application. (The latter two points are why we
need expert teachers.) However, clinical reasoning is also
something that is ‘situated’ in the environment. Thinking and
learning is context-dependent, the result of multiple dynamic
interactions between individuals and the environment. Cognition
is also distributed in team members and in non-humans (e.g.,
computers). It can be adversely affected by poorly designed tech-
nology and systems, as well as sleep deprivation, fatigue, and
excessive workload. Understanding clinical reasoning through
this lens is important too. But sometimes we need to be able to go
beyond the ‘content’ and make sense of the patient’s illness (and
our own response to it) and understand the practice of medicine
in its wider socio-cultural context. This is what we sometimes call
the ‘art’ of medicine, which involves crafting a wise and deliberate
course of action appropriate for the circumstances and may not
involve any technical decision-making at all. Clinical reasoning
through this lens is often what postgraduates are able to start
practicing once their mental resources are freed up from focusing
on the technical aspects of medicine. Many studies demonstrate a
correlation between effective clinician–patient communication
and ‘whole person care’ with improved health outcomes. An
example of this is given in Box 1.5.
Listen to Me; I Am Telling You My Diagnosis
Whatever their level of health literacy, no patient is an empty
vessel devoid of knowledge or insight about their own condition.
By presenting to a clinician, patients have often engaged in their
own reasoning and formulated ideas about a diagnosis or even
several diagnoses. The patient’s perspective is not simply a psy-
chosocial one but may include relevant insights into anatomical
and physiological changes and pathology (see Box 1.6). This does
not mean they are always correct – that is why they attend a clini-
cian – but neither is their perspective irrelevant.
While the clinician arrives at a differential diagnosis (and/or
problem list) following the history, or patient interview, the patient
arrives with their own differential diagnosis (and/or problem list).

Box 1.5 The importance of whole person care
Two patients had similar symptoms. They were experiencing
transient numbness of different parts of the body – one side of the
face or the other, sometimes the arm or hand. These symptoms
were causing a great deal of anxiety. The patients went to see two
different physicians.
The first patient told his story. At the end of the consultation the
physician said, ‘Well you’ve either got migraine or multiple sclerosis
so we’ll do an MRI scan and I’ll let you know the results.’ He was
not given a further appointment. While waiting for his MRI scan, his
anxiety and symptoms increased significantly.
The second patient told her story. Recognising that these
symptoms are common in stress and did not fit any neurological
pattern, the physician said, ‘I see lots of people with these
symptoms and very often it’s because they are working too hard,
not sleeping, or under stress. Even though they might not realise
they are stressed, their body is telling them they’re stressed. Tell me
about your schedule and what’s going on in your life.’ The patient’s
husband looked at her knowingly and sure enough there were lots
of stressors related to work and home that had been an issue. An
MRI scan was arranged, but the patient was advised to make
changes to her lifestyle and her symptoms resolved.
Both patients had normal MRI scans. Explanation and good
communication lead to better outcomes, greater compliance with
recommended treatments, and less re-attendances.
Box 1.6 A patient-centred approach to differential diagnosis
Agreeing the differential diagnosis
Patient’s differential Doctor’s differential
• Leading hypothesis • Leading hypothesis
• Alternative 1 • Alternative 1
• Alternative 2 • Alternative 2
• …… • ……
• ‘Must-not-miss’ • ‘Must-not-miss’
Where is the common understanding?
‘Let us think about this together’
Eventual diagnosis must explain both parties’ data
The history, or patient interview, is a discussion of the patient’s ideas
and insights into their symptoms and diagnosis. The clinician’s role is
crucial to the correct synthesis of this information, but this must be
done with a complete dataset elicited from the patient.
Patients describe their own insight with differing levels of articu-
lacy, but all patients do this. Clinical reasoning should from the
outset be a collaborative and dynamic process between patient and
clinician (see Box 1.7). The benefits include identifying the
patient’s priorities to the eventual goal of shared decision-making.
Yet, how often do we hear, either in a media story, complaint, or
adverse event, that the clinician ‘wouldn’t listen to what we were
saying’? This feeling among patients of dissonance between clini-
cians and themselves is reflected by the evidence base [18–20].
Assessing the patient’s own starting point by defining their own
understanding and experience of their symptoms at the beginning
of the interview is crucial to avoiding diagnostic error.
Introduction to Clinical Reasoning 5
Box 1.7 The patient presents after reasoning through their
symptoms
‘Thank you for speaking to me doctor. I’ve been feeling unwell for
several days. My hay fever is usually bad at this time of year. I know
the pollen count is high at the moment, but my usual medication is
not working. My nose is blocked, and I’ve been sneezing.
My chest is tight as well and I’ve been coughing more at night.
My blue inhaler has helped but I’m using it more than usual and it’s
not as effective. My peak flow is down. I was wondering if I need
some steroids as well.
I was shielding during the first lockdown, and I know COVID is
coming back again. Do I need another jab to boost my immunity?’
Patient’s problem list:
1. My hay fever is not controlled
2. My asthma is deteriorating
3. The prevalence of COVID-19 is increasing. Do I need further
immunisation?
There is a lot of data to unpack here to make the diagnosis and
answer the patient’s concerns.
The different lenses through which we can view clinical
reasoning, whether from the clinician or the patient’s perspec-
tive, are not mutually exclusive. There are situations that call for
rapid technical responses, for example, emergencies. Then there
are others that call for time, wisdom, and care. Clinical reasoning
is complex and takes years to learn. The challenge for educators
is to provide clinical environments with multiple tasks and
strategies in order to equip learners over time to be able to
reason through a variety of clinical problems as effectively as
possible [21].
Summary
At the time of writing, most medical schools and postgraduate
training programmes provide instruction in the basic elements of
the diagnostic process. However, students and trainees largely
learn the knowledge, skills, and behaviours required for effective
clinical reasoning implicitly and ad hoc, through experience and
apprenticeship. Yet a lack of clinical reasoning ability has been
shown to be a major cause of diagnostic errors resulting in
significant preventable harm to patients worldwide. There is a
growing consensus that medical schools and postgraduate
training programmes should teach clinical reasoning in a way
that is explicitly integrated into courses throughout each year of
the programme, adopting a systematic approach consistent with
current evidence.
For teachers and learners, it can be useful to think of clinical
reasoning as a process made up of different components, each of
which requires specific knowledge, skills, and behaviours. These
components are what the following chapters explore in more
detail. If we can start with an understanding of what clinical
reasoning is, why it is important, what the key components are,
and how it develops, we are in a better position to create clinicians
who are good decision makers and who ultimately provide better
care for patients.
6 ABC of Clinical Reasoning
References
1. Croskerry P. Clinical decision making. In: Barach P, Jacobs J, Lipshultz S,
and Laussen P (Eds). Pediatric and Congenital Cardiac Care. London:
Springer, 2015. https://doi.org/10.1007/978-1-4471-6566-8_33 (accessed
April 2022).
2. DID-ACT Project. Developing, implementing, and disseminating an
adaptive clinical reasoning curriculum for healthcare students and educa-
tors. An EU funded project, 2020. https://did-act.eu/home/project
(accessed April 2022).
3. Cooper N, Bartlett M, Gay S et al. On behalf of the UK Clinical Reasoning
in Medical Education (CReME) consensus statement group. (2021).
Consensus statement on the content of clinical reasoning curricula in
undergraduate medical education. Medical Teacher; 43(2): 152–159.
4. Tehrani ASS, Lee HW, Mathews SC et al. (2013). 25-year summary of US
malpractice claims for diagnostic errors 1986-2010: an analysis from the
National Practitioner Data Bank. BMJ Quality & Safety; 22(8): 672–680.
5. Graber ML. (2013). The incidence of diagnostic error in medicine. BMJ
Quality & Safety; 22(Suppl 2): ii21–ii27.
6. Leape LL, Berwick DM and Bates DW. (2002). Counting deaths due to
medical errors. [Letters]. JAMA; 288(19): 2405.
7. Graber ML, Franklin N and Gordon R. (2005). Diagnostic error in
internal medicine. Archives of Internal Medicine; 165: 1493–1499.
8. National Academies of Sciences, Engineering, and Medicine. Improving
diagnosis in health care. Washington (DC): The National Academies
Press, 2015. doi:10.17226/21794 (accessed April 2022).
9. Shwarz A, Landon B, Elshaug A et al. (2014). Measuring low value care in
Medicare. JAMA Internal Medicine; 174(7): 1067–1076.
10. Berwick D and Hackbarth A. (2012). Eliminating waste in US
healthcare. JAMA; 307(14): 1513–1516.
11. Whiting PF, Davenport C, Jameson C et al. (2015). How well do health
professionals interpret diagnostic information? A systematic review.
BMJ Open; 5(7): e008155.
12. Bordage G. (1994). Elaborated knowledge: a key to successful diagnostic
thinking. Academic Medicine; 69(11): 883–885.
13. Koufidis C, Manninen K, Nieminen J et al. (2022). Representation,
interaction, and interpretation. Making sense of the context in clinical
reasoning. Medical Education; 566: 98–109.
14. Elstein AS, Shulman LS and Sprafka SA. Medical problem solving. An
analysis of clinical reasoning. Harvard University Press, 1978.
15. Chase WG and Simon HA. (1973). Perception in chess. Cognitive
Psychology; 4: 55–81.
16. Bereiter C and Scardamalia M. Experts are different from us: they have
more knowledge. In: Surpassing ourselves: an inquiry into the nature and
implications of expertise. Open Court Publishing, 1993. pp. 25–42.
17. Bereiter C and Scardamalia M. Expertise as a process. In: Surpassing
ourselves: an inquiry into the nature and implications of expertise. Open
Court Publishing, 1993. pp. 77–120.
18. Fransen GAJ, Janssen MJR, Muris JWM et al. (2007). Measuring the
severity of upper gastrointestinal complaints: does GP assessment
correspond with patients’ self- assessment? Family Practice; 24: 252–258.
19. Dorval E, Rey JF, Soufflet C et al. (2011). Perspectives on gastroesopha-
geal reflux disease in primary care: the REFLEX study of patient-physi-
cian agreement. BMC Gastroenterology; 11: 25–33.
20. Humphrys E, Walter FM, Rubin G et al. (2020). Patient symptom
experience prior to a diagnosis of oesophageal or gastric cancer: a
multi-methods study. BJGP Open; 4(1): bjgpopen20X101001.
21. Eva K. (2004). What every teacher needs to know about clinical
reasoning. Medical Education; 39: 98–106.
Further Resource
1. Bereiter C and Scardamalia M. Surpassing ourselves: an inquiry into the
nature and implications of expertise. Open Court Publishing, 1993.
 CHAPTER 2
Evidence-based History and Examination
John Frain
OVERVIEW
• The history and physical examination are essential diagnostic tools
• To formulate a differential diagnosis, the history should identify
the patient’s key presenting symptoms and associated symptoms
• The patient’s background and the natural history of a condition
are essential contextual factors in making a correct diagnosis
• An incomplete physical examination increases the risk of diag-
nostic error
• If available, likelihood ratios are a measure of diagnostic accuracy
which are easy to understand and apply at the bedside
• Clinical teachers should be familiar with evidence-based history
and examination
Introduction
Evidence-based history and examination surveys all data from
the clinical encounter, compares it to available evidence, including
recognised diagnostic standards, and quickly identifies those var-
iables with the greatest diagnostic accuracy.
Around 80% of diagnoses are made from the history alone [1].
Its importance is such that Hampton et al. recommended more
emphasis should be placed on teaching students accurate history-
taking and more emphasis should be placed on research into
communication between patients and clinicians [1]. The purpose
of the history is the generation of a differential diagnosis broad
enough to include the actual diagnosis but focussed enough to be
tested by an appropriate physical examination, and investigations
when necessary. The differential diagnosis consists of a leading
hypothesis and two or three other hypotheses including any ‘must
not miss’ diagnoses, all justifiable by the data gathered, and taking
into account the patient’s own concerns. Generating a differential
diagnosis guards against premature closure (see Chapter 9). For
the learner, it aids in developing their clinical reasoning ability.
Generating a differential diagnosis needs to be taught alongside
the history and physical examination, not separately. This chapter
ABC of Clinical Reasoning, Second Edition. Edited by Nicola Cooper and John Frain.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
will introduce the idea of evidence-based history and physical
examination, an important component of clinical reasoning.
The Evidence Base
Most of our knowledge of history and physical examination pre-
dates the development of evidence-based medicine, and from a
time when patients presented later in the course of their illness,
usually with more ‘classic’ features. Nowadays, especially in devel-
oped countries, clinical problems present earlier and are often less
well differentiated from one another. We know that many single
features in the history and physical examination are limited in
their usefulness (e.g., whether someone’s chest discomfort is
‘central and crushing’ or not; or whether Kernig’s sign is present).
Nonetheless, good quality evidence now exists, including
systematic reviews of symptoms and diagnostic accuracy studies
of physical signs. This is being assimilated into textbooks (see
further resources) that provide epidemiological and qualitative
data as well as diagnostic accuracy studies including sensitivities,
specificities, and likelihood ratios. Where statistical evidence is
lacking, authors provide diagnostic guides based on the best
available epidemiological evidence. Evidence-based principles
and knowledge can be reinforced for learners through reflective
coursework (see Box 2.1) which can further enable reflection on
clinical reasoning during workplace training.
Exploring Symptoms: Combining Process
and Content
The process of history-taking cannot be separated from
knowledge of epidemiology, anatomy, and physiology. Nor can it
be separated from effective communication with patients [1].
Irrespective of the cause, each patient seen by a clinician is essen-
tially saying: ‘I’ve noticed some changes in my anatomy and phys-
iology. Can you tell me, is this normal, part of getting older or is it
pathology? If it’s pathology, will I return to my previous health,
will it leave me with some loss of function or could it even shorten
8 ABC of Clinical Reasoning

Box 2.1 Reflective coursework: the presentation of chest pain Box 2.2 The Calgary-Cambridge model: the process required
in women for accurate history-taking

‘I encountered a female patient in her 50s presenting with a • The patient’s opening statement (usually 30–120 seconds)
possible acute coronary syndrome (ACS). We had recently been • Identifying a problem list
discussing in clinical skills about possible differences in the • Agreeing an agenda for the interview
presentation of acute coronary syndrome in women and men. I • Exploring each symptom experienced by the patient
decided to examine the evidence for this. • Patient and clinician agreeing on definition of each symptom
I undertook a systematic search of the literature using the 6S present
evidence pyramid we had been taught. I identified 16 relevant • Gathering data for each symptom using open questions
studies using the SORT criteria.i There was heterogeneity of data • Completing details using closed question
recording and analysis across the studies. However, I was able to • Establishing a sequence of events
draw the following conclusions: • Attentive listening
• Women are more likely to present with ACS atypically compared • Picking up cues
to men • Exploring the patient’s relevant background information
• Men are more likely to present with chest pain than women • Relevant systems review
• Chest pain is the most common symptom presentation for both sexes • Ensuring all the patients concerns have been addressed
• Younger women are more likely than older women to present • Explanation and planning
with typical symptoms • Shared decision-making
• No difference exists between sexes for prevalence of chest pain Adapted from Silverman J, Kurtz SM, Draper J. Skills for
and/or other typical symptoms of ACS Communicating with Patients, 3rd edn. CRC Press, 2013.
• Women reported more associated (non-chest pain) ACS
symptoms than men
Continued development as a clinician requires three things: Box 2.3 Summary of key symptoms by body system
reflective practice, unwavering curiosity, and maintaining an open
General Cardiovascular
mind to new evidence and ideas. Writing this essay has highlighted
Fatigue/malaise Pain
the importance of looking to the highest level of evidence for Fevers/rigors/night sweats Breathlessness
guidance, while maintaining a healthy level of scepticism for the Weight/appetite Palpitations
recommendations by analysing the primary literature and systematic Sleep disturbance Swelling
reviews behind them.’ Rashes/bruising
i. Ebell MH, Siwek J, Weiss BD et al. (2004). Strength of recommenda- Respiratory Alimentary
tion taxonomy (SORT): a patient-centered approach to grading Pain Difficulty swallowing
evidence in the medical literature. Am Fam Physician; 69(3): 548–56. Breathlessness Nausea/vomiting/haematemesis
Wheeze Indigestion/heartburn
This is an excerpt from a patient-based piece of coursework Cough Pain/distension
undertaken by graduate entry medicine students at the University of Sputum/haemoptysis Change in bowel habit
Nottingham, UK. Students examine the evidence underlying a Bleeding
clinical feature encountered in practice.
Genitourinary Nervous system
Frequency Headache
Dysuria Loss of consciousness
my life?’ Clinical reasoning and decision-making is required to Incontinence Dizziness
assess all these concerns. Change in urinary volume Visual disturbance
Models for clinical communication have been developed, most Prostatic symptoms Hearing
notably the Calgary-Cambridge model [2] consisting of 70 skills Menstrual symptoms Weakness
Numbness/tingling
which facilitate accurate history-taking (see Box 2.2). Teaching
Memory or personality change
this model involves deliberate practice with detailed, specific Anxiety/depression
feedback by observers. It is used either one-to-one with a tutor
Musculoskeletal
and patient, with patient actors, or at the bedside with real Pain
patients. An adapted form of the observation guide includes Stiffness
feedback on elements of clinical reasoning [3, 4]. Swelling
When taking a history, key symptoms emerge within the rele- Loss of function or activities of daily living
vant system (see Box 2.3). While symptoms may overlap different
Adapted from the Calgary-Cambridge Guide. In: Silverman J, Kurtz S
systems (e.g., chest pain could be cardiac, musculoskeletal, or and Draper J. Skills for Communicating with Patients, 3rd edn. CRC
respiratory in origin) or be challenging for both patient and doc- Press, 2013.
tor to define (e.g., dizziness), many diseases present with varying
configurations of key symptoms within the relevant system.
Provided the clinical setting of an individual symptom is clearly to reason its significance and thus its usefulness as evidence of the
defined (e.g., nausea and vomiting in patients with suspected presence of the target condition. Course content can be developed
intestinal obstruction, or chest pain in patients with suspected to teach students the evidence-base for each symptom alongside
myocardial infarction in the emergency department) it is possible the process of exploring symptoms with the patient (Box 2.4).

Box 2.4 Summary evidence box for cardiovascular pain
Definition
Impairment of the blood supply to the heart. Pain is precipitated by
exertion and relieved by rest.
Anatomical site
Narrowing of the coronary arteries, usually by atherosclerosis but
occasionally by spasm.
Pathophysiology
Primarily, smoking, high cholesterol, high blood pressure, and
diabetes damage the endothelial lining of the coronary arteries.
What does the patient say?
‘I keep getting pains in my chest whenever I do things.’
‘My angina is getting worse.’
Evidence base
The table shows the European Society of Cardiology clinical
classification of angina:i
Typical angina Meets all three of the following characteristics:
1. C haracteristic retrosternal chest discomfort –
typical quality and duration
2. Provoked by exertion and emotion
3. Relieved by rest or GTN (glyceryl trinitrate) or both
Atypical angina Meets two of the above characteristics
Non-cardiac chest Meets one or none of the above characteristics
pain
Up to 95% of chest pain presents in primary care.ii Of patients
presenting with chest pain at the emergency department, almost a
third have serious cardiovascular disease. Only 11–44% of patients
referred to the cardiology out-patients have coronary artery disease.iii
The presence of atypical symptoms such as pain worse on
inspiration, stabbing pain, positional, reproducible on palpation of the
chest wall and no radiation is more useful in identifying patients who
do not require investigation (positive predictive value = 0.94) than are
the features of typical angina in identifying patients who do require
further investigation (positive predictive value = 0.21). In stable chest
pain, the patient’s own description of the pain is the most important
predictor of coronary heart disease, and in acute pain, the history of
chest pain should be judged alongside the ECG findings.iv
Chest pain in a young person is unlikely to be coronary artery
disease but you should ask about associated dizziness, syncope, and a
family history of sudden death as well as screen for risk factors.
Women present more often with atypical angina. They are more likely
than men to have pain at rest, during sleep or precipitated by stress.
References
i. Talley NJ, O’Connor S. Clinical Examination, 7th edition. Sydney:
Churchill Livingstone, 2014.
ii. Polmear A. Evidence-Based Diagnosis in Primary Care.
Edinburgh: Butterworth Heinemann, 2008.
iii. Buntinx F, Knockaert D, Bruyninckx R et al. Chest pain in general
practice or in the hospital emergency department: is it the
same? Fam Pract (2001) 18:586–589.
iv. Chun AA, McGee S. Bedside diagnosis of coronary artery
disease: a systematic disease. Am J Med (2004) 117:334–343.
Adapted from Frain J. Module 3 Clinical Skills Workbook:
Cardiovascular. Graduate Entry Medicine, University of
Nottingham, UK.
Evidence-based History and Examination 9
Defining Symptoms
Patients and clinicians do not always agree on how a symptom is
experienced. Learners benefit from realising and exploring this at
the outset. Misunderstandings can occur more readily when
symptoms appear to overlap body systems and/or when there are
multiple causes. An example is dizziness, where one classification
lists 33 possible causes. Students, in particular, worry they, ‘Don’t
know what questions to ask’. Providing knowledge and categoris-
ing the underlying causes of symptoms can enable students to
explore and define the symptoms further:
Patient: ‘I feel dizzy.’
Student: ‘What do you mean by that?’
Patient: ‘I feel I’m going to pass out sometimes’ – pre-syncope
‘I feel as though I’m (or the room is) moving’ – vertigo
‘I feel as though I’m falling’ – disequilibrium (often
neurological)
‘I feel light-headed all the time’ – possible anxiety or
depression
Similarly, misunderstandings regarding ‘indigestion’ can be clari-
fied by using the patient’s own definition as the starting point (see
Box 2.5). In the case of upper alimentary symptoms, agreement
between patient and clinician on the patient’s experience is criti-
cal to the diagnosis, including malignancy.
Associated Symptoms
Many students are proficient at obtaining a detailed description
of a presenting symptom but fail to explore associated symptoms.
By associated symptoms, we mean those symptoms which,
though subsidiary to the patient’s main concern (e.g., pain), are
nonetheless present and may contribute to the patient’s overall
concern about the diagnosis. The main associated symptoms for
any presenting symptom most commonly arise from the same
organ system as the presenting one (see Box 2.3). A patient pre-
senting with a cough may be concerned about the inconvenience
of the cough and the impact on their ability to function. However,
the diagnosis is not apparent from this symptom alone. For
example, diagnosing pneumonia requires enquiry about sputum,
fever, breathlessness, chest pain, and haemoptysis. Having to
present the history at the end of the interview and getting the
student to list the problems and formulate a differential diag-
nosis forces students to use associated symptoms in their
reasoning [5] (see Box 2.6).
Interpreting Features in the History
Studies of the history have assessed which features might be
more diagnostic than others for a particular condition. One
looked at what features of the history in chest pain are most help-
ful to clinicians in differentiating cardiac from non-cardiac
causes [6]. The authors found no single element of the chest pain
history was a powerful enough predictor of non-cardiac pain to
allow a clinician to decide on history alone, but researchers have
attempted to combine features in the history which can be of use
in clinical practice (see Box 2.7). Pain that is stabbing, pleuritic,
positional, or reproducible by palpation has likelihood ratios
10 ABC of Clinical Reasoning

Box 2.5 Patient perspectives on upper alimentary tract symptoms

Under CC BY 4.0. Humphrys E, Walter FM, Rubin G et al. (2020). Patient symptom experience prior to a diagnosis of oesophageal or gastric
cancer: a multi-methods study. BJGP Open; 4 (1): bjgpopen20X101001. https://doi.org/10.3399/bjgpopen20X101001.

near zero, meaning the likelihood of this kind of pain being
cardiac is very low. Conversely, chest pain that radiates to one or
both shoulders or arms or is precipitated by exertion has higher
likelihood ratios (LR = 2.3 − 4.7) meaning this kind of pain is
more likely to be cardiac. Likelihood ratios are discussed in more
detail later.
Natural History and Context
The natural history of a disease is the sequence of changes occur-
ring within the body from the beginning of the illness until its
resolution. The disease resolves to either complete restoration of
health, to loss of function, which may also be progressive, or the
patient’s death. Familiarity with the symptoms and signs of a
 Evidence-based History and Examination 11

of the patient’s symptoms and the natural history of the condition

Box 2.6 The importance of associated symptoms is formulating
a reasoned diagnosis is reflected in the New York Heart Association’s functional
classification of heart failure (see Box 2.8). The correlation of each
‘Mr. Jackson had a car crash yesterday when his car was hit from class with echocardiographic findings can be used to guide evi-
behind. The pain (presenting symptom) is worse today and he has
dence-based therapy.
been taking paracetamol and ibuprofen. A hot water bottle has
This concept can be demonstrated to students with a simple
helped to relieve his symptoms, but he has been unable to use his
keyboard at work. I think he has whiplash.’
class exercise of constructing the natural history of a peritonsil-
Exploring the mechanism of injury, the radiation of pain and the lar abscess (quinsy). All will have experienced a viral sore
presence of sensorimotor deficit clarifies the diagnosis: ‘Mr. Jackson throat, many will have experienced bacterial tonsillitis, and a
was hit from the left yesterday just after he had got into his car. few suffered a quinsy. Discussion of the symptoms from onset
Unfortunately, he had not put his seatbelt on. He was thrown to recovery provides the group with appreciation of the natural
against the door and then rebounded back again into his passenger. history of a condition and its relevance to clinical reasoning
He felt a sudden pain on the right side of his neck. His pain is worse (see Box 2.9).
this morning. Mr. Jackson describes pain radiating to his right Similarly, students who are taught lists of features of various
shoulder. His arm feels heavy and weak (associated symptom). He diseases are not as accurate at diagnosis compared with those
has tingling down his arm to his right thumb (associated
taught probabilities of symptoms being present [7]. For example,
symptom), in the C6 dermatome. I am concerned he has a
nearly all adult patients with meningitis in the UK have headache
hyperextension injury and right C6 nerve root irritation.’
and a fever at presentation, the next most common symptom is
Adapted from Bokshan SL, DePasse JM, Eltorai AE et al. (2016). An nausea and vomiting (70%), but only around half complain of
evidence-based approach to differentiating the cause of shoulder photophobia and a stiff neck [8]. Severe, or late bacterial, menin-
and cervical spine pain. Am J Med; 129(9): 913–8. gitis, on the other hand, is associated with prototypal symptoms
and signs as described in textbooks. Simply teaching prototypes
and ‘medical triads’ is likely to encourage superficial pattern rec-
Box 2.7 Differentiating cardiac from non-cardiac chest pain by ognition that results in overconfidence, premature closure, and
history incorrect diagnosis.
The patient’s context, including age and gender, should be
• Low risk of cardiac pain: the 3 P’s – pain that is pleuritic or
emphasised when considering the clinical probability of a disease.
stabbing, positional, and reproduced by palpation
• Probably low risk: pain not related to exertion that occurs in a
Epidemiological studies provide learners with an evidence base to
small inframammary area of the chest wall assist in their clinical reasoning. For example, the Interheart
• Probably high risk: pain described as pressure, similar to a Study [9] found over 90% of all patients suffering their first myo-
previous heart attack/angina or accompanied by nausea, cardial infarctions had the risk factors of smoking, hypertension,
vomiting, and diaphoresis diabetes, abdominal obesity, low physical activity, and poor diet.
• High risk: pain that radiates to one or both shoulders or arms or is Box 2.10 shows the percentage pre-test probability for American
related to exertion
When combined with the patient’s age, sex, and past medical
Box 2.8 New York Heart Association Functional Classification
history, it should be possible to accurately identify those at low risk
of Heart Failure – correlation of symptoms, echocardiographic
of cardiac pain, although these are a minority of patients who findings, and therapeutic options
present to hospital with chest pain. Other serious causes of the
chest pain still need to be considered. Class I II III IV
Adapted from Swap CJ and Nagurney JT. (2005). Value and Symptoms None On On At rest and on
limitations of chest pain history in the evaluation of patients with moderate mild minimal
suspected acute coronary syndromes. JAMA; 294 (20): 2623–9. activity activity activity
Ejection 40–50% 30–40% <30% <30%
fraction
condition facilitates its diagnosis. The classical presentation of
disease as described in textbooks is quite uncommon. Some Use these ACE inhibitor ACE ACE inhibitor ACE inhibitor
drugs Beta-blocker inhibitor Beta-blocker Spironolactone
symptoms and signs occur early in the disease while others occur
Beta-blocker Diuretic Digoxin
later. For example, in early heart failure, the patient may become Low-dose Spironolactone Diuretic
breathless only on severe exertion. Later, breathlessness occurs on diuretic Digoxin Beta-blocker (if
more moderate exertion (e.g., climbing the stairs), while later the Statin Statin compensated)
patient has a problem lying flat in bed (orthopnoea) and may be Sacubitril/ Sacubitril/
valsartan valsartan
breathless at rest.
If a learner interviewing a patient with breathlessness believes
the symptoms of orthopnoea must be present for heart failure to Adapted from The Criteria Committee of the New York Heart
be diagnosed, they will miss patients in the earlier stages of dis- Association. Nomenclature and criteria for diagnosis of diseases of the
heart and great vessels 9th edn. Little, Brown & Co, 1994. pp. 253–256.
ease who may benefit from proven treatment. This combination
12 ABC of Clinical Reasoning

In summary, exploring and defining symptoms, including

Box 2.9 Discuss with your colleagues a possible natural
history of a peritonsillar abscess (quinsy) associated symptoms, has to be accompanied by knowledge – of
the underlying causes of symptoms, what particular features, or
Students will usually come up with the following list, as it within combination of features, are helpful in making a diagnosis, the
their own experience:
natural history of disease, probabilities (rather than lists) of
• Feverish ­symptoms associated with various diseases, and epidemiology.
• Sore throat The process of history-taking illustrated in Box 2.2 is designed to
• Neck pain
obtain accurate data, the content of which can then be interpreted
• Pain on swallowing
by the clinician.
• Yellow spots on the tonsils
• Neck swelling
• Unable to eat or drink/throat feels blocked The Physical Examination
• Generally unwell
While the history is the key component in formulating a diag-
Key discussion points:
nosis, the physical examination, used in conjunction, can double
• Early disease is undifferentiated the diagnostic power of the history [10]. Inadequate physical
• Not every sore throat leads to a quinsy
examination, mostly failure to perform one at all, is a preventable
• Early disease can be difficult to differentiate from serious disease –
source of medical error [11]. Despite these facts, there are well-
hence the importance of red flags
• Signs with higher LRs are likely to occur later in the disease
documented deficiencies in the basic clinical skills of history-
• Red flag/serious symptoms can be used for safety netting/shared taking and physical examination [12].
decision-making – explanation to the patient about the possible In diagnosing lobar pneumonia, an evidence-based approach to
course of events physical examination asks, ‘What findings most accurately increase
the probability of pneumonia?’ by studying patients with respiratory
complaints and comparing their physical examinations to chest
radiographs. Based on evaluation of over 6000 patients, there are
Box 2.10 Estimating the pre-test probability (%) of coronary six traditional physical findings that reliably predict the results of
heart disease
the chest radiograph (see Figure 2.1). The remaining findings,
whether present or absent, add very little to the diagnosis of pneu-
Age Non-anginal Atypical Typical
chest pain (%) angina (%) angina (%)
monia. Using an evidence-based approach can trim the clinician’s
focus from 15 findings of unknown value to six findings with
M F M F M F
proven value, thereby increasing confidence, efficiency, and accu-
30–39 3–35 1–19 8–59 2–39 30–88 10–78 racy. Clinicians applying this method can then approach their next
40–49 9–47 2–22 21–70 5–43 51–92 20–79 patient with cough and dyspnoea as if they had personally exam-
50–59 23–59 4–25 45–79 10–47 80–95 38–82 ined each of the 6000 patients in these studies and then recalled the
60–69 49–69 9–29 71–86 20–51 93–97 56–84 value of the physical examination gleaned from that experience.

The figure on the left of each box shows the percentage probability
at each age and by sex when the patient had no risk factors and the TRADITIONAL FINDINGS EVIDENCE-BASED APPROACH
number on the right-hand side of each box shows the percentage
Fever 5 findings increase probability
probability of coronary heart disease in patients with the risk factors Tachypnea
diabetes, smoking, and hyperlipidaemia. Asymmetrical chest excursion
Tachycardia
Egophony
Reduced oxygen saturation
Reproduced with permission from Henderson MC, Tierney LM, Bronchial breath sounds
Grunting respirations
Percussion dullness
Smetana GW. The Patient History: An Evidence-based Approach to Cyanosis
Oxygen saturation <95%
Asymmetric chest excursion
Differential Diagnosis, 2 edn. New York: Lange/McGraw-Hill, 2012.
Percussion dullness
Diminished breath sounds
Crackles
1 finding decreases probability
Egophony
Bronchophony All vital signs normal
Whispering pectoriloquy
patients of different ages presenting with chest pain. The patients Bronchial breath sounds
all had normal 12-lead electrocardiograms and diagnosis was Pleural rub
based on history alone. Even without any risk factors, age alone
substantially increased the risk of coronary heart disease. The Figure 2.1 Diagnosis of lobar pneumonia. Textbooks present 15 traditional
physical findings of pneumonia (left), along with the assumption that each
presence of risk factors was particularly helpful in diagnosing finding has similar diagnostic weight. The evidence-based method (right),
middle-aged patients. Women lagged men in the incidence of based on study of actual patients, shows that five findings accurately
coronary heart disease until menopause was reached. increase probability of pneumonia, and only one finding decreases it.
 Evidence-based History and Examination 13

Likelihood Ratios Infinity

When a symptom or sign is present (or absent), how do we know

how useful that finding is in making a diagnosis? Likelihood ra-
tios (LRs) are diagnostic weights. The likelihood ratio is the prob- 10 +45%
ability of the finding in someone with the disease over the
probability of the finding in someone without the disease. Thus, if Increase
probability 5 +30%
a finding is equally likely in people with and without the disease,
the likelihood ratio is 1 (i.e., unhelpful). Each finding from the
history and physical examination is associated with a unique LR, 2 +15%
a number whose values ranges from zero to infinity. An LR greater
than 1.0 increases the probability of disease, and the higher the
No change 1 No change
value of the LR, the greater the increase in probability. An LR of
less than 1.0 decreases the probability of disease, and the lower
the value of the LR, the greater the reduction in probability (see 0.5 –15%
Figures 2.2 and 2.3).
One simple method of interpreting LRs is to memorise the
Decrease 0.2 –30%
association between three LR values – 2, 5, and 10 – and the first probability
three multiples of 15 – 15, 30, and 45. A finding with an LR of 2
increases the absolute probability by around 15% (that is, the cli- 0.1 –45%
nician adds 15% to the pre-test probability); a finding with an LR
of 5 increases the probability by around 30%, and one with an LR
of 10 increases the probability by around 45%.
Zero
For those LRs less than 1.0, the clinician simply inverts the 2, 5,
and 10 ‘rule’ (that is 0.5, 0.2, and 0.1). A finding with an LR of 0.5 Figure 2.3 Likelihood ratios: diagnostic weights. Clinicians should classify
LRs into three groups: those with values greater than 1.0 increase proba-
decreases the probability by around 15%; one with an LR of 0.2
bility; those with values less than 1.0 decrease probability; and those with
decreases the probability by around 30%, and one with an LR of values near 1.0 change probability very little or not at all.
0.1 decreases the probability by around 45%. Provided clinicians
round off final probabilities greater than 100% to 100%, and those
Box 2.11 Likelihood ratios and bedside estimates
less than 0% to 0%, this method suffices for the purposes of
clinical reasoning.
Likelihood ratio Approximate change in probability*
Box 2.11 summarises the absolute changes in probability for
the most used LRs. Findings with LRs greater than 3 or less than 0.1 −45%
0.3 are most helpful because these values identify findings that 0.2 −30%
either increase or decrease probability by 20–25% or more. 0.3 −25%
0.5 −15%
Can LRs Be Combined? 1 No change
LRs can be combined only if the two findings are independent of 2 +15%
one another (independence implies the LR for the first finding is 3 +20%

(1) Detecting pneumonia: In patients with acute respiratory 4 +25%

complaints, “percussion dullness” is found in 18% of patients 5 +30%
with pneumonia and in 6% of patients with another cause of
6 +35%
respiratory distress. Therefore,
7
8 +40%
for percussion dullness
LR = 18 = 3.0 9
in detecting pneumonia 6
10 +45%

(2) Detecting coronary artery disease: In patients with chronic *These changes describe absolute increases or decreases in probability.
chest pain, “dysphagia” is reported in 4% of patients found
From McGee (2002). J Gen Intern Med; 17: 646–9.
to have coronary disease and in 20% of patients with another
cause of chest pain. Therefore,

for dysphagia the same whether or not the second finding is present). For
LR in detecting coronary = 4 = 0.2
20 example, typical angina (an LR of 5.8) and hyperlipidaemia (an LR
artery disease
of 2.2) are likely to be independent because the accuracy of a history
Figure 2.2 Likelihood ratios: examples. From McGee (further resources). of typical angina is unlikely to be affected by the presence or
14 ABC of Clinical Reasoning
absence of hyperlipidaemia. To combine findings, the clinician can
simply multiply the two individual LRs (5.8 × 2.2); the resulting
product (12.7 or a +50% probability) becomes the LR for combined
‘typical angina and hyperlipidaemia’. Alternatively, the clinician
could first apply typical angina (LR of 5.8 or a +35% probability),
then hyperlipidaemia (LR of 2.2 or a +15% probability) to obtain
the increment in probability for the combined findings (35% + 15%
or a +50% probability).
Clinicians should not combine the LRs of more than two
individual findings unless clinical studies have proven that the
findings are independent. If there is any possibility that the
individual findings are dependent on each other, their LRs should
not be combined (for example, typical angina and ‘duration of
pain < 5 minutes’ should not be combined, because pain lasting
less than 10 minutes after rest or nitro-glycerine is a criterion for
stable typical angina).
The Limitations of LRs
Statistical calculations are appropriate only when the clinical problem
is defined by a diagnostic (or reference) standard, such as laboratory
testing or clinical imaging (Figure 2.4). Examples, and their reference
standards, are pneumonia (chest radiographs), ascites (ultrasonog-
raphy), coronary artery disease (coronary angiography), anaemia
(full blood count), and hyperthyroidism (thyroid function tests). In
each of these disorders, the evidence-based approach compares find-
ings from the history or examination to the accepted reference stan-
dard and identifies the findings most accurately predicting the results
of that standard. Since many clinical problems lack reference stan-
dards, evidence-based reasoning using LRs is not always applicable.
For these problems, empiric observation based on the clinician’s
prior knowledge and experience of similar patients – what the clini-
cian sees, feels, and hears at the bedside – remains the sole diagnostic
standard and LRs cannot be used.
Although LRs describe how the probability changes, they cannot
determine the pre-test probability of a disease. For example, the LR for
the physical finding ‘fluid wave’ in detecting ascites in patients with
abdominal distension is 5.0 (a +30% probability). If the clinician
works in a hepatology practice in which 60% of all patients with
abdominal distension have ascites (that is a pre-test probability of
60%) the finding of a fluid wave is diagnostic (that is 60% + 30% or
WHAT IS THE
DIAGNOSTIC STANDARD?
Clinical imaging or laboratory Empiric observation
Pneumonia Cellulitis
Ascites Parkinson disease
Coronary artery disease Trochanteric bursitis
Anemia Pericarditis
Hyperthyroidism Serotonin syndrome
Evidence-based reasoning Evidence-based reasoning
can be used does not apply
Figure 2.4 Can evidence-based reasoning be used?
a 90% probability of ascites). On the other hand, if the clinician
works in a community practice where only 20% of patients with
abdominal distension have ascites (the other 80% have increased
abdominal fat or gas), the presence of the fluid wave is less conclu-
sive (20% + 30% or a 50% probability of ascites). Proper application
of evidence-based medicine here requires intimate knowledge of the
types of diseases found in one’s own practice.
The Future of the History and Physical
Examination
Increasingly, researchers are comparing clinical findings to diag-
nostic standards to reveal LRs for a wide variety of clinical disor-
ders. This is through diagnostic accuracy studies reported to the
STARD criteria [13]. These include:
• Both the test (clinical symptom, sign, or laboratory test) and
diagnostic standard are clearly defined
• All enrolled patients have symptoms suggestive of the diagnosis
under study
• Determination of the test result is blinded from determination
of the diagnostic standard
• The study presents enough information to allow calculation of
LRs and their confidence intervals.
Clinicians applying this approach can focus on findings with
greatest diagnostic accuracy. Nonetheless, this does have limita-
tions. Even when a problem has been studied, conclusions often
rest on relatively few patients. Whether diagnostic accuracy
depends on clinical technique is largely unaddressed, although
the few studies on this subject show diagnostic accuracy with stu-
dents as observers is the same as with specialists, provided the
finding is well-defined. Finally, most literature on the subject
focusses on individual findings, although it is well known that
expert clinicians typically combine many findings simultaneously
when diagnosing disease.
Point of care ultrasound is increasingly being used in acute care
settings as an extension of the physical examination (e.g., to
estimate volume status, or differentiate fluid from consolidation in
the lungs). However, the same caveats for all diagnostic tests apply
(see Chapter 3) – the history and physical examination remains
fundamental in establishing the clinical probability of disease and
ultrasound ‘findings’ need to be interpreted in light of this. Point of
care ultrasound has several limitations and should be seen as a
decision aid pending more definitive investigations.
Developing Skills in Teaching
It is challenging for busy clinicians to be experts in clinical com-
munication and in teaching evidence-based history and physical
examination. This has contributed to a decline in bedside teaching
since the 1960s. It is however both a patient and student-centred
activity. The scope for evidence-based history and examination is
exciting, with potential to improve patient safety. Role-modelling
of reflective practice by bedside teachers can assist learners in
developing resilience and dealing with the uncertainty of clinical
practice. Careful planning and engagement with patients can help
develop clinical teachers. Box 2.12 lists some tips for teaching

Box 2.12 Tips for teaching evidence-based physical
examination
• Practice teaching concepts of diagnostic accuracy
• Practice estimating the pre-test probability of disease
• Practice teaching methods to estimate post-test probabilities
• Know where to find evidence-based physical examination data
and prepare to use it
• Prepare an answer to the question, ‘Can the likelihood ratios of
multiple findings be combined?’
• Answer the common question, ‘Why should we examine patients
if it is so unhelpful?’
• Teach the basics of evidence-based physical examination and
prepare students for bedside teaching
• Orientate the patient to the purpose of the teaching and explicitly
discuss evidence-based physical examination
• Encourage students to commit to their own description of
findings
• Encourage students to commit to a next step in management
• Facilitate deliberate practice and give feedback to learn evidence-
based physical examination
• Acknowledge uncertainty and follow up on unresolved issues
Adapted from Mookherjee S, Hunt S, Chou CL. (2015). Twelve tips
for teaching evidence-based physical examination. Medical Teacher;
37(6): 543–550.
evidence-based physical examination. Seeing variations in dem-
onstration of the physical examination is a source of discomfort
for students, particularly around assessment. Reasons for varia-
tion in technique should be discussed with learners to help them
manage their uncertainty and to apply these critical skills.
Summary
Practicing evidence-based history and examination is challenging
but rewarding. Since the history and examination is so critical to
the patient’s care, a robust evidence base is essential, and merits
increased research. An initial step for learners is establishing the
importance of the history and examination not only for initial
formulation of the patient’s problem list and differential diag-
nosis, but the correct interpretation of any subsequent investiga-
tions. Clinical teachers should be supported in developing their
own confidence and skills in teaching evidence-based history and
examination.
Acknowledgements
Thanks are due to my co-author of the first edition of this chapter,
Steven McGee, Emeritus Professor of Medicine, University of
Washington, Seattle, USA, whose work and contribution to evi-
dence-based history and examination continues to be an inspira-
Evidence-based History and Examination 15
tion, including this revision.Thanks also to Lucille Middleton,
Graduate Entry Medicine student at the University of Nottingham,
UK, for contributing Box 2.1 to this chapter.
References
1. Hampton JR, Harrison MJ, Mitchell JR et al. (1975). Relative contribu-
tions of history-taking, physical examination, and laboratory investiga-
tion to diagnosis and management of medical outpatients. British Medical
Journal; 31; 2(5969): 486–489.
2. Silverman J, Kurtz SM and Draper J. Skills for communicating with
patients, 3rd Ed. CRC Press, 2013.
3. Silverman J. The consultation. In: Cooper N and Frain J (Eds). ABC of
Clinical Communication. Wiley-Blackwell, 2018.
4. Frain J and Abdalla M. Teaching clinical communication. In: Cooper N
and Frain J (Eds). ABC of Clinical Communication. Wiley-Blackwell,
2018.
5. Kilian A, Upton LA and Sheagren JN. (2020). Reorganizing the history of
present illness to improve verbal case presenting and clinical diagnostic
reasoning skills of medical students: the all-inclusive history of present
illness. Journal of Medical Education and Curricular Development; 7:
2382120520928996.
6. Swap CJ and Nagurney JT. (2005). Value and limitations of chest pain
history in the evaluation of patients with suspected acute coronary syn-
dromes. JAMA; 294(20): 2623–2629.
7. Elieson SW and Papa FJ. (1994). The effect of various knowledge formats
on diagnostic performance. Academic Medicine; 69(10 Suppl): S81–S83.
8. Thomas KE, Hasbun R, Jekel J and Quagliarello VJ. (2002). The diagnostic
accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults
with suspected meningitis. Clinical Infectious Diseases; 35(1): 46–52.
9. Yusuf S, Hawken S, Ounpuu S et al. (2004). Effect of potentially modifi-
able risk factors associated with myocardial infarction in 52 countries
(the INTERHEART study): case-control study. Lancet; 364: 937–952.
10. Paley L, Zornitzki T, Cohen J et al. (2011). Utility of clinical examination
in the diagnosis of emergency department patients admitted to the
department of medicine of an academic hospital. Archives of Internal
Medicine; 171(15): 1393–1400.
11. Verghese A, Charlton B, Kassirer J et al. (2015). Inadequacies of physical
examination as a cause of medical errors and adverse events: a collection
of vignettes. The American Journal of Medicine; 128(12): 1322–1324.
12. Holboe ES. (2004). Faculty and the observation of trainees’ clinical skills:
problems and opportunities. Academic Medicine; 79: 16–22.
13. Cohen JF, Korevaar DA, Altman DG et al. (2015). STARD guidelines for
reporting diagnostic accuracy studies: explanation and elaboration. BMJ
Open; 6: e012799. doi:10.1136/bmjopen-2016-012799.
Further Resources
1. McGee S. Evidence-based physical diagnosis, 5th Ed. Elsevier/Saunders,
2021.
2. Talley N and O’Connor S. Clinical examination, 9th Ed. Elsevier, 2021.
 CHAPTER 3

Choosing and Interpreting

Diagnostic Tests
Nicola Cooper

OVERVIEW Box 1.1 Tests are affected by a number of factors

• Test results are affected by a number of factors which the clinician
Factor Explanation
has to take into account
How ‘normal’ is • ‘Normal’ can refer to values within the
• There is no such thing as a perfect test
defined reference range for the population to which
• The interpretation of new information depends on what you the patient belongs
believed beforehand, based on your assessment of the patient • It can also refer to a value below or above a
• Predictive values combine information about sensitivity, specificity, pre-determined cut-off point designed to
maximise true positives and minimise false
and prevalence and indicate how likely a test result is to be correct
positives
• Thresholds provide a useful way of thinking about whether a test • It can also be an ‘abnormal’ result that is
should be performed at all actually normal for the particular context in
question
Factors other than • These are biological and/or laboratory factors
disease that influence that make test results ‘abnormal’ when they
Introduction test results are not, or vary when there has not been a
true change
The history and physical examination provide a differential diag-
nosis and/or problem list. This is refined further using diagnostic Operating • This refers to the method of performing the
characteristics test itself which, if not optimal, can affect its
tests. The appropriate selection of tests depends of the quality of
accuracy
the history and physical examination. Test results then have to be
Sensitivity and • The sensitivity of a test refers to its ability to
interpreted in light of the patient’s history and examination find-
specificity correctly identify patients with the disease
ings because test results are affected by a number of factors (see (see Box 3.3) • The specificity of a test refers to its ability to
Box 1.1): correctly identify patients without the
• How ‘normal’ is defined disease
• Factors other than disease that influence test results • Sensitivity and specificity are characteristics
• Operating characteristics relating to the accuracy of a test relative to a
reference standard
• Sensitivity and specificity
• Prevalence of disease in a population Prevalence of disease • The prevalence of disease in a population
in a population can significantly alter the predictive value of
Unfortunately, commonly used measures of test accuracy, such as (see Box 3.5) a test
sensitivity and specificity, are poorly understood. A systematic • The positive predictive value is the
review of 24 studies found that most qualified healthcare profes- proportion of people with a positive test
sionals were poor at providing definitions of sensitivity and spec- result who truly have the disease
ificity, and were poor at estimating the post-test probability of • The negative predictive is the proportion of
people with a negative test result who do
disease [1]. This chapter aims to introduce key concepts and pro- not have the disease
vide further resources for this important area of clinical reasoning.

ABC of Clinical Reasoning, Second Edition. Edited by Nicola Cooper and John Frain.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
18 ABC of Clinical Reasoning
How Normal Is Defined
Many diagnostic test results are expressed as continuous variables
on a numerical scale and many quantitative measurements in
human populations have a Gaussian (normal) distribution. The
‘normal’ range is defined as those values that encompass 95% of
the healthy population, or two standard deviations from the mean.
This means that 2.5% of the healthy population will have values
above, and 2.5% of the population will have values below, the
normal range. For this reason, it is more appropriate to use the
term ‘reference range’ (see Figure 3.1). Diagnostic test results in
people with a disease also have a Gaussian distribution but with a
different mean and reference range. In some diseases there is no
overlap between results from the abnormal and normal population,
but in some diseases there is. In the latter, the greater the difference
between the result and the reference range of the normal
population, the higher the chance that the person has the disease.
Arbitrarily dividing a range of values into ‘normal’ and
‘abnormal’ has disadvantages – it does not take into account the
magnitude of the result. For example, a highly sensitive troponin
T result in a patient with chest pain is more likely to indicate myo-
cardial injury when the value is very high, as opposed to slightly
raised. Some test results have a binary classification (‘normal’ vs
‘abnormal’), for example, an exercise electrocardiogram (ECG)
looking for signs of ischaemic heart disease. However, in deciding
where the cut-off point between ‘normal’ and ‘abnormal’ should
be, there is a trade-off between sensitivity (true positives) and
specificity (true negatives). The optimum cut-off point is calcu-
lated using receiver operating characteristic (ROC) analysis,
which is described in more detail later.
In medicine there are some situations when a normal result is
abnormal, and an abnormal result is normal. For example in a
clinically severe asthma attack when one expects the PaCO2 to be
low, a normal PaCO2 on an arterial blood gas is not normal at all
and indicates life-threatening asthma. On the other hand, a raised
d-dimer is normal in pregnancy. So what is ‘normal’ and
‘abnormal’ has to be interpreted in light of the clinical picture.
Clinicians who use diagnostic tests should have a good working
knowledge of the tests they use in their everyday practice, and
how they should be interpreted in light of the patient’s history and
examination findings.
Number of people
Normal population
Reference range
–3 –2 –1 1 2
Mean Test Result
(standard deviations from the mean)
Figure 3.1 Normal distribution.
Factors Other than Disease Which
Influence Test Results
There are a number of factors other than disease which influence
test results. They include:
• Age
• Sex
• Ethnicity
• Pregnancy
• Body position
• Chance
• Spurious (in vitro) results
• Lab error
• Critical difference values
For example, normal values for paediatric blood results can be sig-
nificantly different to those of adults. Old people often have a
normal white cell count in the presence of infection, and can have a
significantly reduced glomerular filtration rate with a normal creat-
inine. Men have slightly different reference ranges to women (e.g.,
for haemoglobin) and healthy black adults may have an ‘abnormal’
12-lead electrocardiogram (due to early repolarisation) that can
resemble serious disease, but is in fact a ‘normal variant’ [2].
Pregnancy significantly alters many test results due to the
physiological changes that occur, particularly in the third tri-
mester. A large foetus splints the diaphragm and compresses the
lungs causing supine hypoxaemia as well as a respiratory alkalosis
(important facts to remember when considering the possibility of
pulmonary embolism in a pregnant woman). Circulating volume
increases by 50% in late pregnancy causing a flow murmur, tachy-
cardia, and a rightward axis on the 12-lead electrocardiogram.
Kidneys also swell as a result, and renal ultrasound shows increased
size and dilatation.
Body position is important in some tests, for example, lung
function and tests where the patient has to lie in a certain position
to get optimal images. Finally, a test result may be abnormal by
chance (e.g., the patient is an outlier on the normal curve); the
result may be spurious (e.g., hyperkalaemia caused by haemolysis
or some haematological conditions); or may be due to lab error
(e.g., as a result of a technical or human error). It is always worth
pausing before acting when a very unexpected test result crops up.
Lab results also vary in the same person at different times. The criti-
cal difference, also known as the reference change value, is the smallest
difference between sequential laboratory results in the same patient
which is likely to indicate a true change. Let’s imagine a person has
their cholesterol measured every single day. The result will not be
identical every time. The reason for this is natural biological var-
iation but also lab variation. The combination of the two is the
critical difference – the amount by which the test can vary before
it can be considered a true change. This is calculated using
knowledge of normal intra-individual variation and lab variation
for different tests. The critical difference is different for different
lab tests. Some calculated critical difference values for common
3 biochemistry results are shown in Box 3.2. For a person having
their serum cholesterol monitored, the critical difference is 17%.
An initial value of 5.2 mmol/L can therefore vary between
4.3 mmol/L and 6.1 mmol/L without being a true change.

Box 3.2 Calculated critical difference (CD) for some common
biochemistry results
Test CD as %
Albumin 11.2
Alkaline phosphatase 37.1
Aspartate aminotransferase (AST) 27.7
Bilirubin 47.5
Calcium 6.1
Cholesterol 17.0
Glucose 9.9
Total protein 11.2
TSH 63.0
Urea 28.9
Uric acid 25.2
Data from Professor Trefor Higgins, Department of Laboratory Medicine
and Pathology, University of Alberta.
Operating Characteristics
Before ordering a test, it is important to be aware of certain
operating characteristics of the test. This refers to the method of
actually performing the test itself. For example, measuring lung
function requires that the patient be able to hear, understand, and
co-operate with instructions, as well as hold their breath. Exercise
electrocardiograms require patients to be able to walk briskly and
cannot be accurately interpreted in people who have left bundle
branch block.
Some tests are highly operator dependent – in other words, the
skill of the operator influences the results and the report provided.
Ultrasound is the best example of this, as dynamic images have to be
skilfully interpreted by the sonographer. For radiology investiga-
tions in general, the interpretation of results can be highly influ-
enced by the patient’s body habitus or clinical state. In ultrasound,
for example, morbid obesity can make getting good views difficult,
and in people of all sizes, intra-abdominal organs can be obscured
by bowel gas. In computed tomography, images can be severely
degraded by movement artefact, or interpretation can be affected by
whether or not contrast was used, and whether it circulated as antic-
ipated to get optimal images. If a report says, ‘Limited views due to
… but within these limitations, no abnormality detected’ consider
whether it is in fact a non-diagnostic scan, rather than a ‘normal’
scan. It is also important that radiologists, as well as other clinicians
such as physiologists, are provided with a clear clinical question and
key information in the history, past medical/surgical history, and
physical examination. This is so that ‘abnormalities’ or incidental
findings can be interpreted in light of the clinical context.
Sensitivity and Specificity
The sensitivity of a test refers to its ability to correctly identify
patients with the disease. The specificity of a test refers to its ability
to correctly identify patients without the disease. Even a test with
Choosing and Interpreting Diagnostic Tests 19
Box 3.3 Sensitivity and specificity
Disease No disease
Positive test A B
(True positive) (False positive)
Negative test C D
(False negative) (True negative)
The sensitivity of a test refers to its ability to correctly identify
patients with the disease, i.e. A/(A + C) × 100.
The specificity of a test refers to its ability to correctly identify
patients without the disease, i.e. D/(D + B) × 100.
a high sensitivity, for example 95%, will miss 5% of people with
the disease. Unfortunately, there is no such thing as a perfect test.
Test results consist of ‘true positives’ and ‘false positives’; ‘true
negatives’ and ‘false negatives’. Box 3.3 illustrates this. Tests differ
in their sensitivity and specificity for detecting certain diseases, so
clinicians need to have a sound working knowledge of the accu-
racy of the tests they use on a day-to-day basis.
A very sensitive test will detect most disease but generate
abnormal findings in healthy people. We see this with the aptly
named high sensitivity troponin T. On the other hand, a very
specific test may miss significant disease but is likely to establish
the diagnosis beyond doubt when the result is positive. You may
have heard of the acronyms ‘SNOUT’ and ‘SPIN’. SNOUT stands
for ‘sensitive test when negative rules out the disease’ and SPIN
stands for ‘specific test when positive rules in the disease’.
However, SNOUT and SPIN are misleading. This is because the
diagnostic power of any test is determined by both its sensitivity
and specificity, as well as the prevalence of disease in the
population – more of that later. The trade-off between sensitivity
and specificity is explored in what is termed a ‘ROC analysis’.
ROC Analysis
ROC stands for ‘receiver operating characteristic’ – so called
because it was developed by radar engineers during World War II
for discriminating enemy objects in the battlefield. It is also known
as the ‘relative operating characteristic’ because it compares two
operating characteristics (true positive results and false positive
results) at various settings (see Figure 3.2). It is used in medicine to
select the best cut-off point for a test in a way that maximises true
positives while minimising false positives. ROC analysis is con-
ducted in a research setting whenever investigators measure the
ability of a test to detect a diagnosis in a population with the dis-
ease and exclude the diagnosis in those without it. (Of course, the
results of the analysis also depend on what study population was
used – if the same performance is expected in practice, the test
must be used in a similar population). For example, if we define an
exercise electrocardiogram as ‘abnormal’ when there is at least 0.5
mm of ST depression, we could pick up every case of ischaemic
heart disease but generate many false positives. On the other hand,
if we define an exercise electrocardiogram as ‘abnormal’ when
there is at least 2 mm of ST depression, we could detect most cases
of clinically important ischaemic heart disease but with far fewer
false positives, which is far more practical.
20 ABC of Clinical Reasoning

1.0 1.00
Perfect test

Good test
+test
0.75

Posterior Probability
True positive rate

Positive
Moderate test shift

0.5 0.50
Test with no value

Negative
shift
0.25
–test

0 0.5 1.0 0
0 0.25 0.50 0.75 1.00
False positive rate
Prior Probability
Figure 3.2 Receiver operating characteristic (ROC) curve. The curve is
generated by adjusting the cut-off values defining ‘normal’ and ‘abnormal’, Figure 3.3 How a test results shift our thinking using Bayes’ Theorem. The
calculating the effect on sensitivity and specificity, and then plotting these sensitivity of a troponin test is 95% and the specificity is 80%. If we imagine
against each other. The closer the curve gets to the top left-hand corner, the a patient with chest pain and our pre-test or prior probability is 50% (i.e.,
more useful the test is. The dotted line represents a test with no discriminant we are sitting on the fence) a positive or a negative result would significantly
value. shift our thinking about whether the patient is having a heart attack. But if
our prior probability was very low (e.g., 10%) a negative test result would
shift our thinking by very little and a positive test result would not by itself
be conclusive (dotted line). Bayes’ Theorem is a method for interpreting
Conditional Probability
evidence in the context of previous knowledge. It has wide applications and
Conditional probability is the probability that something is true constitutes a mathematical foundation for reasoning. In clinical practice,
given that something else is true. Bayes’ Theorem (named after doctors do not use algebra to work out pre- and post-test probabilities,
English clergyman Thomas Bayes 1702–61) is a mathematical however an understanding of the principles of Bayesian reasoning is
way to describe this. It estimates the post-test probability using important because the ability to accurately estimate probability is important
in clinical reasoning. Bayes’ Theorem:
information about pre-test probability and the sensitivity and
P R  / Dis   P Dis 
specificity of the test. P Dis / R   
P R  / Dis   P Dis   P R  / noDis   P no Dis 
Figure 3.3 illustrates Bayes’ Theorem and more detailed explana-
where P[Dis/R+] is the chance of having the disease given a positive test
tions can be found in the further resources. ‘Bayesian reasoning’ is result; and P is probability, Dis is disease, and R+ is a positive test result.
the term sometimes used for clinical reasoning using probabilities. Figure from Brush JE. Probability: Uncertainty Quantified. In: The Science of
Test results shift our thinking, but sometimes by not very the Art of Medicine, 2015. Reproduced with permission of Dementi
much. The probability that someone actually has a disease Milestone Publishing.
depends on the clinical (pre-test) probability, a judgement based
on the patient’s background, history and examination findings,
and the sensitivity and specificity of the test. Imagine an elderly
woman has been brought to the emergency department after
falling and hurting her left hip. On examination, the left hip is
extremely painful to move and she cannot weight bear. Both
antero-posterior and lateral X-rays of the left hip are normal (see
Figure 3.4). Is there a fracture? Sox and colleagues (see further
resources) state a fundamental assertion, which they describe as a
profound and subtle principle of clinical medicine: the interpreta-
tion of new information depends on what you believed beforehand.
As a simple rule of thumb, in a high clinical probability patient, a
normal test result does not necessarily exclude the disease, but in
a low clinical probability patient, a normal test result does exclude
the disease. Let’s go back to our elderly woman who has fallen.
The sensitivity of plan X-rays of the hip performed in the
emergency department for suspected hip fracture is 95%. That
means 5% of fractures (or 1 in 20) are missed. In an elderly
woman, likely to have osteoporosis, whose left hip is extremely
painful to move and she cannot weight bear, a normal X-ray does Figure 3.4 Is there a fracture?

not necessarily exclude a fracture. But if the examination of the
hip was normal and she could walk easily, a normal X-ray would
be enough to satisfy the clinician that there is probably no frac-
ture. The same test result is interpreted completely differently
when the clinical (pre-test) probability changes.
The example above illustrates that when the clinical probability
and the test result are discordant, we may need to think more care-
fully. For example, CT pulmonary angiography (CTPA) in the
diagnosis of pulmonary embolism (PE) has a specificity of 98%
and a sensitivity of 94%. When patients with an intermediate or
high clinical probability of PE have a positive CTPA, the result can
be trusted. Likewise, when patients with a low clinical probability
of PE have a negative CTPA, the result can also be trusted. But
what if a high clinical probability patient has a negative CTPA, or
a low clinical probability patient has a positive CTPA – what then?
One study found that around 40% of CTPA results were false in
these situations [3]. This is why further imaging (e.g., V/QSPECT)
may be indicated in high clinical probability patients. It is also why
formal clinical probability assessment, D-dimer testing, and CTPA
which includes imaging of the lower limbs is used in combination
before safely withholding anticoagulation in patients being inves-
tigated for possible PE. There are many other examples in medi-
cine where clinical probability really matters in accurately, and
safely, interpreting a diagnostic test result.
The lesson from these examples is that tests, even good tests,
can be wrong.
Tests give us test probabilities, not real probabilities. Tests have
to be interpreted in light of the clinical probability and estimating
clinical probability requires knowledge – formal and experiential
knowledge of basic science, epidemiology, clinical skills, and
clinical medicine.
Prevalence of Disease in a Population
Now let’s get more complicated! Consider this problem that was
given to a group of Harvard doctors: if a test to detect a disease
whose prevalence if 1:1000 has a false positive rate of 5%, what is
the chance that a person found to have a positive result actually
has the disease, assuming you know nothing about the person’s
symptoms or signs? (Assume no false negatives.) Just under half
replied with the answer 95%. Now look at Box 3.4 for the answer.
Sensitivity and specificity are characteristics relating to the
accuracy of a test relative to a reference standard. They are an
assessment of the test. But as a clinicians we are interested in the
question, ‘What are the chances that a person with a positive
result actually has the disease?’ In other words, we want to assess
people. Predictive values do just that – by combining sensitivity,
specificity, and prevalence of the disease in a population to answer
this question (see Box 3.5). Just considering test accuracy can be
misleading when the number of ‘positives’ and ‘negatives’ in dif-
ferent groups varies greatly.
In predictive analytics, a confusion matrix (yes, it’s real name)
is a 2 × 2 table that reports the number of true positives, false pos-
itives, true negatives, and false negatives using information about
the prevalence of disease in the population. This allows more
detailed analysis than simply observing the proportion of correct
classifications (or test accuracy).
Choosing and Interpreting Diagnostic Tests 21
Box 3.4 What is the chance a person found to have a positive
result actually has the disease?
Many doctors give an answer of 95%, but the actual answer is
illustrated in the table below:
Disease No disease Total
Actual 1 999 1000
Positive test 1 50 51
Negative test 0 949 949
If we sent 1000 tests to the lab, we would get 51 positive results – 1
true positive and 50 false positives. This chance of having a positive
result and actually having the disease is 1 out of 51 – or 2%. This
example illustrates the importance of understanding prevalence.
Box 3.5 Predictive values
Disease No disease
Positive test A B
(True positive) (False positive)
Negative test C D
(False negative) (True negative)
The positive predictive value – ‘What is the chance that a person
with a positive test truly has the disease?’ – is A/(A + B) × 100.
The negative predictive value – ‘What is the chance that a person
with a negative test does not have the disease?’ – is D/(D + C) × 100.
Positive and negative predictive values are influenced by the
prevalence of the disease in the population being tested. Using a
test in a population with higher prevalence increases positive
predictive value (and decreases negative predictive value).
John Brush, in his book The Science of the Art of Medicine (see
further resources) uses this next example to illustrate. We know
from angiography results and post-mortem studies the actual
prevalence of coronary artery disease in different patient groups.
Young women with non-cardiac sounding chest pain have a low
prevalence of ischaemic heart disease (1%). On the other hand,
older men with typical symptoms of angina have a high preva-
lence ischaemic heart disease (94%). If we sent a patient from
each of these groups for an imaging stress test, which has a sensi-
tivity of 90% and a specificity of 85%, and both tests came back
positive, how would we interpret the results? In other words, what
is the positive predictive value of the test in these two different
scenarios? Aside from the fact that we should consider whether to
request this test at all in patients with such extreme pre-test prob-
abilities, Box 3.6 shows the results we would get if we tested 100
patients just like each of them.
This example demonstrates the flaws in believing that a positive
result on a highly sensitive test indicates the presence of a condition
and that a negative result on a highly specific test indicates the
absence of a condition. Prevalence matters. In deciding the clinical
(pre-test) probability of disease, novices tend to focus on the patient’s
history and physical examination findings. A more accurate way of
22 ABC of Clinical Reasoning

Box 3.6 Confusion matrix showing results of an imaging Box 3.7 Estimating clinical (pre-test) probability
stress test in a) a 35-year-old woman with non-cardiac
sounding chest pain and b) a 65-year-old man with typical A 30-year-old woman complained of a constant, dull left-sided
symptoms of angina headache. On examination she was tender over her left temple. A
junior doctor remembered learning about temporal arteritis and
a) requested an erythrocyte sedimentation rate (ESR), a test for
temporal arteritis. The result was abnormal. The junior doctor
IHD No IHD
diagnosed temporal arteritis and started steroids.
Actual/total 1 99 The problem with this story is that temporal arteritis almost
Positive test 0.9 14.9 exclusively affects people aged 50 years or more. So even with this
True positive (sensitivity, history, the pre-test probability of temporal arteritis is close to zero
or 90% of 1) in this patient, which affects the predictive value of the test, and
Negative test 0.1 84.1 thus the interpretation of the result.
True negative (specificity,
or 85% of 99)

Positive predictive value = 0.9 / (0.9 + 14.9) × 100 = 5.7%
b)
IHD No IHD
Actual/total 94 6
Positive test 84.6 0.9
True positive (sensitivity,
or 90% of 94)
Negative test 9.4 5.1
True negative
(specificity, or 85% of 6)
Positive predictive value = 84.6 / (84.6 + 0.9) × 100 = 99%
An imaging stress test has a sensitivity of 90% and a specificity of
85%. Although both patients had some kind of chest pain and both
were sent for the same test, how we interpret a positive result is
completely different for each one because the prevalence of disease
in the group to which the patient belongs is so different (see Box
3.5 for predictive values).
estimating pre-test probability is to first ask yourself, ‘Who is my
patient?’ – in other words, the prevalence of disease in the group to
which the patient belongs – then add in information from the his-
tory and physical examination findings to come up with an estimate
of pre-test probability: low, intermediate, or high. Then use this
estimate to choose and interpret diagnostic tests. See Box 3.7 for an
example that illustrates this.
Thresholds
An important consideration in the diagnostic process is whether
to do a test at all. If a test will make no difference to the probability
or outcome of a disease, should the test be done? Tests (when they
are selected rationally, that is) are most helpful when they change
the management of a patient’s condition.
It is also not necessary to know the true state of the patient
before deciding whether to act. The therapeutic threshold com-
bines factors such as test characteristics, risks of the test, the risks
and benefits of treatment, as well as the potential penalty for
being wrong. The point at which the factors are all evenly weighed
is the threshold. If a test or treatment for a disease is effective and
low risk then one would have a lower threshold for going ahead.
On the other hand, if a test or treatment is less effective or high
risk, one requires greater confidence in the diagnosis and poten-
tial benefits of treatment first.
Summary
Tests do not make a diagnosis, clinicians do. Tests give us test
probabilities not real probabilities. A working knowledge of factors
other than disease that influence test results, operating character-
istics, and how accurate the test is for the disease in question is
important. Assessing clinical (pre-test) probability is vital, without
this you cannot interpret any test result. Pre-test probability is
derived from knowledge of the prevalence of the disease in the
group to which the patient belongs and information from the indi-
vidual’s history and physical examination findings. Positive pre-
dictive values and negative predictive values are the proportion of
people with a positive (or negative) test result who have (or do not
have) a disease. They can be thought of as the post-test probability
of a disease. Finally, thresholds provide a useful way of thinking
about whether a test should be performed at all.
References
1. Whiting PF, Davenport C, Jameson C et al. (2015). How well do health pro-
fessionals interpret diagnostic information? A systematic review. BMJ
Open; 5: e008155 (accessed April 2022).
2. Walsh B, Macfarlane PW, Prutkin JM and Smith SW. (2019). Distinctive
ECG patterns in healthy black adults. Journal of Electrocardiology; 56:
15–23.
3. Stein PD, Fowler SE, Goodman LR et al. (2006). Multidetector computed
tomography for acute pulmonary embolism. The New England Journal of
Medicine; 354: 2317–2327.
Further Resources
1. Sox HC, Higgins MC and Owens DK. Medical decision making, 2nd Ed.
Oxford: Wiley-Blackwell, 2013.
2. Brush JE. The Science of the Art of Medicine. Dementi Milestone Publishing,
2015.
3. Stone JV. Bayes’ Rule. A tutorial introduction to Bayesian analysis. Sebtel
Press, 2013.
 CHAPTER 4

Problem Identification and Management

Nicola Cooper and John Frain

moving to a new town is ill-defined. Ill-defined problems can

OVERVIEW
• Clinical reasoning involves problem recognition, definition, and
representation
• The use of specific language helps clinicians match the patient’s
own words and data with illness scripts in long-term memory
• Sometimes problem representation is not possible, in which case
a problem list can be used
• It is still possible to act safely and confidently when dealing with
uncertainty
• Teachers have an essential function in role-modelling how to deal
with uncertainty
• Management reasoning differs significantly from diagnostic
reasoning in several ways
Introduction
Clinical reasoning is a complex cognitive process involving
clinical skills, memory, problem-solving, and decision-making.
In this chapter, we focus on problem-solving, what psychologists
have learned about it, and the factors that contribute to its success
or failure.
have more than one ‘correct’ solution and require different skills
to solve them. Most problems in medicine are ill-defined.
Recognising there is a problem in the first place is the first step
in problem-solving. Problems can be presented (as in case his-
tories on paper) or discovered (as when a problem is teased out
through a careful history). The problem then has to be defined
and represented before it can be solved. Problem representation
refers to how the problem is mentally organised before attempting
to solve it. In psychology, this consists of a description of the
problem, a description of the goal, a set of allowable operators,
and a set of constraints [1]. These are held in memory while we
try to solve the problem. Problem representations can be created
using abstractions (a summary of the problem’s essential charac-
teristics using words), images, diagrams, or equations [2]. The
important thing to note is that the representation of a problem
affects the solution.
Evaluate Recognise
Problem
solution problem
identification

The Problem-solving Cycle

Psychologists have described problem-solving in terms of a cycle, Monitor Define and represent
progress problem
illustrated in Figure 4.1. Not all problem-solving proceeds
sequentially through all stages in this particular order. However,
once the relevant steps are completed, they usually give rise to a
new problem and then the steps need to be repeated. We have
used the term ‘problem identification’ to refer to the first two Allocate
Develop solution
steps which involve problem recognition, definition, and mental/physical
strategy
resources
representation. Organise one‘s
There are two classes of problems: those that are well-defined knowledge
about problem
and those that are ill-defined. A simple maths problem is well-­
defined. How to decide which house to buy, or rent, after Figure 4.1 The problem-solving cycle. Adapted from Pretz et al., 2003.

ABC of Clinical Reasoning, Second Edition. Edited by Nicola Cooper and John Frain.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
24 ABC of Clinical Reasoning
Problem Representation in Medicine
In medicine, the problem representation is a key step in clinical
reasoning. It usually consists of an abstraction in one or two sen-
tences. Sometimes it is referred to as the ‘impression’ (i.e., what
we think is going on). In the problem representation, clinical
findings are transformed into abstractions using ‘semantic quali-
fiers’. These are abstract binary descriptors such as acute/chronic,
unilateral/bilateral etc. (see Box 4.1). An example of a problem
representation would be, ‘A 60-year-old man with acute, recur-
rent attacks of severe left knee pain.’ As this example illustrates,
the problem representation is not the same as the presenting com-
plaint, and it is not a summary of the history and examination
findings either. It is an encapsulation of the key features of the case
using very precise medical language. Patients do not come in
talking this way – clinicians have to transform their findings into
more abstract terms in order to define the type of problem or rep-
resent the problem overall (in this example, an episodic mono-
arthritis as opposed to a chronic poly-arthritis – this distinction is
important when thinking about potential diagnoses) [2].
Why does the precise language described above matter?
Language and memory have historically been studied apart as
unique cognitive abilities and with distinct research traditions
and methods. Over the past several decades, however, a growing
body of evidence suggests that language and memory are heavily
intertwined and may even rely on shared cognitive and neural
mechanisms [3]. The development and refinement of a problem
representation is a critical step that allows clinicians to match the
patient’s words and data with illness scripts (i.e., organised mental
summaries of different diseases) in their long-term memory and
thus start going about solving the problem [4]. Successful diag-
nosticians, whether students or specialists, elaborate using
semantic qualifiers more than unsuccessful ones when represent-
ing problems. They are also able to encapsulate a set of symptoms
and signs into clinical syndromes whenever possible [5]. For
example, a confusing array of neurological symptoms becomes, ‘A
3-day history of progressive, bilateral cerebellar symptoms.’
Symptoms such as polyuria and polydipsia are not seen as sepa-
rate symptoms, but as a clinical syndrome. This immediately
helps to narrow down potential diagnoses and therefore what
tests may be required. Box 4.2 illustrates an example of how
problem representation, or lack thereof, affects the solution, and
Box 4.1 Examples of semantic qualifiers
• Acute/chronic
• Unilateral/bilateral
• Mono/poly
• Progressive/intermittent
• Sharp/dull
• Proximal/distal
• Sudden/gradual
• Single/recurrent
• Productive/non-productive
• Severe/mild
Semantic qualifiers are paired, opposing descriptors that can be
used to compare and contrast diagnostic considerations.
Box 4.3 illustrates an example of how language matters in problem
representation.
Generating an accurate problem representation is something
that is neglected in ‘history–examination–differential diagnosis’
teaching methods, but problem representation really matters.
Studies show the main difference in the discourse of ‘strong’ as
opposed to ‘weak’ diagnosticians is their semantic competence,
that is their use of language to organise their thinking [5]. This
becomes especially important when the case is complex. For
example, an elaborated, encapsulated structure, as described
above, is associated with 75–80% accuracy in resolving complex
problems as opposed to near zero resolution for ‘dispersed’ dis-
courses. Importantly, learners can be taught to solve a problem by
defining and representing it first before blindly generating a series
of diagnostic impressions [6].
An example of a problem representation in need of improve-
ment is ‘A 50-year-old man with chest pain and breathlessness.’
This is not precise enough and automatically takes one’s mind to
thinking about cardiac causes. An example of a good problem rep-
resentation (in this case) is ‘A 50-year-old man, 4 weeks post-op
knee replacement, with acute left-sided pleuritic chest pain and
Box 4.2 Problem representation, or lack thereof, affects the
solution
A final-year medical student working in general practice and had
just seen an 18-year-old man with a two-day history of nausea,
fever, and abdominal pain. He had no past medical history, no
urinary symptoms, and had not opened his bowels for two days. He
had vomited once. On examination, the patient was tender in the
right iliac fossa with no other abnormal findings.
The student gave a good description of the patient’s symptoms
and signs to her supervisor. When asked what she thought the
diagnosis could be, the student thought for a moment and then
said, ‘Constipation.’ The supervisor was surprised. Together, they
worked to represent the problem and came up with: ‘An 18-year-
old man with a 2-day history of nausea and vomiting, fever, and
right lower quadrant tenderness.’ Immediately the student thought
of appendicitis, which was the correct diagnosis.
Box 4.3 Language and problem representation
A final-year medical student had just ‘clerked’ an elderly woman
who had been admitted to hospital because of confusion. The
student had spoken to the patient’s husband to get a good
description of what had been happening at home. After obtaining a
history, examining the patient, and looking at the initial test results,
he summed up her problems as:
1. Acute confusion
2. Raised creatinine
However, the student was unable to formulate a plan for each of
these problems and was unsure about what to do next. He was
encouraged to re-define the problems using more precise medical
language. He was able to re-define them as:
1. Delirium
2. Acute kidney injury
Following this, he was immediately able to retrieve information from
memory to formulate a management plan for the patient.
 Problem Identification and Management 25

Relevant past
history Abstraction* of ANGINA
Age + gender (includes medical, symptoms, signs,
social, family, +/- initial test
medication history) results exertional

Figure 4.2 Example structure for teaching problem representation. *An intermittent
abstraction is a summary of the problem’s essential characteristics using
semantic qualifiers and precise medical language. If relevant, the chronic non-exertional
characteristics can be encapsulated as a clinical syndrome (for example,
instead of saying that a 50-year-old man with chronic kidney disease stage
5 presents with ‘progressive breathlessness, orthopnoea and leg oedema’, Chest pain continuous
you could say ‘fluid overload’).
acute
breathlessness.’ This immediately leads us to think about other
things, for example, pulmonary embolism. An example structure Figure 4.3 An example of forward reasoning.
for teaching problem representation is shown in Figure 4.2.
Box 4.4 Experts go about solving problems differently to
Problem-solving by Experts Vs Novices novices

Studies have found that experts in a particular domain go about Experts Novices
solving problems differently to novices. These differences are
Spend significantly more time on Represent problems quickly and
summarised in Box 4.4. You may have seen this in action when an problem representation and then then spend more time working on
expert spends significantly more time defining and representing a proceed to solve the problem a solution (often leading to
problem (e.g., by asking themselves, ‘Why exactly did the patient quickly mistakes and having to start
come to hospital today?’) and deliberately seeking out further again)
information (e.g., by talking to relatives to get a collateral history) Redefine and reinterpret problems Respond to the task without
before starting to work on a solution. modifying the structure of the
problem
Experts also solve problems by reasoning forwards, which is
less effortful, whereas novices reason backwards, which can be Define and represent problems Define and represent problems
according to underlying principles according to surface features
laborious and unreliable. For example, novices will select a
potential diagnosis and then check out the description to see Generate more efficient problem Include irrelevant details in
representations, stripped of problem representations
whether it contains facts that support or contradict that diag-
irrelevant details
nosis. Errors can arise by accepting a diagnosis because there is
Break the problem-solving task Try to deal with the problem-
some evidence to support it and no evidence against it – even
into parts and are able to monitor solving task as a whole and are
though some other diagnosis, not yet considered, would fit better. their sequential progress easily less able to monitor their progress
Experts, on the other hand, reason forwards by noting significant as a result
facts which they then explore and are thus able to converge on a Adapted from Zimmerman BJ and Campillo M. Motivating self-regulated
diagnosis in a more straightforward manner [7]. However, problem solvers. In: Davidson JE and Sternberg RJ (Eds). The Psychology
experts also resort to reasoning backwards when they encounter of Problem Solving. Cambridge University Press, 2003. pp. 236–37.
difficult problems – in other words, clinicians employ the strategy
that best suits their knowledge. An example of forward reasoning
ence, that result in their inability to discover, define, and represent
is shown in Figure 4.3.
problems accurately [8]. As a result, their case presentations are
likely to contain errors and their learning will be greatly enhanced
Problem-solving in the Classroom Vs by reviewing all the available information (including going back
Clinical Environments to see the patient) together and then practicing problem recogni-
In a classroom environment, problems are usually presented to tion and representation with feedback.
learners ‘on a plate’. Thus, the opportunity to practice problem
recognition, definition, and representation is limited. Because Managing Uncertainty
these are key skills in clinical reasoning, teachers should
endeavour to show, not tell as much as possible during case-based It is not always possible to be certain about what the problem is
learning sessions. This can be done in a classroom environment for every patient. Authentic clinical reasoning requires clinicians
by using videos of patients describing their symptoms, using to gather and interpret imperfect data in real time. Learning how
images or sounds of physical examination findings if possible, to take safe and effective action in complex and ambiguous set-
and providing test results such as 12-lead electrocardiograms and tings is essential for patient safety [9]. Regulators such as the UK’s
blood results without interpretation. General Medical Council include learning to deal with complexity
In the clinical environment, teachers should not take the case and uncertainty in their outcomes for graduates [10]. Learners are
presentations of learners at face value. This is because of significant likely to commence training believing that most clinical decisions
deficiencies in the clinical skills of learners, due to their inexperi- are binary, given adequate knowledge. For clinicians of all levels,
26 ABC of Clinical Reasoning

the ability to diagnose and manage conditions accurately is an

Box 4.6 Example of a problem list
important aspect of professional identity and well-being. This is
true of learners too. Many students struggle with the lived experi- 1. Faecal loading due to opioids
ence of uncertainty in clinical practice. The belief that one must 2. Urinary retention
always know the answer can inhibit open discussion and learning, 3. Urinary tract infection
4. Acute kidney injury (AKI)
particularly in groups. Such attitudes can translate into the stu-
5. Hyperkalaemia
dent’s future practice, inhibiting their confidence and decision-
6. Opioid toxicity
making for fear of being seen to be wrong or harming a patient.
7. Caregiver strain
Adjusting to practice in the context of uncertainty has profound
impacts for clinical decision-making and patient care [11]. This is A problem list is a list of acute or presenting problems, not the past
particularly true in specialities where illness is undifferentiated medical history.
(e.g., primary care) or rapidly evolving (e.g., acute care).
When dealing with complexity and uncertainty, learners can
‘uncertainty’ is not helpful in adequately capturing what is going
sometimes get themselves in a ‘cognitive knot’ by focusing on
on. Instead, they propose more precise terms:
what they do not know. Teachers can encourage them to re-frame
• Ambiguity = the properties of the situation
things in terms what they do know so they can start ‘untangling’
• Uncertainty = the experience of the individual
the problem. This iterative approach can also demonstrate to stu-
Uncertainty, or what the individual is experiencing, can be due to
dents that problem-solving, diagnosis and management evolves
1) recognising a situation is ambiguous, 2) perceiving limitations
during patient care and is not necessarily established at the outset.
in your own knowledge (which could be due to lack of confidence,
Treatment can be given based on either framing a clinical problem
or a well-calibrated judgement), or 3) recognising you have
or a diagnostic hypothesis. Reflection on the patient’s response, in
incomplete information. Certainty is your confidence in inter-
some cases, can further develop the management plan. An
preting the clinical situation. Comfort is your confidence in being
example of getting learners to re-frame things in terms of what
able to act safely and effectively in a situation. This could be as
they know is shown in Box 4.5.
simple as walking into a situation and recognising you need help
In some cases, it may be difficult to come up with a single
straight away. In summary, being comfortable with uncertainty is
problem representation, but it is still possible to identify several
about recognising the situation is ambiguous, or you lack
discrete problems. This is common in geriatric medicine and in
knowledge/skills, or you have incomplete information, but you
patients with multiple co-morbidities. In these cases, a common
are confident you can still act safely and effectively to manage the
approach is to create a problem list. A problem list consists of sev-
situation.
eral mini abstractions which may or may not be diagnoses. An
Finally, when is a good time to start teaching about managing
example of a problem list is shown in Box 4.6. The advantage of a
uncertainty? It may not be helpful to introduce this too early in a
problem list is that each problem is important in its own right and
curriculum for reasons to do with cognitive load and stages of
requires a management plan. In the ‘history–examination–
learning. As a simple example, how would you teach a four-year-
differential diagnosis’ method, important problems, and there-
old to cross the road? How do you cross the road? Learners
fore plans to address them, may inadvertently be missed.
acquire skills through instruction and practice, but novices differ
Ilgen and colleagues have helpfully deconstructed the term
from competent/proficient learners in terms of their recollection,
‘comfort with uncertainty’ to help educators develop the clinical
recognition, decision-making, and awareness [12]. Novices need
reasoning ability of learners in situations that appear to be com-
recipes and rules, may lack confidence, and their learning and
plex and ambiguous [9]. First of all, they unpack what we mean by
practice requires high degrees of concentration. This is why con-
‘uncertainty’. Do we mean low self-efficacy (confidence we can
sistency of teaching is so important at this stage. Competent/pro-
deal with the situation)? Low knowledge? Lack of information?
ficient learners have more conceptual understanding and are able
Discomfort? Clinical ambiguity? They conclude that the word
to use underlying principles to find solutions for the context in
which they find themselves. So, learning to deal with uncertainty
Box 4.5 Getting learners to re-frame things in terms what
is probably something that should be emphasised later in medical
they know school while practicing with real clinical cases.
Role-modelling by teachers serves an important function.
Mrs. Smith is 85 years old and has just been admitted to hospital.
Though it may diminish, uncertainty in practice never wholly
Learner: ‘I have no idea what’s going on, the patient is really disappears. The effective clinician does not practice solely by con-
confused and can’t give me any history, all the blood tests are viction, but recognises practice is uncertain and this is reflected in
normal, the vital signs are normal, and when I examine her, I can’t their management decisions. Not knowing the diagnosis does not
find anything wrong. I phoned the care home and they told me that
prevent making management decisions. Management decisions
Mrs. Smith is normally really with it, but this morning she was really
may themselves reveal or clarify aspects of a diagnosis. Teachers
confused and that’s why they called the ambulance.’
who share their own experience of this process, and their reflec-
Teacher: ‘Let’s try and summarise what we do know’ … [Together]: Mrs. tions on their own development, are being supportive and
Smith, elderly care home resident, has acute confusion, i.e. delirium. respectful of their learners’ own developmental needs. Box 4.7

Box 4.7 Strategies for improving tolerance of uncertainty in
decision-making
• Careful data-gathering (history)
• Structured physical examination
• Working within a framework of differential diagnosis
• Considering alternative hypotheses
• Excluding ‘must-not-miss’ diagnoses
• Using best available evidence
• Re-evaluating the management plan
• Seeking advice from colleagues
• Sharing limitations of knowledge with the patient
• Shared decision-making with the patient
• Role-modelling reflection
From the ABC of Clinical Resilience, Wiley-Blackwell, 2021.
shows strategies for educators in improving tolerance of uncer-
tainty in decision-making.
Management Reasoning
A lot of the focus of the clinical reasoning literature is on diag-
nostic reasoning. That is because diagnosis is something that can
be objectively measured in studies. But management reasoning is
clearly an important part of clinical reasoning. Management
reasoning is the process of making decisions about patient
management, including choices about treatment, follow-up visits,
further testing, and allocation of limited resources [13]. There are
several key differences between diagnostic and management
reasoning. Diagnosis can be either correct or incorrect, whereas
there can be more than one ‘correct’ way to manage a patient’s
problems. Diagnosis can often be done without the patient,
whereas management decisions require communication and
shared decision-making. Management reasoning is also influ-
enced by the preferences, values, resources, and constraints of the
patient, clinician, and healthcare institution. Finally, management
plans are inherently fluid and require ongoing monitoring and
frequent adjustments [13].
Shared decision-making is a topic we discuss further in Chapter 5.
Management decisions are often co-produced with patients and
carers, but shared decision-making also refers to teams, evidence-
based guidelines, technology, scores, and decision aids.
As we stated in Chapter 1, there are situations that call for
decidedly technical and knowledgeable responses (e.g., providing
timely and correct treatment for a myocardial infarction), and
then there are situations that call for wisdom and care (e.g., recog-
nising a person is dying and shifting the goals of treatment towards
caring instead of curing). All of these situations require good
communication skills. The challenge for educators is to provide
multiple opportunities in lots of different contexts for learners to
practice the skills they need for sound management reasoning.
Summary
Clinical reasoning is a complex cognitive process involving
clinical skills, memory, problem-solving, and decision-making.
In medicine, problem identification (recognising, defining, and
Problem Identification and Management 27
representing problems) is important in clinical reasoning. The
kind of language used in representing problems matters, and this
is something that can be taught. Learners need the opportunity to
practice this with coaching and feedback, but this requires that
clinical teachers do not take the case presentations of learners at
face value, because significant deficiencies in the clinical skills of
learners mean that they may be unable to discover, define, and
represent problems accurately.
Managing uncertainty can be overcome, in part, by getting
learners to re-frame things in terms what they do know, gener-
ating problem lists, and teachers and learners having a clear and
shared understanding of what we mean by ‘uncertainty’.
Management reasoning is different in many ways to diagnostic
reasoning; it is influenced by preferences, values, resources, and
constraints. Learning management reasoning requires knowledge
and practice with lots of different cases in lots of different con-
texts with coaching and feedback.
References
1. Pretz JE, Naples AJ and Sternberg RJ. Recognizing, defining, and repre-
senting problems. In: Davidson JE and Sternberg RJ (Eds). The psychology
of problem solving. Cambridge University Press, 2003. pp 3–30.
2. Bordage G. (1999). Why did I miss the diagnosis? Some cognitive expla-
nations and educational implications. Academic Medicine; 74(10):
S138–S143.
3. Duff M and Piai V (Eds). Language and memory: understanding their
interactions, interdependencies, and shared mechanisms. Frontiers Media,
2020. doi:10.3389/978-2-88966-121-3.
4. Erickson B, Dhaliwal G, Henderson MC et al. (2011). Effusive reasoning.
Journal of General Internal Medicine; 26(10): 1204–1208.
5. Bordage G. (1994). Elaborated knowledge: a key to successful diagnostic
thinking. Academic Medicine; 69(11): 883–885.
6. Bordage G and Lemieux M. (1991). Semantic structures and diagnostic
thinking of experts and novices. Academic Medicine; 66(9 Suppl): S70–S72.
7. Bareiter C and Scardamalia M. Experts are different from us: they have
more knowledge. In: Surpassing ourselves: an enquiry into the nature and
implications of expertise. Open Court Publishing, 1993. pp 25–43.
8. Holmboe ES. (2004). Faculty and the observation of trainees’ clinical
skills: problems and opportunities. Academic Medicine; 79(1): 16–22.
9. Ilgen JS, Eva KW, de Bruin A et al. (2019). Comfort with uncertainty:
reframing our conceptions of how clinicians navigate complex clinical sit-
uations. Advances in Health Sciences Education; 24: 797–809.
10. General Medical Council. Outcomes for graduates. GMC, 2018. www.
gmc-uk.org (accessed April 2022).
11. Iannello P, Mottini A, Tirelli S et al. (2017). Ambiguity and uncertainty
tolerance, need for cognition, and their association with stress. A study
among Italian practicing physicians. Medical Education Online; 22(1):
1270009.
12. Dreyfus SE. (2004). The 5-stage model of adult skill acquisition. Bulletin
of Science, Technology & Society; 24(3): 177–181.
13. Cook DA, Sherbino J and Durning SJ. (2018). Management reasoning:
beyond the diagnosis. JAMA; 319(22): 2267–2268.
Further Resource
1. Cooper N and Frain J (Eds). ABC of Clinical Communication. Wiley-
Blackwell, 2018.
 CHAPTER 5
Shared Decision-making
Anna Hammond and Simon Gay
OVERVIEW
• Clinical reasoning continues after a diagnosis is made as part
of subsequent decisions about investigation, management, and
treatment
• Guidelines, scores, and decision aids can help clinicians make
better decisions
• Guidelines, scores, and decision aids can be applied incorrectly,
leading to errors
• Evidence-based medicine is the integration of best, current
research evidence with one’s own clinical expertise and individual
patient values
• Using effective communication skills, clinicians should endeavour
to present information to patients in a way that is easy to under-
stand, whatever their health literacy, in order to facilitate shared
decision-making
• It is important that clinicians are aware of how context influences
clinician decision-making and student learning
Introduction
Shared decision-making refers to decisions that are co-produced
with patients and carers, within clinical teams, or using evidence-
based guidelines, technology, scores, and decision aids. In this
chapter, we will consider how clinical reasoning continues during
decisions about investigations and management, and how those
decisions can be shared. We will also consider the importance of
situated cognition to both the clinical reasoning process and its
development.
Many clinical guidelines, scores, and decision aids function as
heuristics (‘rules of thumb’). They have the advantage of being
externally constructed, incorporate the best available evidence,
and reflect the consensus of a medical community regarding their
validity and reliability. The intention of using them is to increase
the likelihood of patients receiving evidence-based care, with
intended benefits to patients in terms of outcomes, and to health-
care systems in terms of efficiency. The benefits for healthcare
professionals are increased confidence that good care is being
ABC of Clinical Reasoning, Second Edition. Edited by Nicola Cooper and John Frain.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
provided, and in the time saved as a result of the critical appraisal
and synthesis of research evidence being done by external bodies.
Clinical Guidelines
The development of a clinical guideline begins with a systematic
review of the literature on the topic under consideration. The pro-
cess is at risk of bias and conflicts of interest, and a well-conducted
systematic review will include a description of how this risk has
been addressed. It must also assess the strength of the evidence
from each piece of research. Subsequent steps involve consulta-
tion with a wide variety of stakeholders, including patient repre-
sentatives, before the guideline is made available to clinicians [1].
There are many guidelines available, and it can be difficult for
clinicians to judge which are the best ones to use. The features of
a good clinical guideline are shown in Box 5.1.
Box 5.1 Features of a good clinical guideline
• It is based on a well-conducted and transparent systematic review
that includes statements about potential conflicts of interest and
the strength of the evidence
• The guideline’s use should be demonstrated to improve outcomes
for patients in real situations by means of a prospective validation
study
• A range of relevant professionals have been involved in its
development and have reached a consensus about the content
and recommendations
• Patient representatives have been involved in its development and
their views on its acceptability have been incorporated
• A positive impact on outcomes for patients is likely as a result of
its use
• The guideline is applicable to an appropriate range of clinical
situations and individual patients
• The guideline is clearly written and states precisely what its
recommendations are and in what circumstances they apply
• There is enough flexibility in the guidance that patients’ views and
values can be taken into account
• The guideline is updated as new evidence emerges
• It represents a cost-effective use of resources
30 ABC of Clinical Reasoning
Key decisions that clinicians must make when using clinical
guidelines are how well the guideline fits the individual patient
and their situation, and how accurately the population-level data
on which the guideline is based translates to the individual patient
in front of them.
Scores and Decision Aids
The development of scores and decision aids involves a lengthy
process including:
• The identification of predictors from clinical observation
• Validation of the ‘rules’ involving cohort studies or controlled
trials
• Analysis of the usefulness of each rule in terms of its accept-
ability, feasibility, and cost-benefit
• Encouraging its adoption into standard clinical practice
As is true for clinical guidelines, the last phase can be challenging.
There is often resistance from clinicians to using scores and
decision aids. This may arise from uncertainty about how to use
them correctly, doubts about their validity and reliability, or a dis-
quiet about wanting to be patient-centred when using a guideline
developed from population statistics.
There are many examples of clinical decision aids and most cli-
nicians will be familiar with their use. A key consideration of the
role they play in decision-making is knowing in what circum-
stances to apply them. This, in turn, depends on an accurate
clinical assessment through the use of good consultation skills.
When used judiciously, clinical decision aids can enhance a
clinical decision and patient management by adding to its reli-
ability and its acceptability to patients.
The following are situations in which clinical decision aids may
be of use:
• To inform decisions about investigations and therapeutic
interventions
• To screen for specific conditions that need a complex or costly
assessment
• When the clinical decision is a particularly complex one
All make use of clinical assessment findings and some include
numerical scoring systems linked to these findings.
An example of a commonly used score/decision aid in clinical
practice is the Wells’ Score for the investigation of deep vein
thrombosis (DVT) in patients whom, after a history and physical
examination, a clinician has decided may have a DVT [2]. Key
features of the history and physical examination are combined
into a numerical score which is widely available online in an
interactive form. The score is used to estimate the clinical prob-
ability of a DVT. The combination of a low Wells’ Score and a
negative D-dimer eliminates the need for further investigations
(i.e., Doppler ultrasound). This is a good example of the impor-
tance of using a score/decision aid correctly – the Wells’ Score for
suspected DVT cannot be used by itself to rule out a DVT if the
score is low. Care must also be taken not to confuse this score/
decision aid with the Wells’ Score for suspected pulmonary
embolism.
Other clinical decision aids use the presence or absence of
defined symptoms as the basis for predicting the likelihood of a
specific diagnosis, for example, the Rome 4 Criteria for irritable
bowel syndrome [3]. Others use the presence or absence of
defined features to predict outcome, and therefore which patients
require admission to hospital (e.g., the CRB-65 score for commu-
nity-acquired pneumonia) [4].
Pitfalls in the Use of Guidelines, Scores,
and Decision Aids
Using a Clinical Decision Aid Incorrectly
Sometimes, clinicians use clinical decision aids incorrectly. An
example would be a clinician consulting with a patient with calf
pain, using the Wells’ Score for DVT and concluding that a low
Wells’ Score means a DVT is unlikely – and therefore that the
patient does not need further assessment with a D-dimer and
possibly a Doppler ultrasound scan. Using the Wells’ Score in the
first place is for situations when a DVT is suspected following the
history and physical examination.
Applying a Screening Tool to Diagnosis
Sometimes, clinicians mistakenly use clinical decision aids to
make a diagnosis when they were designed as screening tools.
This is inappropriate and can lead to misleading results. The
correct approach is that a positive result on a screening tool
should lead to a more thorough clinical assessment before a diag-
nosis is made. An example of this is the CAGE Questionnaire
which was intended to be a screening tool for alcohol dependence
[5]. It makes use of four questions to be asked during history-
taking. A score of two or more is associated with problem drinking
and is a cue to explore drinking habits further; it does not diag-
nose alcoholism. It is important that clinicians use such tools for
the purpose for which they were designed and in the context of a
fuller clinical assessment.
Entering an Algorithm Inappropriately
Some guidelines and decision aids take the form of algorithms and
are often electronically based. While they can help with some aspects
of making decisions, they may rely on classical presentations and
progression of disease and cannot take into account individual vari-
ation and anomalies, and thus involve the potential for errors. An
example is the management of acute coronary syndromes, when
there can be several underlying causes. Imagine a patient who has
been admitted to hospital following 30 minutes of cardiac-sounding
chest pain, who has ST depression on the 12-lead electrocardiogram
and a significantly raised high-sensitivity troponin. However, the
clinician fails to recognise a three-month history of indigestion, iron
deficiency anaemia, and a history of black, tarry stools for the last
few days which has precipitated the acute coronary syndrome, and
starts treatment with dual anti-platelet therapy and heparin –
leading to severe bleeding.
The possible pitfalls for clinicians in using clinical guidelines
and decision aids are summarised in Box 5.2.
Evidence-based Medicine
The difficulty with guidelines is they are based on evidence from
studies of large groups of people. However, clinicians consult with
individual patients, each in their own specific and unique set of
 Shared Decision-making 31

Box 5.2 Possible pitfalls in using clinical guidelines and Box 5.3 Sackett et al.’s definition of evidence-based medicine
decision aids
‘Evidence-based medicine is the integration of best (current)
• Using a clinical decision tool incorrectly as a diagnostic tool research evidence with clinical expertise and patient values.’
• Using a screening tool incorrectly as a diagnostic tool
Adapted from Sackett DL et al., 1996.
• Applying population-level findings to individuals
• Assuming that all diseases present and progress in a uniform manner
• Failing to take patient factors and preferences into account
• Some decision aids require classical clinical presentations and
progression of diseases

circumstances, with their own unique beliefs, values, and prefer-

ences. A key clinical decision is how applicable this guideline is to
the individual patient. Sackett, known as the father of evidence-
based medicine, defines evidence-based medicine [6] in Box 5.3,
and Figure 5.1 illustrates the application of evidence-based medi-
cine in a specific clinician–patient encounter.
It is important to take account of individual patient factors when
applying a guideline. Otherwise the outcome may be suboptimal
for that patient. As clinicians, we must be mindful that patients may
be harmed if they are subjected to procedures and treatments that
are inappropriate for them in their circumstances, or unacceptable
to them for a variety of reasons, even if they meet ‘the criteria’.

Applying Clinical Guidelines in Practice –

Helping Patients Share Decision-making Figure 5.1 Application of evidence-based medicine (EBM) at the level of
the individual patient and clinician.
Good communication is a vital aspect of clinical reasoning – from
history and physical examination through to using guidelines,
scores, and decision aids in clinical practice. This communication
needs to be directed at reaching a shared understanding with
patients about their illness in order to share decision-making with
them (see Figure 5.2).
The challenge for clinicians is in translating scientific, population-
based data into a practical management plan for the patient in front
of them. This involves many complex decisions, both relating to the
critical appraisal of the information itself and its practical application,
to the assessment of the needs of an individual patient, and how to
maximise the chances of the patient accepting and adhering to the
proposed management plan. The decisions involved in this latter
aspect are about how to communicate risks and benefits of treat-
ments in a way that recognises an individual patient’s health literacy.
There is evidence that many people do not understand per-
centages, proportions, or ratios, and that a more effective strategy
is to use absolute risk. For example, when thinking about women
deciding whether or not to take hormone replacement therapy
because of the risk of breast cancer, consider the three statements
in Box 5.4. They all sound quite different, and it may be difficult
to know what each actually means.
Now consider the statements in Box 5.5. This is the same risk
expressed as the absolute risk and is much easier for many patients
to understand. Patients may feel more confident about making a
decision having been given the information in an absolute risk
format.
Figure 5.2 Shared decision-making with patients. Image created by Dr Mark
Another way of using absolute risk is by talking about absolute Hamilton, Associate Professor, Leicester School of Medicine, using free to
risk reduction, and a variation of this is the concept of ‘prolongation use images from the website of the National Cancer Institute (https://www.
of life’. This can be used when helping patients to decide about cancer.gov).
32 ABC of Clinical Reasoning
Box 5.4 Talking about risk and hormone replacement therapy
(HRT)
• For women who take HRT, the risk of breast cancer increases by
just over a quarter
• For women who take HRT, the risk of breast cancer increases by 27%
• For women who take HRT, the risk of breast cancer is 1.27 times
greater than for those who do not take HRT
From the Medicines & Healthcare Products Regulatory Agency
UK, 2019.
­ reventative measures such as stopping smoking. Consider the case in
p who do not smoke. The GP also knows that the average age of
Box 5.6, for example. As a result of the patient having information as
a simple statement of prolongation of life, she was able to understand
the benefits of stopping smoking in a way that was directly related to
her concerns and priorities. She could perceive a clear and easily com-
prehensible gain if she could manage to stop. This increased her con-
viction that she should stop. The doctor used reasoning skills to make
decisions about how to find, appraise, interpret, and apply evidence-
based information to achieve a good outcome for the patient.
In recent years, extending the concept of giving patients enough
information to make informed decisions about their health has
led to a growing interest in formal Patient Decision Aids (PDAs).
These are intended to present evidence-based information to
patients in a way they can easily understand in order to help them
make decisions with the support of their clinician. An example of
such a decision aid is shown in Box 5.7.
Consider the statements in Box 5.5. The ‘understanding the
risks of breast cancer’ infographic compares lifestyle risk factors
versus HRT treatment which might further help clinicians’ dis-
cussions with some patients regarding the risks of HRT. The
information is simple and visual, but the onus is on the clinician
to communicate the information in a manner that matches the
patient’s health literacy and thus help the clinician and patient
make a shared management decision together.
There is currently rapid development in the field of patient
decision aids that goes hand in hand with the democratisation of data
as a result of better access via electronic records. Often, patients arrive
at their consultations with ideas generated as a result of their own
online searches. An important contributor to many consultations is
the clinician’s willingness to help with the interpretation and explana-
tion of such information and its application to the patient’s individual
circumstances. The patient’s choice of information provides a cue to
their own values and perspective. This is a particularly important
contribution made by the clinician. As can be seen when comparing
the detail of Boxes 5.4 and 5.5, the data offered by different studies
does not always match precisely, and the clinician then has a crucial
role in making sense of the detail through discussion with the patient.
Box 5.5 Talking about absolute risk and hormone replacement
therapy (HRT)
• In a group of 1000 women, there will be 3 new cases of breast
cancer every year
• In a group of 1000 women who take combined HRT, there will be
nearly 4 new cases of breast cancer every year
Adapted from British Menopause Society 2017.
Box 5.6 Using prolongation of life to encourage smoking
cessation
• Donna is 40 years old. She has smoked 25 cigarettes a day since
she was 16. Donna’s general practitioner (GP) wants to convey to
her the benefits of stopping smoking.
• The GP knows that the chance of a woman who smokes surviving
until the age of 79 years is 32% lower than for one who does not,
and that the rate of death from any cause among current smokers
is three times higher for people aged 25–79 years than for those
death for women who do not smoke is 81 years, and 71 years for
those who do smoke. The absolute risk reduction (for dying from a
cause associated with smoking) is 90% for those who stop
smoking before they are 40 years old. Donna has not been
convinced by any of these arguments and thinks that she has
smoked for so long that nothing will make any difference now.
• The GP decides to try a different approach. She wants to convey
to Donna that stopping smoking will have a positive effect on her
life expectancy. After some searching, she finds out that if Donna
were to stop smoking in the next year, she is likely to live for
about 9 years longer than if she does not stop. This would mean
that her life expectancy would become almost the same as if she
had never smoked.
• When the GP used this different approach, Donna found this
information compelling, worked hard at stopping smoking, and
was successful. She also convinced her partner to stop by using
the same argument.
Situated Cognition
Situated cognition, a concept discussed further in Chapter 8,
encompasses a range of theories that are united by the assumption
that cognition is inherently tied to the social and cultural contexts
in which it occurs [7]. In clinical practice, situated cognition
embraces the notion of complex interactions between the individual
participants and the environment, all of which can influence the
outcome (patient care) in the medical encounter [8]. This is very
important to clinical reasoning in two ways:
• The clinician needs to appreciate how the context in which
clinical reasoning is occurring influences both the reasoning
itself and its outcomes.
• As much as students can learn through abstract means such as lec-
tures, books, and tutorials, at some stage they have to engage in
learning clinical reasoning situated in the clinical environment
where they can eventually deploy their clinical reasoning on a rou-
tine basis. In this way the learner can move from the abstract and
theoretical to the practical, experienced in an authentic context [9].

Box 5.7 An example of a Patient Decision Aid (PDA)
Reproduced with permission from the British Menopause Society:
https://thebms.org.uk/publications/tools-for-clinicians (accessed July
2022).
Box 5.8 Mental checklist for use when considering the use of
decision aids
• Is there a decision tool that is helpful here?
• Have I checked that this is the correct tool to use with my
patient?
• Have I gathered all the information that I need from the patient?
• What is this individual patient’s context?
• What are this individual patient’s beliefs, values, and preferences?
• Can I explain this clearly to this individual patient, mindful of their
health literacy?
This emphasises the importance of directly consulting with patients
in the development of clinical reasoning, and some of those patient
encounters at an appropriate stage in learner development should
be unfiltered (e.g., in primary care or hospital assessment areas) to
maximise the learning potential of the encounter.
Box 5.8 shows a mental checklist for clinicians to use when
considering the use of decision aids for a specific consultation
with an individual patient.
Shared Decision-making 33
Summary
Clinical decision-making can be supported by using a variety of
clinical guidelines, scores, and decision aids. These can help with
diagnostic and management decisions. However, the clinician must
ensure that the correct decision aid is used and it must be interpreted
within the context of a comprehensive clinical assessment, in which
good communication skills are crucial to undertaking a purposeful
history and physical examination. After a diagnosis is made, clinical
decision-making continues and should be shared between the clini-
cian and patient whenever possible. During shared decision-making,
evidence-based medicine requires the clinician’s expertise to apply
scientific knowledge appropriately to the patient’s unique circum-
stances, and communicate in a way that is easily understood, being
mindful of each individual patient’s health literacy.
Acknowledgement
A proportion of this chapter is based on the original chapter written
for the first edition of the ABC of Clinical Reasoning. The authors
therefore wish to acknowledge the contribution of Professor Maggie
Bartlett (Professor Emeritus, Dundee University) to this chapter
through her co-authorship of the original chapter.
References
1. Shekelle PG, Woolf SH, Eccles M and Grimshaw J. (1999). Developing
guidelines. BMJ; 318: 593–596 (part of a four article series on the
development and use of clinical guidelines).
2. Wells PS, Anderson DR, Bormanis J et al. (1997). Value of assessment of
pretest probability of deep-vein thrombosis in clinical management. Lancet;
350(9094): 1795–1798.
3. The Rome Foundation. Rome IV Criteria. https://theromefoundation.org/
rome-iv/rome-iv-criteria. (Accessed July, 2022).
4. Lim WS, van der Eerden MM, Laing R et al. (2003). Defining community
acquired pneumonia severity on presentation to hospital: an international
derivation and validation study. Thorax; 58: 377–382.
5. Mayfield D, McCleod G and Hall P. (1974). The CAGE questionnaire: vali-
dation of a new alcoholism screening questionnaire. American Journal of
Psychiatry; 131: 1121–1123.
6. Sackett DL, Strauss SE and Richardson WS. Evidence-based medicine: how
to practice and teach EBM. London: Churchill-Livingstone, 2000.
7. Cobb P. Situated cognition: contemporary developments. In: Smelser NJ
and Baltes PB (Eds). International encyclopedia of the social & behavioral
sciences. Pergamon, 2001. pp 14121–14126.
8. Durning SJ, Artino AR Jr, Pangaro LN, van der Vleuten C and Schuwirth L.
(2010). Perspective: redefining context in the clinical encounter: implica-
tions for research and training in medical education. Academic Medicine;
85(5): 894–901.
9. Brown JS, Collins A and Duguid P. (1989). Situated cognition and the
culture of learning. Educational Researcher; 18(1): 32–42.
 CHAPTER 6
Models of Clinical Reasoning
Nicola Cooper
OVERVIEW
• Models of clinical reasoning can be useful for clinicians, teachers,
and learners
• Clinical reasoning can be viewed from different perspectives
• Critical thinking is not the same as clinical reasoning
• A dual process model is a widely accepted framework with which
to understand diagnostic reasoning and diagnostic error
• There is good evidence that rational decision-making often
requires a third process – termed reflective processing or
metacognition
• Expertise in clinical reasoning requires knowledge and experience,
but also motivation, effort, and metacognitive skills
Introduction
Models of clinical reasoning can be useful to help us understand
the processes underpinning our decision-making, as clinicians,
teachers, and learners. The problem is that clinical reasoning
research has its origins in the medical education, cognitive psy-
chology, diagnostic error, and health systems literature. This frag-
mented literature makes it difficult for clinicians and educators to
access and adopt meaningfully into their practice. This chapter
therefore aims to summarise some of the literature related to
models of clinical reasoning.
Different Perspectives
Clinical reasoning can be viewed from different perspectives (see
Figure 6.1). One perspective is that clinical reasoning is to do with
knowledge, how knowledge is organised in long-term memory as
mental representations, and the cognitive processes responsible
for storing, transforming, and retrieving these. It is also about
how clinicians use analytic and non-analytic strategies inter-
changeably when facing a diagnostic problem [1]. This view of
clinical reasoning is informed by decades of research in the
cognitive sciences and by dual process theorists.
ABC of Clinical Reasoning, Second Edition. Edited by Nicola Cooper and John Frain.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
Another perspective is that clinical reasoning is something that
is ‘situated’ in the environment. Here, clinical reasoning is inter-
dependent with various external factors such as the patient,
information technology (IT) systems, physical space, time con-
straints, and so on. This view of clinical reasoning is informed by
the situativity theories [2]. Accordingly, knowledge is not
something that exists solely inside a person’s organised cognitive
structures, but is entangled in the activity of providing care for the
patient [1].
Yet another perspective is that good clinicians need to be able
to go beyond the ‘content’ and make sense of the patient’s illness
(and their own response to it), to understand the practice of med-
icine in its wider socio-cultural context, and to ask: ‘What is going
on with this particular patient?’ This involves much more than
the application of knowledge or evidence-based guidelines. It
involves the ability to tolerate uncertainty and craft a deliberate
course of action appropriate for the circumstances – what we
might call wisdom [1]. This view of clinical reasoning is informed
by sociology, anthropology, and the humanities, including narra-
tive medicine (see further resources).
All these perspectives are valid and valuable. As we stated in
Chapter 1, these perspectives are not mutually exclusive. However,
the focus for teachers and learners is very much on knowledge
and knowledge organisation, at least to begin with. As learners
progress, they can begin to understand clinical reasoning as
something that is situated in the environment where they can
make use of all the affordances available to them. Hopefully, with
time, they will learn to navigate beyond the content to become
wise clinicians.
Critical Thinking Vs Clinical Reasoning
Before we discuss a widely accepted model of clinical reasoning, it
is important to correct a common misunderstanding. ‘Critical
thinking’ is a term sometimes used interchangeably with clinical
reasoning, but they are not the same thing. Critical thinking is an
important component of reasoning in general. A definition of
critical thinking can be found in Box 6.1. But clinical reasoning
36 ABC of Clinical Reasoning

It’s like a
It’s like a thick wall
huge fan …

Knowledge
It’s like a
rope … Individual
Critical
characteristics*
thinking
ability
It’s like a
snake!
It’s like a Cognitive
tree trunk ability

Figure 6.1 Clinical reasoning and different perspectives. A group of blind

men heard that a strange animal had been brought to town so they went to
investigate. They gathered round and felt the animal carefully, each person
Figure 6.2 Components of rationality. *Individual characteristics include
stating what they thought it was like. The parable of blind men and an
things like cognitive style, personality, gender, age, and other variables.
elephant is found in Buddhist, Hindu, and Jain texts, as they discuss the
Adapted from Croskerry, 2017.
limits of perception and the importance of context. The parable has several
variations.
rational thinking is influenced by several factors, illustrated in
Figure 6.2.
Box 6.1 A definition of critical thinking

‘The intellectually disciplined process of actively and skilfully
conceptualising, applying, analysing, synthesising, or evaluating
information gathered from, or generated by, observation, experi-
ence, reflection, reasoning, or communication, as a guide to belief
and action. In its exemplary form, it is based on universal intellectual
values that transcend subject matter divisions: clarity, accuracy,
precision, consistency, relevance, sound evidence, good reasons,
depth, breadth, and fairness.’
From the US National Council for Excellence in Critical Thinking
https://www.criticalthinking.org/pages/defining-critical-thinking/766
(accessed April 2022).
involves being able to gather data and interpret it. It involves the
senses: vision, touch, hearing, and smell. It requires specific
clinical knowledge, skills, and behaviours.
Critical thinking has its roots in the teaching of Socrates and is
related to logic. Logic is to do with the analysis of arguments – more
specifically the study of arguments which are made up of a set of
premises together with a conclusion. Three types of logical
reasoning are deduction, induction, and abduction (see further
resources). However, good thinking cannot be reduced to logical
thinking. Rationality is the term used by psychologists to describe
good thinking – thinking that is ‘reasonable, based on facts or
reason’ [3]. It not only encompasses logical methods of problem-
solving but also incorporates our beliefs, values, goals, and context.
There are several different models of rationality [4]. The two
Dual Process Theories
In 2009, Croskerry described research on human thinking and
decision-making which provides a basic framework for under-
standing diagnostic reasoning [5]. Since his description of dual
process theories as applied to medicine, a dual process model has
become widely accepted as a framework with which to under-
stand diagnostic reasoning and diagnostic error (see Figure 6.3).
However, this model is often misunderstood, so this next section
aims to describe dual process theories as applied to medicine and
then clarify some common misunderstandings.
Humans have two distinct processes when it comes to thinking
and decision-making – one that is intuitive and subconscious and
one that is analytical and conscious. This ‘dual process’ is sup-
ported by many experiments in psychology as well as functional
magnetic resonance imaging [6, 7]. These two processes are called
Type 1 and Type 2 respectively and their characteristics are listed
in Box 6.2.
Type 1 processing is intuitive and subconscious, a result of sev-
eral systems in the brain that operate autonomously and in
parallel in response to their own stimuli. They are a result of:
• Processes that are hard-wired/evolutionary (e.g., represen-
tativeness)
’Recognised‘ Type 1
processing

most relevant to medicine are epistemic (or evidential) rationality –

what is true – and instrumental rationality – what to do. Epistemic Calibration Diagnosis
Clinical Overlearning
Override
rationality is to do with how well our beliefs are commensurate presentation and practice
with the available evidence. Instrumental rationality is to do with
adopting suitable means to an end given the resources available
Type 2
to us. Thus, rationality in medicine is not about every decision Not processing
being ‘correct’ or error free. On the contrary, rational decision‐ recognised

making takes into account the consequences of possible errors to Figure 6.3 A simplified model of diagnostic reasoning. Adapted from
aid in arriving at desirable outcomes [4]. A person’s capacity for Croskerry, 2009.

Box 6.2 Characteristics of Type 1 and Type 2 processes
Type 1 Type 2
Intuitive, uses heuristics (mental Analytical, systematic
shortcuts/pattern recognition)
Automatic, pre- or subconscious Deliberate, conscious
Low effort High effort
Non-language based Language based
High processing capacity Limited capacity
Highly contextualised Decontextualised
• Processes that are regulated by emotions (e.g., fear of snakes
which is evolutionary, or dislike of certain people groups, which
is learned)
• Processes embedded through overlearning (e.g., driving)
• Processes embedded through implicit learning (e.g., stereotyping)
Type 2 processing, on the other hand, is analytical and conscious
and serial in nature. It is often language based and uses rules. Its
most distinctive characteristic is hypothetical thinking and its
ability to override early Type 1 responses and substitute better
ones via a process of cognitive stimulation.
When you instantly recognise something because you have seen
it before, you have engaged in Type 1 processing. When you have
to go through a deliberate process in order to figure out what
something is, you have engaged in Type 2 processing. When you
think you recognise something, but then pause and say to yourself,
‘Hang on a minute, what else could this be?’ you have over-ridden
your early Type 1 response and engaged in cognitive simulation.
Different dual process theories make different assumptions
about the relationship between Type 1 and Type 2 processing,
with some assuming the two occur in parallel, others assuming
that processing is sequential, and others assuming that one or the
other is used in a given situation. Most dual process theories
assume that Type 1 processing makes use of associations that are
built up through repeated experience, while Type 2 processing can
use information that has been learned only on a single occasion.
In clinical practice, Type 1 processing accesses schemas, or pat-
terns, based on formal and experiential learning, known as ‘illness
scripts’. According to script theory, medical knowledge is bundled
into networks that allow clinicians to integrate new information
with existing knowledge, recognise patterns and irregularities in
clinical presentations, identify similarities and differences bet-
ween diseases, and make predictions about how diseases are likely
to unfold [7]. These knowledge networks become updated and
refined through further experience and learning. Type 2
processing, on the other hand, uses knowledge of rules, proce-
dures, and linguistically coded strategies which are used to think
through problems or simulate alternatives. The knowledge, rules,
procedures, and strategies utilised by Type 2 processing have been
collectively termed ‘mindware’ and includes things like scientific
thinking, probabilistic reasoning (see Chapter 3), and logic.
We spend most of our lives using Type 1 processing in order to
conserve cognitive energy – we simply could not live our lives if
Models of Clinical Reasoning 37
every single decision were conscious, deliberate, and effortful. We
instantly recognise a chair and understand its purpose without
thinking about it. After a while, clinical practice is no different,
but this does not mean we cannot pause to reflect on our thinking
and decision-making in the moment. In fact, engaging in reflec-
tion during diagnostic decision-making has been found to be the
most consistent and precise cognitive intervention for improving
diagnostic accuracy. The benefit of reflection is greatest when the
case is complex relative to the decision-maker [8]. Reflection can
be as simple as asking oneself, ‘What’s the evidence for this? What
else could it be?’ or listing findings that are compatible or not
compatible with each differential diagnosis, a strategy that can be
used in teaching clinical reasoning (see Chapter 10). However,
people vary in their tendency to spontaneously engage in reflec-
tion during decision-making – more of that later.
Common Misunderstandings
It is a common misunderstanding that errors in clinical reasoning
mainly arise because of ‘cognitive biases’ (heuristics gone wrong) –
a result of Type 1 processing and a failure of Type 2 processing to
interrupt and override the initial intuitive response. Humans do
indeed have an overwhelming tendency to default to a fast, low-
effort mode of decision-making (what psychologists call being a
‘cognitive miser’) and this can certainly lead to error – an idea
popularised by Kahneman in his book Thinking, Fast and Slow
[9]. However, experts use Type 1 processing most of the time. For
them, it is fast and highly accurate. More generally, diagnostic
accuracy is associated with spending less time on a task, and get-
ting clinicians to ‘slow down and be more analytical’ under exper-
imental conditions does not improve accuracy. Mistakes can also
occur with Type 2 processing – if the relevant mindware is not
available because it has never been learned, or the relevant mind-
ware is contaminated, then a suboptimal response is not the result
of a failure to override Type 1 processing, but the result of a mind-
ware problem – in other words, a mistake rooted in inadequate or
faulty knowledge. Miserly Type 2 processing can also occur – the
framing effect and search satisficing (see Chapter 7) are examples
of this. Cognitive simulation takes effort, so the most easily con-
structed model is likely to win, especially if the person is operating
under conditions that diminish Type 2 processing, such as fatigue.
The bottom line is that no one type of processing is inherently
better than the other. Both have different functions and different
strengths and weaknesses and experts use multiple strategies
depending on the circumstances.
Tri-Process Theory
There are few differences between individuals when it comes to a
tendency to engage in Type 1 processing. But there are significant
differences when it comes to a tendency to engage in Type 2
processing. Some of these differences are to do with intelligence/
cognitive ability, aspects of the environment, e.g. time pressure, and
motivation or mood. But a person’s cognitive style – their tendency
to seek information, look for evidence, weigh things up, have an
awareness of context, and think about their own thinking – has
been found to account for significant differences in performance
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nourishing food and the avoidance of all debilitating morbid
conditions would indicate the principles of therapeutic management.
 HYPERÆMIA—CONGESTION OF THE
SPLEEN.
Four hours after full meal in splenic diastole. In well fed, high conditioned. From
obstruction of splenic or portal vein or vena cava, heart, liver, or pulmonary
disease, inhibition from encephalon acting through splanchnics or vagi, microbes,
ptomaines, toxins, paresis, albuminoid diet. Spleen may be seven times its normal
weight. Lesions: simple blood engorgement: proliferation of pulp cells: increased
friability; rupture; dark color; hyperplasia of trabeculæ—hypertrophy. Symptoms:
none; or colic; palpation in ruminants; tenderness. Treatment: directed against the
causative disease; quinine, cinchonine, eucalyptus, ergot, cold douche, electricity,
puncture.
Considerable hyperæmia of this organ takes place physiologically
in connection with active digestion in the first four or five hours after
an abundant meal, and especially at intervals of a minute, during
what may be called the diastole of the viscus. The supply of blood is
also much greater in the well fed animal, than in the emaciated and
impoverished one.
Pathological hyperæmias of a passive kind may occur as the result
of obstructions in the veins leading from the spleen, such as the
splenic veins, the posterior vena cava, or that part of the portal vein
comprised between its junction with the splenic and the liver.
Diseases of the right heart or its valves, of the lungs (emphysema), or
of the liver which hinder the onward flow of blood and increase the
blood tension in the vena cava or portal vein have a similar action.
Perhaps we should include inhibition of the nerves (splanchnic, vagi)
and nerve centres (medulla oblongata, cerebral cortex) which preside
over the contraction of the splenic vascular walls, and of the capsular
and trabecular muscles. There is reason to believe that the ptomaines
and toxins of several microbian diseases, operate through these
centres, while other such microbes and toxins operate directly on the
spleen itself.
Active congestions of the spleen are most commonly associated
with microbian diseases and may be attributed partly as above stated
to the action of the toxic products on the contraction nerve centres,
and on the splenic vessels and parenchyma, but also in no small
degree on the active proliferation of the germs themselves in the
splenic pulp, and of the splenic cells. Among the most notable
instances of this kind are, in man, malarious, yellow and typhoid
fevers, and, in animals, anthrax, and Southern cattle fever. In most
febrile diseases, however, there is a tendency in this direction, which
may be fairly attributed to the paresis of the organ and the delay of
the blood in its pulp channels and spaces with the consequent local
increase of microbes and toxins. The microörganisms can usually be
found abundantly in such cases, in the liquid of the pulp, and in the
interior of the leucocytes and other cells that go to make up its solid
constituents.
It has been long recognized by veterinarians that acute congestion
often arises in connection with a sudden transition from a poor or
insufficient diet to an abundant and nutritious one and especially to
one that is rich in albuminoids (beans, peas, vetches, lucerne,
sainfoin, clover, trefoil, in the fresh or preserved condition). If these
are not in themselves the direct causes of acute and fatal
engorgements of the spleen, they at least contribute in no small
degree to the overdistension of the pulp spaces, the paresis of the
organ and its successful invasion by pathogenic microbes.
The acute congestion attendant on specific microbian infection
may be estimated by the increase in weight of the spleen. In the
Southern Cattle fever this organ, which is normally 1.45 ℔., is
habitually 2 to 5 ℔s., and may reach 8 or 10 ℔s. and in anthrax an
equal increase may be noted.
Lesions. In such cases the organ may appear as if there were a
simple blood engorgement, and this is largely the case in the early
stages, but with the persistence of the disease there occurs an active
proliferation of the splenic cells and especially those of the pulp.
With the hyperæmia the consistency of the organ is diminished, and
still more so with the cell hyperplasia, so much so that in extreme
cases rupture may ensue. The color is always darker (purple or blue),
but this is only in part due to the abundance of blood and in part to
the thinness of the splenic capsule. If the condition persists a
hyperplasia of the capsule and trabeculæ ensues, and the condition
becomes essentially one of hypertrophy.
 Symptoms. In the slighter congestions there are no appreciable
symptoms. In the more severe there may be more or less violent
colic, but this is usually marked to some extent by the profound
depression attendant on the specific fever which is the cause of the
congestion. Palpation of the spleen is impossible in the horse. In
ruminants it may sometimes be felt along the upper border of the
rumen just behind the last rib on the left side. It is soft and yielding
retaining the indentation of the finger. If manipulation produces
signs of pain it is all the more significant.
Treatment. As a rule this is the treatment of the fever which
determines the hyperæmia. Apart from this, laxatives, quinia other
alkaloids of cinchona bark, eucalyptus, a current of cold water
directed to the region of the spleen, or induction currents of
electricity to the same region are also decided stimulants to
contraction. Ergot has been used with alleged advantage. In cattle
acupuncture of the spleen has been put in practice in anthrax.
 CHRONIC CONGESTION OF THE SPLEEN.
HYPERTROPHY.

Hypertrophy from chronic congestion, over feeding, hepatic cirrhosis. In horse:

from mechanical obstruction in heart, lungs, posterior cava, splenic veins,
angioma, from glanders or tubercle in lungs, chronic splenic congestion, disease of
splenic plexus. Lesions: increase enormous; mainly of pulp, or largely of fibrous
framework. Special neoplasms. Symptoms: excess of leucocytes in blood,
eosinophile cells, weakness, anæmia, emaciation, bleeding from mucosæ,
stretching, right hypochondriac tenderness, stiff gait, ascites, colic, disorder of the
bowels, rectal exploration. Treatment: is that of primary disease; not encouraging;
quiniae, eucalyptus, saline laxatives, open air, sunshine, electricity. In cattle is
habitually enlarged in Texas fever area. In lymphadenoma increase mainly of
fibrous framework and Paccinian bodies, and of adjacent lymph glands.
Symptoms: leukæmia, employ palpation, percussion, rectal exploration. Treatment
as in the horse. In swine: from high feeding, leukæmia, lymphadenoma,
tuberculosis, neoplasms, liver, heart and lung disease. Lesions: great increase of
Paccinian bodies, fibrous capsule and trabeculæ. In dog: from traumas, leukæmia
and lymphadenoma. Enlarged Paccinian bodies and adjacent lymph glands.
Symptoms: leukæmia, many eosinophile cells, abdominal enlargement, palpation,
icterus. Treatment: as for large animals.

A continuation of passive congestion from the causes enumerated

above, leads to permanent increase of the fibrous reticulum and
connective tissue and increase of the splenic pulp. Even the stimulus
of a rich and abundant alimentation increases the size of the whole
organ, the amount of pulp and the number and development of the
Paccinian bodies. Apart from disease the spleens of well fed cattle or
horses are always decidedly heavier than those of the starved or
debilitated. Of mechanical causes the most potent is cirrhosis of the
liver or some other obstacle to the free passage of blood through that
organ. The most common causes are, however, the continuous
operation of those specific poisons which determine the acute
hyperæmias.
 SPLENIC HYPERTROPHY IN HORSES.
Causes. It occurs as the result of mechanical obstruction of the
posterior vena cava as noticed by Varnell, from obstruction in the
splenic artery or veins by Ellenberger and Schütz, as the result of an
angioma by Martin, as the result of the morbid hyperplasias in
specific diseases—glanders, tuberculosis—taking place in the spleen
or lungs and thus directly or indirectly causing chronic congestion of
the spleen (Morot, Leisering, Nocard, Varnell) and again as the result
of innervation, in disease of the splenic plexus of nerves (Varnell).
Lesions. The increase in size may be enormous (42 lbs. (Bouret
and Druille), 92 lbs. (Cunningham), and over 100 lbs. (Girard)). The
consistency is varied. There may be such a redundancy of blood and
splenic pulp that the capsule is distended to its utmost or even
ruptured (Peuch). In other cases the splenic veins have given way
and the blood has poured out into the abdomen with fatal result
(Crafts, Cunningham, Reis). In other cases the spleen is enlarged,
unevenly swollen and indurated by the formation of angioma
(Jacob), lymphadenoma, glander or tuberculous nodules. In still
others the capsule and fibrous framework are greatly thickened and
the substance of the organ has assumed the consistency of the
hepatized lung (Rodet).
Symptoms. These are suggestive rather than diagnostic. Most
prominent is the condition of the blood with excess of leucocytes and
especially of the eosinophile cells. Weakness, emaciation, feebleness
of pulse, bloodlessness, bleeding from the nose or other natural
passages, are attendant symptoms. In cases of extreme hypertrophy
distension of the abdomen is marked and even the enlarged spleen
may be made out by palpation, there may be special tenderness and
dullness on percussion. Even partial sweats over the region of the
spleen (Cadeac), and stretching with the fore feet far in advance
(Welsby) have been noted as symptoms. In such conditions the
animal walks stiffly, groans in turning, or when suddenly started and
is with difficulty urged beyond a walk. There may be ascites, signs of
colic, or irregularity of the bowels. Rectal exploration may reveal the
hypertrophy.
Treatment is usually the treatment of the primary disease. In
glanders, tuberculosis, lymphadenoma, or leucocythemia there is
little to hope for. Nor is there much in hepatic cirrhosis, obstruction
of the vena cava or valvular disease of the heart. In simple
hypertrophy we may resort to quinia or other bitters, eucalyptus,
saline laxatives, exercise in the open air and sunshine, and local
currents of electricity.
 SPLENIC HYPERTROPHY IN RUMINANTS.
A moderate hypertrophy is the rule in the case of cattle which have
passed through the Southern cattle fever, but have continued to live
within the area of its prevalence. Gamgee’s observations in 1868
were very conclusive on this point. In over 1,000 western cattle the
average weight of the spleen was 1.45 ℔., in 441 Cherokee (Indian
Territory) cattle the average was 2.34 ℔s., and in 262 Texas cattle
the average was 2.66 ℔s. All these animals were killed for beef, in
what was considered to be perfect health. The difference relative to
the weight of the entire animal is even greater than is indicated
above, for at that date even more than at present, the Texas steer was
a small and thin animal in comparison with the portly western
bullock.
In lymphadenoma the organ may weigh 24 ℔s. (Tannenhauser);
in simple hypertrophy it has been found to weigh 37 ℔s. (Koch).
There was usually a marked increase in the size and number of the
Paccinian bodies, and hyperplasia of the fibrous reticulum, while the
pulp might be deficient and the cut surface rather dry. The adjacent
lymph glands are usually enlarged.
Symptoms. Unless in the case of excessive increase, no symptom is
usually observable, apart from leucocythæmia. With enormous
hypertrophy the enlarged organ may be recognized by palpation,
percussion, and perhaps rectal exploration.
Treatment is unsatisfactory apart from the control and arrest of
the primary diseases. For simple hypertrophy, bitters, laxatives and
electricity may be tried.
 SPLENIC HYPERTROPHY IN SWINE.

Causes. This disease appears to be rather frequent in pigs, in

connection with high feeding, and more particularly with
leucocythæmia and lymphadenoma. It is further a complication of
tuberculosis and of neoplasms located in the spleen, and of hepatic,
cardiac and pulmonary disorder.
Lesions. In leucocythæmia there is general enlargement of the
spleen, and especially of the Paccinian bodies which may attain the
size of a pea (Leisering, Fürstenberg, Bollinger, Siedamgrotzky, Röll,
Ellinger). The total weight of the organ may attain to 5 lbs.
(Mathieu), or 13 lbs. (Goubaux). In a remarkable case recorded by
Zell, the organ measured 30 inches in its longest circumference and
20 inches in its shortest. It had an enormous thickening of the
capsule and trabeculæ which enclosed softened contents in a state of
fatty degeneration.
Symptoms are wanting, as most of the observed cases were only
discovered after the animal had been killed for pork.
 SPLENIC HYPERTROPHY IN THE DOG.
This condition has been less frequently seen in dogs, the
recognizable causes having been traumatism (Notz), and
leucocythæmia (Zahn, Forestier, La Forgue, Nocard).
Lymphadenoma is another complication (Nocard, Leblanc,
Siedamgrotzky, Bruckmüller). The spleen has been found to weigh 2
lbs., (Bollinger, Siedamgrotzky). As in other animals the enlargement
of the Paccinian bodies has been a marked feature. In other cases the
splenic lymph glands are enlarged.
The symptoms are obscure as in other animals. Yet the presence of
white cell blood, with a predominance of eosinophile cells,
enlargement of the abdomen, and the detection of a large solid body
in the left hypochondrium which proves tender to the touch may
prove more satisfactory than in other animals. In certain cases it has
obstructed the biliary duct by pressure and entailed hepatic disorder
and jaundice.
The treatment would not differ from that of the larger animals.
Siedamgrotzky has also observed splenic hypertrophy in the cat in
connection with leucocythæmia.
 SPLENITIS. PERISPLENITIS.
Causes: extension from adjacent inflammations, penetrating bodies, contusions,
lacerations, infections, over exertion, cold, damp, over feeding. Symptoms: those of
primary disease, visible traumas, chill, fever, swelling, flatness of percussion
sound, absence of crepitation, anorexia, vomiting, constipation, diarrhœa.
Prognosis usually good. Treatment: castor oil, enemata, cold douche, electricity,
phlebotomy, in infective cases quinine, salol, salicylates, iodides.
No accurate border line can be drawn between splenic hyperæmia
and hypertrophy on the one hand and inflammation of the spleen on
the other. It is, however, not difficult to assign to inflammatory
action all cases that tend to suppuration and abscess. Also in
perisplenitis with adhesions to adjacent parts like the liver, stomach,
intestine, kidney or abdominal wall inflammation cannot be
doubted.
Causes. Extension from the disease of adjacent parts—
perihepatitis, perinephritis, peritonitis, enteritis—is a distinctly
appreciable cause, as are also penetration of the spleen by foreign
bodies, contusions, lacerations and infections of the organ. Cruzel,
who claims an extensive acquaintance with the disease in working
oxen, attributes many cases to violent exertions, overdriving, cold
and damp weather, and an overstimulating alimentation. As
inflammation may supervene on hyperæmia and hypertrophy we
must accept the various causes of these conditions as factors in
producing inflammation.
Symptoms. Most observations of inflammation of the spleen and
its results have been made only post mortem, so that we must allow
that the simple forms occur and undergo resolution without obvious
symptoms. In the perisplenitis supervening on another disease also
in infective cases there will be the antecedent symptoms of such
primary diseases. In those resulting from traumatic injury, bruises,
swellings or wounds, cutaneous or subcutaneous, there will often be
suggestive features. In the more purely idiopathic cases symptoms
are only shown when the lesions are extensive and acute. In oxen,
Cruzel has noted the initial chill, followed by disturbance of the
respiration, more or less hyperthermia, and a swelling of the left
flank and hypochondrium in the absence of tympany of the rumen.
The nature of this swelling is the most characteristic feature, as it
gives a flat instead of a drumlike sound on percussion, and does not
bulge outward and downward over the whole left side of the
abdomen, pit on pressure, nor crepitate uniformly all over from
fermentation, as in overloading of the stomach.
If abscess should form, chills and high febrile reaction are marked
symptoms. In vomiting animals, anorexia, nausea, vomiting,
constipation, and even diarrhœa may appear.
Prognosis. Unless in extreme cases and those due to traumatism
or infection, the result of splenitis is usually favorable.
Treatment would consist in depletion from the portal system and
spleen by rectal injections, and laxatives which like castor oil, will
operate without extensive absorption. Cold water or ice applied to
the left flank and induction currents of electricity may also be
resorted to. General blood-letting is strongly advised by Cruzel, and
Friedberger and Fröhner. In infective cases quinia, salicylates, salol,
and the sulphites, or iodides would be indicated.
 HÆMORRHAGIC INFARCTION OF THE
SPLEEN.
In congestive conditions. Absence of free capillary anastomosis and contraction,
absence of valves in splenic veins. Embolism of splenic artery. Clots in pulp spaces.
Wedge shaped infarcts, first black, later yellow, later caseated, or cicatrized.
Abscess. Prognosis good in non-infective forms. Treatment as for hyperæmia, or
infection, or both.
This condition appears in hyperæmia, hypertrophy, splenitis, and
splenic infection and largely because the structure and circulation in
the organ conduce to such trouble. The splenic arteries terminate in
open vascular spaces filled with splenic pulp and where all trace of a
freely anastomosing capillary network is lost. The splenic veins in the
same manner originate from these open vascular spaces. There is,
therefore, an absence of the free communication of capillary
network, which virtually acts as a safety valve in other vascular
tissues, and the vascular cavities connected with each terminal artery
are independent of those belonging to another, and find no way of
ready relief when they become over distended, or when there occurs
obstruction (thrombosis) of their afferent or efferent vessels. From
blocking of arteries or veins there is at once produced a wedge
shaped area of stagnation which cannot be relieved through any
collateral circulation. Again the splenic veins, being destitute of
valves, offer no obstacle to the reflux of blood into such vascular
spaces whenever the further access of blood has been arrested by the
blocking of the artery. The blocking may occur in the afferent artery
through embolism by clots carried from the lungs or left heart, or
formed within the vessel by the colonization of microbes on its walls.
Even more likely is the formation of coagula in the vascular spaces
themselves as the result of the introduction of pus, or septicæmic
microbes, which are long detained and have ample time for
multiplication in these cavities. In either case the result is
obstruction to the sanguineous current, the filtering of blood
backward from the veins and the engorgement of the cavity with
blood. The plugs consist of fibrinous matter enclosing colonies of
micrococci, and the result is not only black infarction of the spleen,
but a subsequent general infection of the system at large.
The wedgeshaped infarcts are usually situated at the surface of the
organ, the base turned outward and forming a dark projection on the
surface, and the apex turned inward. The aggregation of two or three
in one group may considerably alter the outline. If recent they are of
a dark red color. Later from absorption of the coloring matter and
fatty degeneration of the mass they assume a pale yellow hue and the
swelling flattens or disappears. Later still through complete fatty
degeneration they may be transformed into caseated masses, or
through organization into fibrous tissue they may form thick white
cicatrices. If pus cocci are present suppuration and abscess may be
the outcome.
The simpler forms recover like cases of simple hyperæmia while
the severe infecting forms may become the point of departure for the
formation of multiple abscesses in other organs, and of more or less
fatal general infections.
These conditions can only be discovered post mortem, and any
symptoms directing attention to the spleen could only suggest such
treatment as would be indicated in hyperæmia. Any purulent or
septic disease which might coexist would of course serve to indicate a
germicide line of treatment.
 ABSCESS OF THE SPLEEN.
In Solipeds: in infectious diseases, pyæmia, embolism. Symptoms: of primary
disease or ill health. Involving other organs. In cattle: foreign bodies from
reticulum, distomata, embolism, microbes. Enlargement: involving other organs:
seen in left hypochondrium, fever, albuminuria. Treatment: aspiration, antiseptic
injections, internal antiseptics.
Soliped. Abscess of the spleen in this animal is unusual and has
only been discovered post mortem. It has been found as the result of
the local colonization of pyogenic microbes, in connection with
strangles, contagious pneumonia and other infectious diseases and
can then often be traced to an infected embolus in the splenic blood
vessels. The peculiar vascular structure of the spleen is very
conducive to abscess as it is to infarction, as has been already noticed
and hence this complication of a pre-existing infection in another
part is a natural pathological sequence. Symptoms are rather the
general ones of a rigor followed by hyperthermia than any diagnostic
ones of splenic disease. Bourges found a splenic abscess in a
cachectic, melanic mule but no definite splenic symptom was
observed even on rectal examination. Nottel found an abscess as
large as an infant’s head, in the base of the spleen, closely adherent
by its sac to the left kidney and containing a floating mass of splenic
tissue as large as the closed fist. Rutherford found a neoplasm
connecting the great curvature of the stomach, to the diaphragm, and
hollowed out into a series of pus cavities. Fetzner and Cadeac report
cases of extensive abscesses in the head of the spleen and intimately
connected to both stomach and diaphragm. Hahn found abscesses in
connection with the penetration of the spleen by foreign bodies. In
other cases the substance of the spleen was studded with abscesses
varying in size from a pea upward and containing necrotic tissue or
adjoining such dead tissue.
Ruminants. In cattle the penetration of the spleen by sharp
pointed bodies coming from the reticulum appears to be the most
common cause of abscess. Other cases depend on the penetration of
distomata carrying the pyogenic microbes, and still others are due, as
in the horse, to local infection with embolism. External traumatisms
are unusual causes. There is usually considerable enlargement of the
spleen as a whole, rounded swellings indicating the seat of the
abscess, and adhesions to surrounding parts, such as the rumen, the
left kidney or the diaphragm. When the abscess is chronic, there is
emaciation, unusual flatness on percussion of the left
hypochondrium, and, at times, of the flank, swelling and tenderness
of the flank, above all, according to Imminger, a persistent elevation
of temperature (104° to 106° F.), which is not lowered by
antithermics, and albuminuria. In cattle it is sometimes possible to
diagnose the disease, and if the abscess can be definitely located,
aspiration and antiseptic injections into the sac would be indicated,
conjoined with calcium sulphide, or sodium sulphite internally.
 FOREIGN BODIES IN THE SPLEEN.
In horse: body from intestine. In ruminants bodies from reticulum. Laparotomy.
One such case in the Horse is reported by Hahn. A mare had loss
of appetite, slight colics, frequent efforts to urinate, dullness,
prostration, profuse perspirations, and tremors of the muscular walls
of the abdomen. Rectal examination detected a staff-shaped body
extended from behind forward in the direction of the stomach. The
mare survived twenty days, when it was carried off by a more violent
access of colic. At the necropsy, the spleen was found to measure 28
inches by 8; its base was adherent to a loop of intestine, and
presented a large cavity filled with a grayish brown fœtid liquid, and
a piece of oak measuring 17 inches by ½ inch.
Ruminants. In cattle and especially in those that are stabled,
needles, pins, nails, wires and other sharp pointed bodies, that have
been swallowed with the food, and have become entangled in the
reticulated walls of the second stomach, have been found to
penetrate the spleen and determine local abscess and fistulæ. The
offending body in such cases is found in the interior of the abscess or
in its walls. If such cases can be diagnosed the superficial position of
the spleen would seem to warrant surgical interference for the
removal of the foreign body.
 RUPTURE OF THE SPLEEN.
Solipeds: Causes: Blows, kicks, goring, leukæmia, compression of splenic or
gastric veins, anthrax infection. Lesions: Blood may escape into peritoneum or
remain confined under serosa. Splenic degeneration or pulpy condition. Fractured
ribs, ecchymosis, surface swellings. Spontaneous arrest. Symptoms: Of internal
hemorrhage. Vomiting. Trembling. Vertigo. Coma. Treatment: Rest, quiet, locally
ice, snow, cold, internally iron chloride, matico, astringents, anodynes. Cattle:
Blows, crowding, leukæmia, youth, anthrax, Texas fever, microbes. Symptoms:
Persistent lying down, advancing bloodlessness, surface coldness, stiffness, local
tenderness, fluctuation. Treatment as in horse.
Horse. This is not a frequent lesion in solipeds, yet the number of
cicatrices of the spleen which are found post mortem in old horses
would indicate a considerable number of slight and non-fatal cases.
The most common cause appears to be external violence and
especially kicks or blows with horns on the left hypochondriac
region. Horses running at large in pastures, or in yards, or standing
side by side in short stalls or tied with too long halters are the usual
victims. Cadeac refers to cases reported by Tausch, Millot, Berndt,
Humbert and Pont, and one case occurring in a three year old colt
came under the notice of the author. The subject stood in a stall to
the right of an irritable mare, and though the kick left no noticeable
skin lesion the colt died in three hours with symptoms of internal
hemorrhage. At the necropsy a laceration of the spleen of about five
inches long was disclosed, and a large quantity of blood had
accumulated in the peritoneum.
Brandis mentions a case consequent on a violent fall on the left
hypochondrium.
In other cases pre-existing disease of the spleen or its blood-
vessels have proved active factors. In the friable degenerated spleen
of leucocythæmia multiple small lacerations have been found (Peuch,
Laulanie); in engorgement of the spleen consequent on thrombosis
of the splenic vein (Wiart); in chronic indigestion with habitually
loaded stomach compressing the gastric and hepatic arteries and
determining a reflux of blood through the cæliac axis into the spleen
(Mongin).
 Finally, though less frequently than in the ox, the engorgement of
the spleen with blood in cases of anthrax may be a cause of rupture.
Lesions. The rupture may be on any part of the spleen and it may
be complete or incomplete; in the latter event the capsule may have
ruptured while the more elastic peritoneal covering has remained
intact enclosing a coagulum of variable size bulging above the level of
the spleen. When the peritoneal coat has given way, its laceration is
usually smaller than that in the spleen and its proper envelope. Any
degeneration of the spleen will affect the appearance of the lesion. In
one case caused by external violence the adjacent portions of the
spleen were reduced to a soft pulp. In such a case there is a slow but
continuous flow of blood in a small stream which may, however,
prove fatal (Humbert and Pont).
Again in cases caused by external violence there may be fractures
of the ribs, ecchymosis, local swellings or even wounds of the skin,
but all these may be absent. The blood effused into the peritoneum is
usually clotted. If the effusion has taken place slowly it is more or
less coagulated around the edges of the wound or even in its depth
and in this way the hemorrhage may be arrested. When the
peritoneum is still intact the pressure of the clot beneath it has
served to arrest the flow. In such cases the clot may be in part
liquefied and absorbed and in part organized into fibrous tissue,
constituting the cicatrices of the spleen found in old horses.
Symptoms appear to have been varied. Colicy pains are generally
noted. Tausch has observed vomiting, Millot vertigo, and Wiart coma
and trembling. In the author’s case the animal was found down,
unable to rise, almost unconscious, pulseless, with great pallor of the
visible mucous membranes, dilated pupils, and cold extremities. A
diagnosis was made of internal hemorrhage, but its actual seat was
only revealed post mortem.
Treatment. The early mortality usually forbids treatment. When
opportunity is furnished keep the animal absolutely still and quiet,
apply snow, ice or other refrigerant to the left hypochondrium, give
internally tincture of muriate of iron, matico, or other astringent,
and relieve any severe suffering by anodynes (hyoscyamus,
belladonna, opium). External wounds may be treated antiseptically.
Cattle. The causes of laceration and hemorrhage of the spleen are
similar to those acting in the horse. Blows with the horns on the left