Clinical reasoning – what it is

Clinical or diagnostic reasoning is about:

The traditional medical history model (Box 2.1) aims, through many questions, to converge gradually towards a diagnosis. Alternative models tend to be based upon, or at least incorporate, communication skills.

Clinical reasoning strategies

Various strategies can be used to get to the diagnosis. Three main ones are hypothetico-deductive reasoning, scheme-inductive reasoning and pattern recognition. Imagine three diagnosticians presented with a four-legged animal. Diagnostician 1 thinks it is a zebra because it looks like one. Diagnostician 2 agrees it is a zebra because it has hooves and stripes and weighs around 300 kg. Diagnostician 3 is from the North Pole and has only ever seen Arctic animals before; he agrees it might be zebra, but also thinks it might be a giraffe because of its hooves or a tiger because of its stripes.

The traditional model

The traditional model is an essential checklist of the content to be covered in a medical history (Box 2.1).

Understanding what patients are thinking

In PACES you have 15 minutes to take a history, witnessed by examiners examining your history-taking skills – the communication skills that make history taking effective.

Fifteen minutes may seem a short time in which to take a medical history, although general practitioners regularly have less than 10 minutes, relying on focused questions incorporating the patient’s perspective. In PACES, as in practice, feeling pressured because you are short of time and trying to extract the ‘facts’ at all costs from the patient is ultimately less effective than demonstrating these skills. Patients often report things in what seems a chaotic order, dodging from one area of the history to another; candidates might prefer patients to quickly and simply answer questions rather than volunteer extra information. Yet this extra information often contains vital elements of the real problem.

History taking is a way of guiding what patients say. The best way to understand how history-taking skills can guide patients is to understand what patients are thinking.

The patient’s perspective – ideas, concerns and expectations (ICE)

Having taken such a history, you should of course consider the possibility of deep venous thrombosis (DVT). DVT is the most serious of the differential diagnoses, although intuitively you may have some doubts; the duration of symptoms is long and the flight 2 months ago probably irrelevant. Hypothesis testing (pursuing possibilities in turn until they are either excluded or warrant further testing) may also bring a popliteal cyst and muscle strain into the differential diagnosis. You might also wonder whether as a nurse she might be particularly worried about a DVT. She will have seen DVTs on the surgical wards and know them to be dangerous. She might also be aware of the risks of air travel, but unaware that 2 months is a long time to ‘harbour’ a thrombosis. She is probably apprehensive. Being a patient in hospital or clinic – as a health-care professional to a greater or lesser extent – is being in an alien environment amidst other unwell and sometimes dying people. Many patients have strong preconceptions about doctors and hospitals learned from relatives, friends or the media; doctors seem not to tell patients much, and what they do tell can be difficult to understand; they make mistakes, sometimes with fatal outcomes. This patient might have already decided that she has a blood clot in her leg until proven otherwise. She might know that blood clots can travel to the lung and prove fatal. Much convincing to the contrary might be needed if, for example, her grandmother died from a blood clot (albeit after a fractured hip). She may have seen patients on warfarin, a dangerous drug sometimes taken for life. She might be scared that she has a serious condition requiring dangerous treatment.

These sorts of thoughts going through her mind may be summarised as her ideas (beliefs), concerns and expectations about what her symptoms might represent. She might:

A 30-year-old athlete with similar symptoms might believe them to represent a strained muscle, have very few concerns and expect them to go away.

ICE in practice

Overt doctor centredness (pure information gathering) and overt patient centredness (purely addressing the patient’s perspective) are extremes of a spectrum. History taking naturally undulates within the spectrum, generally starting with patient-centred open questions:

Patient-centred history taking aims to identify a patient’s ICE. The following questions are examples of this patient-centred approach:

Patient centredness taken too far can render history taking just as ineffective as pure doctor centredness. History taking should certainly involve guiding a patient back on track if the account starts to wander into areas you feel will not yield useful information; it is perfectly acceptable to say something like:

How it all affects the patient

Exploring the patient’s perspective fully should explore not just ICE, but how the illness or problem(s) affects that patient. This overlaps significantly with the social history. The principle is that it is as important to understand the person who has the disease as it is to understand the disease itself, and it can be helpful to encourage the patient to express their feelings. Opening questions could be:

• Listening skills

• Use of appropriate questions

• ‘Eliciting’ or facilitating skills

• Recognising and responding to cues

• Use of appropriate language

• Summarising.

Listening skills

As with examining patients and starting with inspection, good history-taking candidates are alert to how patients look, talk and behave. The patient may be relaxed or anxious, waiting for questions, may have already started talking or may pre-empt your opening question:

The important thing is not to rush in with questions, suppressing information that may provide a valuable insight into what the patient is thinking. Useful opening questions might be:

The response might be:

Again, it is very important to continue listening. Many candidates respond immediately with questions, for example by asking about cardiac symptoms or by assuming the problem to be tiredness and asking about thyroid symptoms. Remember that asking a direct question usually only gives you the answer to that question! Careful listening for a minute or two, encouraging the patient to elaborate, will help you form a much more accurate assessment of what the problem is likely to be about:

Your thoughts may now be quite different. Heart failure? Angina? Pulmonary emboli? Chronic obstructive pulmonary disease? Pulmonary fibrosis? The point is that listening, giving a little time for the patient to tell you what has been happening in their words, will give you a clearer idea of the direction you need to take.

Use of appropriate questions

Eliciting or facilitating skills

Disclosure of relevant medical information and information important to a patient needs to be facilitated. Some patients need little encouragement to talk, and their account should be guided towards what you see as clinically relevant. Some patients are reserved, and need encouragement. Probably the two most important eliciting skills are active listening and the use of appropriate questions. As well as asking open and closed questions, remember that some questions may seem irrelevant to patients and it is important to explain why you are asking them. This may be especially important for sensitive issues:

Recognising and responding to cues

A cue is hard to define, and more easily recognisable. It could be defined as a signpost to an area in the history you might otherwise ignore but which may be very important to the patient. Cues are very common. They are often not consciously presented by patients, but offer an insight into undeclared concerns.

Use of appropriate language

Most importantly, use clear and concise language that you think the patient will understand, and avoid technical terms or jargon that might not be understood, or at least explain any necessary jargon. It can sometimes help to ‘match’ a patient’s verbal and non-verbal behaviour. Patients often speak in visual or auditory terms or in concepts and might say:

Sometimes harnessing the patient’s language in this way can enhance rapport and you may find yourself doing it naturally:

Sometimes, in subtle ways, it is possible to match body language as well as speech. Matching is a two-way process. Speaking loudly and clearly will often encourage a patient to do the same.

Summarising

Content versus process

The traditional history model describes the content of the interview – what to cover. Communication models describe the process of the interview – how to do it. Doctors often revert to closed questions and a tightly structured history directed towards gathering medical information. This is understandable because most doctors learned this model, and doctors are seldom observed taking histories but often observed presenting their findings, engendering the erroneous belief that the format for presenting information is the same as that of gathering information. Further, doctors document their findings using the traditional model, augmenting this belief. Because communication skills have previously been taught on courses separate to content skills taught at the bedside, the belief that ‘real’ doctors take ‘histories’ and communication skills disregard the clinical history is all too common. Yet the traditional model fails to elicit much of the information needed to understand and manage a patient’s problems. Indeed, studies of patient satisfaction, concordance, recall and physiological outcomes validate the need to combine the traditional model with communication skills models. Many communication models exist, such as the Calgary–Cambridge guides. Communication models provide alternative frameworks and lists of skills that are the means by which doctors get through the medical interview, develop rapport, gather information and then discuss their findings and management options with patients.

Content plus process

Because content and process are different frameworks it is easy to see them as alternatives and use only one. Indeed, if not learned and practised together, the tendency is to allow one (usually the traditional model) to inhibit the other. This can lead to many of the common faults in history taking (Box 2.3).

Comprehensive clinical methods that explicitly integrate the traditional model with effective communication skills have been proposed. Table 2.1 is a summary of content working with process that is suitable for Station 2 of PACES.

Candidate information

Patient information

Mr John Thorn is a 56-year-old man who has been troubled by progressive breathlessness on exertion for the past 6 months, with a dry cough. He saw his GP 3 months ago when he developed purulent sputum and although this settled over about 2 weeks with two different courses of antibiotics, his breathlessness and dry cough persisted. He is not breathless at rest, or lying down. He thinks he may have lost a little weight, but has no other notable symptoms. He has smoked 20 cigarettes a day since he was a young man and attributes his symptoms to this. He has no other past medical history of note. He has worked for 30 years as a road-builder. He has never worked in shipyards or building construction and to his knowledge has not been exposed to asbestos. He is not prone to allergies. He has owned the same parrot for the last 8 years and has no other pets. Inhalers have not helped his breathlessness. A course of steroids helped his breathing only marginally. He is worried that if his breathing deteriorates he will no longer be able to visit his brother, who lives in America.

How to approach the case

Data gathering in the interview and interpretation and use of information gathered

Presenting problem(s) and symptom exploration

Elicit details of breathlessness.

Find out:

• If it is chronic, and, if so, if it is progressive

• If it came on suddenly or insidiously

• If it is continuous, discrete or with stepwise episodes of worsening (pulmonary emboli; infective exacerbations of chronic obstructive pulmonary disease (COPD))

• If it is present only on exertion, or also at rest, and if there is orthopnoea (left ventricular failure).

Ask about trigger factors.

Ask about exercise, cold, smoking and allergens.

Explore associated symptoms.

Ask about:

• Cough, with sputum (characteristics and volumes – large volumes suggest bronchiectasis) or dry (interstitial lung disease)

• Haemoptysis (lung cancer, pneumonia, pulmonary tuberculosis, bronchiectasis, pulmonary embolus, vasculitis, pulmonary haemorrhage)

• Wheeze (asthma, COPD)

• Symptoms suggesting a cardiac cause (exertional chest pain, orthopnoea, paroxysmal nocturnal dyspnoea, ankle swelling – which may also be due to cor pulmonale)

• Alarm symptoms for malignancy such as weight loss, anorexia, haemoptysis or hoarseness.

Patient perspective

Explore his concerns about the limitations caused by breathlessness, and reassure him that you will do all you can to improve his breathing to enable him to fly.

Past medical history

Ask breathless patients about previous respiratory diseases, such as tuberculosis or asthma, cardiovascular disease or risk factors, and atopy (personal or family history of asthma, eczema or allergic rhinitis).

Drug and allergy history

Many drugs may contribute to dyspnoea, cough or wheeze; specifically ask about non-steroidal anti-inflammatory drugs and angiotensin-converting enzyme inhibitors.

Family history

Ask about atopy or respiratory disease.

Social history

Ask about:

• Smoking (including passive smoking and pipe smoking – when started / stopped, quantity and pack years)

• Occupations past and present (specifically about the shipyard and building industries for asbestos exposure and road-building for silicosis)

• Travel (atypical pneumonia)

• Pets (cats and dogs commonly trigger asthma, and birds can trigger atypical pneumonia and extrinsic allergic alveolitis).

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