An Introduction to Clinical Reasoning (Strong Diagnosis)

Summary

In the 'Strong Diagnosis' series by Dr. Eric Strong, a hospitalist and professor at Stanford University, he explores clinical reasoning, a critical skill for clinicians. The series is designed for viewers with little to no knowledge in the field, starting from the basics of differential diagnosis and advancing to complex topics like the use of mathematics and decision-making models in diagnostics. Dr. Strong explains that clinical reasoning encompasses both diagnostic and therapeutic aspects, is imprecise and probabilistic, and is an iterative process. The course is divided into three parts, covering foundational diagnostic reasoning, intermediate topics like cognitive theories and decision-making, and advanced quantitative reasoning, aiming to complement the 'Strong Medicine' series on symptom approaches.

Takeaways

• 👨‍⚕️ Eric Strong, a practicing hospitalist and clinical associate professor at Stanford University, introduces a new series called 'Strong Diagnosis'.
• 🧠 The series focuses on clinical reasoning, which involves hypothesizing possible diagnoses, selecting tests, and developing treatment strategies.
• 📚 It's designed for intelligent and motivated viewers who are new to the topic of clinical reasoning.
• 🔍 Clinical reasoning includes diagnostic reasoning (identifying the disease) and therapeutic reasoning (deciding on treatment).
• 🤔 The process is imprecise, often without a single 'right' answer, and can vary between clinicians due to experience, bias, and uncertainty.
• 📈 The course is structured in three parts: foundations of diagnostic reasoning, intermediate topics, and quantitative reasoning with biostats and game theory.
• 📊 Part one covers basics like differential diagnosis, diagnostic frameworks, and test selection without using math.
• 🧠 Part two delves into cognitive theories, prediction rules, decision-making models, and common diagnostic errors.
• 📊 Part three applies biostatistics and expected value analysis to clinical reasoning, including the impact of cost and digital tools.
• 🔗 'Strong Diagnosis' complements the 'Strong Medicine' series, which covers symptom approaches, diagnostic frameworks, and flowcharts.

Q & A

What is clinical reasoning?

Clinical reasoning is the collection of cognitive processes through which a clinician hypothesizes possible diagnoses, selects appropriate tests to confirm or refute those hypotheses, and develops treatment strategies. It integrates pathophysiology, biostatistics, patient values, and communication with healthcare professionals.

What are the two branches of clinical reasoning?

The two branches of clinical reasoning are diagnostic reasoning, which focuses on determining what disease a patient has, and therapeutic reasoning, which focuses on how to treat the disease in a particular patient.

Why is clinical reasoning considered imprecise?

Clinical reasoning is imprecise because situations often don’t have a single correct answer, and different clinicians may reach different conclusions based on their experiences, cognitive biases, and the weight given to the patient's values.

How is clinical reasoning probabilistic?

Clinical reasoning is probabilistic because even with perfect reasoning, clinicians can still make misdiagnoses due to uncertainty, incomplete information, and the need to make educated guesses in certain situations.

What is meant by clinical reasoning being iterative?

Clinical reasoning is iterative, meaning the reasoning process is continuously updated with new relevant data as it becomes available, allowing clinicians to refine their diagnoses and treatment plans.

What topics are covered in part one of the Strong Diagnosis series?

Part one covers the foundations of diagnostic reasoning, including diagnostic frameworks, differential diagnosis, illness scripts, problem lists, test selection, and hypothesis refinement.

What cognitive biases can affect clinical reasoning?

Cognitive biases that can affect clinical reasoning include different weight given to patient preferences and values, as well as biases introduced by previous experiences and gaps in knowledge.

What intermediate topics are covered in part two of the series?

Part two covers cognitive theories behind clinical reasoning, clinical prediction rules, the threshold model of decision-making, cognitive bias, diagnostic errors, and the assessment of clinical reasoning skills.

How does part three of the series relate to quantitative reasoning?

Part three focuses on quantitative reasoning, including biostatistics, Bayesian analysis, expected value decision-making, expected utility analysis, high-value care, and the influence of costs on clinical decisions.

How does the digital age affect clinical reasoning?

In the digital age, clinical reasoning is impacted by the use of electronic medical records (EMRs), artificial intelligence in diagnosis, and crowd-sourcing diagnostic problems through social media, all of which influence decision-making processes.

Outlines

00:00

👨‍⚕️ Introduction to Clinical Reasoning

Dr. Eric Strong introduces the 'Strong Diagnosis' series, focusing on clinical reasoning within the context of 'Strong Medicine.' The series aims to educate viewers from the basics of differential diagnosis to advanced topics like the application of mathematics in diagnostics and decision-making. It is designed for intelligent and motivated individuals with no prior knowledge of the subject. The video explains the concept of clinical reasoning, which includes diagnostic and therapeutic reasoning, and highlights its imprecision, probabilistic nature, and iterative process. The course is structured into three parts, each with six videos, covering foundational diagnostic reasoning, intermediate topics like cognitive theories and decision-making models, and advanced quantitative reasoning with biostatistics and game theory. The series complements the 'Strong Medicine' series on symptom approaches and diagnostic frameworks.

05:03

🔍 Key Takeaways from Strong Diagnosis

This segment summarizes the key points of the introduction to 'Strong Diagnosis.' Clinical reasoning is defined as the cognitive process clinicians use to make decisions about possible diagnoses and treatment strategies for patients. It is divided into diagnostic reasoning, which focuses on identifying diseases, and therapeutic reasoning, which addresses treatment approaches. The segment emphasizes that clinical reasoning is imprecise, meaning that different clinicians can reach different conclusions based on their experiences and biases. It is also probabilistic, acknowledging the possibility of misdiagnosis despite perfect reasoning, and iterative, as the reasoning process is continuously updated with new data. The video concludes with a reminder to explore the 'Strong Medicine' series for a comprehensive understanding of symptom approaches and diagnostic frameworks.

Keywords

💡Clinical Reasoning

Clinical reasoning is the cognitive process by which a clinician hypothesizes about the possible diagnosis of a patient, selects appropriate tests, and develops treatment strategies. It is central to the video's theme as it encompasses the core skills that clinicians use to make decisions regarding patient care. The video discusses how clinical reasoning involves knowledge of pathophysiology, biostatistics, and epidemiology, and is integral to the practice of medicine as described by Eric Strong.

💡Differential Diagnosis

Differential diagnosis is a systematic method used by clinicians to identify the possible causes of a patient's signs and symptoms. It is a foundational concept in the video, which is part of the educational series 'Strong Diagnosis' aimed at explaining the process of clinical reasoning. The script mentions that the series will cover the basics of differential diagnosis, which is crucial for narrowing down the potential diagnoses.

💡Pathophysiology

Pathophysiology refers to the study of the mechanisms of disease, focusing on the functional changes that occur as a disease progresses. In the context of the video, pathophysiology is part of the clinicians' knowledge base that is applied during clinical reasoning to understand the underlying mechanisms of a patient's condition and to formulate an accurate diagnosis.

💡Biostatistics

Biostatistics is the application of statistical methods to the analysis of data in the biomedical field. The video mentions that clinicians often use biostatistics qualitatively, but the series will also explore the quantitative use of statistics in clinical reasoning. This includes the use of mathematical models to assess the probability of diseases and the effectiveness of treatments.

💡Epidemiology

Epidemiology is the study of the distribution and determinants of health-related states in populations. It plays a role in clinical reasoning by providing insights into the prevalence and risk factors of diseases, which can inform diagnostic and treatment decisions. The video script discusses the incorporation of epidemiological knowledge into the clinical reasoning process.

💡Shared Decision-Making

Shared decision-making is a model where healthcare decisions are made jointly by healthcare professionals and patients. It is highlighted in the video as an important aspect of clinical reasoning, emphasizing the integration of the patient's values and preferences into the decision-making process. This approach is seen as a way to enhance patient-centered care.

💡Diagnostic Reasoning

Diagnostic reasoning, also known simply as clinical reasoning, is the process of determining the cause of a patient's symptoms. It is a key part of the video's narrative, focusing on how clinicians use clinical reasoning to answer the question of what disease a patient has. The video series 'Strong Diagnosis' is designed to explore this aspect of clinical reasoning in depth.

💡Therapeutic Reasoning

Therapeutic reasoning is the process of deciding on the appropriate treatment for a diagnosed disease. It is mentioned in the video as a branch of clinical reasoning that focuses on the question of how to treat a disease. The video series aims to cover both diagnostic and therapeutic reasoning, providing a comprehensive view of clinical decision-making.

💡Iterative Process

An iterative process is one that is repeated with the expectation of improvement or refinement. In the context of the video, clinical reasoning is described as iterative, meaning that it is continuously updated with new data. This aligns with the video's theme of clinical reasoning as a dynamic and evolving process that adapts to new information.

💡Cognitive Bias

Cognitive bias refers to the systematic errors in thinking that affect the decisions and judgments that people make. The video discusses cognitive bias as a factor that can influence clinical reasoning, potentially leading to different conclusions among clinicians even when they have access to the same information. Understanding and mitigating cognitive biases is important for improving the accuracy of clinical decisions.

💡Quantitative Reasoning

Quantitative reasoning involves the use of numerical data and mathematical techniques to solve problems. The video mentions that the series will cover the application of biostatistics and game theory concepts to clinical reasoning, which is part of the quantitative approach to understanding and making decisions in healthcare. This aspect of the video series aims to provide a more data-driven perspective on clinical reasoning.

Highlights

Eric Strong introduces a new series on clinical reasoning called 'Strong Diagnosis'.

The series is designed for intelligent and motivated viewers with no prior knowledge of clinical reasoning.

Clinical reasoning involves hypothesizing possible diagnoses, selecting tests, and developing treatment strategies.

It includes knowledge of pathophysiology, biostatistics, and epidemiology, as well as cost considerations and patient values.

Clinical reasoning is divided into diagnostic and therapeutic reasoning.

Diagnostic reasoning focuses on identifying the patient's disease.

Therapeutic reasoning addresses how to treat the identified disease.

Clinical reasoning is imprecise, with situations often lacking a single correct answer.

Clinicians can reach different conclusions due to experiences, cognitive biases, and the need to make best guesses in uncertain situations.

Clinical reasoning is probabilistic, meaning misdiagnoses can occur even with perfect reasoning.

The process is iterative, continuously updated with new data.

The course is organized into three parts, covering foundational, intermediate, and advanced topics in clinical reasoning.

Part one focuses on the foundations of diagnostic reasoning, with no mathematical components.

Part two delves into cognitive theories, clinical prediction rules, and common diagnostic errors.

Part three applies biostatistics and game theory concepts to clinical reasoning.

The series complements the 'Strong Medicine' series on an approach to symptoms, which includes diagnostic frameworks and flowcharts.

Clinical reasoning is described as the cognitive process for decision-making regarding diagnoses and treatment strategies.

The series aims to enhance understanding of clinical reasoning skills in the digital age, including the impact of EMRs and AI on diagnosis.

Transcripts

hello everyone it's Eric strong a

practicing hospitalist

and a clinical associate professor at

Stanford University welcome to a new

series here on strong medicine which I'm

calling strong diagnosis in this series

I'll be talking about the process of

clinical reasoning consistent with

strong medicine in general this series

will assume a viewer who is intelligent

is motivated and who knows nothing about

this particular topic so I'll be taking

you from the absolute basics of what a

differential diagnosis is and will

gradually progress all the way through

some advanced topics like the use of

mathematics in making diagnoses choosing

diagnostic tests and modeling decision

making this video will serve as an

introduction to the subject of clinical

reasoning in general and an introduction

to this course specifically so let's

just start off with the most basic of

questions what is clinical reasoning

clinical reasoning is the collection of

cognitive processes by which a clinician

hypothesizes the possible diagnosis an

individual patient may have selects

appropriate tests to confirm or refute

their hypothesis and develops treatment

strategies for the diagnosis under

consideration it involves the

incorporation of the clinicians

knowledge of pathophysiology the

application of biostatistics and

epidemiology usually qualitatively

though the final videos in this series

will discuss the use of statistics

quantitatively the consideration of the

cost of both tests and treatments both

to the patient and to the healthcare

system in which one is working the

integration of the patient's values and

preferences usually under a model

referred to as shared decision-making

and lastly the communication of one's

thought processes to other healthcare

professionals there are actually two

branches of clinical reasoning and as

typical for medicine the common

terminology is confusing in common usage

the term clinical reasoning is usually

applied just to diagnostic reasoning

that is answering the question what

disease does this patient have

but there is also therapeutic reasoning

that is answering the question how

should we treat that disease in this

patient clinical reasoning both

diagnostic and therapeutic is imprecise

situations often don't have one single

right answer and outstanding clinicians

working with the same information can

reach different conclusions throughout

the series I'll talk about why this

happens but as a spoiler it's partly due

to different or previous experiences

cognitive bias different weight given to

the patient's values and preferences and

because in situations in which

uncertainty or gaps in knowledge exist

clinicians need to insert best guesses

into their analyses guesses which will

vary from person to person in addition

to clinical reasoning and being

imprecise it is also probabilistic this

means that even using perfect reasoning

clinicians can still make misdiagnosis

and clinical reasoning is iterative the

reasoning process whether it's focused

on disease probabilities or treatment

plans is continuously updated with each

new piece of relevant data

this course is organized into three

parts each consisting of six videos part

one will cover the foundations of

diagnostic reasoning these videos will

be relatively short and fully

qualitative meaning no math topics here

include this introduction diagnostic

frameworks and differential diagnosis

Samantha qualifiers and summary

statements illness scripts problem lists

and test selection and apophysis

refinement part two will cover more

intermediate topics including cognitive

theories behind the reasoning process

clinical prediction rules the threshold

model of decision-making cognitive bias

an overview of common diagnostic errors

and the assessment of clinical reasoning

skills and last part three is all about

quantitative reasoning how we apply

biostats and even concepts from game

theory to clinical reasoning the six

topics here will include a bio stats

crash course Bayesian analysis expected

value decision-making expected utility

analysis high-value care and the

influence of cost and finally clinical

reasoning in a digital age from the

effect of using an EMR on the reasoning

process to ai8 at diagnosis to crowd

sourcing diagnostic problems on social

media due to their complexity the videos

for these topics will be a bit longer

than in parts one and two strong

diagnosis this series on clinical

reasoning skills is intended to be a

complement to strong medicine series on

an approach to symptoms which itself

covers the ideologies of common symptoms

along with the appropriate workup full

of diagnostic frameworks and flowcharts

so please check out that series as well

the key takeaway points for this

introduction to strong diagnosis

clinical reasoning is the cognitive

process for which a clinician makes

decisions regarding possible diagnosis

and treatment strategies for an

individual patient it's typically

subdivided into diagnostic reasoning

also known as just clinical reasoning

and therapeutic reasoning and last

clinical reasoning is imprecise

probabilistic and iterative

[Music]

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