Conceptualization of category-oriented likelihood ratio: a useful tool for clinical diagnostic reasoning

<p>Abstract</p> <p>Background</p> <p>In the diagnostic reasoning process medical students and novice physicians need to be made aware of the diagnostic values of the clinical findings (including history, signs, and symptoms) to make an appropriate diagnostic decision. Diagnostic reasoning has been understood in light of two paradigms on clinical reasoning: <it>problem solving </it>and <it>decision making</it>. They advocate the reasoning strategies used by expert physicians and the statistical models of reasoning, respectively. Evidence-based medicine (EBM) applies <it>decision theory </it>to the clinical diagnosis, which can be a challenging topic in medical education.</p> <p>This theoretical article tries to compare evidence-based diagnosis with expert-based strategies in clinical diagnosis and also defines a novel concept <it>of category-oriented likelihood ratio (LR) </it>to propose a new model combining both aforementioned methods.</p> <p>Discussion</p> <p>Evidence-based medicine advocates the use of quantitative evidence to estimate the probability of diseases more accurately and objectively; however, the published evidence for a given diagnosis cannot practically be utilized in primary care, especially if the patient is complaining of a nonspecific problem such as abdominal pain that could have a long list of differential diagnoses. In this case, expert physicians examine the key clinical findings that could differentiate between broader categories of diseases such as organic and non-organic disease categories to shorten the list of differential diagnoses. To approach nonspecific problems, not only do the experts revise the probability estimate of specific diseases, but also they revise the probability estimate of the <it>categories of diseases </it>by using the available clinical findings.</p> <p>Summary</p> <p>To make this approach analytical and objective, we need to know how much more likely it is for a key clinical finding to be present in patients with one of the diseases of a specific category versus those with a disease not included in that category. In this paper, we call this value <it>category-oriented LR</it>.</p

The Assessment of Clinical Reasoning in Preceptors Across the Athletic Training Profession

Clinical reasoning (CR) is defined as a complex multi-factorial metacognitive process for diagnosis formulation. Clinical reasoning begins as a student and develops over a career. Students are typically taught an analytical approach defined as hypothetico-deductive reasoning (HDR). Expert clinicians use a non-analytical approach defined as the Knowledge Based Model (KBM) of CR. It is accepted that clinicians use the KBM with cases that they have more experience to streamline the evaluation process. Unfortunately, because of the nuance of CR there have been limited investigations within athletic training to evaluate CR outside of the student population. The overarching purpose of this dissertation was to investigate CR in athletic training preceptors. To achieve this purpose, three interrelated projects were conducted. The first project involved a systematic review to investigate the use of the Diagnostic Thinking Inventory (DTI). The second project assessed clinical reasoning using the Diagnostic Thinking Inventory for Athletic Trainers (DTI-AT) in athletic training preceptors. The second project was guided by the Longitudinal Framework for Fostering Critical Thinking and Diagnostic Reasoning to establish appropriate demographic questions associated with CR development. The final project explored preceptors’ perceptions of CR in athletic training. The systematic review confirmed that the DTI was a valid, reliable, and widely used instrument to assess CR in healthcare professions. The instrument was used in medicine, physiotherapy, and athletic training. Project II indicated that the athletic training preceptors studied scored higher on the DTI than the averages of all other professions assessed in the literature, however, all other professions included both students and professionals. Professional sociability was found to be the only demographic factor related to higher scores on the DTI-AT. This finding contrasted with the Longitudinal Framework for Fostering Critical Thinking and Diagnostic Reasoning. Project III identified that CR processes in athletic training are highly variable between individual clinicians based on their experiences, confidence, patients, and external factors. Findings from these three projects indicate the importance of continued CR assessment of athletic training professionals, inclusion of soft skills in athletic training education, and encouraging professional sociability both inter- and intraprofessionally

Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room

Background: Diagnostic errors occur frequently, especially in the emergency room. Estimates about the consequences of diagnostic error vary widely and little is known about the factors predicting error. Our objectives thus was to determine the rate of discrepancy between diagnoses at hospital admission and discharge in patients presenting through the emergency room, the discrepancies’ consequences, and factors predicting them. Methods: Prospective observational clinical study combined with a survey in a University-affiliated tertiary care hospital. Patients’ hospital discharge diagnosis was compared with the diagnosis at hospital admittance through the emergency room and classified as similar or discrepant according to a predefined scheme by two independent expert raters. Generalized linear mixed-effects models were used to estimate the effect of diagnostic discrepancy on mortality and length of hospital stay and to determine whether characteristics of patients, diagnosing physicians, and context predicted diagnostic discrepancy. Results: 755 consecutive patients (322 [42.7%] female; mean age 65.14 years) were included. The discharge diagnosis differed substantially from the admittance diagnosis in 12.3% of cases. Diagnostic discrepancy was associated with a longer hospital stay (mean 10.29 vs. 6.90 days; Cohen’s d 0.47; 95% confidence interval 0.26 to 0.70; P = 0.002) and increased patient mortality (8 (8.60%) vs. 25(3.78%); OR 2.40; 95% CI 1.05 to 5.5 P = 0.038). A factor available at admittance that predicted diagnostic discrepancy was the diagnosing physician’s assessment that the patient presented atypically for the diagnosis assigned (OR 3.04; 95% CI 1.33–6.96; P = 0.009). Conclusions: Diagnostic discrepancies are a relevant healthcare problem in patients admitted through the emergency room because they occur in every ninth patient and are associated with increased in-hospital mortality. Discrepancies are not readily predictable by fixed patient or physician characteristics; attention should focus on context

Osteopathic clinical reasoning: an ethnographic study of perceptual diagnostic judgments, metacognition, and reflective practice

A thesis submitted to the University of Bedfordshire in partial fulfilment of the requirements for the degree of Professional DoctorateThis thesis explores the use of reflective practice in osteopathic medicine and uses the method to narrate my work as an osteopathic practitioner. It explores the development of perceptual diagnostic judgments, and the role of metacognition, intuition and palpation in osteopathic clinical reasoning. A qualitative interpretive approach was used with a novel narrative method as an organising structure. This was broadly based around reflective practice models of Gibbs, (1988), Kolb, (1984) and Carper (1978) and the ideas of Schön (1983). Descriptive texts were constructed from notes taken of my thoughts whilst in the presence of patients. This allowed access, as closely as possible, to my decision making process. Finally, the descriptive texts were expanded into narratives through dialogue with the existing literature and peer review. The narratives were then analysed using thematic analysis to derive an understanding of concepts arising from the data. This thesis argues that osteopathic clinical reasoning involves multisensory perceptual diagnostic judgments that begin as soon as the patient enters the clinic, and arise as a result of the use of mental and visual imagery and embodied senses. The multisensory information that is detected by a practitioner activates pattern recognition, analytic reasoning and provides explicit feedback used in decision making. Diagnosis occurs as a result of piecing together and interpreting the multisensory information whilst maintaining awareness of other diagnostic possibilities. The findings also suggest that osteopathic clinical reasoning involves the supervision of cognition by the metacognitive processes of meta-knowledge (MK), meta-experiences (ME), and meta-skills (MS). The latter are used to plan, monitor, analyse, predict, evaluate and revise the consultation and patient management as suggested by Pesut and Herman (1992). ME is demonstrated by the presence of judgments of learning used to ensure sufficient information has been gathered, and feelings of rightness that are used to perceive the correctness of information arriving and decisions made. The use of reflective practice in this research has developed the understanding of osteopathic clinical reasoning, and demonstrated that it provides a powerful conduit for change in practice. As a result, it enables the provision of better patient-centred osteopathic healthcare incorporating the biopsychosocial model of healthcare. Although rooted in my own osteopathic practice style and strategies, it should have resonance for those within the discipline of osteopathy and has implications for osteopathic education, training and research

A review of clinical decision-making: Models and current research

Aims and objectives: The aim of this paper was to review the current literature with respect to clinical decision-making models and the educational application of models to clinical practice. This was achieved by exploring the function and related research of the three available models of clinical decision making: information processing model, the intuitive-humanist model and the clinical decision making model. Background: Clinical decision-making is a unique process that involves the interplay between knowledge of pre-existing pathological conditions, explicit patient information, nursing care and experiential learning. Historically, two models of clinical decision making are recognised from the literature; the information processing model and the intuitive-humanist model. The usefulness and application of both models has been examined in relation the provision of nursing care and care related outcomes. More recently a third model of clinical decision making has been proposed. This new multidimensional model contains elements of the information processing model but also examines patient specific elements that are necessary for cue and pattern recognition. Design: Literature review Methods: Evaluation of the literature generated from MEDLINE, CINAHL, OVID, PUBMED and EBESCO systems and the Internet from 1980 – November 2005

The influence of patient and doctor gender on diagnosing coronary heart disease

Using novel methods, this paper explores sources of uncertainty and gender bias in primary care doctors’ diagnostic decision making about coronary heart disease (CHD). Claims about gendered consultation styles and quality of care are re-examined, along with the adequacy of CHD models for women. Randomly selected doctors in the UK and the US (n=112, 56 per country, stratified by gender) were shown standardised videotaped vignettes of actors portraying patients with CHD. ‘Patients’ age, gender, ethnicity and social class were varied systematically. During interviews, doctors gave free-recall accounts of their decision making, which were analysed to determine patient and doctor gender effects. We found differences in male and female doctors’ responses to different types of patient information. Female doctors recall more patient cues overall, particularly about history presentation, and particularly amongst women. Male doctors appear less affected by patient gender but both male and especially female doctors take more account of male patients’ age and consider more age-related disease possibilities for men than women. Findings highlight the need for better integration of knowledge about female presentations within accepted CHD risk models, and do not support the contention that women receive better quality care from female doctors

Deliberate clinical inertia: Using meta-cognition to improve decision-making

Deliberate clinical inertia is the art of doing nothing as a positive response. To be able to apply this concept, individual clinicians need to specifically focus on their clinical decision-making. The skill of solving problems and making optimal clinical decisions requires more attention in medical training and should play a more prominent part of the medical curriculum. This paper provides suggestions on how this may be achieved. Strategies to mitigate common biases are outlined, with an emphasis on reversing a 'more is better' culture towards more temperate, critical thinking. To incorporate such an approach in medical curricula and in clinical practice, institutional endorsement and support is required