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Physicians undergo training to acquire knowledge and understanding of various diseases and illnesses and how to treat them. It is worth mentioning that the healing or curing of illness depends entirely on the diagnosis, which involves an interaction of the physician with the patient for the physician to accurately understand what the patient is suffering from.
Diagnosis is, therefore, a very crucial aspect of treatment because the wrong diagnosis leads to the wrong prescription and thus no healing while correct diagnosis leads to healing of the sickness (Bendall and Morrison, 2009). Sometimes physicians may make errors either due to intuitive or analytical judgment.
In clinical reasoning, intuitive judgment is based on previous experiences and encounters while analytical judgment is based on some medical analysis and or investigations of an illness in the laboratory. However, the two do not happen in isolation with each other but rather exist in a continuum. This is because for one to make an intuitive judgment, he or she must have performed an analysis of the same disease or illness.
For one to make an analytical judgment, he or she must borrow from experience to make sense of the analytical judgment. For this reason, it is not easy to distinguish clinical decision-making errors made due to intuitive or analytical judgments (Rajkomar and Dhaliwal, 2001, pp. 68-73).
The medical field is a professional one. As a profession, it is guided by certain principles, rules, regulations, and guidelines which are aimed at ensuring that the relationship between physicians and patients remains purely professional. No politics, emotions or other biases which are supposed to interfere with the relationship between physicians and patients (Sibbald and Cavalcanti, 2011, pp.827-834).
The medical profession is considered as a helping profession, just like social work and religion. This is to mean that physicians usually empathize with patients for the physicians to be effective in treating the patients. Being empathetic makes the physicians put themselves in the shoes of the patients; and because the physicians are also humans with biological bodies, they can understand what the patients are going through.
Due to the sensitivity of the issue of diagnosis, there has been an ongoing debate on the reliability of intuitive clinical reasoning in comparison to analytical, clinical reasoning and the role of each in diagnosis errors (Ferreira, Ferreira, Rajgor, Shah, Menezes, and Pietrobon, 2010, p.265).
Some commentators have argued that intuitive clinical reasoning is characterized by many assumptions and subjectivity. For instance, some physicians have been said to make conclusions about some common symptoms or have been said to look for a particular symptom in the patient to diagnose the illness.
This sometimes leads to the wrong diagnosis because it has been demonstrated that various illnesses share symptoms; for example, fever is known to be a symptom of many illnesses. The critics of intuitive clinical reasoning argue that it does not embrace the evolvement of diseases or the emergence of new diseases or strains of diseases with symptoms similar to those of common illnesses.
Intuitive clinical reasoning has also been criticized for ignoring new research as well as feedback from the hypotheticodeductive approach (Jensen, Croskerry, and Travers, 2009, p.17). Compared to intuitive reasoning, hypothetico-deductive reasoning seems more plausible and appealing to many clinical commentators. This is because it is very reliable and trusted to produce reliable results.
Since the process is based on some analysis and tests, it leaves no room for any doubt in the results. Even though it is difficult to isolate it from intuitive reasoning, the analytical aspect of the approach makes it cushioned from any biased assumptions which may lead to wrong diagnosis (Pelaccia, Tardif, Triby and Charlin, 2011, p.16).
It is therefore difficult to distinguish clinical errors as to whether they are as a result of an intuitive judgment or analytical judgment. This is because something may go wrong during the analysis, which may lead to wrong deductions.
If for example, a physician makes a mistake of using the wrong reagents in a lab, the results will be different and therefore misleading. However, if carefully followed, hypothetico-deductive reasoning is arguably more reliable than intuitive clinical reasoning (Fournier, Demeester, and Charlin, 2008, p.18).
Why is clinical reasoning a ‘bounded’ process? Clinical reasoning is the thought process which goes in the minds of clinicians and physicians during the diagnosis of illnesses. Clinicians encounter patients with various medical conditions ranging from simple to complex. Irrespective of the nature of the condition, the physician has the task of interpreting the symptoms and coming up with a possible diagnosis (Ilgen, Bowen, Yarris, Fu, Lowe and Eva, 2011p.79-86).
When physicians encounter patients, there is what goes through their minds as they try to grasp the condition of the patient. The thought process involves rapid scanning of information in their minds. This happens consciously and deliberately because the physicians only retrieve the information relevant to the case at hand.
Clinicians and physicians always rely on simple but robust heuristics when making their clinical decisions as opposed to the criteria outlined in the diagnostic clinical practice guidelines (CPG). In most cases, they start by asking the patients several simple questions such as family history, diseases they suffered while young and their general health history.
While doing this, they usually look for clues as to what the patient may be suffering from. Once they get such clues, they narrow down to specific symptoms to confirm what they suspect the patient is suffering from. In doing this, they argue that they usually avoid time wastage in the complex and tedious lab tests, which they argue usually yield the same results.
This makes clinical reasoning a ‘bounded’ process in the sense that it is bounded by simple rules of reasoning, which yield robust results with minimal errors in diagnosis. Clinical reasoning ignores complex procedures and this makes the work of clinicians cut out for them, especially in areas where the number of patients is relatively higher than the number of physicians.
Clinical reasoning is also bounded by past experiences. Clinicians and physicians usually base their diagnosis on their past experiences or on unique cases which they have handled before. They also isolate some cases which they find unique or complicated. Such cases are subjected to investigations as stipulated in the diagnostic clinical practice guidelines (CPG).
By so doing, the clinicians and physicians increase their efficiency and contrary to many, increase the confidence of the patients (Mamede and Schmidt, 2007, pp.1185-1192). Clinical reasoning is also bounded by the social environment in which clinicians operate. It is known that some illnesses have got no diagnosis irrespective of subjecting them to lab tests.
Such illnesses may be due to witchcraft or some funny beliefs. When the physicians fail to diagnose any illnesses in patients with clinical symptoms, they usually refer them to religions leaders for prayers, in the sense that the healing aspect is not only based on clinical diagnosis but also the psychological condition or beliefs of the patient.
Reference List
Bendall, J & Morrison, A 2009, Clinical Judgement’ in Paramedics in Australia Contemporary challenges of practice, P O’Meara & C Grbich, Pearson Education Australia, Frenchs Forest, NSW.
Ferreira, A. P. R. B., Ferreira, R. F, Rajgor, D, Shah, J., Menezes, A, & Pietrobon, R 2010, “Clinical reasoning in the real world is mediated by bounded rationality: implications for diagnostic clinical practice guidelines”. PloS one, 5(4), p.265.
Fournier, J, Demeester, A, & Charlin, B 2008, Script concordance tests: guidelines for construction. BMC medical informatics and decision making, 8(1), p.18.
Ilgen, J. S, Bowen, J. L., Yarris, L. M, Fu, R, Lowe, R. A, & Eva, K 2011, Adjusting Our Lens: Can Developmental Differences in Diagnostic Reasoning Be Harnessed to Improve Health Professional and Trainee Assessment?. Academic Emergency Medicine, 18, pp.79-86.
Jensen, J. L, Croskerry, P, & Travers, A. H 2009, “Consensus on Paramedic clinical decision making during high-acuity emergency calls: results of a Canadian Delphi study”, BMC emergency medicine, 9(1), p. 17.
Mamede, S., H. G, Schmidt, E 2007, “Breaking down automaticity: case ambiguity and the shift to reflective approaches in clinical reasoning.” Medical Education, 41(12): pp.1185-1192.
Pelaccia, T, Tardif, J, Triby, E, & Charlin, B 2011, “An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory”, Medical education online, p.16.
Rajkomar, A & Dhaliwal, G 2001, ‘Improving diagnostic reasoning to improve patient safety’, Perm J 15(3): pp. 68-73.
Sibbald, M. & Cavalcanti, R. B 2011, “The biasing effect of clinical history on physical examination diagnostic accuracy.” Medical Education 45(8): pp. 827-834.
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