As a GP, we are undertaking clinical reasoning with nearly every patient. It is most often automatic. However, in preparation for the KFP exam, it can be helpful to deconstruct the clinical reasoning process. The ultimate goal, however, is to make us better clinicians, not just to pass the exam!
A definition of clinical reasoning includes an ability to integrate and apply knowledge, to weigh evidence, critically think about arguments and to reflect upon the process used to arrive at a diagnosis. We learn this at the bedside of our consultants and supervisors. It implies that we have a good knowledge of medicine, and the conditions that we encounter. We should have an “illness script” for each condition, so that we can compare it to the bank of other conditions in our illness script “filing cabinet” (pattern recognition).
Dual Process Theory
It is important to know about Dual Process Theory when we are talking about Clinical Reasoning. As medical students, we are taught Type 2 thinking – this is a slow, methodical, logical process driven type of thinking, where we are taught to take a history from the patient, formulate differential diagnoses, and rule those differentials in or out by further history, physical examination and investigations. Type 1 thinking is intuitive, fast, automatic and experiential. This is developed as you become more experienced.
A good clinical thinker routinely approaches a clinical presentation by using a combination of Type 1 and Type 2 thinking. The nonanalytic approach is more common, accounting for 80% of clinical reasoning and is based on pattern (or illness script) recognition(2).
Preparing for the KFP
When preparing for the KFP, be aware of which type of thinking you are using. It is important to see as many patients as possible in the lead up to the exam, and use them to practice your clinical reasoning. Practice your Type 2 Reasoning, and use Murtagh’s PROMPT as a framework to do this.
Any history questions, physical examination and investigations should be targeted at ruling in and ruling out your differentials and red flags. The 'Masquerades' and 'Often Missed' should be thought of, and investigated if appropriate.
There are several good resources to help improve your clinical reasoning.
- Being aware of Diagnostic error is important. This article on Life in the Fastlane is helpful.
- IM Reasoning Podcast is helpful, particularly the “Stump the Chumps” Episodes. If you do a lot of driving or walking, these podcasts are invaluable. Can be downloaded from App store, or found at IM Reasoning
- An AFP article on learning Clinical Reasoning
- The Society to Improve Diagnosis in Medicine has a website, which has a Clinical Reasoning Toolkit, with several resources. If you are interested in reading more about this area, I suggest that you look at this.