Diagnostic reasoning in internal medicine: a practical reappraisal
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IM - REVIEW
Diagnostic reasoning in internal medicine: a practical reappraisal Gino Roberto Corazza1,3 · Marco Vincenzo Lenti1 · Peter David Howdle2 Received: 20 August 2020 / Accepted: 26 October 2020 © The Author(s) 2020
Abstract The practice of clinical medicine needs to be a very flexible discipline which can adapt promptly to continuously changing surrounding events. Despite the huge advances and progress made in recent decades, clinical reasoning to achieve an accurate diagnosis still seems to be the most appropriate and distinctive feature of clinical medicine. This is particularly evident in internal medicine where diagnostic boundaries are often blurred. Making a diagnosis is a multi-stage process which requires proper data collection, the formulation of an illness script and testing of the diagnostic hypothesis. To make sense of a number of variables, physicians may follow an analytical or an intuitive approach to clinical reasoning, depending on their personal experience and level of professionalism. Intuitive thinking is more typical of experienced physicians, but is not devoid of shortcomings. Particularly, the high risk of biases must be counteracted by de-biasing techniques, which require constant critical thinking. In this review, we discuss critically the current knowledge regarding diagnostic reasoning from an internal medicine perspective. Keywords Clinical reasoning · Diagnosis · Internal medicine
Introduction The burden of disease is always changing [1] and the current COVID-19 pandemic [2] represents an example of this phenomenon. Health systems tend to adapt to the changing burden of disease by developing a variety of strategies including more precise and advanced techniques, such as molecular analysis, genetic mapping, enhanced imaging modalities, or innovative and targeted drugs [3]. However, even in such a time of transition and technological advance, clinical medicine remains an area dominated by uncertainty and probability, and a correct diagnostic reasoning, the prerequisite for correct management, still remains the cornerstone of good clinical practice. Making a diagnosis is a cognitive process of logic which involves an element of considering different options (i.e. * Gino Roberto Corazza [email protected] 1
First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
2
The School of Medicine, University of Leeds, Leeds, UK
3
Emeritus Professor of Internal Medicine, Clinica Medica, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 19, 27100 Pavia, Italy
categorical approximation) and is, therefore, liable to errors that result in adverse patient outcomes [4]. As already mentioned, making mistakes in clinical practice has not been alleviated by progressive technology improvement [5]; on the contrary, an overreliance on new procedures has directly increased the occurrence of such adverse outcomes [6]. A focus on diagnosis is what has been said to define and to differentiate internal medicine from other medical
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