Clinical reasoning and making decisions based on such reasoning are both critical in any veterinarian’s role (not dissimilar to the physician’s position, in fact). However, the process seems to be less well accepted and embraced in the veterinary profession, sometimes associated with an increase in erroneous statements about it in veterinary educational circles than other of the skills we expect practitioners to possess.
In an age that correctly prides itself on an evidence-based approach to medicine, it is surprising the way that a surprisingly increased repetition of statements doubting clinical reasoning such as ‘students should not engage in pattern recognition’, ‘scientific method is used to reach diagnosis’, or ‘analytical approaches are more accurate than pattern recognition’ has led to them becoming accepted as the de facto ‘truth’, even by the experts in charge of the education of the next wave of practitioners yet to join our profession.
From our own experiences, we suggest that in any small animal practice, the application of clinical reasoning is essential. Based on a combination of direct experience of the challenges of different personal caseloads over many years and our ideas about how best to apply what we’ve learned, we hope to bring some enlightenment to the subject matter.
With advances in the general understanding of the way our brains work, it is increasingly possible to link whatever insights we have to an approach that is being more commonly proposed.
To begin with, it is now widely accepted that our processes of reasoning can be grouped into two categories: type I (often termed pattern recognition) and type II or, the analytical process. Where possible in our lives, we try to use type I ‘tactic’ in making decisions, as it is rapid and efficient. It is predicated on our remembering similar problems encountered in our own past, and, assuming we correctly analyse and apply these established patterns, it is every bit as precise and accurate as analytical thinking or reasoning.
However, the modern ‘need for speed’, our desire to get things done as quickly as possible, can easily but erroneously lull us into a mistaken state of ‘cognitive miserliness’ (Stanovich 2009) where we ignore all lack of compatibility or fit of our remembered pattern system. In such a scenario, when we are commonly confronted by genuine ‘life and death’ decisions such as the health and well-being of a valued patient, we must always remind ourselves to cross-check our initial impulse with an analytical ‘back up’.
Some veterinarians believe that the analytical approach to clinical reasoning is ‘scientific’, involving hypothesis testing, but it seems to me that this might be misleading. Here’s why.
Scientific method necessitates creating and testing ideas and hypotheses by predicting data followed by an experiment to test what we believe to be true. By making observations on whether our predictions are correct, we extend and supplement our knowledge. This is sometimes referred to – not entirely accurately – as ‘backwards reasoning’.
On the face of it, this is an extremely robust and sensible approach, one that makes perfect sense in the right circumstances and situation. However, in a primary care setting like a front live veterinary clinic, where the range and scope of possible diagnoses of a condition in any individual patient are boundless, a scientific approach of this nature is impossible. It would lead to massive cognitive overload such that – even is a vet could continue to apply such a deductive, hypothetical approach – they would almost certainly be overwhelmed by the endless realm of possibilities open to them.
In other words, it is ironically undermined by the very features that are meant to make it efficient and effective, as the sheer scope of the potential data sets it could potentially generate induces too many options leading to ‘analysis paralysis’, leading in turn to a failure to act even when action is vital.
From our own experiences and those of veterinary colleagues everywhere, clinicians working with real cases and extensive knowledge from reading, it seems clear that clinical reasoning must be an inductive process, one that runs forward from data to diagnosis, rather than the other way around. In contrast with the ‘rear view mirror’ methods highlighted above, which I suggest is likely to fail to improve or develop pattern recognition, a repeated adoption of a systemised forward thinking pattern must help to develop improved structured patterns for future use.
In this, it seems equally clear that from an early juncture, it is crucial to limit the mass of the data set we use, best achieved by clustering recognisable signs to identify the organ system or systems suspected and how it (they) might be affected. Only after doing so should we begin to consider a provisional diagnosis, as this approach hopefully means that we have a more concise and accurate list, one that is genuinely based on taking account of every clinical sign on its own merits, which seems to embrace what a truly ‘scientific approach’ is really all about.
Of course, the ‘elephant in the room’ is always the lack of time that everyone engaged in veterinary medicine is all too stressfully familiar with. Nevertheless, clinical reasoning is important and – applied appropriately – it should help you to improve your skill set as long as you work at it.
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