The Heart of Clinical Reasoning

“What brought you in to the hospital?” I asked the young 21-year-old patient lying in the hospital bed before me. I was meeting her for the first time. She was admitted from the emergency department with a diagnosis of inflammatory bowel disease. The plan was a colonoscopy.

She looked at me for a second and said, “I don’t know. Y’all keep asking the same questions. Can you not look at the chart? I told you guys I was having abdominal pain but I’m better now.” She barely made eye contact and no matter what I said she wouldn’t elaborate further. Multiple clinicians had seen her before me, and the plan seemed appropriate. She was agreeable with the plan, so I went on my way to attend to other patients and hospital discharges.

I was off the following day so I reviewed her care through the electronic health record. To my disbelief the plan had drastically changed. She was diagnosed with pelvic inflammatory disease. I wondered what had happened and how I’d missed the diagnosis. Seeking feedback I discussed her care with the clinician who had made the correct diagnosis. Here’s what I learned from the experience:

 1. Include non-medical conversations to connect with patients.

The Improving Diagnosis in Health Care report suggests that accurate, timely, and patient-centered diagnosis relies on proficiency in clinical reasoning. Accurate information gathering is a key component of clinical reasoning. Patients will only share critical information with healthcare professionals they trust. In my patient’s care, a non-medical conversation by my colleague helped the patient to open up and share information that she hadn’t felt comfortable to share with anyone, which was a recent history of multiple sexual partners and new vaginal discharge.

2. Avoid labeling patients as “difficult historians.”

This isn’t helpful to the diagnostic process and may lead to biased clinical reasoning. How a disease affects each person is dependent on their unique circumstances such as their personalities, resilience, and resources. Knowing this “personome” is critical to accurate clinical reasoning.

3. Be present and alert to subtle clues.

In my encounter with the patient, she didn’t make eye contact and chose not to elaborate on her history. I noticed this, but chose not to delve further. Presence is defined as a purposeful practice of awareness, focus, and attention with the intent to understand and connect with patients. By being present and open to subtle clues during the patient encounter, my colleague was able to get to the correct diagnosis. These clues cannot be garnered from the EHR.

4. Go back for a second look.

Time! In acute care settings, time is of the essence. Patients frequently state that healthcare professionals don’t spend adequate time listening to them. Connecting with patients who are in a vulnerable condition in the hospital takes time. This is especially true for challenging patient encounters. Going back to the patient’s bedside to re-connect isn’t just efficient use of time, but may also provide further clues about the correct diagnosis.

“To learn how to treat a disease, one must learn how to recognize it. The diagnosis is the best trump in the scheme of treatment”

– Jean Martin Charcot

I humbly suggest the following addition to Charcot’s quotation: “To learn how to recognize disease, one must also deeply connect with patients on a personal level. And there ain’t no two ways about it!”

This piece expresses the views solely of the author. It does not represent the views of any organization, including Johns Hopkins Medicine.