We make tens of decisions everyday in our clinical practice using a process called clinical reasoning. How do you sift all the data to arrive at a clinical diagnosis? Do you then treat or order investigations? How do you make sense of the results in the clinical context?  What helps you choose amongst alternatives when it comes to therapy? All these questions are seamlessly answered unconsciously in our brains while we go about our daily business. It is something that is felt to be learned by osmosis when newly qualified doctors start practising independently. Not many undergraduate courses focus on these aspects and unsurprisingly not many books are on the market to help guide the students on this journey. Books that are available are often aimed at teachers rather than students and are hence inaccessible.

What is clinical reasoning?

It is merely the process by which we make the aforementioned decisions and more in clinical practice. The theoretical knowledge so far on this subject distinguishes between conscious (analytical) and unconscious (non-analytical) decision making. The former is deliberate whilst the latter is reflexive. For instance, an elderly patient is admitted with sepsis. We blame a urinary tract infection (UTI) because we think that this is the most common cause of this presentation. This mental shortcut, although based on a false premise is called a heuristic. Diagnosing a UTI despite not having much evidence to support it is said to be using the non-analytical mode of thinking. Alternatively, actively thinking of other causes of sepsis whilst looking for evidence to support or refute our suspicions is said to be engaging with the analytical mode of thinking.

A lot of the literature makes out that the non-analytical mode of thinking is the villain and as long as we beat it out of our system everything will be fine. Unfortunately this cannot be further from the truth. For instance, heuristics are not inherently bad. If not for these mental shortcuts we would be run down by the information overload and our clinical practice would be tedious. We have still not completely understood how our mind works since we tend to use both these thinking processes quite interchangeably and sometimes together. So, the newer theories are an amalgamation of both these thinking processes that acknowledge both processes being in action.

How do we learn clinical reasoning?

The key is to have an awareness of our own thinking processes, the biases that we are prone to as human beings and the ways in which we can manage them. In other words we should learn when to use both analytical and non-analytical modes of thinking. The single most important thing that I can tell you is to always have an open mind. Remaining open to other diagnostic possibilities, other management options, including investigations and therapies keeps us primed to approach things with a fresh perspective. It makes us more receptive to the thoughts and opinions of our own patients. This in turn helps us to respect patient autonomy and enables decision-making as a collective endeavour. Learning about clinical reasoning not only makes us better clinicians but also gives a fresh lease of life to the diluted patient-doctor relationships that are common in this era.

Hands-on Guide to Clinical Reasoning in Medicine is a humble attempt to tease out these reasoning processes but in a language that is not only accessible but also fun and engaging. Clinical scenarios are used in plenty to show the issues in action. A clear, conversational style with phantom students helps move the dialogue without burdening the reader with complex theories. I hope that you will enjoy reading this as much as I have enjoyed writing it.

Irfan