Reasoning is important in any walk of life, not just medical practice. It’s what sets humans apart from the rest of creation. Simply put, you encounter a situation, get some input or information from it, make a reasoned-out assessment, do some research on the subject, and then carry out a response.
The practise of Medicine involves the same approach but modified for the specific purpose of managing illness. The steps are:
- History and physical examination.
- Making a provisional diagnosis.
- Ordering carefully chosen tests and investigations to clarify states of uncertainty.
- Making a final diagnosis.
- Outlining a management plan.
This process, done well, provides efficiency and economy; quality healthcare that is cost-effective. Even today, there are no short cuts or quick fixes.
A detailed history and a careful physical exam will, in most cases, be all that is needed to make a confident diagnosis. This is often skipped or done in a very cursory fashion. It’s quite common to hear patients complain that the doctor didn’t listen to what the patient had to say, didn’t lay hands or examine at all, and proceeded to write out a string of investigations and medications.
Unfortunately, largely due to the plethora of tests and investigations that are on offer, the chain of reasoning is dispensed with. There is a misplaced belief that tests will tell us what’s going on. Panels of tests are ordered, most of which are unnecessary. A shotgun approach is taken, frequently under the guise of time constraints.
Unthinking testing will often complicate, rather than clarify, states of uncertainty. False positive results will set off another round of probing in the chase of a chimera. False negative results will provide false reassurance.
Overdiagnosis and medicalisation are problems that come out of unthinking approaches to patient care.
Structured, algorithmic, evidence-based clinical reasoning has always been and always will be the backbone of good medical practice.