Clinical reasoning and decision making

1. CLINICAL CONTEXT, PATIENT
PERSPECTIVES & DECISION
SUPPORT TOOLS

2. CLINICAL CONTEXT & SERVICE USER PERSPECTIVES
Patients bring:
• Views about causes (stress, lifestyle, punishment, genetics).
• Expectations (tests, referrals, “scans to be sure”).
• Constraints (work, caring responsibilities, finances, transport).
• Past experiences of health services.
These influence:
• What they disclose.
• Which diagnoses they accept or reject.
• Their adherence to recommended tests or treatments.
Useful questions in practice:
• “What worries you most about this?”
• “What ideas do you have about what might be going on?”
• “What’s most important to you as we plan next steps?”

3. ETHICS, LAW AND PROFESSIONAL RESPONSIBILITIES
Key issues:
• Diagnostic error and delay:
⚬ Usually multifactorial: system, communication, cognitive.
• Duty of candour:
⚬ Being open and honest when things go wrong.
• Documentation:
⚬ Record reasoning, uncertainties, discussions about risk.
• Safety netting:
⚬ Explicit advice about red flags, when/where to seek help, and
follow-up.
ACP role:
• Model open discussion of uncertainty with patients and team.
• Advocate for appropriate testing and follow-up.

4. DECISION SUPPORT TOOLS
Types:
• Paper-based scores (e.g. early warning scores, risk prediction
tools).
• Clinical pathways and flowcharts.
• Computerised decision support embedded in EHRs.
• Checklists.
Potential benefits:
• Prompt recognition of deterioration/red flags.
• Standardise minimum assessment.
• Support less experienced clinicians.
Potential problems:
• Over-simplification.
• Poor fit with complex, multi-morbid patients.
• “Tick-box mentality” – replacing thinking instead of supporting it.

5. PRINCIPLES FOR DESIGNING A GOOD CLINICAL TOOL
• Clear purpose
⚬ What decision does it support? (e.g. “admit vs discharge,”
“urgent imaging vs observe”).
• Evidence-informed
⚬ Based on best available guidelines, studies, and
pathophysiology.
• Usable
⚬ Short, simple, intuitive in real clinical conditions.
• Safe
⚬ Includes clear red flags and escalation routes.
⚬ Makes limitations explicit (“for adults only”, “not for
pregnancy”, etc.).
• Auditable
⚬ Can be evaluated: does it improve outcomes? reduce harm?

6. To end the module:
• Recap the journey:
⚬ Week 1: What diagnosis is and how context shapes it.
⚬ Week 2: How we think and how we get biased.
⚬ Week 3: What tests are for and their costs.
⚬ Week 4: Test accuracy and probability.
⚬ Week 5: Pathophysiology and investigations.
⚬ Week 6: Patient context and decision support.