Diagnostic reasoning as a medium for promoting patient safety

Document Type : Review Article


1 School of Medicine, National University of Ireland, Galway, Ireland.

2 Sligo Medical Academy, Sligo University Hospital, Sligo, Ireland.


Introduction:Diagnostic reasoning is a key skill practised by clinicians. It is a process by which correct clinical diagnosis is reached. Learning theories offer some guidance on how this cognitive skill is best taught; what curriculum best supports it and how it is learned and used by expert and novice learners. Novice and expert learners have different needs when it comes to developing this skill. This paper aims to explore the unique role of the medical educator; exploring how they facilitate diagnostic reasoning amongst learners with an emphasis on improving patient safety.
Materials and methods:The bibliography assembled for this literature review includes original articles, quantitative and qualitative papers, narrative review articles, editorials and other documents identified through PubMed, Scopus, ERIC, Australian Education Index, British Education Index and Google Scholar Database searches.
Results – Medical educators employ a variety of teaching strategies including ‘thinking aloud’ techniques and hypothesis generation. There is some dispute in the literature as to which teaching strategies and which curricula best support the learning of diagnostic reasoning. The contribution of good diagnostic reasoning skills in reducing clinical error and maintaining patient safety is clear.
Conclusions – It is important to continue to encourage the teaching of diagnostic reasoning with an emphasis on patient safety and its role in reducing clinical error and adverse events for patients.


1. Nuland SB. How we die: reflection on life’s final chapter. New York: Vintage Books; 1994.
2. Croskerry P. A universal model of diagnostic reasoning. Acad Med. 2009; 84(8):1022-8.
3. Eva KW. What every teacher needs to know about clinical reasoning. Med Educ. 2005; 39(1):98-106.
4. Charlin B, Lubarsky S, Millette B, Crevier F, Audétat MC, Charbonneau A, et al. Clinical reasoning processes: unravelling complexity through graphical representation. Med Educ. 2012; 46(5):454-63.
5. Norman G. Research in clinical reasoning: past history and current trends. Med Educ. 2005; 39(4):418-27.
6. Newman-Toker DE, Pronovost PJ. Diagnostic reasoning-the next frontier for patient safety. JAMA. 2009; 301(10):1060-2.
7. Shojania KG, Burton EC, McDonald KM, Goldman L.Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA. 2003; 289(21):2849-56.
8. Croskerry P. Critical thinking and decision making: avoiding the perils of thin-slicing. Ann Emerg Med.2006; 48(6):720-2.
9. Neufeld VR, Norman GR, Feightner JW, Barrows HS. Clinical problem solving by medical students: across-sectional and longitudinal analysis. Med Educ. 1981; 15(5):315-22.
10. Risen J, Gilovich T, Sternberg RJ, Halpern D, Roediger H. Informal logical fallacies. In: Sternberg RJ, Roediger HL, Halpern DF, editors. Critical thinking in psychology. New York: Cambridge University Press; 2007. P. 110-30.
11. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, et al. Effect of reducing interns’work hours on serious medical errors in intensive care units. N Engl J Med. 2004; 351(18):1838-48.
12. Elstein AS, Schulman LS, Sprafka SA. Medical problem solving: an analysis of clinical reasoning.Cambridge: Harvard University Press; 1978. P.49-59.
13. Coderre S, Mandin H, Harasym PH, Fick GH.Diagnostic reasoning strategies and diagnostic success. Med Educ. 2003; 37(8):695-703.
14. Rajkomar A, Dhaliwal G. Improving diagnostic reasoning to improve patient safety. Perm J. 2011;15(3):68-73.
15. Bowen JL. Educational strategies to promote clinical diagnostic reasoning. N Engl J Med. 2014;355(21):2217-25.
16. Norman G. Building on experience-the development of clinical reasoning. N Engl J Med. 2006; 355(21):2251-2.
17. Wigton RS, Patel KD, Hoellerick VL. The effect of feedback in learning clinical diagnosis. J Med Educ.1986; 61(10):816-22.
18. Ark T, Brooks LR, Eva KW. The best of both worlds:adoption of a combined (analytic and non- analytic) reasoning strategy improves diagnostic accuracy relative to either strategy in isolation. Presented at the Annual Meeting at the Association of American Medical Colleges; Boston, MA; 6 November 2004.
19. Eva KW, Brooks LR, Norman GR. Forward reasoning as a hallmark of expertise in medicine:logical, psycho- logical and phenomenological inconsistencies. Adv Psychol Res. 2002; 8:41-69.
20. Eva KW, Neville AJ, Norman GR. Exploring the aetiology of content specificity: factors influencing analogic transfer and problem solving. Acad Med.1998; 73:1-5.
21. Moulton CA, Regehr G, Mylopoulus M, MacRae HM.Slowing down when you should: a new model of expert judgement. Acad Med. 2007; 82(10Suppl):S109-16.
22. Delany C, Golding C. Teaching clinical reasoning by making thinking visible: an action research project with allied health clinical educators. BMC Med Educ. 2014; 14:20.
23. Barrows HS, Tamblyn RM. Problem-based learning an approach to medical education. New York Springer Publishing; 1980. P. 3077-80.
24. Barrows HS. Problem-based, self-directed learning JAMA. 1983; 250(22):3077-80.
25. Patel VL, Evans DA, Groen GJ. Reconciling basic science and clinical reasoning. Teach Learn Med In J. 1989; 1(3):116-21.
26. Goss B, Reid K, Dodds A, McColl G. Comparison of medical students’ diagnostic reasoning skills in a traditional and a problem based learning curriculum. Int J Med Educ. 2011; 2:87-93.
27. Amjad A. Clinical diagnostic reasoning and the curriculum: a medical student’s perspective. Med Teach. 2008; 30(4):426-7.
28. Fyrenius A, Bergdahl B, Silen C. Lectures in problem-based learning--why, when and how? An example of interactive lecturing that stimulate meaningful learning. Med Teach. 2005; 27(1):61-5
29. Mandin H, Harasym P, Eagle C, Watanabe M .Developing a ‘clinical presentation’ curriculum at the University of Calgary. Acad Med. 1995 .70(3):186-93.
30. Page G, Bordage G, Allen T. Developing key-featur problems and examinations to assess clinica decision-making skills. Acad Med. 1995; 70(3)194-201.
31. General Medical Council. Tomorrow’s doctors recommendations on undergraduate medical education. London: General Medical Council; 2002
32. O’Neill PA, Metcalfe D, David TJ. The core content of the undergraduate curriculum in Manchester. Med Educ. 1999; 33(2):121-9.
33. Medical Council Medical Education. Training and practice in Ireland 2008-2013 a progress report. Dublin: Medical Council; 2014.
34. Graber ML. The incidence of diagnostic error in medicine. BMJ Qual Saf. 2013; 22:ii21-7.
35. Monteiro S, Norman G. Diagnostic reasoning: where we’ve been, where we’re going. Teach Learn Med.2013; 25(Suppl 1):S26-32.
36. Ericsson KA, Krampe RT, Tesct-Romer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev. 1993; 100(3):363-406.
37. Croskerry P. Cognitive forcing strategies in clinical decision making. Ann Emerg Med. 2003; 41(1).110-20.
38. Ely JW, Graber ML, Croskerry P. Checklists to reduce cognitive errors. Acad Med. 2011; 86(3).307-13.