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    Differential diagnosis

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    Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]

    Overview[edit | edit source]

    In medicine, differential diagnosis (sometimes abbreviated DDx or ΔΔ) is the systematic method physicians use to identify the disease causing a patient's symptoms.

    Before a medical condition can be treated, it must be identified. In the process of listening to a patient's complaints, examining the patient, and taking the patient's personal, family and social history, the physician makes a mental list of the most likely causes. The doctor asks additional questions and performs tests to eliminate possibilities until he or she is satisfied that the single most likely cause has been identified.

    Once a working diagnosis is reached, the physician prescribes a therapy. If the patient's condition does not improve, the diagnosis must be reassessed. The method of differential diagnosis was first suggested for use in the diagnosis of mental disorders by Emil Kraepelin. It is more systematic than the old-fashioned method of diagnosis by gestalt (impression).

    The term differential diagnosis also refers to medical information specially organized to aid in diagnosis, particularly a list of the most common causes of a given symptom, annotated with advice on how to narrow down the list.

    Tactics[edit | edit source]

    There are various methods of clinical reasoning include probabilistic (Bayesian), causal (physiologic), and deterministic (rule-based).[1] In addition, medical experts rely more on pattern recognition which is faster[2]; however, clinical experts seem flexible and may use whichever method of reasoning most easily represents and solves a given problem.[3] When confronted with non-challenging cases physicians may use 'nonanalytical reasoning' such as pattern recognition; however, during more difficult cases physicians may switch to 'reflective reasoning'.[4] Reflective reasoning may especially help complex cases.[5] Explicit Bayesian thinking with precise numbers is rarely done.[6][7] Basic science knowledge is probably "encapsulated" into clinical knowledge.[8]

    Possible strategies to improve clinical reasoning have been reviewed[9][10] and using problem-based learning[10], include teaching appropriate problem representation creating a one-sentence summary of a case[9], standardized patients[11], teaching hypothetico-deductive reasoning[12][13], cognitive forcing strategies[14][15][16] to avoid premature closure[17], teaching the competing-hypotheses heuristic[18], using fuzzy-trace theory[19] and mixed-methods interventions[20][21][20]. Studies are unclear about teaching logic.[22][23]

    Scales to measure clinical reasoning have been proposed.[24]

    Hypothetico-deductive reasoning[edit | edit source]

    Regarding hypothetico-deductive reasoning, an observational study on the methods used by experts solving clinicopathological exercises reported that these experts use the following six steps:[13]

    1. aggregation of groups of findings into patterns
    2. selection of a "pivot" or key finding
    3. generation of a cause list
    4. pruning of the cause list
    5. selection of a diagnosis
    6. validation of the diagnosis

    Mnemonics[edit | edit source]

    For the differential diagnosis of systemic disorders, the mnemonic VINDICATE[25] or VITAMINSABCEDK[26] may help prompt considerations.

    Deliberate practice with cases and simulations[edit | edit source]

    Deliberate practice with cases and simulations maybe helpful[27][28].

    Problem representation[edit | edit source]

    Successfully distilling complex information into a short summary, perhaps using semantic qualifiers, may help diagnostic accuracy.[29][30][31][32] Problem representation, "usually as a one-sentence summary defining the specific case in abstract terms," may help clinical reasoning[9][30][33].


    Numeracy[edit | edit source]

    Various methods have been proposed for improving quantitative literacy. For diagnosis, likelihood ratios[34] or sensitivity and specificity are two methods. It is unclear which method is better according to the results of a controlled trial.[35] Studies are inconclusive on using cognitive feedback.[36]. Framing bias is best avoided by using numeracy with absolute measures of efficacy.[37]

    See also[edit | edit source]

    External Resources[edit | edit source]

    References[edit | edit source]

    1. ↑ Kassirer JP (1989). "Diagnostic reasoning". Ann Intern Med. 110: 893–900. PMID 2655522.
    2. ↑ Leape LL (1994). "Error in medicine". JAMA. 272: 1851–7. PMID 7503827.
    3. ↑ Norman G (2006). "Building on experience--the development of clinical reasoning". N Engl J Med. 355: 2251–2. doi:10.1056/NEJMe068134. PMID 17124025.
    4. ↑ Mamede S, et al. (2008) Influence of Perceived Difficulty of Cases on Physicians' Diagnostic Reasoning. Academic Medicine. 83(12):1210-1216. doi:10.1097/ACM.0b013e31818c71d7
    5. ↑ Mamede S, Schmidt HG, Penaforte JC (2008). "Effects of reflective practice on the accuracy of medical diagnoses". Med Educ. 42 (5): 468–75. doi:10.1111/j.1365-2923.2008.03030.x. PMID 18412886. Unknown parameter |month= ignored (help)
    6. ↑ Moskowitz AJ; et al. (1988). "Dealing with uncertainty, risks, and tradeoffs in clinical decisions. A cognitive science approach". Ann. Intern. Med. 108: 435–49. PMID 3277516.
    7. ↑ Reid MC, Lane DA, Feinstein AR (1998). "Academic calculations versus clinical judgments: practicing physicians' use of quantitative measures of test accuracy". Am J Med. 104: 374–80. PMID 9576412.
    8. ↑ de Bruin AB; et al. (2005). "The role of basic science knowledge and clinical knowledge in diagnostic reasoning: a structural equation modeling approach". Academic Medicine. 80: 765–73. PMID 16043534.
    9. ↑ 9.0 9.1 9.2 Bowen JL (2006). "Educational strategies to promote clinical diagnostic reasoning". N Engl J Med. 355: 2217–25. doi:10.1056/NEJMra054782. PMID 17124019.
    10. ↑ 10.0 10.1 Graber M; et al. (2002). "Reducing diagnostic errors in medicine: what's the goal?". Academic Medicine. 77: 981–92. PMID 12377672.
    11. ↑ Windish DM; et al. (2005). "Teaching medical students the important connection between communication and clinical reasoning". J Gen Intern Med. 20: 1108–13. doi:10.1111/j.1525-1497.2005.0244.x. PMID 16423099.
    12. ↑ Wiese J; et al. (2002). "Improving oral presentation skills with a clinical reasoning curriculum: a prospective controlled study". Am J Med. 112: 212–8. PMID 11893348.
    13. ↑ 13.0 13.1 Eddy DM, Clanton CH (1982). "The art of diagnosis: solving the clinicopathological exercise". N Engl J Med. 306: 1263–8. PMID 7070446.
    14. ↑ Croskerry P (2000). "The cognitive imperative: thinking about how we think". Academic Emergency Medicine. 7: 1223–31. PMID 11073470.
    15. ↑ Croskerry P (2002). "Achieving quality in clinical decision making: cognitive strategies and detection of bias". Academic Emergency Medicine. 9: 1184–204. PMID 12414468.
    16. ↑ Croskerry P (2003). "Cognitive forcing strategies in clinical decisionmaking". Ann Emerg Med. 41 (1): 110–20. doi:10.1067/mem.2003.22. PMID 12514691.
    17. ↑ Dubeau CE; et al. (1986). "Premature conclusions in the diagnosis of iron-deficiency anemia: cause and effect". Medical Decision Making. 6: 169–73. PMID 3736379.
    18. ↑ 18.0 18.1 Wolf FM; et al. (1988). "Use of the competing-hypotheses heuristic to reduce 'pseudodiagnosticity'". J Med Educ. 63: 548–54. PMID 3385753.
    19. ↑ Lloyd FJ, Reyna VF (2001). "A web exercise in evidence-based medicine using cognitive theory". J Gen Intern Med. 16: 94–9. PMID 11251760. PubMed Central
    20. ↑ 20.0 20.1 Windish DM (2000). "Teaching medical students clinical reasoning skills". Acad Med. 75 (1): 90. PMID 10667884.
    21. ↑ Struyf E, Beullens J, Van Damme B, Janssen P, Jaspaert H (2005). "A new methodology for teaching clinical reasoning skills: problem solving clinical seminars". Med Teach. 27 (4): 364–8. doi:10.1080/01421590500046411. PMID 16024422.
    22. ↑ Cheng PW; et al. (1986). "Pragmatic versus syntactic approaches to training deductive reasoning". Cognitive Psychology. 18: 293–328. doi:10.1016/0010-0285(86)90002-2. PMID 3742999.
    23. ↑ Jenicek M (2006). "The hard art of soft science: Evidence-Based Medicine, Reasoned Medicine or both?". Journal of Evaluation in Clinical Practice. 12: 410–9. doi:10.1111/j.1365-2753.2006.00718.x. PMID 16907682.
    24. ↑ Boshuizen HP; et al. (1997). "Measuring knowledge and clinical reasoning skills in a problem-based curriculum". Medical education. 31: 115–21. PMID 9231115.
    25. ↑ Johnson SM, Shah LM (2019). "Imaging of Acute Low Back Pain". Radiol Clin North Am. 57 (2): 397–413. doi:10.1016/j.rcl.2018.10.001. PMID 30709477.
    26. ↑ Zabidi-Hussin ZA (2016). "Practical way of creating differential diagnoses through an expanded VITAMINSABCDEK mnemonic". Adv Med Educ Pract. 7: 247–8. doi:10.2147/AMEP.S106507. PMC 4853007. PMID 27217805.
    27. ↑ Abdulnour RE, Parsons AS, Muller D, Drazen J, Rubin EJ, Rencic J (2022). "Deliberate Practice at the Virtual Bedside to Improve Clinical Reasoning". N Engl J Med. 386 (20): 1946–1947. doi:10.1056/NEJMe2204540. PMID 35385627 Check |pmid= value (help).
    28. ↑ Ericsson KA (2004). "Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains". Acad Med. 79 (10 Suppl): S70–81. doi:10.1097/00001888-200410001-00022. PMID 15383395.
    29. ↑ Chang RW, Bordage G, Connell KJ (1998). "The importance of early problem representation during case presentations". Acad Med. 73 (10 Suppl): S109–11. PMID 9795669.
    30. ↑ 30.0 30.1 Bordage G, Lemieux M (1991). "Semantic structures and diagnostic thinking of experts and novices". Acad Med. 66 (9 Suppl): S70–2. PMID 1930535.
    31. ↑ Nendaz MR, Bordage G (2002). "Promoting diagnostic problem representation". Med Educ. 36 (8): 760–6. PMID 12191059.
    32. ↑ Kulatunga-Moruzi C, Brooks LR, Norman GR (2004). "Using comprehensive feature lists to bias medical diagnosis". J Exp Psychol Learn Mem Cogn. 30 (3): 563–72. doi:10.1037/0278-7393.30.3.563. PMID 15099125.
    33. ↑ Schmidt HG, Norman GR, Boshuizen HP (1990). "A cognitive perspective on medical expertise: theory and implication". Acad Med. 65 (10): 611–21. doi:10.1097/00001888-199010000-00001. PMID 2261032.
    34. ↑ Richardson WS, Wilson MC, Keitz SA, Wyer PC (2007). "Tips for Teachers of Evidence-based Medicine: Making Sense of Diagnostic Test Results Using Likelihood Ratios". J Gen Intern Med. doi:10.1007/s11606-007-0330-1. PMID 18064524.
    35. ↑ Puhan MA, Steurer J, Bachmann LM, ter Riet G (2005). "A randomized trial of ways to describe test accuracy: the effect on physicians' post-test probability estimates". Ann. Intern. Med. 143 (3): 184–9. PMID 16061916.
    36. ↑ Poses RM; et al. (1995). "You can lead a horse to water--improving physicians' knowledge of probabilities may not affect their decisions". Medical Decision Making. 15: 65–75. PMID 7898300.
    37. ↑ Perneger TV, Agoritsas T (2011). "Doctors and Patients' Susceptibility to Framing Bias: A Randomized Trial". J Gen Intern Med. doi:10.1007/s11606-011-1810-x. PMID 21792695.


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