Embracing complexity with systems thinking in general practitioners&apos; clinical reasoning helps handling uncertainty

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Abstract

Clinical reasoning in general practice is increasingly challenging because of the rise in the number of patients with multimorbidity. This creates uncertainty because of unpredictable interactions between the symptoms from multiple medical problems and the patient's personality, psychosocial context and life history. Case analysis may then be more appropriately managed by systems thinking than by hypothetic‐deductive reasoning, the predominant paradigm in the current teaching of clinical reasoning. Application of “systems thinking” tools such as causal loop diagrams allows the patient's problems to be viewed holistically and facilitates understanding of the complex interactions. We will show how complexity levels can be graded in clinical reasoning and demonstrate where and how systems thinking can have added value by means of a case history.

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Most cited references 36

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Studying complexity in health services research: desperately seeking an overdue paradigm shift

Trisha Greenhalgh, Chrysanthi Papoutsi (2018)

Complexity is much talked about but sub-optimally studied in health services research. Although the significance of the complex system as an analytic lens is increasingly recognised, many researchers are still using methods that assume a closed system in which predictive studies in general, and controlled experiments in particular, are possible and preferred. We argue that in open systems characterised by dynamically changing inter-relationships and tensions, conventional research designs predicated on linearity and predictability must be augmented by the study of how we can best deal with uncertainty, unpredictability and emergent causality. Accordingly, the study of complexity in health services and systems requires new standards of research quality, namely (for example) rich theorising, generative learning, and pragmatic adaptation to changing contexts. This framing of complexity-informed health services research provides a backdrop for a new collection of empirical studies. Each of the initial five papers in this collection illustrates, in different ways, the value of theoretically grounded, methodologically pluralistic, flexible and adaptive study designs. We propose an agenda for future research and invite researchers to contribute to this on-going series.

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The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them

Pat Croskerry (2003)

In the area of patient safety, recent attention has focused on diagnostic error. The reduction of diagnostic error is an important goal because of its associated morbidity and potential preventability. A critical subset of diagnostic errors arises through cognitive errors, especially those associated with failures in perception, failed heuristics, and biases; collectively, these have been referred to as cognitive dispositions to respond (CDRs). Historically, models of decision-making have given insufficient attention to the contribution of such biases, and there has been a prevailing pessimism against improving cognitive performance through debiasing techniques. Recent work has catalogued the major cognitive biases in medicine; the author lists these and describes a number of strategies for reducing them ("cognitive debiasing"). Principle among them is metacognition, a reflective approach to problem solving that involves stepping back from the immediate problem to examine and reflect on the thinking process. Further research effort should be directed at a full and complete description and analysis of CDRs in the context of medicine and the development of techniques for avoiding their associated adverse outcomes. Considerable potential exists for reducing cognitive diagnostic errors with this approach. The author provides an extensive list of CDRs and a list of strategies to reduce diagnostic errors.

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Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses.

M C Peterson, J H Holbrook, D Von Hales … (1992)

We report an attempt to quantitate the relative contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. In this prospective study of 80 medical outpatients with new or previously undiagnosed conditions, internists were asked to list their differential diagnoses and to estimate their confidence in each diagnostic possibility after the history, after the physical examination, and after the laboratory investigation. In 61 patients (76%), the history led to the final diagnosis. The physical examination led to the diagnosis in 10 patients (12%), and the laboratory investigation led to the diagnosis in 9 patients (11%). The internists' confidence in the correct diagnosis increased from 7.1 on a scale of 1 to 10 after the history to 8.2 after the physical examination and 9.3 after the laboratory investigation. These data support the concept that most diagnoses are made from the medical history. The results of physical examination and the laboratory investigation led to fewer diagnoses, but they were instrumental in excluding certain diagnostic possibilities and in increasing the physicians' confidence in their diagnoses.

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Author and article information

Contributors

Erik Stolper:

ORCID: https://orcid.org/0000-0001-8854-3269

cf.stolper@maastrichtuniversity.nl

Journal

Journal ID (nlm-ta): J Eval Clin Pract

Journal ID (iso-abbrev): J Eval Clin Pract

Journal ID (doi): 10.1111/(ISSN)1365-2753

Journal ID (publisher-id): JEP

Title: Journal of Evaluation in Clinical Practice

Publisher: John Wiley & Sons, Inc. (Chichester, UK )

ISSN (Print): 1356-1294

ISSN (Electronic): 1365-2753

Publication date (Electronic): 16 February 2021

Publication date (Print): October 2021

Volume: 27

Issue: 5 ( doiID: 10.1111/jep.v27.5 )

Pages: 1175-1181

Affiliations

[ ¹ ] Faculty of Health, Medicine and Life Sciences, CAPHRI School for Public Health and Primary Care Maastricht University Maastricht Netherlands

[ ² ] Faculty of Medicine and Health Sciences, Department of Family Medicine and Population Health University of Antwerp Antwerp Belgium

[ ³ ] South West Peninsula National Institute for Health Research Applied Research Collaboration and University of Plymouth Community and Primary Care Group, University of Plymouth Plymouth UK

[ ⁴ ] Deptartment of Geriatric Medicine Radboud University Medical Center Nijmegen Netherlands

Author notes

[*] [* ] Correspondence

Erik Stolper, general practitioner, Maastricht University, P.O. Box 616 6200MD Maastricht, Netherlands.

Email: cf.stolper@ 123456maastrichtuniversity.nl

Author information

Erik Stolper https://orcid.org/0000-0001-8854-3269

Article

Publisher ID: JEP13549

DOI: 10.1111/jep.13549

PMC ID: 8518614

PubMed ID: 33592677

SO-VID: 283e2f60-39a3-41cd-aa3e-6880d7db6d95

License:

This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

History

Date revision received : 17 January 2021

Date received : 27 July 2020

Date accepted : 23 January 2021

Page count

Figures: 2, Tables: 1, Pages: 7, Words: 5099

Custom metadata

source-schema-version-number 2.0

cover-date October 2021

details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:6.0.8 mode:remove_FC converted:15.10.2021

ScienceOpen disciplines: Medicine

Keywords: clinical reasoning,complexity‐informed,general practice,gut feelings,multimorbidity,uncertainty

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ScienceOpen disciplines: Medicine

Keywords: clinical reasoning, complexity‐informed, general practice, gut feelings, multimorbidity, uncertainty

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Embracing complexity with systems thinking in general practitioners' clinical reasoning helps handling uncertainty

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Chinese Journal of General Practice

Most cited references 36

Studying complexity in health services research: desperately seeking an overdue paradigm shift

The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them

Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses.

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