When we think about clinical reasoning, most talks focus on diagnostic errors and the reasons for those errors. The legacy of Kahneman and Tversky focuses on errors and the many named mistakes we make. We focus on avoiding errors, but their work and too often our teaching does not focus on the road to diagnostic excellence.

Gary Klein, the pioneer of naturalistic decision making, has focused more on the road to excellence. These are not two sides of a coin, but rather separate important concepts for us to understand. The road to excellence is likely more challenging than the road to avoiding errors. The road to excellence develops “instincts” and type 1 reasoning. The excellent diagnostician feels uncomfortable first, and then can explain why. That diagnostician must resolve the uncomfortable feeling.

The problem arises from the complexity of human beings, interviewing skills, physical diagnosis, and test interpretation. As I reconstruct my best diagnostic coups, the road to the correct diagnosis is rarely straight. Each diagnostic triumph takes a different looking path.

The first step towards diagnostic excellence requires an understanding that the simple assumptions (or at least previous assumptions) might need revisiting. Once we recognize the need to reconsider the diagnosis, then we have to use many skills.

Experts attack the diagnostic process like jazz artists attack a musical performance. In order to be a great jazz musician, you must first master the basics of your instrument, an understanding of scales, keys, and tempo. Only then can you successfully feel the proper notes to play.

Likewise, learning to retake the history, refocus the physical exam, and reconsider test interpretation, requires that we know the basics, understand illness scripts, and then have the ability to think without hindrance of previous proposed diagnoses. The great jazz artist plays off other musicians. The great diagnostician plays off the data to reconsider diagnostic possibilities.

We all know great diagnosticians. Every medical school has these individuals, who seemed gifted. But like great jazz, while we know it when we hear it (think Miles Davis’s Kind of Blue), we have difficulty explaining or measuring this excellence.

Like jazz or art, diagnostic stars emerge from hard work on the basics, and an ability to listen to their own discomfort with the diagnostic status quo.

Likely, we will never really be able to “measure” diagnostic excellence. Artificial conferences like CPC and CPS can showcase some of the reasoning skills, but the omit the skill of getting the patient to retell the story and ask the key questions. They omit the ability to “read the patient’s body language.”

Many strive for diagnostic excellence, and some achieve it. It requires one to approach all clinical situations with appropriate, healthy skepticism. It requires one to challenge one’s own assumptions, as well as others. But this skepticism is necessary to take that road less traveled. We must understand that the diagnostic process rarely resembles a symphony because it most often requires improvisation, like the jazz greats.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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