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This interactive case discussion is interesting from an educational viewpoint. The case presentation is one of the most complex that has featured in this series, and it attracted thoughtful responses from clinicians of many specialties and levels of experience. It was good to see a medical student reasoning his way through the dilemmas posed by this patient's presentation. Most responses showed evidence of more than a “stab in the dark” approach to diagnosis and management of the complex case.1 Clinical reasoning approaches in the responses included generating diagnostic hypotheses and testing them; using pattern recognition; and the process of “chunking” information and constructing schema excluding some pathways and exploring others (such as acute or chronic renal failure; primary or secondary hypertension). These processes are used by experts and novices alike (in differing proportions and to different effect) in test situations.2 What is less certain is how clinicians respond to complex and demanding cases like this, where the stressful situation involves volatility, uncertainty, complexity, ambiguity, and delayed feedback and information flow (VUCAD).3 We need more evidence about the reasoning processes that clinicians use in complex medical situations (rather than evidence from artificial tests of reasoning used in research) if we are to understand, let alone teach, the skills that clinicians need to determine appropriate priorities in managing a case presentation such as this.
Comprehensive mapping of clinical judgments, decision making, and analysis led Jack Dowie to stress the importance of a comprehensive Bayesian stochastic decision model that places equal weight on knowledge and input of values.4 But can we realistically expect doctors to use such complex modelling processes when dealing with desperately ill patients?
For teaching purposes I illustrate the patient's presentation as a circle which expands as history, examination, and investigation add to our knowledge (figure(figure).). The clinician constructs a square frame composed of two adjacent sides that represent “diagnosis” and two that represent “management.” The clinician's frame is “squared down” to meet the expanding rings of the emerging patient picture. Actions result when the management possibilities are reduced to an appropriate choice to frame what we now know about our patient. The process is dynamic and is repeated when decisions are made. In this case, a decision to admit the patient is made early on, and the dialysis decisions of early management follow rapidly and logically. The diagnosis becomes clearer as emergency management proceeds.
Although research into understanding effective complex clinical decision processes is necessarily complex, we may benefit from keeping simple models in our heads as we teach.
Competing interests: None declared.