How clinical reasoning underpins effective consultations

Clinical reasoning skills are essential for effective consultations that lead to likely diagnoses and appropriate treatment or referral, argues Paul Rutter, Professor of Pharmacy Practice at Portsmouth University and author of a new book on differential diagnosis for non-medical prescribers.

Professor Rutter’s new book follows a case study format because this is an effective way to “contextualise facts and figures and knowledge into something more ‘real life’”, he says. For example, a symptom such as cough would be approached very differently in a 75-year-old man from a 5-year-old child.

Clinical reasoning plays a critical role here. “It’s about bringing forward to the conscious level your thinking. So, it’s about testing a hypothesis,  it’s about thinking “Well, if I’ve got a 5-year-old child with a cough, what’s the likely diagnosis?” and then testing that hypothesis by asking those questions which are pertinent at that time in the conversation. And the type of question will change depending on the context and it will depend on the response of the patient as to what question you would then ask next”, he explains.  “Clinical reasoning is very flexible it responds to what the patient says and you as the clinician are directed to ask your next question based on the information that’s been provided by the patient”, he adds. Each clinician might use a different series of questions for a given problem, depending on their experiences and the way in which they process the information from the patient, but should arrive at the same endpoint.

Returning to the examples above – a 5-year-old child who’s had a cough for a couple of weeks and a 75-year- old man who’s had a cough for three weeks – would call for slightly different questions. Whereas asking about the number of cigarettes smoked daily might be routine for an adult, it would not be appropriate for a 5-year-old child. The objective of the consultation is to sift out from the list of possible causes of cough those that are most likely in the patient in question. Clinical reasoning “allows you to take that long list of conditions and narrow it down into a smaller number of possible conditions which you then can test as to what is it likely to be. So, you might have 20 conditions which cause cough but straight away by the person that you’re talking to and the context that they present in – i.e. how long they’ve had it or things like that – you can go down from say 20 conditions to two or three or four quite quickly, but then you’re very targeted in the questions that you ask”, says Professor Rutter.

About Paul Rutter

Paul Rutter is  Professor of Pharmacy Practice at Portsmouth University. His main area of interest is differential diagnosis of minor conditions for pharmacists and his academic teaching deals mainly with this topic. He is the author of the textbook, Symptoms, Diagnosis and Treatment in Community Pharmacy, now in its fifth edition. His new book, Differential diagnosis for non-medical prescribers, nurses and pharmacists: A case-based approach, was published in August 2024.

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