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ABG
Clinical Reasoning
SECOND EDITION

Edited by Nicola Cooper and John Frain

WILEY Blackwell
Clinical Reasoning
Clinical
Reasoning
2nd Edition
EDITED BY

Nicola Cooper
Consultant Physician & Clinical Associate Professor in Medical Education
Medical Education Centre
University of Nottingham, UK

John Frain
General Practitioner & Clinical Associate Professor
Director of Clinical Skills
Division of Medical Sciences & Graduate Entry Medicine
University of Nottingham, UK
This edition first published 2023
© 2023 John Wiley & Sons Ltd

Edition History
1e © 2016 John Wiley & Sons Ltd

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Library of Congress Cataloging-in-Publication Data

Names: Cooper, Nicola, editor. | Frain, John (John Patrick James), editor.
Title: ABC of clinical reasoning / edited by Nicola Cooper, Consultant Physician & Clinical Associate Professor in
Medical Education, Medical Education Centre, University of Nottingham, UK, John Frain, General Practitioner & Clinical Associate
Professor, Director of Clinical Skills, Division of Medical Sciences & Graduate Entry Medicine, University of Nottingham, UK.
Description: 2nd edition. | Hoboken, NJ, USA : John Wiley & Sons, Inc., 2023. | Includes bibliographical references and index.
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Subjects: LCSH: Medical care--Decision making. | Medical care--Quality control. | Diagnostic errors. | Evidence-based medicine.
Classification: LCC RA399.A1 A215 2023 (print) | LCC RA399.A1 (ebook) | DDC 362.1--dc23/eng/20221007
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Cover design: Wiley

Set in 9.5/12pt Minion by Integra Software Services Pvt. Ltd, Pondicherry, India
Contents

Contributors, vi
Preface (Second Edition), vii
1 Introduction to Clinical Reasoning, 1
Nicola Cooper and John Frain
2 Evidence-based History and Examination, 7
John Frain
3 Choosing and Interpreting Diagnostic Tests, 17
Nicola Cooper
4 Problem Identification and Management, 23
Nicola Cooper and John Frain
5 Shared Decision-making, 29
Anna Hammond and Simon Gay
6 Models of Clinical Reasoning, 35
Nicola Cooper
7 Cognitive Biases, 41
Nicola Cooper
8 Situativity and Human Factors, 47
Nicola Cooper
9 Metacognition and Cognitive Strategies, 53
Pat Croskerry
10 Teaching Clinical Reasoning, 61
Nicola Cooper and Mini Singh
Index, 71
 Contributors

Nicola Cooper Simon Gay

MBChB MMedSci FRCPE FRACP FAcadMEd SFHEA MBBS MSc MMedEd FRCGP SFHEA
Consultant Physician and Clinical Associate Professor in Medical Education Professor of Medical Education (Primary Care)
Medical Education Centre, University of Nottingham, UK University of Leicester School of Medicine, UK

Pat Croskerry Anna Hammond

MD PhD FRCP(Edin) MBChB DRCOG FRCGP MClinEd SFHEA
Director, Critical Thinking Program General Practitioner and Academic Lead for Clinical Skills and Reasoning
Division of Medical Education, Dalhousie University, Canada Hull York Medical School, UK

John Frain Mini Singh

MBChB MSc FRCGP DGM DCH DRCOG PGDipCard SFHEA MBChB MMEd FRCP PFHEA
General Practitioner and Clinical Associate Professor Professor of Medical Education and Honorary Consultant Dermatologist
Director of Clinical Skills University of Manchester, UK
Division of Medical Sciences and Graduate Entry Medicine
University of Nottingham, UK

vi
 Preface (Second Edition)

Excellence in clinical practice is not just about good knowledge, and also an up-to-date resource for teachers and curriculum plan-
skills, and behaviours. As fellow author Pat Croskerry points out, ners. Each chapter describes a component of clinical reasoning
how doctors think, reason, and make decisions is arguably their and its applications for clinical practice, teaching, and learning.
most critical skill. While medical schools and postgraduate This second edition has been extensively re-written and updated,
training programmes teach and assess the knowledge and skills and key references and further resources have been included for
required to practice as a doctor, few currently offer comprehensive readers who want to explore topics in more detail.
training in clinical reasoning and decision making. This matters Clinical reasoning is relevant to every clinical specialty in every
because studies show that diagnostic error is common and results setting, and it is not confined to medical students and doctors –
in significant harm to patients, and the majority of the root causes we have written this book with advanced clinical practitioners
of diagnostic error involve errors in clinical reasoning. and other clinicians in mind as well. We hope you enjoy reading it
Clinical reasoning is complex and takes years to learn. Most of as much as we enjoyed re-writing and editing it.
the time it is learned implicitly and in an ad hoc fashion. In this
book, we have made it explicit, broken down into its core compo- Nicola Cooper
nents. This book is designed to be an introduction for individuals John Frain
 CHAPTER 1

Introduction to Clinical Reasoning

Nicola Cooper and John Frain

OVERVIEW
Definitions
• Clinical reasoning describes the application of knowledge to Clinical reasoning describes the application of knowledge to col-
collect and integrate information from various sources to arrive at lect and integrate information from various sources to arrive at a
a diagnosis and/or management plan diagnosis and/or management plan for patients [2]. It is a com-
• A lack of clinical reasoning ability has been shown to be a major plex cognitive process involving clinical skills, memory, problem-
cause of diagnostic error solving, and decision-making. A definition of clinical reasoning is
• Several components of clinical reasoning have been identified given in Box 1.1.
• Expertise in clinical reasoning develops as a result of different
As the definition in Box 1.1 states, clinical reasoning can be
types of knowledge plus some other important factors defined as a skill, process, or outcome and multiple components
of clinical reasoning have been identified. However, for teachers
• Clinical reasoning can be viewed from different perspectives that
each give insights into how it can be taught and learned and why
and learners, it can be useful to think of clinical reasoning as a
it goes wrong process made up of different components, each of which requires
specific knowledge, skills, and behaviours. The UK Clinical
Reasoning in Medical Education group has defined five broad
areas of clinical reasoning education [3]:
Introduction 1. History and physical examination
Fellow author, Pat Croskerry, argues that although there are sev- 2. Choosing and interpreting diagnostic tests
eral qualities we would look for in a good clinician, the two abso- 3. Problem identification and management
lute basic requirements for someone who is going to give you the
best chance of being correctly diagnosed and appropriately
managed are these: someone who is both knowledgeable and a Box 1.1 A definition of clinical reasoning
good decision maker. At the time of writing, medical schools and ‘Clinical reasoning can be defined as a skill, process, or outcome
postgraduate training programmes teach and assess the knowledge wherein clinicians observe, collect, and interpret data to diagnose
and skills required to practice as a doctor, but few offer a compre- and treat patients. Clinical reasoning entails both conscious and
hensive curriculum in decision-making. This is a problem because unconscious cognitive operations interacting with contextual
how doctors think, reason, and make decisions is arguably their factors. Contextual factors include, but are not limited to, the
most critical skill [1]. patient’s unique circumstances and preferences and the characteris-
This book covers the core components of clinical decision- tics of the practice environment. Multiple components of clinical
making – or clinical reasoning. It is designed for individuals but reasoning can be identified: information gathering, hypothesis
generation, forming a problem representation, generating a
also for teachers and learners as part of a curriculum in clinical
differential diagnosis, selecting a leading or working diagnosis,
reasoning. Chapter 10 specifically covers teaching clinical
providing a diagnostic justification, and developing a management
reasoning in undergraduate and postgraduate settings. In this
or treatment plan. A number of theories (e.g., script, dual process,
chapter we define clinical reasoning, explain why it is important, and cognitive load theories) from diverse fields (e.g., cognitive
and introduce some of the different components of clinical psychology, sociology, education) inform research on clinical
reasoning that are explored in this book. We will consider how reasoning.’
expertise in clinical reasoning develops, and also look at clinical
From Daniel et al. (2019). Acad Med; 94(6): 902–12.
reasoning through different lenses.

ABC of Clinical Reasoning, Second Edition. Edited by Nicola Cooper and John Frain.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
2 ABC of Clinical Reasoning

educational approaches that are aligned with evidence from the

learning sciences.
Diagnostic error definitely causes harm, but increasing attention
is also being paid to another problem which can be caused by
faulty clinical reasoning – the harm caused by unnecessary tests
and overdiagnosis. A study of over one million Medicare patients
in the USA looked at how often people received one of 26 tests or
treatments deemed by scientific and professional organisations to
be of no benefit [9]. These included things like brain imaging in
syncope, screening for carotid artery disease in asymptomatic
patients, and imaging of the spine in low back pain with no red
flags. In one year, at least 25% of patients received at least one of
these tests or treatments. It has been estimated that at least 20% of
healthcare spending is waste [10]. This waste has a huge impact on
patients and the wider healthcare economy. Overdiagnosis occurs
when people without relevant symptoms are diagnosed with a dis-
ease that ultimately will not cause them to experience symptoms
Figure 1.1 Five broad areas of clinical reasoning education. Clinical or early death. There are many factors contributing to overdiagno-
reasoning concepts include key theories (e.g., script, dual process), how sis (see Box 1.3), but one of them is the increasing availability of
clinical reasoning ability develops, the problem of diagnostic error, the role of increasingly sensitive tests.
clinical reasoning in safe and effective care for patients, cognitive errors, and The growing recognition of the problem of diagnostic error,
other factors that may impair the clinical reasoning process or outcome.
unnecessary tests, and overdiagnosis is why clinical reasoning is

4. Shared decision-making Box 1.2 Categories of misdiagnosis

5. Clinical reasoning concepts
In this second edition, we have used this framework and explore Error category Examples
each of these areas (see Figure 1.1) in more detail.
No fault Unusual presentation of a disease
Missing information
Why Is Clinical Reasoning Important? System errors Technical, e.g. unavailable tests/results
Organisational, e.g. poor supervision of junior
Diagnostic errors tend to occur in common diseases and are a staff, error-prone processes, impossible workload
significant cause of preventable harm to patients worldwide [4]. It
Human Faulty data gathering
has been estimated that diagnosis is wrong 10–15% of the time cognitive error Inadequate reasoning
[5]. Post-mortem studies consistently find undiagnosed disease
Adapted from Graber ML et al., 2005 [7].
as the cause of death in 10–20% of patients, of which half could
have been successfully treated [6]. Diagnostic error is by far the
leading source of paid malpractice claims in the UK, and diag- Box 1.3 Factors contributing to overdiagnosis
nostic error has been identified as a high-priority patient safety
• Screening programmes that detect ‘pseudodisease’ – disease in a
problem by the World Health Organization.
person without symptoms in a form that will never cause
A lack of clinical reasoning ability has been shown to be a
symptoms or early death
major cause of diagnostic errors which can result in unnecessary
• Increasingly sensitive tests
pain, treatments, or procedures, and increase the costs of health- • Greater access to scanning – diagnostic scanning of the head and
care [2]. There are many reasons why diagnostic errors occur. A body reveals incidental findings in up to 40% of those being
comprehensive review of studies of misdiagnosis assigned three scanned for other reasons, often leading to anxiety and further
main categories, shown in Box 1.2. However, faulty synthesis of the testing for an abnormality that would never have caused harm
available information was found to be the most common reason • Widening definitions of disease and lower treatment thresholds,
for diagnostic errors leading to death and serious harm [7]. In for example:
other words, the clinician had all the information to make the • Chronic kidney disease
right diagnosis but made the wrong diagnosis. There is a growing • High cholesterol
• Attention-deficit hyperactivity disorder
consensus that medical schools and postgraduate training pro-
• Cultural considerations – medicalisation, commission bias (better
grammes need to do more to teach clinical reasoning in an explicit
to do something than nothing), fear of litigation
and systematic way. The National Academy of Medicine’s report
• Individual clinicians’ lack of understanding of statistics relevant to
Improving Diagnosis in Health Care [8] found that diagnosis and the disease, diagnostic test, and intervention in question
diagnostic errors have been largely unappreciated in efforts to
improve the quality and safety of healthcare and called for cur- Adapted from Moynihan R. Preventing overdiagnosis: how to stop
harming the healthy. BMJ 2012; 344: e3502.
ricula to explicitly address teaching the diagnostic process, using
 Introduction to Clinical Reasoning 3

of such interest to researchers, medical educators, and policy errors, we need to focus on improving processes, systems, and
makers. Improving clinical reasoning outcomes is a patient safety technology, as well as education and training in cognitive strat-
and healthcare economy priority. egies. Pat Croskerry explores metacognition and cognitive strat-
egies further in Chapter 9.
Finally, we look at teaching clinical reasoning in Chapter 10.
Components of Clinical Reasoning
There is no evidence that teaching clinical reasoning concepts
Several components of clinical reasoning have been identified. A alone, or short courses, improves clinical reasoning ability. The
fundamental one is the application of knowledge to gather and most effective way to teach clinical reasoning is to use strategies
interpret data in the patient’s history and physical examination. that build knowledge and understanding, and to practice with as
The purpose is to establish the clinical probability of disease – a many different cases as possible in as many different contexts as
judgement based on the clinician’s knowledge of epidemiology possible with coaching and feedback. We explore key concepts in
and what we call evidence-based history and physical examination, teaching clinical reasoning, specific evidence-based strategies
a topic which we explore in Chapter 2. The clinical probability of that teachers can use, and describe one approach to introducing a
disease is a prerequisite for choosing and interpreting diagnostic clinical reasoning curriculum at undergraduate level.
tests. Interpreting diagnostic tests is something even qualified
health professionals find difficult [11]. This is because tests lie;
How Does Expertise in Clinical Reasoning
very often, tests give us test probabilities, not real probabilities,
Develop?
which is why test results have to be interpreted by knowledgeable
clinicians, a topic which we explore in Chapter 3. If how clinicians think, reason, and make decisions is arguably their
Problem representation is something that is neglected in tradi- most critical skill, it is useful to consider how expertise in clinical
tional ‘history–examination–differential diagnosis’ teaching reasoning develops. In the 1970s, expertise in medicine was thought
methods, but studies show that being able to represent the problem to be related to superior general thinking skills. However, when
before attempting to solve it (i.e., think of a diagnosis) is a key step researchers observed experts and novices, they found there was no
in problem-solving, and dramatically increases diagnostic accu- difference in the processes or thinking strategies used – both
racy, especially in more complex cases [12]. This is a skill that can quickly came up with one or more diagnostic hypotheses which
be learned, and a topic which we explore in Chapter 4. guided the search for further information. Experts were more accu-
Clinical reasoning often takes place within teams. Clinicians rate because they knew more, and because the knowledge of experts
also make use of guidelines, scores and decision aids, and co-pro- varied from case to case, their performance varied from case to case
duce decisions with patients and carers. The important topic of as well [14]. This led to researchers changing direction and exam-
shared decision-making is explored further in Chapter 5. ining the role of knowledge in medical expertise.
Simply knowing about clinical reasoning concepts does not One of the next questions for researchers was, do experts have
help people reason better. But it is important for clinicians, bigger, better memories? The answer was no – given unlimited
teachers, and learners to have a shared definition, vocabulary and time, novices can remember as much as experts about a clinical
understanding of clinical reasoning in order to facilitate mean- case on paper. But experts appear to acquire information more
ingful discussion and learning. Models of clinical reasoning can efficiently and pay attention to more critical information (you
be useful to help us understand the processes underpinning our have probably seen this in action). In a series of well-known
decision-making – as clinicians, teachers, and learners. Chapter 6 experiments, Chase and Simon showed chess players of varying
explores dual process theories which are widely accepted as a strength – from master to novice – chessboards set up as if in the
framework with which to understand diagnostic reasoning and middle of a game for only 5 seconds and then asked them to
diagnostic error. Some common misunderstandings are identi- reconstruct the position of 28 pieces on a blank chessboard imme-
fied, and we explore critical thinking, rationality, the different diately afterwards. What they found was the chess masters showed
types of knowledge used by Type 1 and Type 2 processing, and a remarkable ability to reconstruct the board almost perfectly,
thinking about one’s own thinking (metacognition). whereas the novices could only recall the position of four or five
The topic of cognitive biases in clinical reasoning is controver- pieces. However, when the experiment was repeated with the
sial. This is partly because there are several key fallacies in the chess pieces arranged randomly, chess masters performed no
received view of dual process theories. There is definitely better than anyone else [15]. Chase and Simon concluded that
agreement that cognitive biases exist in medicine, but disagree- chess masters had stored in memory a large number of recogni-
ment as to whether they are a significant source of diagnostic sable ‘chunks’, or meaningful patterns (see Box 1.4). Similar results
errors compared with knowledge deficits. Chapter 7 explores this have been found in other fields – experts can reconstruct a briefly
topic further using a case history and analysis. examined scene provided it portrays a realistic (as opposed to
Clinical reasoning does not exist solely inside a clinician’s random or meaningless) pattern. But pattern recognition by itself
organised cognitive structures but is entangled in the activity of does not explain expertise. Non-chess players can be trained to
providing care for the patient [13]. Chapter 8 explores ‘situativity’ memorise chess patterns. Experts recognise patterns of high sig-
and human factors (the science of the limitations of human nificance because of their formal as well as experiential knowledge
performance). ‘To err is human’, therefore in order to minimise of chess – in other words, they study [16].
4 ABC of Clinical Reasoning

We know that knowledge is fundamental to expertise in clinical between normal learning and expert learning is what people do
reasoning. (As we will see in Chapter 6, other things matter as with those freed up resources. People who become experts rein-
well.) But by knowledge, we do not mean only facts. That is like vest their mental resources in further learning. They seek out
saying the raw ingredients are the same as the cake. Figure 1.2 more difficult problems. They tackle more complex representa-
refers to different types of knowledge; all these types of knowledge tions of common problems. They continue to work at the edge of
matter in clinical reasoning. their competence [17].
With learning, the process of chunking and automating, as In summary, we know that expertise in clinical reasoning is
described in Box 1.4, frees up mental resources. The difference highly dependent on knowledge, but that is not the whole story.
We will explore this further in Chapters 6 and 10.

Clinical Reasoning through Different

Metacognitive
• Knowledge of cognition in general as well as Lenses
awareness of one’s own cognition
At its most basic level, clinical reasoning is to do with knowledge,
Procedural how knowledge is organised in long-term memory as mental rep-
• How to do something, methods of inquiry, and
criteria for using skills, algorithms, techniques, and resentations, and the cognitive processes responsible for storing,
methods transforming, and retrieving these. This view of clinical reasoning
Conceptual is important for learners, who must have a) a deep foundation of
• The inter-relationships among the basic elements
within a larger structure that enable them to factual knowledge, b) understand facts and ideas in a conceptual
function together framework, and c) organise their knowledge in a way that facili-
Factual
tates retrieval and application. (The latter two points are why we
• The basic elements learners must know to be need expert teachers.) However, clinical reasoning is also
acquainted with a discipline or solve problems in it
something that is ‘situated’ in the environment. Thinking and
learning is context-dependent, the result of multiple dynamic
interactions between individuals and the environment. Cognition
Figure 1.2 Different types of knowledge. Adapted from: A model of
is also distributed in team members and in non-humans (e.g.,
learning objectives–based on: a taxonomy for learning, teaching, and computers). It can be adversely affected by poorly designed tech-
assessing: a revision of Bloom’s Taxonomy of educational objectives by Rex nology and systems, as well as sleep deprivation, fatigue, and
Heer, Center for Excellence in Learning and Teaching, Iowa State University. excessive workload. Understanding clinical reasoning through
https://www.celt.iastate.edu/teaching/effective-teaching-practices/
this lens is important too. But sometimes we need to be able to go
revised-blooms-taxonomy (accessed April 2022).
beyond the ‘content’ and make sense of the patient’s illness (and
our own response to it) and understand the practice of medicine
in its wider socio-cultural context. This is what we sometimes call
Box 1.4 Chunking and automating: how we can think more
complex thoughts the ‘art’ of medicine, which involves crafting a wise and deliberate
course of action appropriate for the circumstances and may not
Human working memory can only process a limited number of involve any technical decision-making at all. Clinical reasoning
elements at a time. But not all elements are created equal. The
through this lens is often what postgraduates are able to start
elements of information stored in our long-term memory increase in
practicing once their mental resources are freed up from focusing
complexity over time, with smaller elements combining to form
on the technical aspects of medicine. Many studies demonstrate a
larger ones. This process is called ‘chunking’ and it is what allows us
to think more complex thoughts. correlation between effective clinician–patient communication
For example, a child who has not yet learned the alphabet will see and ‘whole person care’ with improved health outcomes. An
the letter ‘H’ as three straight lines. Reproducing these three straight example of this is given in Box 1.5.
lines correctly could be a cognitively demanding task. Over time,
they will chunk and automate drawing the letter ‘H’ until it becomes Listen to Me; I Am Telling You My Diagnosis
effortless. Once they have mastered individual letters, whole words Whatever their level of health literacy, no patient is an empty
will still be new to them. The word ‘H, o, u, s, e’ will consist of five vessel devoid of knowledge or insight about their own condition.
separate elements. But over time, this will be chunked as the word By presenting to a clinician, patients have often engaged in their
‘House’ in long-term memory which can then be read and written own reasoning and formulated ideas about a diagnosis or even
effortlessly.
several diagnoses. The patient’s perspective is not simply a psy-
Chunking and automation is a result of learning. Experts store
chosocial one but may include relevant insights into anatomical
knowledge in long-term memory as rich chunks called schemas
and physiological changes and pathology (see Box 1.6). This does
which allows them to overcome the limitations of working memory
when solving problems. (See Chapter 10 for information on how not mean they are always correct – that is why they attend a clini-
teachers can facilitate the process of schema formation.) cian – but neither is their perspective irrelevant.
While the clinician arrives at a differential diagnosis (and/or
Adapted from Lovell O. Sweller’s cognitive load theory in action. A
problem list) following the history, or patient interview, the patient
John Catt Publication, 2020. pp. 20.
arrives with their own differential diagnosis (and/or problem list).
 Introduction to Clinical Reasoning 5

Box 1.5 The importance of whole person care Box 1.7 The patient presents after reasoning through their
symptoms
Two patients had similar symptoms. They were experiencing
transient numbness of different parts of the body – one side of the ‘Thank you for speaking to me doctor. I’ve been feeling unwell for
face or the other, sometimes the arm or hand. These symptoms several days. My hay fever is usually bad at this time of year. I know
were causing a great deal of anxiety. The patients went to see two the pollen count is high at the moment, but my usual medication is
different physicians. not working. My nose is blocked, and I’ve been sneezing.
The first patient told his story. At the end of the consultation the My chest is tight as well and I’ve been coughing more at night.
physician said, ‘Well you’ve either got migraine or multiple sclerosis My blue inhaler has helped but I’m using it more than usual and it’s
so we’ll do an MRI scan and I’ll let you know the results.’ He was not as effective. My peak flow is down. I was wondering if I need
not given a further appointment. While waiting for his MRI scan, his some steroids as well.
anxiety and symptoms increased significantly. I was shielding during the first lockdown, and I know COVID is
The second patient told her story. Recognising that these coming back again. Do I need another jab to boost my immunity?’
symptoms are common in stress and did not fit any neurological Patient’s problem list:
pattern, the physician said, ‘I see lots of people with these 1. My hay fever is not controlled
symptoms and very often it’s because they are working too hard, 2. My asthma is deteriorating
not sleeping, or under stress. Even though they might not realise 3. The prevalence of COVID-19 is increasing. Do I need further
they are stressed, their body is telling them they’re stressed. Tell me immunisation?
about your schedule and what’s going on in your life.’ The patient’s
There is a lot of data to unpack here to make the diagnosis and
husband looked at her knowingly and sure enough there were lots
answer the patient’s concerns.
of stressors related to work and home that had been an issue. An
MRI scan was arranged, but the patient was advised to make
changes to her lifestyle and her symptoms resolved. The different lenses through which we can view clinical
Both patients had normal MRI scans. Explanation and good
reasoning, whether from the clinician or the patient’s perspec-
communication lead to better outcomes, greater compliance with
tive, are not mutually exclusive. There are situations that call for
recommended treatments, and less re-attendances.
rapid technical responses, for example, emergencies. Then there
are others that call for time, wisdom, and care. Clinical reasoning
is complex and takes years to learn. The challenge for educators
Box 1.6 A patient-centred approach to differential diagnosis is to provide clinical environments with multiple tasks and
strategies in order to equip learners over time to be able to
Agreeing the differential diagnosis
reason through a variety of clinical problems as effectively as
Patient’s differential Doctor’s differential possible [21].
• Leading hypothesis • Leading hypothesis
• Alternative 1 • Alternative 1
• Alternative 2 • Alternative 2
Summary
• …… • ……
At the time of writing, most medical schools and postgraduate
• ‘Must-not-miss’ • ‘Must-not-miss’
training programmes provide instruction in the basic elements of
Where is the common understanding?
the diagnostic process. However, students and trainees largely
‘Let us think about this together’
Eventual diagnosis must explain both parties’ data
learn the knowledge, skills, and behaviours required for effective
clinical reasoning implicitly and ad hoc, through experience and
The history, or patient interview, is a discussion of the patient’s ideas apprenticeship. Yet a lack of clinical reasoning ability has been
and insights into their symptoms and diagnosis. The clinician’s role is shown to be a major cause of diagnostic errors resulting in
crucial to the correct synthesis of this information, but this must be significant preventable harm to patients worldwide. There is a
done with a complete dataset elicited from the patient. growing consensus that medical schools and postgraduate
training programmes should teach clinical reasoning in a way
Patients describe their own insight with differing levels of articu- that is explicitly integrated into courses throughout each year of
lacy, but all patients do this. Clinical reasoning should from the the programme, adopting a systematic approach consistent with
outset be a collaborative and dynamic process between patient and current evidence.
clinician (see Box 1.7). The benefits include identifying the For teachers and learners, it can be useful to think of clinical
patient’s priorities to the eventual goal of shared decision-making. reasoning as a process made up of different components, each of
Yet, how often do we hear, either in a media story, complaint, or which requires specific knowledge, skills, and behaviours. These
adverse event, that the clinician ‘wouldn’t listen to what we were components are what the following chapters explore in more
saying’? This feeling among patients of dissonance between clini- detail. If we can start with an understanding of what clinical
cians and themselves is reflected by the evidence base [18–20]. reasoning is, why it is important, what the key components are,
Assessing the patient’s own starting point by defining their own and how it develops, we are in a better position to create clinicians
understanding and experience of their symptoms at the beginning who are good decision makers and who ultimately provide better
of the interview is crucial to avoiding diagnostic error. care for patients.
6 ABC of Clinical Reasoning

References 12. Bordage G. (1994). Elaborated knowledge: a key to successful diagnostic

thinking. Academic Medicine; 69(11): 883–885.
1. Croskerry P. Clinical decision making. In: Barach P, Jacobs J, Lipshultz S, 13. Koufidis C, Manninen K, Nieminen J et al. (2022). Representation,
and Laussen P (Eds). Pediatric and Congenital Cardiac Care. London: interaction, and interpretation. Making sense of the context in clinical
Springer, 2015. https://doi.org/10.1007/978-1-4471-6566-8_33 (accessed reasoning. Medical Education; 566: 98–109.
April 2022). 14. Elstein AS, Shulman LS and Sprafka SA. Medical problem solving. An
2. DID-ACT Project. Developing, implementing, and disseminating an analysis of clinical reasoning. Harvard University Press, 1978.
adaptive clinical reasoning curriculum for healthcare students and educa- 15. Chase WG and Simon HA. (1973). Perception in chess. Cognitive
tors. An EU funded project, 2020. https://did-act.eu/home/project Psychology; 4: 55–81.
(accessed April 2022). 16. Bereiter C and Scardamalia M. Experts are different from us: they have
3. Cooper N, Bartlett M, Gay S et al. On behalf of the UK Clinical Reasoning more knowledge. In: Surpassing ourselves: an inquiry into the nature and
in Medical Education (CReME) consensus statement group. (2021). implications of expertise. Open Court Publishing, 1993. pp. 25–42.
Consensus statement on the content of clinical reasoning curricula in 17. Bereiter C and Scardamalia M. Expertise as a process. In: Surpassing
undergraduate medical education. Medical Teacher; 43(2): 152–159. ourselves: an inquiry into the nature and implications of expertise. Open
4. Tehrani ASS, Lee HW, Mathews SC et al. (2013). 25-year summary of US Court Publishing, 1993. pp. 77–120.
malpractice claims for diagnostic errors 1986-2010: an analysis from the 18. Fransen GAJ, Janssen MJR, Muris JWM et al. (2007). Measuring the
National Practitioner Data Bank. BMJ Quality & Safety; 22(8): 672–680. severity of upper gastrointestinal complaints: does GP assessment
5. Graber ML. (2013). The incidence of diagnostic error in medicine. BMJ correspond with patients’ self- assessment? Family Practice; 24: 252–258.
Quality & Safety; 22(Suppl 2): ii21–ii27. 19. Dorval E, Rey JF, Soufflet C et al. (2011). Perspectives on gastroesopha-
6. Leape LL, Berwick DM and Bates DW. (2002). Counting deaths due to geal reflux disease in primary care: the REFLEX study of patient-physi-
medical errors. [Letters]. JAMA; 288(19): 2405. cian agreement. BMC Gastroenterology; 11: 25–33.
7. Graber ML, Franklin N and Gordon R. (2005). Diagnostic error in 20. Humphrys E, Walter FM, Rubin G et al. (2020). Patient symptom
internal medicine. Archives of Internal Medicine; 165: 1493–1499. experience prior to a diagnosis of oesophageal or gastric cancer: a
8. National Academies of Sciences, Engineering, and Medicine. Improving multi-methods study. BJGP Open; 4(1): bjgpopen20X101001.
diagnosis in health care. Washington (DC): The National Academies 21. Eva K. (2004). What every teacher needs to know about clinical
Press, 2015. doi:10.17226/21794 (accessed April 2022). reasoning. Medical Education; 39: 98–106.
9. Shwarz A, Landon B, Elshaug A et al. (2014). Measuring low value care in
Medicare. JAMA Internal Medicine; 174(7): 1067–1076.
10. Berwick D and Hackbarth A. (2012). Eliminating waste in US Further Resource
healthcare. JAMA; 307(14): 1513–1516. 1. Bereiter C and Scardamalia M. Surpassing ourselves: an inquiry into the
11. Whiting PF, Davenport C, Jameson C et al. (2015). How well do health nature and implications of expertise. Open Court Publishing, 1993.
professionals interpret diagnostic information? A systematic review.
BMJ Open; 5(7): e008155.
 CHAPTER 2

Evidence-based History and Examination

John Frain

will introduce the idea of evidence-based history and physical

OVERVIEW
examination, an important component of clinical reasoning.
• The history and physical examination are essential diagnostic tools
• To formulate a differential diagnosis, the history should identify
the patient’s key presenting symptoms and associated symptoms
The Evidence Base
• The patient’s background and the natural history of a condition Most of our knowledge of history and physical examination pre-
are essential contextual factors in making a correct diagnosis dates the development of evidence-based medicine, and from a
• An incomplete physical examination increases the risk of diag- time when patients presented later in the course of their illness,
nostic error usually with more ‘classic’ features. Nowadays, especially in devel-
• If available, likelihood ratios are a measure of diagnostic accuracy oped countries, clinical problems present earlier and are often less
which are easy to understand and apply at the bedside well differentiated from one another. We know that many single
• Clinical teachers should be familiar with evidence-based history features in the history and physical examination are limited in
and examination their usefulness (e.g., whether someone’s chest discomfort is
‘central and crushing’ or not; or whether Kernig’s sign is present).
Nonetheless, good quality evidence now exists, including
systematic reviews of symptoms and diagnostic accuracy studies
Introduction of physical signs. This is being assimilated into textbooks (see
Evidence-based history and examination surveys all data from further resources) that provide epidemiological and qualitative
the clinical encounter, compares it to available evidence, including data as well as diagnostic accuracy studies including sensitivities,
recognised diagnostic standards, and quickly identifies those var- specificities, and likelihood ratios. Where statistical evidence is
iables with the greatest diagnostic accuracy. lacking, authors provide diagnostic guides based on the best
Around 80% of diagnoses are made from the history alone [1]. available epidemiological evidence. Evidence-based principles
Its importance is such that Hampton et al. recommended more and knowledge can be reinforced for learners through reflective
emphasis should be placed on teaching students accurate history- coursework (see Box 2.1) which can further enable reflection on
taking and more emphasis should be placed on research into clinical reasoning during workplace training.
communication between patients and clinicians [1]. The purpose
of the history is the generation of a differential diagnosis broad Exploring Symptoms: Combining Process
enough to include the actual diagnosis but focussed enough to be and Content
tested by an appropriate physical examination, and investigations
when necessary. The differential diagnosis consists of a leading The process of history-taking cannot be separated from
hypothesis and two or three other hypotheses including any ‘must knowledge of epidemiology, anatomy, and physiology. Nor can it
not miss’ diagnoses, all justifiable by the data gathered, and taking be separated from effective communication with patients [1].
into account the patient’s own concerns. Generating a differential Irrespective of the cause, each patient seen by a clinician is essen-
diagnosis guards against premature closure (see Chapter 9). For tially saying: ‘I’ve noticed some changes in my anatomy and phys-
the learner, it aids in developing their clinical reasoning ability. iology. Can you tell me, is this normal, part of getting older or is it
Generating a differential diagnosis needs to be taught alongside pathology? If it’s pathology, will I return to my previous health,
the history and physical examination, not separately. This chapter will it leave me with some loss of function or could it even shorten

ABC of Clinical Reasoning, Second Edition. Edited by Nicola Cooper and John Frain.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
8 ABC of Clinical Reasoning

Box 2.1 Reflective coursework: the presentation of chest pain Box 2.2 The Calgary-Cambridge model: the process required
in women for accurate history-taking

‘I encountered a female patient in her 50s presenting with a • The patient’s opening statement (usually 30–120 seconds)
possible acute coronary syndrome (ACS). We had recently been • Identifying a problem list
discussing in clinical skills about possible differences in the • Agreeing an agenda for the interview
presentation of acute coronary syndrome in women and men. I • Exploring each symptom experienced by the patient
decided to examine the evidence for this. • Patient and clinician agreeing on definition of each symptom
I undertook a systematic search of the literature using the 6S present
evidence pyramid we had been taught. I identified 16 relevant • Gathering data for each symptom using open questions
studies using the SORT criteria.i There was heterogeneity of data • Completing details using closed question
recording and analysis across the studies. However, I was able to • Establishing a sequence of events
draw the following conclusions: • Attentive listening
• Women are more likely to present with ACS atypically compared • Picking up cues
to men • Exploring the patient’s relevant background information
• Men are more likely to present with chest pain than women • Relevant systems review
• Chest pain is the most common symptom presentation for both sexes • Ensuring all the patients concerns have been addressed
• Younger women are more likely than older women to present • Explanation and planning
with typical symptoms • Shared decision-making
• No difference exists between sexes for prevalence of chest pain Adapted from Silverman J, Kurtz SM, Draper J. Skills for
and/or other typical symptoms of ACS Communicating with Patients, 3rd edn. CRC Press, 2013.
• Women reported more associated (non-chest pain) ACS
symptoms than men
Continued development as a clinician requires three things: Box 2.3 Summary of key symptoms by body system
reflective practice, unwavering curiosity, and maintaining an open
General Cardiovascular
mind to new evidence and ideas. Writing this essay has highlighted
Fatigue/malaise Pain
the importance of looking to the highest level of evidence for Fevers/rigors/night sweats Breathlessness
guidance, while maintaining a healthy level of scepticism for the Weight/appetite Palpitations
recommendations by analysing the primary literature and systematic Sleep disturbance Swelling
reviews behind them.’ Rashes/bruising
i. Ebell MH, Siwek J, Weiss BD et al. (2004). Strength of recommenda- Respiratory Alimentary
tion taxonomy (SORT): a patient-centered approach to grading Pain Difficulty swallowing
evidence in the medical literature. Am Fam Physician; 69(3): 548–56. Breathlessness Nausea/vomiting/haematemesis
Wheeze Indigestion/heartburn
This is an excerpt from a patient-based piece of coursework Cough Pain/distension
undertaken by graduate entry medicine students at the University of Sputum/haemoptysis Change in bowel habit
Nottingham, UK. Students examine the evidence underlying a Bleeding
clinical feature encountered in practice.
Genitourinary Nervous system
Frequency Headache
Dysuria Loss of consciousness
my life?’ Clinical reasoning and decision-making is required to Incontinence Dizziness
assess all these concerns. Change in urinary volume Visual disturbance
Models for clinical communication have been developed, most Prostatic symptoms Hearing
notably the Calgary-Cambridge model [2] consisting of 70 skills Menstrual symptoms Weakness
Numbness/tingling
which facilitate accurate history-taking (see Box 2.2). Teaching
Memory or personality change
this model involves deliberate practice with detailed, specific Anxiety/depression
feedback by observers. It is used either one-to-one with a tutor
Musculoskeletal
and patient, with patient actors, or at the bedside with real Pain
patients. An adapted form of the observation guide includes Stiffness
feedback on elements of clinical reasoning [3, 4]. Swelling
When taking a history, key symptoms emerge within the rele- Loss of function or activities of daily living
vant system (see Box 2.3). While symptoms may overlap different
Adapted from the Calgary-Cambridge Guide. In: Silverman J, Kurtz S
systems (e.g., chest pain could be cardiac, musculoskeletal, or and Draper J. Skills for Communicating with Patients, 3rd edn. CRC
respiratory in origin) or be challenging for both patient and doc- Press, 2013.
tor to define (e.g., dizziness), many diseases present with varying
configurations of key symptoms within the relevant system.
Provided the clinical setting of an individual symptom is clearly to reason its significance and thus its usefulness as evidence of the
defined (e.g., nausea and vomiting in patients with suspected presence of the target condition. Course content can be developed
intestinal obstruction, or chest pain in patients with suspected to teach students the evidence-base for each symptom alongside
myocardial infarction in the emergency department) it is possible the process of exploring symptoms with the patient (Box 2.4).
 Evidence-based History and Examination 9

Box 2.4 Summary evidence box for cardiovascular pain

Defining Symptoms
Patients and clinicians do not always agree on how a symptom is
Definition experienced. Learners benefit from realising and exploring this at
Impairment of the blood supply to the heart. Pain is precipitated by the outset. Misunderstandings can occur more readily when
exertion and relieved by rest.
symptoms appear to overlap body systems and/or when there are
Anatomical site multiple causes. An example is dizziness, where one classification
Narrowing of the coronary arteries, usually by atherosclerosis but lists 33 possible causes. Students, in particular, worry they, ‘Don’t
occasionally by spasm.
know what questions to ask’. Providing knowledge and categoris-
Pathophysiology ing the underlying causes of symptoms can enable students to
Primarily, smoking, high cholesterol, high blood pressure, and explore and define the symptoms further:
diabetes damage the endothelial lining of the coronary arteries.
What does the patient say? Patient: ‘I feel dizzy.’
‘I keep getting pains in my chest whenever I do things.’ Student: ‘What do you mean by that?’
‘My angina is getting worse.’ Patient: ‘I feel I’m going to pass out sometimes’ – pre-syncope
Evidence base ‘I feel as though I’m (or the room is) moving’ – vertigo
The table shows the European Society of Cardiology clinical ‘I feel as though I’m falling’ – disequilibrium (often
classification of angina:i neurological)
‘I feel light-headed all the time’ – possible anxiety or
Typical angina Meets all three of the following characteristics: depression
1. C haracteristic retrosternal chest discomfort –
typical quality and duration Similarly, misunderstandings regarding ‘indigestion’ can be clari-
2. Provoked by exertion and emotion fied by using the patient’s own definition as the starting point (see
3. Relieved by rest or GTN (glyceryl trinitrate) or both Box 2.5). In the case of upper alimentary symptoms, agreement
Atypical angina Meets two of the above characteristics between patient and clinician on the patient’s experience is criti-
Non-cardiac chest Meets one or none of the above characteristics cal to the diagnosis, including malignancy.
pain

Up to 95% of chest pain presents in primary care.ii Of patients Associated Symptoms

presenting with chest pain at the emergency department, almost a Many students are proficient at obtaining a detailed description
third have serious cardiovascular disease. Only 11–44% of patients of a presenting symptom but fail to explore associated symptoms.
referred to the cardiology out-patients have coronary artery disease.iii By associated symptoms, we mean those symptoms which,
The presence of atypical symptoms such as pain worse on though subsidiary to the patient’s main concern (e.g., pain), are
inspiration, stabbing pain, positional, reproducible on palpation of the nonetheless present and may contribute to the patient’s overall
chest wall and no radiation is more useful in identifying patients who
concern about the diagnosis. The main associated symptoms for
do not require investigation (positive predictive value = 0.94) than are
any presenting symptom most commonly arise from the same
the features of typical angina in identifying patients who do require
organ system as the presenting one (see Box 2.3). A patient pre-
further investigation (positive predictive value = 0.21). In stable chest
pain, the patient’s own description of the pain is the most important senting with a cough may be concerned about the inconvenience
predictor of coronary heart disease, and in acute pain, the history of of the cough and the impact on their ability to function. However,
chest pain should be judged alongside the ECG findings.iv the diagnosis is not apparent from this symptom alone. For
Chest pain in a young person is unlikely to be coronary artery example, diagnosing pneumonia requires enquiry about sputum,
disease but you should ask about associated dizziness, syncope, and a fever, breathlessness, chest pain, and haemoptysis. Having to
family history of sudden death as well as screen for risk factors. present the history at the end of the interview and getting the
Women present more often with atypical angina. They are more likely student to list the problems and formulate a differential diag-
than men to have pain at rest, during sleep or precipitated by stress. nosis forces students to use associated symptoms in their
References reasoning [5] (see Box 2.6).
i. Talley NJ, O’Connor S. Clinical Examination, 7th edition. Sydney:
Churchill Livingstone, 2014. Interpreting Features in the History
ii. Polmear A. Evidence-Based Diagnosis in Primary Care. Studies of the history have assessed which features might be
Edinburgh: Butterworth Heinemann, 2008. more diagnostic than others for a particular condition. One
iii. Buntinx F, Knockaert D, Bruyninckx R et al. Chest pain in general looked at what features of the history in chest pain are most help-
practice or in the hospital emergency department: is it the ful to clinicians in differentiating cardiac from non-cardiac
same? Fam Pract (2001) 18:586–589. causes [6]. The authors found no single element of the chest pain
iv. Chun AA, McGee S. Bedside diagnosis of coronary artery history was a powerful enough predictor of non-cardiac pain to
disease: a systematic disease. Am J Med (2004) 117:334–343.
allow a clinician to decide on history alone, but researchers have
Adapted from Frain J. Module 3 Clinical Skills Workbook: attempted to combine features in the history which can be of use
Cardiovascular. Graduate Entry Medicine, University of in clinical practice (see Box 2.7). Pain that is stabbing, pleuritic,
Nottingham, UK. positional, or reproducible by palpation has likelihood ratios
10 ABC of Clinical Reasoning

Box 2.5 Patient perspectives on upper alimentary tract symptoms

Under CC BY 4.0. Humphrys E, Walter FM, Rubin G et al. (2020). Patient symptom experience prior to a diagnosis of oesophageal or gastric
cancer: a multi-methods study. BJGP Open; 4 (1): bjgpopen20X101001. https://doi.org/10.3399/bjgpopen20X101001.

near zero, meaning the likelihood of this kind of pain being Natural History and Context
cardiac is very low. Conversely, chest pain that radiates to one or The natural history of a disease is the sequence of changes occur-
both shoulders or arms or is precipitated by exertion has higher ring within the body from the beginning of the illness until its
likelihood ratios (LR = 2.3 − 4.7) meaning this kind of pain is resolution. The disease resolves to either complete restoration of
more likely to be cardiac. Likelihood ratios are discussed in more health, to loss of function, which may also be progressive, or the
detail later. patient’s death. Familiarity with the symptoms and signs of a
 Evidence-based History and Examination 11

of the patient’s symptoms and the natural history of the condition

Box 2.6 The importance of associated symptoms is formulating
a reasoned diagnosis is reflected in the New York Heart Association’s functional
classification of heart failure (see Box 2.8). The correlation of each
‘Mr. Jackson had a car crash yesterday when his car was hit from class with echocardiographic findings can be used to guide evi-
behind. The pain (presenting symptom) is worse today and he has
dence-based therapy.
been taking paracetamol and ibuprofen. A hot water bottle has
This concept can be demonstrated to students with a simple
helped to relieve his symptoms, but he has been unable to use his
keyboard at work. I think he has whiplash.’
class exercise of constructing the natural history of a peritonsil-
Exploring the mechanism of injury, the radiation of pain and the lar abscess (quinsy). All will have experienced a viral sore
presence of sensorimotor deficit clarifies the diagnosis: ‘Mr. Jackson throat, many will have experienced bacterial tonsillitis, and a
was hit from the left yesterday just after he had got into his car. few suffered a quinsy. Discussion of the symptoms from onset
Unfortunately, he had not put his seatbelt on. He was thrown to recovery provides the group with appreciation of the natural
against the door and then rebounded back again into his passenger. history of a condition and its relevance to clinical reasoning
He felt a sudden pain on the right side of his neck. His pain is worse (see Box 2.9).
this morning. Mr. Jackson describes pain radiating to his right Similarly, students who are taught lists of features of various
shoulder. His arm feels heavy and weak (associated symptom). He diseases are not as accurate at diagnosis compared with those
has tingling down his arm to his right thumb (associated
taught probabilities of symptoms being present [7]. For example,
symptom), in the C6 dermatome. I am concerned he has a
nearly all adult patients with meningitis in the UK have headache
hyperextension injury and right C6 nerve root irritation.’
and a fever at presentation, the next most common symptom is
Adapted from Bokshan SL, DePasse JM, Eltorai AE et al. (2016). An nausea and vomiting (70%), but only around half complain of
evidence-based approach to differentiating the cause of shoulder photophobia and a stiff neck [8]. Severe, or late bacterial, menin-
and cervical spine pain. Am J Med; 129(9): 913–8. gitis, on the other hand, is associated with prototypal symptoms
and signs as described in textbooks. Simply teaching prototypes
and ‘medical triads’ is likely to encourage superficial pattern rec-
Box 2.7 Differentiating cardiac from non-cardiac chest pain by ognition that results in overconfidence, premature closure, and
history incorrect diagnosis.
The patient’s context, including age and gender, should be
• Low risk of cardiac pain: the 3 P’s – pain that is pleuritic or
emphasised when considering the clinical probability of a disease.
stabbing, positional, and reproduced by palpation
• Probably low risk: pain not related to exertion that occurs in a
Epidemiological studies provide learners with an evidence base to
small inframammary area of the chest wall assist in their clinical reasoning. For example, the Interheart
• Probably high risk: pain described as pressure, similar to a Study [9] found over 90% of all patients suffering their first myo-
previous heart attack/angina or accompanied by nausea, cardial infarctions had the risk factors of smoking, hypertension,
vomiting, and diaphoresis diabetes, abdominal obesity, low physical activity, and poor diet.
• High risk: pain that radiates to one or both shoulders or arms or is Box 2.10 shows the percentage pre-test probability for American
related to exertion
When combined with the patient’s age, sex, and past medical
Box 2.8 New York Heart Association Functional Classification
history, it should be possible to accurately identify those at low risk
of Heart Failure – correlation of symptoms, echocardiographic
of cardiac pain, although these are a minority of patients who findings, and therapeutic options
present to hospital with chest pain. Other serious causes of the
chest pain still need to be considered. Class I II III IV
Adapted from Swap CJ and Nagurney JT. (2005). Value and Symptoms None On On At rest and on
limitations of chest pain history in the evaluation of patients with moderate mild minimal
suspected acute coronary syndromes. JAMA; 294 (20): 2623–9. activity activity activity
Ejection 40–50% 30–40% <30% <30%
fraction
condition facilitates its diagnosis. The classical presentation of
disease as described in textbooks is quite uncommon. Some Use these ACE inhibitor ACE ACE inhibitor ACE inhibitor
drugs Beta-blocker inhibitor Beta-blocker Spironolactone
symptoms and signs occur early in the disease while others occur
Beta-blocker Diuretic Digoxin
later. For example, in early heart failure, the patient may become Low-dose Spironolactone Diuretic
breathless only on severe exertion. Later, breathlessness occurs on diuretic Digoxin Beta-blocker (if
more moderate exertion (e.g., climbing the stairs), while later the Statin Statin compensated)
patient has a problem lying flat in bed (orthopnoea) and may be Sacubitril/ Sacubitril/
valsartan valsartan
breathless at rest.
If a learner interviewing a patient with breathlessness believes
the symptoms of orthopnoea must be present for heart failure to Adapted from The Criteria Committee of the New York Heart
be diagnosed, they will miss patients in the earlier stages of dis- Association. Nomenclature and criteria for diagnosis of diseases of the
heart and great vessels 9th edn. Little, Brown & Co, 1994. pp. 253–256.
ease who may benefit from proven treatment. This combination
12 ABC of Clinical Reasoning

In summary, exploring and defining symptoms, including

Box 2.9 Discuss with your colleagues a possible natural
history of a peritonsillar abscess (quinsy) associated symptoms, has to be accompanied by knowledge – of
the underlying causes of symptoms, what particular features, or
Students will usually come up with the following list, as it within combination of features, are helpful in making a diagnosis, the
their own experience:
natural history of disease, probabilities (rather than lists) of
• Feverish ­symptoms associated with various diseases, and epidemiology.
• Sore throat The process of history-taking illustrated in Box 2.2 is designed to
• Neck pain
obtain accurate data, the content of which can then be interpreted
• Pain on swallowing
by the clinician.
• Yellow spots on the tonsils
• Neck swelling
• Unable to eat or drink/throat feels blocked The Physical Examination
• Generally unwell
While the history is the key component in formulating a diag-
Key discussion points:
nosis, the physical examination, used in conjunction, can double
• Early disease is undifferentiated the diagnostic power of the history [10]. Inadequate physical
• Not every sore throat leads to a quinsy
examination, mostly failure to perform one at all, is a preventable
• Early disease can be difficult to differentiate from serious disease –
source of medical error [11]. Despite these facts, there are well-
hence the importance of red flags
• Signs with higher LRs are likely to occur later in the disease
documented deficiencies in the basic clinical skills of history-
• Red flag/serious symptoms can be used for safety netting/shared taking and physical examination [12].
decision-making – explanation to the patient about the possible In diagnosing lobar pneumonia, an evidence-based approach to
course of events physical examination asks, ‘What findings most accurately increase
the probability of pneumonia?’ by studying patients with respiratory
complaints and comparing their physical examinations to chest
radiographs. Based on evaluation of over 6000 patients, there are
Box 2.10 Estimating the pre-test probability (%) of coronary six traditional physical findings that reliably predict the results of
heart disease
the chest radiograph (see Figure 2.1). The remaining findings,
whether present or absent, add very little to the diagnosis of pneu-
Age Non-anginal Atypical Typical
chest pain (%) angina (%) angina (%)
monia. Using an evidence-based approach can trim the clinician’s
focus from 15 findings of unknown value to six findings with
M F M F M F
proven value, thereby increasing confidence, efficiency, and accu-
30–39 3–35 1–19 8–59 2–39 30–88 10–78 racy. Clinicians applying this method can then approach their next
40–49 9–47 2–22 21–70 5–43 51–92 20–79 patient with cough and dyspnoea as if they had personally exam-
50–59 23–59 4–25 45–79 10–47 80–95 38–82 ined each of the 6000 patients in these studies and then recalled the
60–69 49–69 9–29 71–86 20–51 93–97 56–84 value of the physical examination gleaned from that experience.

The figure on the left of each box shows the percentage probability
at each age and by sex when the patient had no risk factors and the TRADITIONAL FINDINGS EVIDENCE-BASED APPROACH
number on the right-hand side of each box shows the percentage
Fever 5 findings increase probability
probability of coronary heart disease in patients with the risk factors Tachypnea
diabetes, smoking, and hyperlipidaemia. Asymmetrical chest excursion
Tachycardia
Egophony
Reduced oxygen saturation
Reproduced with permission from Henderson MC, Tierney LM, Bronchial breath sounds
Grunting respirations
Percussion dullness
Smetana GW. The Patient History: An Evidence-based Approach to Cyanosis
Oxygen saturation <95%
Asymmetric chest excursion
Differential Diagnosis, 2 edn. New York: Lange/McGraw-Hill, 2012.
Percussion dullness
Diminished breath sounds
Crackles
1 finding decreases probability
Egophony
Bronchophony All vital signs normal
Whispering pectoriloquy
patients of different ages presenting with chest pain. The patients Bronchial breath sounds
all had normal 12-lead electrocardiograms and diagnosis was Pleural rub
based on history alone. Even without any risk factors, age alone
substantially increased the risk of coronary heart disease. The Figure 2.1 Diagnosis of lobar pneumonia. Textbooks present 15 traditional
physical findings of pneumonia (left), along with the assumption that each
presence of risk factors was particularly helpful in diagnosing finding has similar diagnostic weight. The evidence-based method (right),
middle-aged patients. Women lagged men in the incidence of based on study of actual patients, shows that five findings accurately
coronary heart disease until menopause was reached. increase probability of pneumonia, and only one finding decreases it.
 Evidence-based History and Examination 13

Likelihood Ratios Infinity

When a symptom or sign is present (or absent), how do we know

how useful that finding is in making a diagnosis? Likelihood ra-
tios (LRs) are diagnostic weights. The likelihood ratio is the prob- 10 +45%
ability of the finding in someone with the disease over the
probability of the finding in someone without the disease. Thus, if Increase
probability 5 +30%
a finding is equally likely in people with and without the disease,
the likelihood ratio is 1 (i.e., unhelpful). Each finding from the
history and physical examination is associated with a unique LR, 2 +15%
a number whose values ranges from zero to infinity. An LR greater
than 1.0 increases the probability of disease, and the higher the
No change 1 No change
value of the LR, the greater the increase in probability. An LR of
less than 1.0 decreases the probability of disease, and the lower
the value of the LR, the greater the reduction in probability (see 0.5 –15%
Figures 2.2 and 2.3).
One simple method of interpreting LRs is to memorise the
Decrease 0.2 –30%
association between three LR values – 2, 5, and 10 – and the first probability
three multiples of 15 – 15, 30, and 45. A finding with an LR of 2
increases the absolute probability by around 15% (that is, the cli- 0.1 –45%
nician adds 15% to the pre-test probability); a finding with an LR
of 5 increases the probability by around 30%, and one with an LR
of 10 increases the probability by around 45%.
Zero
For those LRs less than 1.0, the clinician simply inverts the 2, 5,
and 10 ‘rule’ (that is 0.5, 0.2, and 0.1). A finding with an LR of 0.5 Figure 2.3 Likelihood ratios: diagnostic weights. Clinicians should classify
LRs into three groups: those with values greater than 1.0 increase proba-
decreases the probability by around 15%; one with an LR of 0.2
bility; those with values less than 1.0 decrease probability; and those with
decreases the probability by around 30%, and one with an LR of values near 1.0 change probability very little or not at all.
0.1 decreases the probability by around 45%. Provided clinicians
round off final probabilities greater than 100% to 100%, and those
Box 2.11 Likelihood ratios and bedside estimates
less than 0% to 0%, this method suffices for the purposes of
clinical reasoning.
Likelihood ratio Approximate change in probability*
Box 2.11 summarises the absolute changes in probability for
the most used LRs. Findings with LRs greater than 3 or less than 0.1 −45%
0.3 are most helpful because these values identify findings that 0.2 −30%
either increase or decrease probability by 20–25% or more. 0.3 −25%
0.5 −15%
Can LRs Be Combined? 1 No change
LRs can be combined only if the two findings are independent of 2 +15%
one another (independence implies the LR for the first finding is 3 +20%

(1) Detecting pneumonia: In patients with acute respiratory 4 +25%

complaints, “percussion dullness” is found in 18% of patients 5 +30%
with pneumonia and in 6% of patients with another cause of
6 +35%
respiratory distress. Therefore,
7
8 +40%
for percussion dullness
LR = 18 = 3.0 9
in detecting pneumonia 6
10 +45%

(2) Detecting coronary artery disease: In patients with chronic *These changes describe absolute increases or decreases in probability.
chest pain, “dysphagia” is reported in 4% of patients found
From McGee (2002). J Gen Intern Med; 17: 646–9.
to have coronary disease and in 20% of patients with another
cause of chest pain. Therefore,

for dysphagia the same whether or not the second finding is present). For
LR in detecting coronary = 4 = 0.2
20 example, typical angina (an LR of 5.8) and hyperlipidaemia (an LR
artery disease
of 2.2) are likely to be independent because the accuracy of a history
Figure 2.2 Likelihood ratios: examples. From McGee (further resources). of typical angina is unlikely to be affected by the presence or
14 ABC of Clinical Reasoning

absence of hyperlipidaemia. To combine findings, the clinician can a 90% probability of ascites). On the other hand, if the clinician
simply multiply the two individual LRs (5.8 × 2.2); the resulting works in a community practice where only 20% of patients with
product (12.7 or a +50% probability) becomes the LR for combined abdominal distension have ascites (the other 80% have increased
‘typical angina and hyperlipidaemia’. Alternatively, the clinician abdominal fat or gas), the presence of the fluid wave is less conclu-
could first apply typical angina (LR of 5.8 or a +35% probability), sive (20% + 30% or a 50% probability of ascites). Proper application
then hyperlipidaemia (LR of 2.2 or a +15% probability) to obtain of evidence-based medicine here requires intimate knowledge of the
the increment in probability for the combined findings (35% + 15% types of diseases found in one’s own practice.
or a +50% probability).
Clinicians should not combine the LRs of more than two
The Future of the History and Physical
individual findings unless clinical studies have proven that the
Examination
findings are independent. If there is any possibility that the
individual findings are dependent on each other, their LRs should Increasingly, researchers are comparing clinical findings to diag-
not be combined (for example, typical angina and ‘duration of nostic standards to reveal LRs for a wide variety of clinical disor-
pain < 5 minutes’ should not be combined, because pain lasting ders. This is through diagnostic accuracy studies reported to the
less than 10 minutes after rest or nitro-glycerine is a criterion for STARD criteria [13]. These include:
stable typical angina). • Both the test (clinical symptom, sign, or laboratory test) and
diagnostic standard are clearly defined
The Limitations of LRs • All enrolled patients have symptoms suggestive of the diagnosis
Statistical calculations are appropriate only when the clinical problem under study
is defined by a diagnostic (or reference) standard, such as laboratory • Determination of the test result is blinded from determination
testing or clinical imaging (Figure 2.4). Examples, and their reference of the diagnostic standard
standards, are pneumonia (chest radiographs), ascites (ultrasonog- • The study presents enough information to allow calculation of
raphy), coronary artery disease (coronary angiography), anaemia LRs and their confidence intervals.
(full blood count), and hyperthyroidism (thyroid function tests). In Clinicians applying this approach can focus on findings with
each of these disorders, the evidence-based approach compares find- greatest diagnostic accuracy. Nonetheless, this does have limita-
ings from the history or examination to the accepted reference stan- tions. Even when a problem has been studied, conclusions often
dard and identifies the findings most accurately predicting the results rest on relatively few patients. Whether diagnostic accuracy
of that standard. Since many clinical problems lack reference stan- depends on clinical technique is largely unaddressed, although
dards, evidence-based reasoning using LRs is not always applicable. the few studies on this subject show diagnostic accuracy with stu-
For these problems, empiric observation based on the clinician’s dents as observers is the same as with specialists, provided the
prior knowledge and experience of similar patients – what the clini- finding is well-defined. Finally, most literature on the subject
cian sees, feels, and hears at the bedside – remains the sole diagnostic focusses on individual findings, although it is well known that
standard and LRs cannot be used. expert clinicians typically combine many findings simultaneously
Although LRs describe how the probability changes, they cannot when diagnosing disease.
determine the pre-test probability of a disease. For example, the LR for Point of care ultrasound is increasingly being used in acute care
the physical finding ‘fluid wave’ in detecting ascites in patients with settings as an extension of the physical examination (e.g., to
abdominal distension is 5.0 (a +30% probability). If the clinician estimate volume status, or differentiate fluid from consolidation in
works in a hepatology practice in which 60% of all patients with the lungs). However, the same caveats for all diagnostic tests apply
abdominal distension have ascites (that is a pre-test probability of (see Chapter 3) – the history and physical examination remains
60%) the finding of a fluid wave is diagnostic (that is 60% + 30% or fundamental in establishing the clinical probability of disease and
ultrasound ‘findings’ need to be interpreted in light of this. Point of
care ultrasound has several limitations and should be seen as a
WHAT IS THE decision aid pending more definitive investigations.
DIAGNOSTIC STANDARD?

Developing Skills in Teaching

Clinical imaging or laboratory Empiric observation It is challenging for busy clinicians to be experts in clinical com-
Pneumonia Cellulitis
munication and in teaching evidence-based history and physical
Ascites Parkinson disease examination. This has contributed to a decline in bedside teaching
Coronary artery disease Trochanteric bursitis since the 1960s. It is however both a patient and student-centred
Anemia Pericarditis
Hyperthyroidism Serotonin syndrome activity. The scope for evidence-based history and examination is
exciting, with potential to improve patient safety. Role-modelling
of reflective practice by bedside teachers can assist learners in
Evidence-based reasoning Evidence-based reasoning developing resilience and dealing with the uncertainty of clinical
can be used does not apply
practice. Careful planning and engagement with patients can help
Figure 2.4 Can evidence-based reasoning be used? develop clinical teachers. Box 2.12 lists some tips for teaching
 Evidence-based History and Examination 15

tion, including this revision.Thanks also to Lucille Middleton,

Box 2.12 Tips for teaching evidence-based physical
examination Graduate Entry Medicine student at the University of Nottingham,
UK, for contributing Box 2.1 to this chapter.
• Practice teaching concepts of diagnostic accuracy
• Practice estimating the pre-test probability of disease
• Practice teaching methods to estimate post-test probabilities References
• Know where to find evidence-based physical examination data
1. Hampton JR, Harrison MJ, Mitchell JR et al. (1975). Relative contribu-
and prepare to use it
tions of history-taking, physical examination, and laboratory investiga-
• Prepare an answer to the question, ‘Can the likelihood ratios of
tion to diagnosis and management of medical outpatients. British Medical
multiple findings be combined?’
Journal; 31; 2(5969): 486–489.
• Answer the common question, ‘Why should we examine patients
2. Silverman J, Kurtz SM and Draper J. Skills for communicating with
if it is so unhelpful?’
patients, 3rd Ed. CRC Press, 2013.
• Teach the basics of evidence-based physical examination and
prepare students for bedside teaching 3. Silverman J. The consultation. In: Cooper N and Frain J (Eds). ABC of
• Orientate the patient to the purpose of the teaching and explicitly Clinical Communication. Wiley-Blackwell, 2018.
discuss evidence-based physical examination 4. Frain J and Abdalla M. Teaching clinical communication. In: Cooper N
• Encourage students to commit to their own description of and Frain J (Eds). ABC of Clinical Communication. Wiley-Blackwell,
findings 2018.
• Encourage students to commit to a next step in management 5. Kilian A, Upton LA and Sheagren JN. (2020). Reorganizing the history of
• Facilitate deliberate practice and give feedback to learn evidence- present illness to improve verbal case presenting and clinical diagnostic
based physical examination reasoning skills of medical students: the all-inclusive history of present
• Acknowledge uncertainty and follow up on unresolved issues illness. Journal of Medical Education and Curricular Development; 7:
2382120520928996.
Adapted from Mookherjee S, Hunt S, Chou CL. (2015). Twelve tips
6. Swap CJ and Nagurney JT. (2005). Value and limitations of chest pain
for teaching evidence-based physical examination. Medical Teacher;
37(6): 543–550. history in the evaluation of patients with suspected acute coronary syn-
dromes. JAMA; 294(20): 2623–2629.
7. Elieson SW and Papa FJ. (1994). The effect of various knowledge formats
on diagnostic performance. Academic Medicine; 69(10 Suppl): S81–S83.
evidence-based physical examination. Seeing variations in dem- 8. Thomas KE, Hasbun R, Jekel J and Quagliarello VJ. (2002). The diagnostic
onstration of the physical examination is a source of discomfort accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults
for students, particularly around assessment. Reasons for varia- with suspected meningitis. Clinical Infectious Diseases; 35(1): 46–52.
tion in technique should be discussed with learners to help them 9. Yusuf S, Hawken S, Ounpuu S et al. (2004). Effect of potentially modifi-
manage their uncertainty and to apply these critical skills. able risk factors associated with myocardial infarction in 52 countries
(the INTERHEART study): case-control study. Lancet; 364: 937–952.
Summary 10. Paley L, Zornitzki T, Cohen J et al. (2011). Utility of clinical examination
in the diagnosis of emergency department patients admitted to the
Practicing evidence-based history and examination is challenging department of medicine of an academic hospital. Archives of Internal
but rewarding. Since the history and examination is so critical to Medicine; 171(15): 1393–1400.
the patient’s care, a robust evidence base is essential, and merits 11. Verghese A, Charlton B, Kassirer J et al. (2015). Inadequacies of physical
increased research. An initial step for learners is establishing the examination as a cause of medical errors and adverse events: a collection
importance of the history and examination not only for initial of vignettes. The American Journal of Medicine; 128(12): 1322–1324.
formulation of the patient’s problem list and differential diag- 12. Holboe ES. (2004). Faculty and the observation of trainees’ clinical skills:
nosis, but the correct interpretation of any subsequent investiga- problems and opportunities. Academic Medicine; 79: 16–22.
tions. Clinical teachers should be supported in developing their 13. Cohen JF, Korevaar DA, Altman DG et al. (2015). STARD guidelines for
own confidence and skills in teaching evidence-based history and reporting diagnostic accuracy studies: explanation and elaboration. BMJ
examination. Open; 6: e012799. doi:10.1136/bmjopen-2016-012799.

Acknowledgements Further Resources

1. McGee S. Evidence-based physical diagnosis, 5th Ed. Elsevier/Saunders,
Thanks are due to my co-author of the first edition of this chapter,
2021.
Steven McGee, Emeritus Professor of Medicine, University of
2. Talley N and O’Connor S. Clinical examination, 9th Ed. Elsevier, 2021.
Washington, Seattle, USA, whose work and contribution to evi-
dence-based history and examination continues to be an inspira-
 CHAPTER 3

Choosing and Interpreting

Diagnostic Tests
Nicola Cooper

OVERVIEW Box 1.1 Tests are affected by a number of factors

• Test results are affected by a number of factors which the clinician
Factor Explanation
has to take into account
How ‘normal’ is • ‘Normal’ can refer to values within the
• There is no such thing as a perfect test
defined reference range for the population to which
• The interpretation of new information depends on what you the patient belongs
believed beforehand, based on your assessment of the patient • It can also refer to a value below or above a
• Predictive values combine information about sensitivity, specificity, pre-determined cut-off point designed to
maximise true positives and minimise false
and prevalence and indicate how likely a test result is to be correct
positives
• Thresholds provide a useful way of thinking about whether a test • It can also be an ‘abnormal’ result that is
should be performed at all actually normal for the particular context in
question
Factors other than • These are biological and/or laboratory factors
disease that influence that make test results ‘abnormal’ when they
Introduction test results are not, or vary when there has not been a
true change
The history and physical examination provide a differential diag-
nosis and/or problem list. This is refined further using diagnostic Operating • This refers to the method of performing the
characteristics test itself which, if not optimal, can affect its
tests. The appropriate selection of tests depends of the quality of
accuracy
the history and physical examination. Test results then have to be
Sensitivity and • The sensitivity of a test refers to its ability to
interpreted in light of the patient’s history and examination find-
specificity correctly identify patients with the disease
ings because test results are affected by a number of factors (see (see Box 3.3) • The specificity of a test refers to its ability to
Box 1.1): correctly identify patients without the
• How ‘normal’ is defined disease
• Factors other than disease that influence test results • Sensitivity and specificity are characteristics
• Operating characteristics relating to the accuracy of a test relative to a
reference standard
• Sensitivity and specificity
• Prevalence of disease in a population Prevalence of disease • The prevalence of disease in a population
in a population can significantly alter the predictive value of
Unfortunately, commonly used measures of test accuracy, such as (see Box 3.5) a test
sensitivity and specificity, are poorly understood. A systematic • The positive predictive value is the
review of 24 studies found that most qualified healthcare profes- proportion of people with a positive test
sionals were poor at providing definitions of sensitivity and spec- result who truly have the disease
ificity, and were poor at estimating the post-test probability of • The negative predictive is the proportion of
people with a negative test result who do
disease [1]. This chapter aims to introduce key concepts and pro- not have the disease
vide further resources for this important area of clinical reasoning.

ABC of Clinical Reasoning, Second Edition. Edited by Nicola Cooper and John Frain.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
18 ABC of Clinical Reasoning

How Normal Is Defined Factors Other than Disease Which

Influence Test Results
Many diagnostic test results are expressed as continuous variables
on a numerical scale and many quantitative measurements in There are a number of factors other than disease which influence
human populations have a Gaussian (normal) distribution. The test results. They include:
‘normal’ range is defined as those values that encompass 95% of • Age
the healthy population, or two standard deviations from the mean. • Sex
This means that 2.5% of the healthy population will have values • Ethnicity
above, and 2.5% of the population will have values below, the • Pregnancy
normal range. For this reason, it is more appropriate to use the • Body position
term ‘reference range’ (see Figure 3.1). Diagnostic test results in • Chance
people with a disease also have a Gaussian distribution but with a • Spurious (in vitro) results
different mean and reference range. In some diseases there is no • Lab error
overlap between results from the abnormal and normal population, • Critical difference values
but in some diseases there is. In the latter, the greater the difference For example, normal values for paediatric blood results can be sig-
between the result and the reference range of the normal nificantly different to those of adults. Old people often have a
population, the higher the chance that the person has the disease. normal white cell count in the presence of infection, and can have a
Arbitrarily dividing a range of values into ‘normal’ and significantly reduced glomerular filtration rate with a normal creat-
‘abnormal’ has disadvantages – it does not take into account the inine. Men have slightly different reference ranges to women (e.g.,
magnitude of the result. For example, a highly sensitive troponin for haemoglobin) and healthy black adults may have an ‘abnormal’
T result in a patient with chest pain is more likely to indicate myo- 12-lead electrocardiogram (due to early repolarisation) that can
cardial injury when the value is very high, as opposed to slightly resemble serious disease, but is in fact a ‘normal variant’ [2].
raised. Some test results have a binary classification (‘normal’ vs Pregnancy significantly alters many test results due to the
‘abnormal’), for example, an exercise electrocardiogram (ECG) physiological changes that occur, particularly in the third tri-
looking for signs of ischaemic heart disease. However, in deciding mester. A large foetus splints the diaphragm and compresses the
where the cut-off point between ‘normal’ and ‘abnormal’ should lungs causing supine hypoxaemia as well as a respiratory alkalosis
be, there is a trade-off between sensitivity (true positives) and (important facts to remember when considering the possibility of
specificity (true negatives). The optimum cut-off point is calcu- pulmonary embolism in a pregnant woman). Circulating volume
lated using receiver operating characteristic (ROC) analysis, increases by 50% in late pregnancy causing a flow murmur, tachy-
which is described in more detail later. cardia, and a rightward axis on the 12-lead electrocardiogram.
In medicine there are some situations when a normal result is Kidneys also swell as a result, and renal ultrasound shows increased
abnormal, and an abnormal result is normal. For example in a size and dilatation.
clinically severe asthma attack when one expects the PaCO2 to be Body position is important in some tests, for example, lung
low, a normal PaCO2 on an arterial blood gas is not normal at all function and tests where the patient has to lie in a certain position
and indicates life-threatening asthma. On the other hand, a raised to get optimal images. Finally, a test result may be abnormal by
d-dimer is normal in pregnancy. So what is ‘normal’ and chance (e.g., the patient is an outlier on the normal curve); the
‘abnormal’ has to be interpreted in light of the clinical picture. result may be spurious (e.g., hyperkalaemia caused by haemolysis
Clinicians who use diagnostic tests should have a good working or some haematological conditions); or may be due to lab error
knowledge of the tests they use in their everyday practice, and (e.g., as a result of a technical or human error). It is always worth
how they should be interpreted in light of the patient’s history and pausing before acting when a very unexpected test result crops up.
examination findings. Lab results also vary in the same person at different times. The criti-
cal difference, also known as the reference change value, is the smallest
difference between sequential laboratory results in the same patient
Number of people

which is likely to indicate a true change. Let’s imagine a person has

their cholesterol measured every single day. The result will not be
Normal population
identical every time. The reason for this is natural biological var-
iation but also lab variation. The combination of the two is the
critical difference – the amount by which the test can vary before
it can be considered a true change. This is calculated using
knowledge of normal intra-individual variation and lab variation
Reference range
for different tests. The critical difference is different for different
lab tests. Some calculated critical difference values for common
–3 –2 –1 1 2 3 biochemistry results are shown in Box 3.2. For a person having
Mean Test Result their serum cholesterol monitored, the critical difference is 17%.
(standard deviations from the mean)
An initial value of 5.2 mmol/L can therefore vary between
Figure 3.1 Normal distribution. 4.3 mmol/L and 6.1 mmol/L without being a true change.
 Choosing and Interpreting Diagnostic Tests 19

Box 3.2 Calculated critical difference (CD) for some common Box 3.3 Sensitivity and specificity
biochemistry results
Disease No disease
Test CD as %
Positive test A B
Albumin 11.2
(True positive) (False positive)
Alkaline phosphatase 37.1
Negative test C D
Aspartate aminotransferase (AST) 27.7 (False negative) (True negative)
Bilirubin 47.5
The sensitivity of a test refers to its ability to correctly identify
Calcium 6.1 patients with the disease, i.e. A/(A + C) × 100.
Cholesterol 17.0 The specificity of a test refers to its ability to correctly identify
Glucose 9.9 patients without the disease, i.e. D/(D + B) × 100.

Total protein 11.2

TSH 63.0
a high sensitivity, for example 95%, will miss 5% of people with
the disease. Unfortunately, there is no such thing as a perfect test.
Urea 28.9
Test results consist of ‘true positives’ and ‘false positives’; ‘true
Uric acid 25.2 negatives’ and ‘false negatives’. Box 3.3 illustrates this. Tests differ
Data from Professor Trefor Higgins, Department of Laboratory Medicine
in their sensitivity and specificity for detecting certain diseases, so
and Pathology, University of Alberta. clinicians need to have a sound working knowledge of the accu-
racy of the tests they use on a day-to-day basis.
A very sensitive test will detect most disease but generate
Operating Characteristics abnormal findings in healthy people. We see this with the aptly
named high sensitivity troponin T. On the other hand, a very
Before ordering a test, it is important to be aware of certain
specific test may miss significant disease but is likely to establish
operating characteristics of the test. This refers to the method of
the diagnosis beyond doubt when the result is positive. You may
actually performing the test itself. For example, measuring lung
have heard of the acronyms ‘SNOUT’ and ‘SPIN’. SNOUT stands
function requires that the patient be able to hear, understand, and
for ‘sensitive test when negative rules out the disease’ and SPIN
co-operate with instructions, as well as hold their breath. Exercise
stands for ‘specific test when positive rules in the disease’.
electrocardiograms require patients to be able to walk briskly and
However, SNOUT and SPIN are misleading. This is because the
cannot be accurately interpreted in people who have left bundle
diagnostic power of any test is determined by both its sensitivity
branch block.
and specificity, as well as the prevalence of disease in the
Some tests are highly operator dependent – in other words, the
population – more of that later. The trade-off between sensitivity
skill of the operator influences the results and the report provided.
and specificity is explored in what is termed a ‘ROC analysis’.
Ultrasound is the best example of this, as dynamic images have to be
skilfully interpreted by the sonographer. For radiology investiga- ROC Analysis
tions in general, the interpretation of results can be highly influ- ROC stands for ‘receiver operating characteristic’ – so called
enced by the patient’s body habitus or clinical state. In ultrasound, because it was developed by radar engineers during World War II
for example, morbid obesity can make getting good views difficult, for discriminating enemy objects in the battlefield. It is also known
and in people of all sizes, intra-abdominal organs can be obscured as the ‘relative operating characteristic’ because it compares two
by bowel gas. In computed tomography, images can be severely operating characteristics (true positive results and false positive
degraded by movement artefact, or interpretation can be affected by results) at various settings (see Figure 3.2). It is used in medicine to
whether or not contrast was used, and whether it circulated as antic- select the best cut-off point for a test in a way that maximises true
ipated to get optimal images. If a report says, ‘Limited views due to positives while minimising false positives. ROC analysis is con-
… but within these limitations, no abnormality detected’ consider ducted in a research setting whenever investigators measure the
whether it is in fact a non-diagnostic scan, rather than a ‘normal’ ability of a test to detect a diagnosis in a population with the dis-
scan. It is also important that radiologists, as well as other clinicians ease and exclude the diagnosis in those without it. (Of course, the
such as physiologists, are provided with a clear clinical question and results of the analysis also depend on what study population was
key information in the history, past medical/surgical history, and used – if the same performance is expected in practice, the test
physical examination. This is so that ‘abnormalities’ or incidental must be used in a similar population). For example, if we define an
findings can be interpreted in light of the clinical context. exercise electrocardiogram as ‘abnormal’ when there is at least 0.5
mm of ST depression, we could pick up every case of ischaemic
heart disease but generate many false positives. On the other hand,
Sensitivity and Specificity
if we define an exercise electrocardiogram as ‘abnormal’ when
The sensitivity of a test refers to its ability to correctly identify there is at least 2 mm of ST depression, we could detect most cases
patients with the disease. The specificity of a test refers to its ability of clinically important ischaemic heart disease but with far fewer
to correctly identify patients without the disease. Even a test with false positives, which is far more practical.
20 ABC of Clinical Reasoning

1.0 1.00
Perfect test

Good test
+test
0.75

Posterior Probability
True positive rate

Positive
Moderate test shift

0.5 0.50
Test with no value

Negative
shift
0.25
–test

0 0.5 1.0 0
0 0.25 0.50 0.75 1.00
False positive rate
Prior Probability
Figure 3.2 Receiver operating characteristic (ROC) curve. The curve is
generated by adjusting the cut-off values defining ‘normal’ and ‘abnormal’, Figure 3.3 How a test results shift our thinking using Bayes’ Theorem. The
calculating the effect on sensitivity and specificity, and then plotting these sensitivity of a troponin test is 95% and the specificity is 80%. If we imagine
against each other. The closer the curve gets to the top left-hand corner, the a patient with chest pain and our pre-test or prior probability is 50% (i.e.,
more useful the test is. The dotted line represents a test with no discriminant we are sitting on the fence) a positive or a negative result would significantly
value. shift our thinking about whether the patient is having a heart attack. But if
our prior probability was very low (e.g., 10%) a negative test result would
shift our thinking by very little and a positive test result would not by itself
be conclusive (dotted line). Bayes’ Theorem is a method for interpreting
Conditional Probability
evidence in the context of previous knowledge. It has wide applications and
Conditional probability is the probability that something is true constitutes a mathematical foundation for reasoning. In clinical practice,
given that something else is true. Bayes’ Theorem (named after doctors do not use algebra to work out pre- and post-test probabilities,
English clergyman Thomas Bayes 1702–61) is a mathematical however an understanding of the principles of Bayesian reasoning is
way to describe this. It estimates the post-test probability using important because the ability to accurately estimate probability is important
in clinical reasoning. Bayes’ Theorem:
information about pre-test probability and the sensitivity and
P R  / Dis   P Dis 
specificity of the test. P Dis / R   
P R  / Dis   P Dis   P R  / noDis   P no Dis 
Figure 3.3 illustrates Bayes’ Theorem and more detailed explana-
where P[Dis/R+] is the chance of having the disease given a positive test
tions can be found in the further resources. ‘Bayesian reasoning’ is result; and P is probability, Dis is disease, and R+ is a positive test result.
the term sometimes used for clinical reasoning using probabilities. Figure from Brush JE. Probability: Uncertainty Quantified. In: The Science of
Test results shift our thinking, but sometimes by not very the Art of Medicine, 2015. Reproduced with permission of Dementi
much. The probability that someone actually has a disease Milestone Publishing.
depends on the clinical (pre-test) probability, a judgement based
on the patient’s background, history and examination findings,
and the sensitivity and specificity of the test. Imagine an elderly
woman has been brought to the emergency department after
falling and hurting her left hip. On examination, the left hip is
extremely painful to move and she cannot weight bear. Both
antero-posterior and lateral X-rays of the left hip are normal (see
Figure 3.4). Is there a fracture? Sox and colleagues (see further
resources) state a fundamental assertion, which they describe as a
profound and subtle principle of clinical medicine: the interpreta-
tion of new information depends on what you believed beforehand.
As a simple rule of thumb, in a high clinical probability patient, a
normal test result does not necessarily exclude the disease, but in
a low clinical probability patient, a normal test result does exclude
the disease. Let’s go back to our elderly woman who has fallen.
The sensitivity of plan X-rays of the hip performed in the
emergency department for suspected hip fracture is 95%. That
means 5% of fractures (or 1 in 20) are missed. In an elderly
woman, likely to have osteoporosis, whose left hip is extremely
painful to move and she cannot weight bear, a normal X-ray does Figure 3.4 Is there a fracture?
 Choosing and Interpreting Diagnostic Tests 21

not necessarily exclude a fracture. But if the examination of the

hip was normal and she could walk easily, a normal X-ray would Box 3.4 What is the chance a person found to have a positive
result actually has the disease?
be enough to satisfy the clinician that there is probably no frac-
ture. The same test result is interpreted completely differently Many doctors give an answer of 95%, but the actual answer is
when the clinical (pre-test) probability changes. illustrated in the table below:
The example above illustrates that when the clinical probability Disease No disease Total
and the test result are discordant, we may need to think more care-
Actual 1 999 1000
fully. For example, CT pulmonary angiography (CTPA) in the
diagnosis of pulmonary embolism (PE) has a specificity of 98% Positive test 1 50 51

and a sensitivity of 94%. When patients with an intermediate or Negative test 0 949 949
high clinical probability of PE have a positive CTPA, the result can
If we sent 1000 tests to the lab, we would get 51 positive results – 1
be trusted. Likewise, when patients with a low clinical probability
true positive and 50 false positives. This chance of having a positive
of PE have a negative CTPA, the result can also be trusted. But
result and actually having the disease is 1 out of 51 – or 2%. This
what if a high clinical probability patient has a negative CTPA, or example illustrates the importance of understanding prevalence.
a low clinical probability patient has a positive CTPA – what then?
One study found that around 40% of CTPA results were false in
these situations [3]. This is why further imaging (e.g., V/QSPECT)
may be indicated in high clinical probability patients. It is also why
Box 3.5 Predictive values
formal clinical probability assessment, D-dimer testing, and CTPA
which includes imaging of the lower limbs is used in combination
Disease No disease
before safely withholding anticoagulation in patients being inves-
tigated for possible PE. There are many other examples in medi- Positive test A B
(True positive) (False positive)
cine where clinical probability really matters in accurately, and
safely, interpreting a diagnostic test result. Negative test C D
(False negative) (True negative)
The lesson from these examples is that tests, even good tests,
can be wrong. The positive predictive value – ‘What is the chance that a person
Tests give us test probabilities, not real probabilities. Tests have with a positive test truly has the disease?’ – is A/(A + B) × 100.
to be interpreted in light of the clinical probability and estimating The negative predictive value – ‘What is the chance that a person
clinical probability requires knowledge – formal and experiential with a negative test does not have the disease?’ – is D/(D + C) × 100.
knowledge of basic science, epidemiology, clinical skills, and Positive and negative predictive values are influenced by the
clinical medicine. prevalence of the disease in the population being tested. Using a
test in a population with higher prevalence increases positive
predictive value (and decreases negative predictive value).
Prevalence of Disease in a Population
Now let’s get more complicated! Consider this problem that was
given to a group of Harvard doctors: if a test to detect a disease John Brush, in his book The Science of the Art of Medicine (see
whose prevalence if 1:1000 has a false positive rate of 5%, what is further resources) uses this next example to illustrate. We know
the chance that a person found to have a positive result actually from angiography results and post-mortem studies the actual
has the disease, assuming you know nothing about the person’s prevalence of coronary artery disease in different patient groups.
symptoms or signs? (Assume no false negatives.) Just under half Young women with non-cardiac sounding chest pain have a low
replied with the answer 95%. Now look at Box 3.4 for the answer. prevalence of ischaemic heart disease (1%). On the other hand,
Sensitivity and specificity are characteristics relating to the older men with typical symptoms of angina have a high preva-
accuracy of a test relative to a reference standard. They are an lence ischaemic heart disease (94%). If we sent a patient from
assessment of the test. But as a clinicians we are interested in the each of these groups for an imaging stress test, which has a sensi-
question, ‘What are the chances that a person with a positive tivity of 90% and a specificity of 85%, and both tests came back
result actually has the disease?’ In other words, we want to assess positive, how would we interpret the results? In other words, what
people. Predictive values do just that – by combining sensitivity, is the positive predictive value of the test in these two different
specificity, and prevalence of the disease in a population to answer scenarios? Aside from the fact that we should consider whether to
this question (see Box 3.5). Just considering test accuracy can be request this test at all in patients with such extreme pre-test prob-
misleading when the number of ‘positives’ and ‘negatives’ in dif- abilities, Box 3.6 shows the results we would get if we tested 100
ferent groups varies greatly. patients just like each of them.
In predictive analytics, a confusion matrix (yes, it’s real name) This example demonstrates the flaws in believing that a positive
is a 2 × 2 table that reports the number of true positives, false pos- result on a highly sensitive test indicates the presence of a condition
itives, true negatives, and false negatives using information about and that a negative result on a highly specific test indicates the
the prevalence of disease in the population. This allows more absence of a condition. Prevalence matters. In deciding the clinical
detailed analysis than simply observing the proportion of correct (pre-test) probability of disease, novices tend to focus on the patient’s
classifications (or test accuracy). history and physical examination findings. A more accurate way of
22 ABC of Clinical Reasoning

Box 3.6 Confusion matrix showing results of an imaging Box 3.7 Estimating clinical (pre-test) probability
stress test in a) a 35-year-old woman with non-cardiac
sounding chest pain and b) a 65-year-old man with typical A 30-year-old woman complained of a constant, dull left-sided
symptoms of angina headache. On examination she was tender over her left temple. A
junior doctor remembered learning about temporal arteritis and
a) requested an erythrocyte sedimentation rate (ESR), a test for
temporal arteritis. The result was abnormal. The junior doctor
IHD No IHD
diagnosed temporal arteritis and started steroids.
Actual/total 1 99 The problem with this story is that temporal arteritis almost
Positive test 0.9 14.9 exclusively affects people aged 50 years or more. So even with this
True positive (sensitivity, history, the pre-test probability of temporal arteritis is close to zero
or 90% of 1) in this patient, which affects the predictive value of the test, and
Negative test 0.1 84.1 thus the interpretation of the result.
True negative (specificity,
or 85% of 99)

Positive predictive value = 0.9 / (0.9 + 14.9) × 100 = 5.7% low risk then one would have a lower threshold for going ahead.
On the other hand, if a test or treatment is less effective or high
b) risk, one requires greater confidence in the diagnosis and poten-
tial benefits of treatment first.
IHD No IHD
Actual/total 94 6
Positive test 84.6 0.9
Summary
True positive (sensitivity, Tests do not make a diagnosis, clinicians do. Tests give us test
or 90% of 94)
probabilities not real probabilities. A working knowledge of factors
Negative test 9.4 5.1 other than disease that influence test results, operating character-
True negative
(specificity, or 85% of 6)
istics, and how accurate the test is for the disease in question is
important. Assessing clinical (pre-test) probability is vital, without
Positive predictive value = 84.6 / (84.6 + 0.9) × 100 = 99% this you cannot interpret any test result. Pre-test probability is
An imaging stress test has a sensitivity of 90% and a specificity of
derived from knowledge of the prevalence of the disease in the
85%. Although both patients had some kind of chest pain and both group to which the patient belongs and information from the indi-
were sent for the same test, how we interpret a positive result is vidual’s history and physical examination findings. Positive pre-
completely different for each one because the prevalence of disease dictive values and negative predictive values are the proportion of
in the group to which the patient belongs is so different (see Box people with a positive (or negative) test result who have (or do not
3.5 for predictive values). have) a disease. They can be thought of as the post-test probability
of a disease. Finally, thresholds provide a useful way of thinking
about whether a test should be performed at all.
estimating pre-test probability is to first ask yourself, ‘Who is my
patient?’ – in other words, the prevalence of disease in the group to References
which the patient belongs – then add in information from the his-
tory and physical examination findings to come up with an estimate 1. Whiting PF, Davenport C, Jameson C et al. (2015). How well do health pro-
of pre-test probability: low, intermediate, or high. Then use this fessionals interpret diagnostic information? A systematic review. BMJ
Open; 5: e008155 (accessed April 2022).
estimate to choose and interpret diagnostic tests. See Box 3.7 for an
2. Walsh B, Macfarlane PW, Prutkin JM and Smith SW. (2019). Distinctive
example that illustrates this.
ECG patterns in healthy black adults. Journal of Electrocardiology; 56:
15–23.
Thresholds 3. Stein PD, Fowler SE, Goodman LR et al. (2006). Multidetector computed
tomography for acute pulmonary embolism. The New England Journal of
An important consideration in the diagnostic process is whether
Medicine; 354: 2317–2327.
to do a test at all. If a test will make no difference to the probability
or outcome of a disease, should the test be done? Tests (when they
are selected rationally, that is) are most helpful when they change Further Resources
the management of a patient’s condition. 1. Sox HC, Higgins MC and Owens DK. Medical decision making, 2nd Ed.
It is also not necessary to know the true state of the patient Oxford: Wiley-Blackwell, 2013.
before deciding whether to act. The therapeutic threshold com- 2. Brush JE. The Science of the Art of Medicine. Dementi Milestone Publishing,
bines factors such as test characteristics, risks of the test, the risks 2015.
and benefits of treatment, as well as the potential penalty for 3. Stone JV. Bayes’ Rule. A tutorial introduction to Bayesian analysis. Sebtel
being wrong. The point at which the factors are all evenly weighed Press, 2013.
is the threshold. If a test or treatment for a disease is effective and
 CHAPTER 4

Problem Identification and Management

Nicola Cooper and John Frain

moving to a new town is ill-defined. Ill-defined problems can

OVERVIEW
have more than one ‘correct’ solution and require different skills
• Clinical reasoning involves problem recognition, definition, and
to solve them. Most problems in medicine are ill-defined.
representation
Recognising there is a problem in the first place is the first step
• The use of specific language helps clinicians match the patient’s in problem-solving. Problems can be presented (as in case his-
own words and data with illness scripts in long-term memory tories on paper) or discovered (as when a problem is teased out
• Sometimes problem representation is not possible, in which case through a careful history). The problem then has to be defined
a problem list can be used and represented before it can be solved. Problem representation
• It is still possible to act safely and confidently when dealing with refers to how the problem is mentally organised before attempting
uncertainty to solve it. In psychology, this consists of a description of the
• Teachers have an essential function in role-modelling how to deal problem, a description of the goal, a set of allowable operators,
with uncertainty and a set of constraints [1]. These are held in memory while we
• Management reasoning differs significantly from diagnostic try to solve the problem. Problem representations can be created
reasoning in several ways using abstractions (a summary of the problem’s essential charac-
teristics using words), images, diagrams, or equations [2]. The
important thing to note is that the representation of a problem
affects the solution.
Introduction
Clinical reasoning is a complex cognitive process involving
clinical skills, memory, problem-solving, and decision-making.
In this chapter, we focus on problem-solving, what psychologists
have learned about it, and the factors that contribute to its success Evaluate Recognise
Problem
or failure. solution problem
identification

The Problem-solving Cycle

Psychologists have described problem-solving in terms of a cycle, Monitor Define and represent
progress problem
illustrated in Figure 4.1. Not all problem-solving proceeds
sequentially through all stages in this particular order. However,
once the relevant steps are completed, they usually give rise to a
new problem and then the steps need to be repeated. We have
used the term ‘problem identification’ to refer to the first two Allocate
Develop solution
steps which involve problem recognition, definition, and mental/physical
strategy
resources
representation. Organise one‘s
There are two classes of problems: those that are well-defined knowledge
about problem
and those that are ill-defined. A simple maths problem is well-­
defined. How to decide which house to buy, or rent, after Figure 4.1 The problem-solving cycle. Adapted from Pretz et al., 2003.

ABC of Clinical Reasoning, Second Edition. Edited by Nicola Cooper and John Frain.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
24 ABC of Clinical Reasoning

Problem Representation in Medicine Box 4.3 illustrates an example of how language matters in problem
representation.
In medicine, the problem representation is a key step in clinical Generating an accurate problem representation is something
reasoning. It usually consists of an abstraction in one or two sen- that is neglected in ‘history–examination–differential diagnosis’
tences. Sometimes it is referred to as the ‘impression’ (i.e., what teaching methods, but problem representation really matters.
we think is going on). In the problem representation, clinical Studies show the main difference in the discourse of ‘strong’ as
findings are transformed into abstractions using ‘semantic quali- opposed to ‘weak’ diagnosticians is their semantic competence,
fiers’. These are abstract binary descriptors such as acute/chronic, that is their use of language to organise their thinking [5]. This
unilateral/bilateral etc. (see Box 4.1). An example of a problem becomes especially important when the case is complex. For
representation would be, ‘A 60-year-old man with acute, recur- example, an elaborated, encapsulated structure, as described
rent attacks of severe left knee pain.’ As this example illustrates, above, is associated with 75–80% accuracy in resolving complex
the problem representation is not the same as the presenting com- problems as opposed to near zero resolution for ‘dispersed’ dis-
plaint, and it is not a summary of the history and examination courses. Importantly, learners can be taught to solve a problem by
findings either. It is an encapsulation of the key features of the case defining and representing it first before blindly generating a series
using very precise medical language. Patients do not come in of diagnostic impressions [6].
talking this way – clinicians have to transform their findings into An example of a problem representation in need of improve-
more abstract terms in order to define the type of problem or rep- ment is ‘A 50-year-old man with chest pain and breathlessness.’
resent the problem overall (in this example, an episodic mono- This is not precise enough and automatically takes one’s mind to
arthritis as opposed to a chronic poly-arthritis – this distinction is thinking about cardiac causes. An example of a good problem rep-
important when thinking about potential diagnoses) [2]. resentation (in this case) is ‘A 50-year-old man, 4 weeks post-op
Why does the precise language described above matter? knee replacement, with acute left-sided pleuritic chest pain and
Language and memory have historically been studied apart as
unique cognitive abilities and with distinct research traditions
and methods. Over the past several decades, however, a growing Box 4.2 Problem representation, or lack thereof, affects the
solution
body of evidence suggests that language and memory are heavily
intertwined and may even rely on shared cognitive and neural A final-year medical student working in general practice and had
mechanisms [3]. The development and refinement of a problem just seen an 18-year-old man with a two-day history of nausea,
representation is a critical step that allows clinicians to match the fever, and abdominal pain. He had no past medical history, no
patient’s words and data with illness scripts (i.e., organised mental urinary symptoms, and had not opened his bowels for two days. He
summaries of different diseases) in their long-term memory and had vomited once. On examination, the patient was tender in the
right iliac fossa with no other abnormal findings.
thus start going about solving the problem [4]. Successful diag-
The student gave a good description of the patient’s symptoms
nosticians, whether students or specialists, elaborate using
and signs to her supervisor. When asked what she thought the
semantic qualifiers more than unsuccessful ones when represent-
diagnosis could be, the student thought for a moment and then
ing problems. They are also able to encapsulate a set of symptoms said, ‘Constipation.’ The supervisor was surprised. Together, they
and signs into clinical syndromes whenever possible [5]. For worked to represent the problem and came up with: ‘An 18-year-
example, a confusing array of neurological symptoms becomes, ‘A old man with a 2-day history of nausea and vomiting, fever, and
3-day history of progressive, bilateral cerebellar symptoms.’ right lower quadrant tenderness.’ Immediately the student thought
Symptoms such as polyuria and polydipsia are not seen as sepa- of appendicitis, which was the correct diagnosis.
rate symptoms, but as a clinical syndrome. This immediately
helps to narrow down potential diagnoses and therefore what
tests may be required. Box 4.2 illustrates an example of how Box 4.3 Language and problem representation
problem representation, or lack thereof, affects the solution, and A final-year medical student had just ‘clerked’ an elderly woman
who had been admitted to hospital because of confusion. The
student had spoken to the patient’s husband to get a good
Box 4.1 Examples of semantic qualifiers description of what had been happening at home. After obtaining a
history, examining the patient, and looking at the initial test results,
• Acute/chronic
he summed up her problems as:
• Unilateral/bilateral
• Mono/poly 1. Acute confusion
• Progressive/intermittent 2. Raised creatinine
• Sharp/dull However, the student was unable to formulate a plan for each of
• Proximal/distal these problems and was unsure about what to do next. He was
• Sudden/gradual encouraged to re-define the problems using more precise medical
• Single/recurrent language. He was able to re-define them as:
• Productive/non-productive
1. Delirium
• Severe/mild
2. Acute kidney injury
Semantic qualifiers are paired, opposing descriptors that can be Following this, he was immediately able to retrieve information from
used to compare and contrast diagnostic considerations. memory to formulate a management plan for the patient.
 Problem Identification and Management 25

Relevant past
history Abstraction* of ANGINA
Age + gender (includes medical, symptoms, signs,
social, family, +/- initial test
medication history) results exertional

Figure 4.2 Example structure for teaching problem representation. *An intermittent
abstraction is a summary of the problem’s essential characteristics using
semantic qualifiers and precise medical language. If relevant, the chronic non-exertional
characteristics can be encapsulated as a clinical syndrome (for example,
instead of saying that a 50-year-old man with chronic kidney disease stage
5 presents with ‘progressive breathlessness, orthopnoea and leg oedema’, Chest pain continuous
you could say ‘fluid overload’).
acute
breathlessness.’ This immediately leads us to think about other
things, for example, pulmonary embolism. An example structure Figure 4.3 An example of forward reasoning.
for teaching problem representation is shown in Figure 4.2.
Box 4.4 Experts go about solving problems differently to
Problem-solving by Experts Vs Novices novices

Studies have found that experts in a particular domain go about Experts Novices
solving problems differently to novices. These differences are
Spend significantly more time on Represent problems quickly and
summarised in Box 4.4. You may have seen this in action when an problem representation and then then spend more time working on
expert spends significantly more time defining and representing a proceed to solve the problem a solution (often leading to
problem (e.g., by asking themselves, ‘Why exactly did the patient quickly mistakes and having to start
come to hospital today?’) and deliberately seeking out further again)
information (e.g., by talking to relatives to get a collateral history) Redefine and reinterpret problems Respond to the task without
before starting to work on a solution. modifying the structure of the
problem
Experts also solve problems by reasoning forwards, which is
less effortful, whereas novices reason backwards, which can be Define and represent problems Define and represent problems
according to underlying principles according to surface features
laborious and unreliable. For example, novices will select a
potential diagnosis and then check out the description to see Generate more efficient problem Include irrelevant details in
representations, stripped of problem representations
whether it contains facts that support or contradict that diag-
irrelevant details
nosis. Errors can arise by accepting a diagnosis because there is
Break the problem-solving task Try to deal with the problem-
some evidence to support it and no evidence against it – even
into parts and are able to monitor solving task as a whole and are
though some other diagnosis, not yet considered, would fit better. their sequential progress easily less able to monitor their progress
Experts, on the other hand, reason forwards by noting significant as a result
facts which they then explore and are thus able to converge on a Adapted from Zimmerman BJ and Campillo M. Motivating self-regulated
diagnosis in a more straightforward manner [7]. However, problem solvers. In: Davidson JE and Sternberg RJ (Eds). The Psychology
experts also resort to reasoning backwards when they encounter of Problem Solving. Cambridge University Press, 2003. pp. 236–37.
difficult problems – in other words, clinicians employ the strategy
that best suits their knowledge. An example of forward reasoning
ence, that result in their inability to discover, define, and represent
is shown in Figure 4.3.
problems accurately [8]. As a result, their case presentations are
likely to contain errors and their learning will be greatly enhanced
Problem-solving in the Classroom Vs by reviewing all the available information (including going back
Clinical Environments to see the patient) together and then practicing problem recogni-
In a classroom environment, problems are usually presented to tion and representation with feedback.
learners ‘on a plate’. Thus, the opportunity to practice problem
recognition, definition, and representation is limited. Because Managing Uncertainty
these are key skills in clinical reasoning, teachers should
endeavour to show, not tell as much as possible during case-based It is not always possible to be certain about what the problem is
learning sessions. This can be done in a classroom environment for every patient. Authentic clinical reasoning requires clinicians
by using videos of patients describing their symptoms, using to gather and interpret imperfect data in real time. Learning how
images or sounds of physical examination findings if possible, to take safe and effective action in complex and ambiguous set-
and providing test results such as 12-lead electrocardiograms and tings is essential for patient safety [9]. Regulators such as the UK’s
blood results without interpretation. General Medical Council include learning to deal with complexity
In the clinical environment, teachers should not take the case and uncertainty in their outcomes for graduates [10]. Learners are
presentations of learners at face value. This is because of significant likely to commence training believing that most clinical decisions
deficiencies in the clinical skills of learners, due to their inexperi- are binary, given adequate knowledge. For clinicians of all levels,
26 ABC of Clinical Reasoning

the ability to diagnose and manage conditions accurately is an

Box 4.6 Example of a problem list
important aspect of professional identity and well-being. This is
true of learners too. Many students struggle with the lived experi- 1. Faecal loading due to opioids
ence of uncertainty in clinical practice. The belief that one must 2. Urinary retention
always know the answer can inhibit open discussion and learning, 3. Urinary tract infection
4. Acute kidney injury (AKI)
particularly in groups. Such attitudes can translate into the stu-
5. Hyperkalaemia
dent’s future practice, inhibiting their confidence and decision-
6. Opioid toxicity
making for fear of being seen to be wrong or harming a patient.
7. Caregiver strain
Adjusting to practice in the context of uncertainty has profound
impacts for clinical decision-making and patient care [11]. This is A problem list is a list of acute or presenting problems, not the past
particularly true in specialities where illness is undifferentiated medical history.
(e.g., primary care) or rapidly evolving (e.g., acute care).
When dealing with complexity and uncertainty, learners can
‘uncertainty’ is not helpful in adequately capturing what is going
sometimes get themselves in a ‘cognitive knot’ by focusing on
on. Instead, they propose more precise terms:
what they do not know. Teachers can encourage them to re-frame
• Ambiguity = the properties of the situation
things in terms what they do know so they can start ‘untangling’
• Uncertainty = the experience of the individual
the problem. This iterative approach can also demonstrate to stu-
Uncertainty, or what the individual is experiencing, can be due to
dents that problem-solving, diagnosis and management evolves
1) recognising a situation is ambiguous, 2) perceiving limitations
during patient care and is not necessarily established at the outset.
in your own knowledge (which could be due to lack of confidence,
Treatment can be given based on either framing a clinical problem
or a well-calibrated judgement), or 3) recognising you have
or a diagnostic hypothesis. Reflection on the patient’s response, in
incomplete information. Certainty is your confidence in inter-
some cases, can further develop the management plan. An
preting the clinical situation. Comfort is your confidence in being
example of getting learners to re-frame things in terms of what
able to act safely and effectively in a situation. This could be as
they know is shown in Box 4.5.
simple as walking into a situation and recognising you need help
In some cases, it may be difficult to come up with a single
straight away. In summary, being comfortable with uncertainty is
problem representation, but it is still possible to identify several
about recognising the situation is ambiguous, or you lack
discrete problems. This is common in geriatric medicine and in
knowledge/skills, or you have incomplete information, but you
patients with multiple co-morbidities. In these cases, a common
are confident you can still act safely and effectively to manage the
approach is to create a problem list. A problem list consists of sev-
situation.
eral mini abstractions which may or may not be diagnoses. An
Finally, when is a good time to start teaching about managing
example of a problem list is shown in Box 4.6. The advantage of a
uncertainty? It may not be helpful to introduce this too early in a
problem list is that each problem is important in its own right and
curriculum for reasons to do with cognitive load and stages of
requires a management plan. In the ‘history–examination–
learning. As a simple example, how would you teach a four-year-
differential diagnosis’ method, important problems, and there-
old to cross the road? How do you cross the road? Learners
fore plans to address them, may inadvertently be missed.
acquire skills through instruction and practice, but novices differ
Ilgen and colleagues have helpfully deconstructed the term
from competent/proficient learners in terms of their recollection,
‘comfort with uncertainty’ to help educators develop the clinical
recognition, decision-making, and awareness [12]. Novices need
reasoning ability of learners in situations that appear to be com-
recipes and rules, may lack confidence, and their learning and
plex and ambiguous [9]. First of all, they unpack what we mean by
practice requires high degrees of concentration. This is why con-
‘uncertainty’. Do we mean low self-efficacy (confidence we can
sistency of teaching is so important at this stage. Competent/pro-
deal with the situation)? Low knowledge? Lack of information?
ficient learners have more conceptual understanding and are able
Discomfort? Clinical ambiguity? They conclude that the word
to use underlying principles to find solutions for the context in
which they find themselves. So, learning to deal with uncertainty
Box 4.5 Getting learners to re-frame things in terms what
is probably something that should be emphasised later in medical
they know school while practicing with real clinical cases.
Role-modelling by teachers serves an important function.
Mrs. Smith is 85 years old and has just been admitted to hospital.
Though it may diminish, uncertainty in practice never wholly
Learner: ‘I have no idea what’s going on, the patient is really disappears. The effective clinician does not practice solely by con-
confused and can’t give me any history, all the blood tests are viction, but recognises practice is uncertain and this is reflected in
normal, the vital signs are normal, and when I examine her, I can’t their management decisions. Not knowing the diagnosis does not
find anything wrong. I phoned the care home and they told me that
prevent making management decisions. Management decisions
Mrs. Smith is normally really with it, but this morning she was really
may themselves reveal or clarify aspects of a diagnosis. Teachers
confused and that’s why they called the ambulance.’
who share their own experience of this process, and their reflec-
Teacher: ‘Let’s try and summarise what we do know’ … [Together]: Mrs. tions on their own development, are being supportive and
Smith, elderly care home resident, has acute confusion, i.e. delirium. respectful of their learners’ own developmental needs. Box 4.7
 Problem Identification and Management 27

representing problems) is important in clinical reasoning. The

Box 4.7 Strategies for improving tolerance of uncertainty in
decision-making kind of language used in representing problems matters, and this
is something that can be taught. Learners need the opportunity to
• Careful data-gathering (history) practice this with coaching and feedback, but this requires that
• Structured physical examination
clinical teachers do not take the case presentations of learners at
• Working within a framework of differential diagnosis
face value, because significant deficiencies in the clinical skills of
• Considering alternative hypotheses
• Excluding ‘must-not-miss’ diagnoses
learners mean that they may be unable to discover, define, and
• Using best available evidence represent problems accurately.
• Re-evaluating the management plan Managing uncertainty can be overcome, in part, by getting
• Seeking advice from colleagues learners to re-frame things in terms what they do know, gener-
• Sharing limitations of knowledge with the patient ating problem lists, and teachers and learners having a clear and
• Shared decision-making with the patient shared understanding of what we mean by ‘uncertainty’.
• Role-modelling reflection Management reasoning is different in many ways to diagnostic
From the ABC of Clinical Resilience, Wiley-Blackwell, 2021. reasoning; it is influenced by preferences, values, resources, and
constraints. Learning management reasoning requires knowledge
and practice with lots of different cases in lots of different con-
shows strategies for educators in improving tolerance of uncer- texts with coaching and feedback.
tainty in decision-making.

Management Reasoning References

1. Pretz JE, Naples AJ and Sternberg RJ. Recognizing, defining, and repre-
A lot of the focus of the clinical reasoning literature is on diag-
senting problems. In: Davidson JE and Sternberg RJ (Eds). The psychology
nostic reasoning. That is because diagnosis is something that can
of problem solving. Cambridge University Press, 2003. pp 3–30.
be objectively measured in studies. But management reasoning is 2. Bordage G. (1999). Why did I miss the diagnosis? Some cognitive expla-
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Summary
Clinical reasoning is a complex cognitive process involving Further Resource
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In medicine, problem identification (recognising, defining, and Blackwell, 2018.
Other documents randomly have
different content
that he fails to understand the importance attached by Greeks to
those arts which the Romans most rightly despise.
Valerius Maximus, who lived at the time of Tiberius, that is to
say when Rome had fully completed its education in art, calls the
profession of the painter a vile occupation (sordidum studium), and
wonders how Fabius, a Roman and patrician, can bring himself to
sign his painting with full name and qualification, “Fabius Pictor”
(VIII, 14, 6).
In one of his letters (No. 88) Seneca, the contemporary of Nero,
states that sculpture and painting are unworthy to be classified as
liberal arts. Petronius, the magister elegantiorum of Rome, two
hundred years after the destruction of Corinth, that is to say when
Rome had reached its maturity in the understanding of art, calls
Apelles, Phidias and other famous artists of Greece, crack-brained
(græculi delirantes).
With such an innately negative sense of art and strong racial
prejudice, it is not surprising that when brought to an appreciation
of art by circumstances, the Romans, though willing and fully
prepared to pay extravagant prices for works of art, should still
retain their old contempt for artists, those græculi delirantes who
had come to beautify the Capital as slaves or tempted by gain.
As a result of this peculiar feeling and in full contrast with the
Greek sentiment which has handed down to posterity a great deal
about the artists who lived in Athens and the honours they received,
Rome has preserved for us hardly a name of painter, sculptor or
architect. And they must have been legion if we consider the
magnitude of the work accomplished. Vitruvius (VII, 15) informs us
that Damophilus, Gorgas, Agesilas, Pasiteles and other artists were
called to Rome by Julius Cæsar, and that so many Greek artists were
in Rome that when the temple of Jupiter Olympicus was to be
finished in Athens the citizens were obliged to send to Rome, as
none of their architects were to be found in Greece.
 It is interesting to trace how the Romans gradually became
collectors of art, and how there gradually developed in Rome a
whole world of lovers of art with all its true and fictitious
enthusiasms, furnishing a group of varied types of collectors not
altogether dissimilar from those of our modern society of lovers of
art.
As we have said, conquest and booty furnished the first articles
of virtu. At first statues and objects of art of all kinds were brought
to Rome without discrimination, then education gradually
progressed, taste developed and plunder became more enlightened.
Fulvius Nobilior, to quote one of the many conquerors who brought
artistic war booty to Rome, enriched it with 285 bronze statues, 230
marble ones, and 112 pounds of gold ornaments. Following the
custom of the Greeks, the Romans at first presented statues and
paintings to various temples as ornaments.
Later on, with more discrimination and less greed, Roman
officials proceeded to a systematic spoliation of Greece and the
Orient of their treasures of art. Statues and paintings followed in the
triumphs of Roman generals as did slaves and prisoners of war.
Occasionally returning officials brought home with them pillaged
artistic mementoes of the place they had been ruling in the name of
mighty Rome. Thus Fulvius, consul in Ambracia, brought home the
finest statues of that country. One of these mementoes was
excavated in the year 1867; it bore the naive and candid confession
of the consul:—

Marcus Fulvius Marci Filius

Servii Nepos Nobilior
Consul Ambracia
Cepit
Having carried off the statues of the Nine Muses in his conquest
of Ambracia, this same Fulvius Nobilior placed them in the temple of
Hercules. At this time Roman conquerors had progressed, and they
already travelled with experts and advisers. Fulvius Nobilior was
accompanied by the poet Ennius (Strabo, B. X, 5), whose suggestion
it may have been to place Hercules in the midst of the Nine Muses
playing the lyre like an Apollo, a metamorphosis of the god showing
that the Roman had finally harmonized “Strength,” his chief and
most cherished quality, with the gentler feelings of an understanding
of art. This “Hercules Musagetes” seems to symbolize a first
conquest of art over the rude, sturdy Roman character.
Departing from the established rule of presenting their artistic
plunder to the temples after it had followed in their triumphs to
enhance the importance of their conquest, in time the generals
began to keep part of the spoil themselves. In this way were the first
private collections in Rome formed.
The real artistic education of the Romans dates from this time.
The passion and ambition to enrich and embellish private houses
helped to teach what was worth consideration. Sulla, who plundered
Greece and Asia Minor, is said to have acquired a sure eye for
valuable objets de virtu; Verres, who with an excellent eye had
robbed and collected all that came within his reach, was perhaps
Rome’s best connoisseur of art. He and Sulla were practically the
first to organize that enlightened manner of plundering subjugated
countries that finally made Rome the first emporium of art in the
world.
Naturally, these early Roman collectors rarely bought their
articles of virtu. When they could not obtain by pillage they had
ready to hand a speedy and coercive means of gratifying their
artistic craving. Sulla placed on the proscription list the names of all
possessors of artistic objects who were so unwise as to refuse to
give them up to him. Mark Antony did the same to Verres. The latter
paid with his life his refusal to offer the despotic Triumvir some
famous vases of Corinthian bronze which he sorely longed to have in
his collection.
It was, we repeat, in Sulla’s time that the passion for collecting
arose among the Romans, not only guided by an artistic sense of
discrimination, but with all the peculiar characteristics that seem to
attend the development of this passion.
Sulla’s collection—to which the spoils of the temple of Apollo in
Delphi and of the temples of Jupiter in Elis and Æsculapius in
Epidaurus, considered the richest emporium of art in Greece, had
contributed—must have been magnificent and without an equal—
except, perhaps, that of Verres, Sulla’s pupil, who surpassed his
master in the art of plundering, and sacked Sicily of all the island
possessed of art.
 CHAPTER II

COLLECTOMANIA IN ROME
Collectomania develops—Rampant parvenuism in Rome—Extravagant
prices paid for art and curio—Faking arrives—Good and foolish
collectors as seen by writers and satirists of the time—Art dealing—
The septæ, shops and auction rooms.

Such was the earliest type of the real collector of art in Rome, a first
phase in a city where the passion for art was, generally speaking,
rarely genuine. This phase led first to the acquisition of what might
be styled something between ambition and love of display. Then the
trade in objects of art eventually appeared, and as a logical
consequence, imitation and fraudulent art finally had their scope.
Fictitious masterpieces of painting and sculpture, often signed, as in
modern times, with the forged names of noted artists, were already
on the market before Cicero’s time. “Odi falsas inscriptiones
statuarum alienarum” (I hate the forged inscriptions on statues not
one’s own), remarks Cicero, who although somewhat of a collector
himself never missed a chance to ridicule the pretentious amateur
lost in hysterical ecstasy before imitations supposed to be original
works, or of fanning the art lover’s pseudo-enthusiasm for the work
of Polycletus, which was extremely fashionable at one time among
art collectors.
Thus forgery received a great impulse when art reached its
climax in Rome and multiplied the number of collectors, dragging
after it in its triumphal march wealth and all the fickle forces of
wealth. Taste in art, then, became apparently more exclusive, or
rather, according to Quintilian, more unstable in its standards.
“Nowadays,” says the Latin rhetorician and critic, “they prefer the
childish monochrome works of Polycletus and Aglæphon to the more
expressive and more recent artists.” Yet, very likely not
understanding this not unusual love for the archaic and the odd, so
common in collectors of all ages, Quintilian cannot explain the
preference for work he considers gross, except by fashion or what
we should call to-day a snobbish sentiment. Criticizing the art in
vogue, he adds, in fact: “I should call this art childish compared to
that of most illustrious artists who came afterwards, but in my
judgment it is, of course, only pretension” (XII, 10).
It is evident that with the Romans as with us—the times are not
entirely dissimilar; indeed but for art critics, the new modern fad,
they might be called identical—prices paid for works of art, or simple
curiosities, became freakish and fabulous, going up or down in a
single period according to fickle fashion. The momentary passion for
murrhines, for instance, tempted a collector to pay for one of these
cups of fluor-spar a sum approximating to £14,200. Another mania
succeeded, that of tables made of citrus, a species of rare wood,
possibly Thuja, grown on the slopes of Mount Athos. Cathegus
invested in one of these fashionable tables a sum equivalent to
twelve thousand pounds. Then at another time wrought silver
becomes the rage, and prices for this article soon reached absurd
figures. When Chrysogon, Sulla’s wealthy freedman, was bidding at
an auction for a silver autepsa (a plate warmer), people standing
outside the auction room imagined he was buying a farm from the
high sum he offered.
As might be expected, high prices tempted brainless parvenus.
There were many in Rome like that Demasippus of whom Horace
said, “Insanit veteres statuas Demasippus emendo” (Sat., 3), the
type of a snobbish visionary and sham art-seeker who bought
roughly carved statues, supplying their defects with his fancy, and
who, in speaking of his historical pieces, stated that to be admitted
into his very choicest collection a basin must at least have served
Sisyphus, son of Æolus, as a foot-bath!
Next to this foolish type of collector of art Rome possessed a
great many other characters, who, like those of to-day, might be
classified as odd specimens of art lovers.
“Isn’t Euctus a bore with his historical silver?” asks Martial,
adding that he would rather eat off the common earthenware of
Saguntus than hear all the gabble concerning Euctus’ table-silver.
“Think of it! His cups belonged to Laomedon, king of Troy. And,
mind, to obtain these rarities Apollo played upon his lyre and
destroyed the wall of the city by inducing the stones to follow him by
his music.” But concerning this odd type of collector Martial merits
quotation. “Now, what do you think of this vase?” asks Euctus of his
table companions. “Well, it belonged to old Nestor himself. Do you
see that part all worn away, there where the dove is? It was reduced
to that state by the hand of the king of Pylos.” Then showing one of
those mixing bowls that Latins called crater, “This was the cause of
the battle between the ferocious Rheucus and the Lapithæ.”
Naturally every cup has its particular history. “This is the very cup
used by the sons of Eacus when offering most generous wine to
their friend—That is the cup from which Dido drank to the health of
Bythias when she offered him that supper in Phrygia.” Finally, when
he has bored his guests to death, Euctus offers them, in the cup
from which Pyramus used to drink, “wine as young as Astyanax.”
Trimalcho is so well known that we are dispensed from a
detailed illustration. Petronius must have drawn from life this capital
character of his Satyricon. Like Euctus, Trimalcho extols the historical
merits of his articles of virtu; he has the same mania for inviting
people to his table and forcing them to admire his rarities. He talks
very much in the same manner as the type quoted by Martial. Thus
he informs his guests that his Corinthian vases are the best and
most genuine in existence, because they were made at his order by
a workman named Corinth. As a side explanation of this remark,
fearing that the guest might suppose he did not know the historical
origin of the metal, he adds: “Yes, yes, I know all about it. Don’t
take me for an ignoramus. I know the origin of this metal perfectly
well. It was at the capture of Troy, when Hannibal, a shrewd brigand
by the way, threw on to a burning pyre all the statues of gold and
silver and bronze. The mixture of the metals produced the alloy from
which goldsmiths have made plates, vases and figures. From this, of
course, comes the name of Corinth to designate this mix-up of three
metals, which, of course, is no more any of the three!” Trimalcho
also possesses a cup with a bas-relief representing Cassandra
cutting her children’s throats. Not content with this gorgeous
historical blunder, and forgetting that he is talking of the bas-relief of
a cup, Trimalcho adds as an artistic comment that the bodies of
Cassandra’s children are so life-like that one might suspect they had
been cast from nature.
Continuing our comparison with Euctus we may add that
Trimalcho also possesses a rare pitcher with a bas-relief representing
Dædalus putting Niobe inside the wooden horse of Troy! When he
has finished maiming history, and the guests have patiently listened
to his fantastic tales, like a true parvenu, Trimalcho never fails to
add, “Mind, it is all massive precious metal, it is all my very own as
you see, and not to be sold at any price.”
Except for the wording, a trifling difference—the word
“expensive” would play a conspicuous part with the Trimalcho of to-
day, decorated, be it understood, with “precious,” “rare,” “unique”
and all the rest of the arch-superlatives of modern idioms—such
collectors have not been lost to our day.
But there are other types worth quoting. They will certainly help
us to understand the part played by art imitations and forgery
among the Romans, and how the existence of fraud was in some
way justified, that in the end the one chiefly responsible for the
existence of faking was the collector himself. This understanding will
be greatly aided by a glimpse at the septæ, antiquity or simple bric-
à-brac shops, that were grouped together in certain streets of
ancient Rome like they are nowadays.
 Like to-day, too, sales of art were effected by auctions or by
private dealing, the latter in shops or through the usual go-between,
the so-called courtier of our time.
Public auctions were announced by placards or a simple writing
on the walls. An idea of what these announcements were like is
given by the following one from Plautus’ Menœchme:
“Within seven days, in the morning, sale of Menœchme. There
will be sold slaves, furniture, houses, farms. Every article bought
must be paid for at the time of buying.”
As in our days, an exhibition of the goods preceded the auction.
These shows were held in appropriate rooms adorned with porticos,
called atria auctionaria. In speaking of such exhibitions and
commenting upon some special one, Cicero remarks, Auctionis vero
miserabilis adspectus (Phil., II, 29).
Curiously enough the auction sales of the Urbs were provided
with an employé whose function seems to have survived in the
public sales of Paris. The Latin præco is something like the French
crieur whose office it is at public auctions to extol and praise the
objects offered for sale. It must be said that the præco, however,
was not only a simple crieur but at times a sort of director of the
sale, thus combining the functions of commissaire priseur, expert
and crieur, but it was certainly in the latter function that his ability
best contributed to the success of the sale. Some of these employés
must have enriched themselves like regular commissaires priseurs.
Horace (I. Ep., 7) describes one of these crieurs as indulging in
luxury, making money easily and scattering it like water, allowing
himself every kind of pleasure and yielding tremendously to fashion.
A curious description, suggesting that this Vulteius Menas of Horace
must have had the lucky career of some of the Parisian auction
employés and cannot have been indifferent to that form of gay self-
indulgence that Parisians call: Faire la bombe.
Speaking of auctions and the way Romans disposed of their
goods to the highest bidder, it is worth while to refer to what
Suetonius tells us happened at the sale held by Caligula, who being
short of money thought fit one day to put up to auction everything
in the royal palace that was either useless or considered out of
fashion, quidquid instrumenti veteris aulæ erat. According to
Suetonius not only was the Emperor himself present at the auction,
but he put prices on the various objects, bidding on them as well. An
old prætor, Aponius Saturninus, became sleepy during the sale, and
in dozing kept on nodding his head. Caligula noticed it, and told the
auctioneer not to lose sight of that buyer and to put up the price
each time Saturninus nodded. When the old man finally awoke he
realized that without knowing it he had bought at the Imperial
auction about £80,000 worth of goods (Cal., 39).
Pliny relates an amusing story, which shows that then, as now,
the auctioneer was allowed to group objects.
“At a sale,” he says, “Theonius, the crieur, made a single lot of a
fine bronze candelabra, and a slave named Clesippus, humpbacked
and extremely ugly. The courtesan Gegania bought the lot for
50,000 sesterces (about £400). The same night at supper she
showed her acquisitions, exhibiting the naked slave to the gibes of
the guests. Then yielding to a freakish passion, made of him her
lover and heir. Clesippus thus became extremely wealthy and
worshipped the candelabra with a devotion as though it were his
god” (XXXIV, 6).
As stated above, other sales generally took place in various parts
of Rome where antiquaries and bric-à-brac dealers had assembled
their shops. A great many of these merchants had gathered in the
Via Sacra or the Septa of the Villa Publica, or Septa Julia.
Those parts of Roman streets called Septæ, where antiquaries
and bric-à-brac dealers had their dens, were the amateur’s fool’s
paradise and trap, and very likely they were as inviting and
picturesque as similar places in modern European towns to-day.
These shops and shows, it is said, offered real rarities at times,
such as bronzes of Ægina by Myron, Delos bronzes by Polycletus,
genuine rarities in Corinthian bronze, marvels in chiselling signed by
Boethus or Mys. The septæ not only exhibited artistic pieces but also
sham rarities that had won public appreciation in a moment of
fashion. Among these was a certain kind of candelabra shaped like a
tree with one or more branches. Concerning these candelabras
which were almost made to supplant the more artistic ones by a fad,
Pliny remarks, “Arborum mala ferentium modo lucentes” (like trees
bearing shining apples), and states with caustic humour that
although their name bore a common etymology with the word
candela (candle), a cheap means of lighting, they were sold at prices
equivalent to the yearly appointment of a military tribune (Plin.,
XXXIV, 8).
Speaking of candelabras, it may be stated that the finest ever
seen in Rome belonged to Verres, being part of the vast plunder of
Sicily he accumulated when stationed there by Rome as proconsul.
This fact prompted the sarcastic remark in Cicero’s indictment of the
proconsul, that Verres had in his triclinium a candelabra casting light
where darkness would have been more appropriate. This rich
candelabra must have been of a statuesque style, the kind Lucretius
describes:—
Si non aurea sunt juvenum simulacra per ædes
Lampadas igniferas manibus retinentia dextris (II, 24).
(Figures of youths holding lighted lamps in their right hands.)

Naturally it was not only a single speciality, valued through

fashion or fad, that was to be found on the market, it was a regular
emporium of antiquities in art, and of all kinds of bric-à-brac.
Besides murrhines, tables of citrus and other specialities there were
paintings of all schools and sizes, down to miniatures, an art not
unknown to the Romans. There were also sculpture, ceramics, fine
pieces of Rhegium and Cumæ, Maltese tapestries, Oriental
embroideries, etc. In fact, mixed with a good deal that was dubious,
these places also offered fine treasures, as Martial says:—
 Hic ubi Roma suas aurea vexit opes.
(Here where golden Rome brought her treasure.)

It is easy to understand that the people moving in this milieu

were not dissimilar from those who indulge in articles of virtu in our
enlightened times, or who are somewhat of a victim to the collector
passion. Such a milieu, not to be found in Athens where the passion
for art was genuine and essential, was quite consistent in Rome
where improvised Crœsuses and rich parvenus abounded; parvenus
who, like many of the collectors of our times, took to buying objects
of art as a fad or hobby. This type of collector is easily recognized
and in its grotesqueness is not essentially different from some of our
modern society.
It is true that Rome also produced many genuine lovers of art,
many first-rate connoisseurs and collectors such as Agrippa,
magnificent collectors of the calibre of Cæsar, keen, intelligent,
lovers of art, as greedy as unscrupulous, such as Sulla, Verres and
Mark Antony, but as in America to-day, the magnitude of quickly-
made fortunes, the impetus of a passion suddenly aroused without
any previous preparation, produced only a few types of the true
collector. As in America now, for one Quincy Shaw, how many a—
Trimalcho and Euctus.
Needless to say, the art market generally follows the inclination
of the client, it tries to meet his taste, whims and fads, it may be
scrupulous or unscrupulous according to circumstances and,
particularly in art and antiques, these circumstances chiefly depend
upon the great despotic ruler of all markets, the client.
Thus in the septæ, side by side with Firminius, Clodius and
Gratianus, dealers enjoying an undisputed reputation in the sigillaria
(image market) and other quarters where antiquary shops were
gathered, there were to be noted types like the Milonius of whom
Martial says:—
“Rare stuffs, chiselled silver, cloaks, togas, precious stones, there
is nothing you don’t sell, Milo, and your clients invariably carry their
acquisitions away with them! After all your wife is the best article in
your emporium, always bought and never taken away from your
shop” (VII-XII, 102).
The whole gamut of oddities with which the collecting mania
abounds were really to be found in the septæ.
There was the particular collector who has no eyes but for one
certain thing, no enthusiasm but for the objects specializing his
particular hobby, as Horace remarks in his “Satires” about people
who have either the passion for silver pieces or bronzes:
Hunc capit argenti splendor, stupet Albius are.
(This one the glitter of silver holds, Albius stands dumb before
bronze.)

Seneca informs us that in his time there was an amateur with

the hobby of collecting rusty fragments, another who had gone so
crazy over small vases of Corinthian bronze that he spent his days
handling the pieces of his collection, taking them down from the
shelves, putting them back again and continually arranging and
rearranging them (De Brev. Vit., XII).
Martial tells us of a man who made a collection of pieces of
amber containing fossilized insects, and of another collector who
boasted that he had a fragment of the ship Argo among the rare
pieces of his collection. There was also Clarinus, a debauchee,
according to Martial, who vaunted himself upon possessing samples
of all the goldsmith’s art of his time. “But,” remarks Martial, “this
man’s silver cannot be pure!”
Another type noted by Martial makes one realize that there is a
species of collector that will never die. Of “Paullus” Martial,
observes: “... his friends, like his paintings and his antiques: all for
show” (XII, 69).
Codrus, quoted by Juvenal, is the needy collector. He keeps his
books “in an old basket where mice allow themselves the luxury of
nibbling the works of divine Greece.” He sleeps “on a pallet shorter
than his little wife.” His collection and furniture are all in his
bedroom, the only room he has for living and sleeping in, and
conspicuous are six cups, a small cantarium on a console with a
figure of Chiron the Centaur below it (III).
Eros is another type, that of the mournful collector. This is the
way Martial describes this not unusual type:—
“Eros weeps every time he comes across some fine murrhine of
jasper or a finely marked table of citrus. He sighs and sighs from the
bottom of his heart, for he is not rich enough to buy all the objects
of the septa.” And here Martial comments, “How many are like Eros
without showing it, and how many banter him for his tears and sighs
and yet in their hearts feel like him!” (X, 80).
Mamurra, another type handed down to us by the inexhaustible
Martial, never misses a day without visiting the septa. “Spends hours
in gadding about, reviews the rows of young slaves which he
devours with the eye of a critic, not, if you please, the common ones
but the choicest samples, those that are not on show to every one,
not to common people like us,” adds Martial. “When he has had
enough of this show, he goes to examine the furniture; there he
discovers some rich tables (orbes, round tables) hidden under some
covering; then he orders that some pieces of ivory furniture he
wishes to examine be taken down from the highest spot; afterwards
he passes on to examine a hexaclinon, a couch used in the
triclinium, with six places, veneered with tortoise-shell, and
measures it four times. What a pity it is not big enough to match his
citrus table! A minute later he goes to smell a bronze: Does it really
smell of the Corinthian alloy? Of course he is ready to criticize even
your statues, O Polycletus! Then those two rock crystals are not
pure, some are a trifle nebulous, others are marred by slight
imperfections. Ah! here’s a murrhine. He orders about a dozen to be
put aside. He goes to handle some old cups as if he would weigh the
merit of each one, more especially that of Mentor. He goes to count
the emeralds on a golden vase, and the enormous pearls we see
dangling together on the ears of our elegant ladies. Afterwards he
goes to look everywhere on every side for real sardonyx; his
speciality is to collect large and rare pieces of jasper. Finally, about
the eleventh hour of the day, Mamurra is completely exhausted, he
must go home. He buys for an as (less than three farthings) two
bowls and takes them with him” (IX, 59).
Tongilius is the ponderous, important collector. He goes through
the places where the antiques are sold in an over-sized palanquin
and with his cortège and train of followers upsets everybody and
everything. Juvenal, by whom his character is handed down to us,
remarks rather sarcastically:
Spondet enim Tyrio stlataria purpura filo,
Et tamen est illis hoc utile (Sat. VII).

Licinius is the type of the lunatic lover of art. He has a fine

collection, is wealthy and can buy the most expensive objects of
virtu, but he is far from happy. His mania is the fear that his rarities
may be stolen or become the prey of fire. He keeps hoards of slaves
watching his precious curios, night and day. “At night,” says Juvenal,
“a cohort of guardians sits up with buckets of water ready to hand in
case of emergencies; the poor man is in continual fear for his
statues, his amber figures, his ivory and tortoise-shell veneered
furniture.”
Naturally, in contrast to the foolish type of collector who seems
to have kindled the verve of Roman satirists, the true amateur was
to be found, and most select collections of art were known in Rome.
Among these also the city afforded all the types of the true collector,
the selfish one who never showed his collection to anyone, and the
man who gathered objects of art chiefly to share the enjoyment of
them with others. Some of these latter wished the public to have the
benefit of their purchases, and adorned porticoes and public places
with their collections.
According to Statius, Vindex is the real connoisseur. “Who can
compete with him,” remarks the poet in his Silvæ, lib. IV, “who
possesses so sober an eye? He is deeply versed in the technical
procedure of all the artists of antiquity, and when a work bears no
signature he can decide at sight to which master it belongs. He will
point you out a bronze that has cost the learned Myron many a day’s
and night’s work, the marble to which Praxiteles’ untiring chisel has
given life, the ivory polished by the hand of Phidias, the bronzes of
Polycletus which seem to breathe life on coming out of the furnace,
he can see the artistic line, the true mark of all authentic Apelles.”
 CHAPTER III

RAPACIOUS ROMAN COLLECTORS

Some collectors’ hobbies—Sulla idolized statuette—Verres the most
rapacious of Roman art collectors—Mark Antony and his speedy
methods—Cicero as an art lover—Pompey the unselfish art lover—
Julius Cæsar.

Shrewd and impassive connoisseurs like Sulla also had their hobbies
and fancies. Sulla’s particular fancy was a little statue of Apollo he
had pillaged from the temple of Delphi. This statue was more to him
than all the rest of the precious things forming his unique collection.
From this little god, called by Winckelmann “Sulla’s private travelling
god,” he never separated. He used to kiss it devoutly and seems to
have consulted it in great emergencies. At times he used to carry it
in his breast, says Plutarch. We may note by the way that this Apollo
was not considered by connoisseurs the best piece of Sulla’s
collection, the real gem was his Hercules, a work by Lysippus. The
story of this Hercules is told by Martial and Statius, who inform us
that it measured a little less than a Roman foot, about nine inches.
Notwithstanding its modest dimensions the statuette was modelled
with such grandeur and majestic sentiment as to cause Statius to
comment, “parvusque videri, sentirique ingens” (small in
appearance, but immense in effect). It represented Hercules in a
smilingly serene attitude, seated on a rock, holding a club in his right
hand and in the other a cup. It was in fact one of those statuettes
which Romans called by the Greek word epitrapezios, and which
were placed on dining-tables as the genius loci of the repast.
The history of this gem of Sulla’s collection is uncommon, and its
vicissitudes most remarkable. The statue was originally a gift made
by Lysippus to Alexander the Great. This sovereign and conqueror
was so attached to Lysippus’ present that he carried the statue with
him wherever he went. When dying he indulged in a touching adieu
to the cherished statuette.
After Alexander, the little Hercules fell into the hands of another
conqueror, Hannibal. It is not known how he came to be the
possessor of Lysippus’ work, but it may be explained by the fact that
Hannibal, being a collector of art and somewhat of a connoisseur
and, above all, as Cornelius Nepos states, a great admirer of Greek
art, was a keen-eyed hunter after rarities in art. However, be that as
it may, Hannibal seems to have been possessed by the same fancy
as Alexander, for he carried the little statue with him on all his
peregrinations, and even took it to Bithynia, where, as history
informs us, he destroyed himself by poison. At his death the
Hercules passed, in all probability, into the hands of Prusias at whose
court Hannibal died.
A century later the statue reappeared in Sulla’s collection. Very
likely it came into Sulla’s possession as a present from King
Nicomedes, who owed gratitude to Sulla for the restitution of the
throne of Bithynia.
After Sulla’s death it is difficult to locate this precious statue of
his famous collection. Presumably it passed from one collector to
another, and never left Rome. “Perhaps,” says Statius, “it found its
place in more than one Imperial collection.” The statue reappears
officially, however, under Domitian. At this time it is in the
possession of the above-quoted Vindex, a Gaul living in Rome, a
friend of Martial and Statius and one of the best art connoisseurs of
his time.
 At Vindex’s death the statuette disappears again, and no
mention of it has ever been made since by any writer. What may the
fate have been of this chef-d’œuvre of Lysippus which passed from
one collection to another for more than four centuries?
Among greedy lovers of art, with a connoisseur’s eye as good as
his soul was unscrupulous, Verres takes the prize. He had learned
the rapacious trade of art looting under Sulla. Later on, not being
powerful enough nor daring to go to the length of the Dictator by
placing reluctant amateurs on the list of proscribed, he studiously
sought to gain his end by all forms of violence and vexatious
methods. When in Sicily as proconsul, he actually despoiled and
denuded every temple in the island.
“I defy you,” says Cicero in his indictment of Verres, “to find now
in Sicily, this rich province, so old, with opulent families and cities, a
single silver vase, a bronze of Corinth or Delos, one single precious
stone or pearl, a single work in gold or ivory, a single bronze, marble
or ivory statue; I defy you to find a single painting, a tapestry, that
Verres has not been after, examined and, if pleasing to him,
pillaged.”
As for private property, when he heard of a citizen possessing
some object that excited his cupidity, to Verres all means of extortion
seemed good, including torture and fustigation. His passion was of
such an uncontrollable nature that even when invited to dinner by
his friends he could not resist scraping with his knife the fine bas-
reliefs of the silver plates and hiding them in the folds of his toga.
Yet this greedy, unscrupulous amateur, whom Cicero mercilessly
indicted in his In Verrem, was such a lover of the objects of his
collection that he faced death rather than give up some fine vases of
Corinthian bronze which Mark Antony had demanded from him as a
forced gift.
Mark Antony, who followed Sulla’s methods in forming one of the
finest of collections, was, like his violent predecessors, a type of
collector which finds no counterpart in our times. His fine library had
cost many victims, his taste being rather eclectic, there seems to
have been no security in Rome for any kind of amateur who
happened to possess rare and interesting curios. Nonius was
proscribed because he refused to part with a rare opal, a precious
stone of the size of a hazelnut. “What an obstinate man, that
Nonius,” remarks Pliny (XXXVII, 21) most candidly, “to be so
attached to an object for which he was proscribed! Animals are
certainly wiser when they abandon to the hunter that part of their
body for which they are being chased.”
Mark Antony was not so good a connoisseur as Verres, but
having no less a passion for collecting art and being no less
unscrupulous and more in a position to use violence without the risk
of being accused before the Roman citizens, as happened to Verres
in the end, there was no limit to his schemes. After the battle of
Pharsalia he managed to seize all Pompey’s artistic property, as well
as his furniture and gardens, and after Cæsar’s murder Antony, to
whom we owe one of the finest orations ever conceived, the one he
delivered before the dead body of his friend, lost no time in
plundering Cæsar’s property and transporting to his gardens all the
objects of art Cæsar had left to the people of Rome. The information
comes from Cicero with these words: “The statues and pictures
which with his gardens Cæsar bequeathed to the people, he
(Antony) carried off partly to his garden at Pompeii, partly to his
country-house.”
Speaking of this collection, it is believed that the colossal Jupiter
now in the Louvre Museum not only belonged to Mark Antony, but
was the work of Myron which the Triumvir had stolen from Samos.
Should this be so, the pedigree of this statue is one of the few that
can be actually traced through the centuries. Brought to Rome by
Mark Antony, this Jupiter was later placed in the Capitol by
Augustus. The fine statue was then passed from one emperor to
another, to sink into the general oblivion of art at the end of the
Roman Empire. It reappears in Rome in the sixteenth century. It was
then in the possession of Marguerite of Antioch, Duchess of
Camerino. The statue was greatly mutilated, having lost both legs
and arms. The Duchess presented what remained of this famous
Jupiter to Perronet de Granvelle. Subsequently cardinal and minister
of Charles V, on his retirement to his native country, Perronet de
Granvelle took the Jupiter to Besançon and placed it in the garden of
his castle. When Louis XIV took Besançon, the magistrates of the
city offered the French monarch what he might otherwise have
taken, the statue of Jupiter. Transferred from Besançon to Versailles,
this magnificent statue which by rare chance had escaped serious
damage during the barbarian ages finally met two authentic
barbarians in the artists charged with its restoration. To clean off the
old patina from the statue—think of it—Girardon had a layer of
marble taken off with the chisel, and Drouilly, not perceiving that the
god had been formerly in a sitting posture, or more probably not
choosing to notice the fact as not appealing to his artistic
conception, made the Jupiter a standing statue by adjusting and
cutting the parts otherwise in the way for this kind of adaptation.
The only part of the statue that does not seem to have suffered any
damage is the head.
Even Brutus and Cassius appear not to have been indifferent to
the collector passion. Brutus, more especially, used to devote to the
collecting of art the less agitated moments of his troubled life. The
gem of his collection was considered to be a bronze by Strongylion.
Pliny tells us that this statue of Brutus was called “the young
Philippian,” Strongylion fecit puerum, quem amando Brutus
Philippiensis cognomine suo illustravit (XXXIV, 19).
Cicero may be quoted as a type of the inconsistent art collector.
A man of dubious artistic taste and snobbish tendencies but who
becomes a true art lover when he specializes in that part of art
collecting more closely in keeping with his studies. Thus in his letter
to Atticus he reveals his love of books and old Greek works, and how
fond he was of good bindings, etc. As a collector of art Cicero leaves
one doubtful as to his taste and connoisseurship, qualities to which
he seems to lay claim in more than one of his speeches. When he
writes to his friend Atticus, his good counsellor, the man charged to
buy art for him, he does not express himself either as a real lover of
art or a genuine connoisseur. “Buy me anything that is suited for the
decoration of my Tusculum,” he writes to Atticus. “Hermathena
might be an excellent ornament for my Academy, Hermes are placed
now in all Gymnasia.... I have built exedras according to the latest
fashion. I should like to put paintings there as an ornament,” etc.
In Paradoxa, a collection of philosophical thoughts called Socratic
in style by Cicero, in which he says he has called a spade a spade,
Socratica longeque verissima, Cicero has the courage to write the
following paragraph in defence of Carneades, who maintained that a
head of a Faun had been found in the raw marble of a quarry at
Chios:—
“One calls the thing imaginary, a freak of chance, just as if
marble could not contain the forms of all kinds of heads, even those
of Praxiteles. It is a fact that these heads are made by taking away
the superfluous marble, and in modelling them even a Praxiteles
does not add anything of his own, because when much marble has
been taken away one reaches the real form, and we see the
accomplished work which was there before. This is what may have
happened in the quarry of Chios.”
The gamut of art collectors would not be complete without
quoting a few samples of worthy art lovers who either understood
art, like the Greeks, as a means of public enjoyment, or in some way
showed genuine and most praiseworthy qualities as true collectors of
art.
It is doubtful whether the great Pompey really felt any pleasure
in collecting art pieces, or whether he simply did it to ingratiate
himself with the public. But as a matter of fact his attitude towards
the enjoyment of art was certainly of a most unselfish character.
Though he very sumptuously embellished his gardens on the
Janiculum, this was nothing compared with the public buildings he
enriched with rare statues, paintings, etc. His theatre was a
magnificent emporium of art of which we possess some samples in
the colossal Melpomene of the Louvre Museum and the bronze
Hercules excavated under Pius IX, now one of the finest pieces of
the Vatican collection. Both these statues were found buried on the
spot where once the monumental theatre of Pompey had stood.
But the artistic glories of this theatre were perhaps even
surpassed by the interminable portico Pompey constructed and
adorned for the benefit of the public. This spot, which was called the
Promenade of Pompeius, became one of the fashionable walks of
Rome.
“You disdain,” asks Propertius of his lady love, “the shady
colonnades of Pompey’s portico, its magnificent tapestries and the
fine avenue of leafy plane-trees?” (IV, 8). And in another place
Cynthia forbids her paramour this promenade with the words: “I
prohibit you ever to strut in your best fineries in that promenade.”
Pliny (XXXV, 9), says that Pompey had some famous paintings in
his galleries and seems to have been more especially struck by a
work by Polygnotus, representing “a man on a ladder,” and a
landscape by Pausias. Curiously enough the characteristics that
seem to have attracted Pliny in the two works do not point to the
noted writer as a great art critic. He says that the remarkable side of
Polygnotus’ painting was that the beholder could not tell whether the
man on the ladder was ascending or descending, and that the main
characteristic of Pausias’ work consisted in two black oxen outlined
on a dark landscape.
Cæsar, who showed himself to be a better connoisseur than his
rival Pompey, and who, being of a more refined nature, would not,
as did Pompey, have indulged in the gratification of parading the
chlamys of Alexander the Great in a triumphal car drawn by four
elephants, spent considerable sums on the embellishment of Rome
with art. He also, like many collectors of art, had his hobbies,
carrying with him through his various campaigns an endless number
of precious mosaic tables, and always keeping in his tent a fine work
of a Greek artist, a statue of Venus, with whom he claimed
relationship. Though he showed eclectic taste in his gifts to the town
and temples, he was in private, like a true connoisseur and refined
lover of art, somewhat of a specialist, being extremely fond of
cameos and cut stones. Of these he had six distinct collections that
held the admiration of all the connoisseurs of the city.
He was, however, not only a passionate seeker after antiques,
most boldly acquiring precious stones, curiosities, statues, pictures
by old masters (gemmas, tereumata, signa, tabulas operis antiqui
animosissime comparasse), as Suetonius tells us, but also the ever-
ready patron of modern art. In this character he paid 80 talents
(about £16,000) for a painting by Timonacus. Damophilus and
Gorgas, painters, sculptors and decorators, worked for him to
embellish the Arena he built in Rome, an edifice capable of holding
2500 spectators. Many artists worked at his Forum, a monument to
his name for which he paid a sum equivalent to twenty million liras
for the ground alone. Meanwhile he was also busy embellishing
other cities of Italy, Gaul, Spain, Greece, and even Asia. Suetonius
states that Cæsar sent a company of artists and workers to rebuild
destroyed Corinth and to replace its statues on their pedestals.
Being a most unselfish kind of lover of art, Cæsar was one of the
few who did not yield to the momentary fashion that led patricians
to send their art pieces out of Rome, to embellish and decorate their
country houses and magnificent villas.
This peculiar fashion that exiled so many fine statues from
Rome, leads us to speak of another noble type of collector, Marcus
Agrippa, who, like Cæsar, not only set a good example by keeping all
his treasures of art in Rome, mostly for the enjoyment of the public,
but protested against the new custom, and held meetings and
lectures to dissuade wealthy Romans from sending away from the
city their chef-d’œuvres.
Such was the spirit characterizing Agrippa as a lover of art.