Describing complex clinical scenarios at the bed-side: Is a systems science approach useful? Exploring a novel diagrammatic approach to facilitate clinical reasoning Approaches to teaching and learning

Abstract

Clinicians often encounter patients having complex clinical scenarios (CCS) where diverse and dynamic diagnostic and therapeutic issues interact. A limited range of bedside methods are available to describe such patients and most often it is a diagnostic summary, a problem list, or a list of differential diagnoses. These methods fail to portray the interconnected nature of CCCs. They prevent visualization of a system of networks or a web of causation operative in CCSs. A more holistic conceptualization is required and the author argues for an approach based on systems science. The latter views the human body to consist of several closely linked organ systems, constantly interacting with each other and embedded in, and 'open' to the external environment. In order to capture the systems nature at bedside, a tool based on network diagrams, termed a Clinical Reasoning Map (CRM) is proposed which depicts diseases or conditions as nodes linked to each other by lines or arrows. The latter linkages follow simple rules: Possible causes or associations as mere lines; probable cause using a single dotted arrow with directionality (from 'cause' to 'effect'); definite causal pathways by directional arrows; and bi-directional arrows to indicate organs-systems influencing each other. CRM's utility was investigated in several groups of undergraduate medical students. The results varied: 289, 5th year and 4th year medical students showed that 245 (85.5 %) perceived CRM improve their understanding of the case. However, there was no clear advantage in the CRM over a list of diagnoses in recall of key information. A majority (83.9 %) were keen to learn the technique of drawing a CRM. Postgraduates too found the tool to be useful to understand the interconnected nature of real-life complex case scenarios and pathogenesis of their multifaceted condition to generate differential diagnosis and to select appropriate investigations. Effectiveness of CRM is supported by adult learning theories such as meaningful learning and experiential learning. The author proposes that systems science and tools based in this approach such as CRM has utility in understanding and managing complex case scenarios. They differ significantly from other diagrammatic methods available in the medical literature.