Diagnostic Reasoning: The (Online) Game

Introduction

Welcome to Diagnostic Reasoning, the fun learning resource designed to help the medical student and GP in-Training to develop their reasoning skills in the clinical setting!

Number of players: 

1-2

Aim:

To take a randomly-generated presentation and practice diagnostic reasoning using different reasoning methods to generate a broad list of differential diagnoses. As more cards are drawn and more information becomes available, this differential diagnosis list will be refined. The game ends when it is no longer possible to explain all the  information with a single diagnosis.

Purpose:

This game is not competitive. There is no ‘right’ answer. You win by sharpening your diagnostic reasoning skills.

This resource, under the branding “Clinical Reasoning: The Game”, was originally created by GP Synergy with the support of the Australian Commonwealth Government under the AGPT Program. To maximise accessibility, General Practice Supervision Australia (GPSA) has adapted the physical game to an online version under Intellectual Property rights granted in January 2023.

There are multiple approaches to diagnostic reasoning.

Randomly selecting a model avoids the temptation to fall back on a favoured approach.

The aim of this game is to explore different styles of thinking, and to find potential blind-spots or biases in your thinking. This is best done by giving a full effort to using the randomly-selected Reasoning Model, even if this is difficult.

To refresh the cards and ensure you are always randomly selecting the next one, use the 2-way arrow beneath the deck before clicking on the facing card.

It is possible to draw a combination of cards which do not make sense, usually due to a clash of the age or gender of the patient with a presenting complaint or observations. 

For example:

  • Demographics: 6 week-old male
  • Presenting complaint: Fevers
  • Initial observation: Talking in short sentences

If this happens, you can either consider a more appropriate similar presentation for the duration of the game e.g. consider “talking in short sentences” to mean “respiratory distress,” and proceed on this basis, or discard that card and draw another by clicking on the 2-way arrow icon beneath the card.

How to Play

Step 1: Click on the Demographics card from the blue deck

Step 2: Click on the Presenting complaint card from the green deck

Step 3: Spin the wheel for the Reasoning Model you will use to play the game

Consider the body anatomically, starting with the head, and think about any pathology of that particular structure which could explain the information shown on the cards.

This reasoning model uses a mnemonic to prompt the clinician through a list of possible causes or types of conditions in an effort to aid recall of known diagnoses:
V – Vascular
I – Infectious or Inflammatory
N – Neoplastic
D – Drugs or Degenerative
I – Intoxication or Idiopathic
C – Congenital
A – Autoimmune or Allergic
T – Trauma
E – Endocrine
M – Metabolic or Mental

Also known as Murtagh’s Model, PROMPT follows a series of logical steps in considering a differential:
A. What is the probability diagnosis (what is most likely)?
B. What serious conditions must be ruled out?
C. What conditions are often missed?
D. Consider the seven masquerades (conditions which can be difficult to diagnose because of their many possible presentations):

1. Depression

2. Diabetes

3. Drugs

4. Anaemia

5. Thyroid dysfunction

6. Spinal dysfunction

7. Urinary tract infection

E. Is this patient trying to tell me something?

This model relies heavily on pattern recognition, or ‘illness scripts’. The clinician spots patterns in the information available which resemble the known patterns of particular conditions.

Similar to the Anatomic Model, but in this case work through the major body systems (cardiovascular, respiratory etc), considering whether there is a condition affecting each system which would explain the clinical features.

The most complex of the reasoning models, ‘pivot and cluster’ relies on identifying the patterns within the data, and then considering if there are any other possible diagnoses which have the same pattern. For example, if the patient presents with fever and right iliac fossa pain, a possible diagnosis is appendicitis. This is your pivot.
Now, consider other things which follow the same pattern: for example, pelvic inflammatory disease, or diverticulitis. This is the cluster.
Consider whether any of the possible diagnoses in the cluster is more or less likely. If one is considered more likely, it becomes the new pivot.

Step 4: Use the selected model to generate a list of possible diagnoses which could explain the presentation, then choose an Initial Observation card.

Refine your differential diagnosis based on this extra information: this may mean  discarding diagnoses or adding new ones.

Step 5: Choose a Findings or Results card. Further refine your differential diagnoses based on this new information.

Choose another card from the Findings or Results deck and further refine your  differential diagnoses.

Step 6: Repeat Step 5 until there is only one single possible diagnosis which explains all the information present, at which point the game ends.

If there is no single possible diagnosis (leaving you to conclude that the patient must have two or more conditions to explain all the information gathered)… the game ends!

Date reviewed: 17 October 2023

Please note that while reasonable care is taken to provide accurate information at the time of creation, we frequently update content and links as needed. If you identify any inconsistencies or broken links, please let us know by email.

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