Diagnostic Reasoning in the Pain-Focused Encounter

Abstract

Chapter 7 addresses the processes and pitfalls of evaluating, reasoning about, and attending to the needs of patients with pain. This chapter builds on Chapter 6, which addressed clinical assessment, explaining in detail the process of extracting and abstracting information from the pain narrative (clinical history or interview) to lay the foundation for a problem list and differential diagnosis. The problem list and differential diagnosis are described and contrasted so that clinicians will be comfortable with both. A clinical model explains the need for patient-centered approaches to be omnipresent but balanced with an appropriate disease-centered knowledge base that is likewise informed by understanding the patient’s healthcare-related values and motivations. A balanced approach is emphasized. The process of planning for diagnostic testing, including imaging, laboratory testing, provocative maneuvers, and targeted referrals, is described. The last section of the chapter addresses the impact and nature of cognitive and affective biases that can mitigate the effectiveness of diagnostic reasoning. A coordinated strategy to limit the negative impact of diagnostic reasoning biases is presented in a memorable way. Finally, the ethics of errors and error disclosure are discussed as well as the process of error disclosure.