Clinical Competency Rubric

3. Making a diagnosis, decision making and reasoning

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Table of contents

This is about a conscious, structured approach to making diagnoses and decision-making. This focuses on all the steps leading up to formulating a diagnosis or problem list. This also includes diagnostic accuracy that does not necessarily require the correct diagnosis, but that the direction of reasoning was appropriate and accurate. The doctor’s ability to think about and reflect on their reasoning is another aspect of this assessment domain. This WBA competency is closely aligned with information gathering but can be assessed in different ways.

Required knowledge

Human body and disease
Safe management of common and important presentations in general practice

Required attitudes

Empathy
Ability to deal with uncertainty and ambiguity
Curiosity
Professionalism
Commitment to learning and development

Required skills

High-level problem solving
Critical thinking
Comprehensive diagnostic skills
Patient-centred and safe clinical decision making

Skills focus: Problem solving, decision-making, dealing with uncertainty

Criteria

Integrates and synthesises knowledge to make decisions in complex clinical situations
Modifies differential diagnoses based on clinical course and other data as appropriate
Demonstrates diagnostic accuracy: This does not require the correct diagnosis, but that the direction of reasoning was appropriate and accurate
Collects/reports clinical information in a hypothesis driven manner
Articulates an appropriate problem definition
Formulates a rational list of differential diagnoses including most likely, less likely, unlikely and can’t miss diagnoses
Directs evaluation and treatment towards high priority diagnoses
Demonstrates metacognition (thinking about own thinking)

Performance lists

Criteria (competent at level of Fellowship)	Performs consistently at the standard expected
Integrates and synthesises knowledge to make decisions in complex clinical situations	Is comfortable with the range of patients who present to the practice Discusses key and differentiating features of symptoms and uses this to sort them into likely diagnoses Discusses epidemiology of symptoms (who gets the disease) including demographics, risk factors Considers the temporal course including the duration of the symptoms and pattern of symptoms Outlines the pathophysiology of the disease
Modifies differential diagnoses based on clinical course and other data as appropriate	Reviews history, progress and current status at follow up Reviews discharge summaries, specialist reports Reflects on feedback from the patient or others and incorporates this
Demonstrates diagnostic accuracy - this does not require the correct diagnosis, but that the direction of reasoning was appropriate and accurate	Discusses patterns of disease presentation and how the pattern recognition enabled diagnostic accuracy Gathers information appropriately targeted to the most likely diagnosis
Collects/reports clinical information in a hypothesis driven manner	Follows a clear line of enquiry, directing questioning and examination to specific findings likely to increase or decrease the likelihood of a specific diagnosis
Articulates an appropriate problem definition	Provides a clear synopsis of the clinical problem Emphasises important positive and negative findings
Formulates a rational list of differential diagnoses (including most likely, less likely, unlikely and can’t miss diagnoses)	Provides an accurately ranked differential diagnosis Demonstrates the use of a safe diagnostic strategy
Directs evaluation and treatment towards high priority diagnoses	Defers investigations that are directed to less likely/less important diagnoses Efficiently directs evaluation and treatment towards more likely and can’t miss diagnoses
Demonstrates metacognition (thinking about own thinking)	Can discuss factors that influenced decision-making, including any emotional or situational factors
Aboriginal and Torres Strait Islander health context Demonstrate effective diagnostic and management strategies that enhance health outcomes for Aboriginal and Torres Strait Islander patients

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