Intended for healthcare professionals

Clinical Review State of the Art Review

Diagnostic reasoning in cardiovascular medicine

BMJ 2022; 376 doi: (Published 05 January 2022) Cite this as: BMJ 2022;376:e064389
  1. John E Brush Jr, senior medical director, professor of medicine12,
  2. Jonathan Sherbino, assistant dean, professor34,
  3. Geoffrey R Norman, professor emeritus and scientist3
  1. 1Sentara Health Research Center, Norfolk, VA, USA
  2. 2Eastern Virginia Medical School, Norfolk, VA, USA
  3. 3McMaster Education Research, Innovation and Theory (MERIT) Program, McMaster University, Hamilton, ON, Canada
  4. 4Department of Medicine, McMaster University, Hamilton, ON, Canada
  1. Correspondence to: J E Brush jebrush{at}


Research in cognitive psychology shows that expert clinicians make a medical diagnosis through a two step process of hypothesis generation and hypothesis testing. Experts generate a list of possible diagnoses quickly and intuitively, drawing on previous experience. Experts remember specific examples of various disease categories as exemplars, which enables rapid access to diagnostic possibilities and gives them an intuitive sense of the base rates of various diagnoses. After generating diagnostic hypotheses, clinicians then test the hypotheses and subjectively estimate the probability of each diagnostic possibility by using a heuristic called anchoring and adjusting. Although both novices and experts use this two step diagnostic process, experts distinguish themselves as better diagnosticians through their ability to mobilize experiential knowledge in a manner that is content specific. Experience is clearly the best teacher, but some educational strategies have been shown to modestly improve diagnostic accuracy. Increased knowledge about the cognitive psychology of the diagnostic process and the pitfalls inherent in the process may inform clinical teachers and help learners and clinicians to improve the accuracy of diagnostic reasoning. This article reviews the literature on the cognitive psychology of diagnostic reasoning in the context of cardiovascular disease.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: All of the authors contributed to all aspects of the preparation of this review. JEB is the guarantor.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: JEB receives royalties from Dementi Milestone Publishing for the book The Science of the Art of Medicine: A Guide to Medical Reasoning.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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