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dOI: 10.1177/1098612X15623112 © The Author(s) 2016 Reaching a diagnosis in veterinary practice may seem fairly straightforward for an experienced clinician – most of the time. However, occasionally a difficult case comes along which not only leads to confusion, but undermines confidence. Why do we find some cases more difficult to diagnose than others? Have we been misled by the information provided by the client? Perhaps we have misunderstood the significance of, overlooked, or not asked for some piece of critical information? Confronted with a dyspnoeic cat, for example, did we forget to ask about any change in the meow? This might have alerted us to laryngeal cancer as the potential cause (Figure 1a). Or is the difficulty in diagnosis because we have never seen a case like this before (Figure 1b) and can’t think of a logical way to start the investigation? Conversely, is it because we have seen similar cases before, but this one turns out to be more complicated than we thought? Perhaps the presenting signs are due to a second or even a third disease process superimposed on the primary disease; not just diabetes mellitus, but pancreatitis and a bacterial urinary tract infection as well. Maybe the case seems difficult purely because it is the first patient of the morning and we don’t think well first thing. Possibly we just had an argument with our spouse or colleague and feel in no fit state to rationally tackle a complex case. Is it because we work on our own with no-one to bounce ideas off, or simply get bogged down in too much detail? Perhaps we have lost faith in our intuition (or never really had any in the first place). These and related issues can all too easily give rise to diagnostic errors. In the medical literature, it is recognised that diagnostic error can be divided into three categories: (1) ‘no-fault’ error – due to unusual presentation of disease or deliberate or unknowing deception by the patient (client in a veterinary context); (2) system-related error – due to organisational or technical failures and bias leading to lack of results, delayed results, or false or misleading results; and (3) cognitive error (flawed or misleading thinking) – due to faulty knowledge, data gathering or synthesis. This division is somewhat arbitrary, as there is some overlap between the categories and it can be argued that all three impact on clinical reasoning. However, what is indisputable is that all three types of error apply to veterinary diagnosis.

Think about how you think about cases