2Objectives Be able to define clinical reasoning Understand the complementary roles ofdeductive and inductive clinical reasoningstrategy models3. Understand and be able to explain the clinicalreasoning of expert clinicians compared tonovice cliniciansUnderstand and identify errors in clinicalreasoning strategies
3Common types of clinical decisions include: Who needs treatment and why?What are you treating?How do you know where the pain is coming from?What interventions should be used?What are the expected outcomes of treatment?How should outcomes be measured and documented?What intervention, instructions, services, and number of visits are necessary to meet these outcomes?How should the patient and caregivers be included in the decision-making process?How should the success of the intervention and cost- effectiveness be evaluated?Are referrals needed for other health care services and screenings?
4Clinical Reasoning Definitions: Application of relevant knowledge and clinical skills to the evaluation, diagnosis and management of a patient problem- Barrows HS, Feltovich PJ. Med Ed 1987Cognitive process or thinking used in the evaluation and management of a patient.- Jones, MA Phys Ther 1992-In other words, it is the thinking and associated decision making of the clinician in the practice of physical therapy
5A process of reflective inquiry in collaboration with a patient or familyseeks to promote a deep and contextually relevant understanding of the clinical problemto provide a sound basis for clinical interventions
6Clinical Reasoning:Involves the interaction of individuals in a collaborative exchange to achieve mutual understanding of the problem and to negotiate an agreed-upon plan for addressing that problemIs patient centered and situated within a biopsychosocial model of healthInvolves both deductive and inductive reasoningIs complex, nonlinear, and cyclical in naturePlays a critical role in reflective learning from practice experiences and in the development of clinical expertiseDeductive: general to specific= get all T/M, and baselines, have all information collected the look for a diagnosis from results (more novice)Inductive: specific to general forward thinking (more expert)
7Clinical Reasoning Models Hypothesis GenerationHypothesis are generated from patient history, signs and symptoms and tested in the examination processUtilizes Pattern RecognitionCan be the greatest source of error in thinking-jump to conclusion, ignore needed tests to confirm/counter-dict.Narrative ReasoningHypothesis regarding patients’ interpretation of their experiences are validated through consensus between therapist and patientNot so much what happens to people but how they interpret it
9Development of Clinical Reasoning Dependent upon experienceClinicalPersonalDidacticHypothesis formation and testingConfirm or refute hypothesis
10Clinical Reasoning: Reflection/Re-evaluation Hypothesis Oriented Algorithm for CliniciansHOAC method provides a good algorithm to use for reflection of clinical practice.
11HOAC Conceptual Scheme Guide for evaluation and interventions, and modification of interventionsLogical sequence of activitiesIndependent of treatment philosophiesAssists therapists in seeking consultationsMeans of using evidence in decision makingMeans to document nature and extent of evidence used
12Evaluation Scheme Ideally not linked to an intervention scheme Intervention Schemes:Lack ability to be generalizedDeal only with information important to that schemeContain inherent assumptions of cause based on those schemes but not mechanism for testing outside the scheme
13Clinical Reasoning Strategies Model Dynamic relationship between the diagnostic or deductive reasoning process and the narrative inductive reasoning.Using both processes provides a more complete understanding than either aloneUsing both of these processes together should help to collect and analyze the patient data and tests and measures.
15Physical Therapy Responsibilities PT must determine the patient goalsPT must generate hypotheses concerning cause of dysfunctionsPT must determine if the goals have been metPT must determine modifications if goals haven’t been achieved
161. Collect Initial Data Interview History Chart review Subjective informationWhat are the patient’s reasons for seeking physical therapy?
18Case History 51 year old male employed as an electrician Work is mainly installing ceiling light fixtures for several stores in his areaHas difficulty working at presentPain in in the right anterior shoulder especially with movement into elevation and depression of GH jointPMH: shoulder impingement and ? Tear of right supraspinatus several years ago; generalized arthritis, bouts of gout since age 28, no exacerbation at presentPSH: right rotator cuff surgery one year agoMedications: None
192. Generate a Problem Statement Before doing the actual examination, you would already be establishing goals for the patientMust be functional and measurableGuides the development of goals, put into the problem oriented formatWhat can your patient not do?What would your goals be for this patient?How would you make them functional and measurable?
20Not for diagnostic terms and clinical impressions Anticipated problems could be listed here (NPIP)Problems Identified by the Patient (PIP)Functional limitations and disabilitiesWhat would be some anticipated problems if this patient didn’t undergo treatment successfully?
22Two Types of Problems PIP’s: patient identified problems Functional limitationsDisabilitiesTherapist needs to generate hypotheses as to problem cause and establish testing criteriaNPIP’s: non patient identified problemsProblems not identified by the patientMay be seen by therapist or reported by family member
233. Examination Testing criteria established before exam begins Critical values for measurementsWhat will your testing criteria be?Can you list three working hypothesis for this patient?
24Independent from treatment goals Collection of objective dataWhy would you test this?What do you need to know more about?
295. Plan for Re-evaluation Mechanisms for testingHas the patient met the goals set?What modifications are needed?Schedule for reexamination should occurWhen will you see this patient again?How often will you re- evaluate the patient?
306. Treatment Strategy Overall approach that will be adopted Only established by the therapistWhat overall treatment philosophy will you use to treat this patient?
317. Intervention TacticsSpecific interventions that will be used to meet the strategiesPrescribed for a finite period of timeWhat are the specific techniques that will apply to the goals?How much time will you spend on interventions?
328. Treatment Implementation of program Who will do what when? May be implemented by a number of different people, not just the PTWho will do what when?
339. Reassessment Goals met Criteria for discharge Modification of interventionsDid your treatment interventions allow this patient to achieve her goals?
34Self Assessment of Patient Management Strategy correct?Hypothesis viable?New hypothesis and strategy necessary?Will you have to change your strategy? Your hypothesis?How will you know change is necessary?
35Summary of HOAC Method Conceptual scheme Generate hypothesis prior to seeing the patientGenerate testing criteriaDevelop rational for physical therapy interventionDevelop goals, outcomes, prognosisSet Criteria for re-evaluation
36Clinical ReasoningThe cognitive processes used in the evaluation and management of a patientApplication of relevant knowledge and clinical skills to the evaluation, diagnosis and management of a patient problem (Barrows and Feltovich, 1987)As first contact (direct access) PT’s must be able to use clinical reasoning and decision making to assist the patient in getting the proper care.Information obtained is only as useful as the clinician’s reasoning skills.Characterized by:1. skills in problem solving2. clinical reasoning3. reflective process4. critical self-evaluation5. Self directed learning
38Steps taken by a clinician to reach physical therapy diagnosis and management (intervention) decisionsHOAC method may be utilized hereHow does the physical therapy diagnosis used in clinical reasoning differ from the hypothesis development in the HOAC method?Process involvescollecting and analyzing information,generating hypotheses concerning the cause or nature of the conditionInvestigating or testing the hypothesesDetermining the optimum diagnostic and treatment decisions based on data obtained
39Professional Development of Expert Clinicians Stage One: accumulation of biomedical, basic scientific knowledgeKnowledge is linked in a network presented through formal educationClinical reasoning is based on biomedical conceptsStudents have difficulty differentiating between relevant and irrelevant patient findings – excessive hypothesis develop
40Stage Two DevelopmentIntegration of biomedical knowledge into clinical knowledgeOccurs with increase experience with patientsLinks are formed between patient findings and clinical conceptsHypothesis formation is more refined
41Stage Three Development “illness scripts” begin to developClinical patterns plus the information on predisposing factors, medical hereditary conditions, patho-physiological process that occurs, presenting signs and symptomsIncreases efficiency of knowledge network, search less for information
42Stage Four Development Content and structure involved in the storage of clinical encounters as “instant scripts” in memoryStored separately from the clinical knowledgeRecognize variations of the “instant scripts” of basic clinical patterns seen in practiceJones M (1994) Clinical Reasoning in Orthopedic Manual Therapy in Physical Therapy of the Cervical and Thoracic Spine, 2nd ed. Churchill Livingston
43Clinical Reasoning: Reflection/Re-evaluation Hypothesis OrientedHOAC method provides a good algorithm to use for reflection of clinical practice.
44Errors in Clinical Reasoning Framing Errors:Forming a wrong initial concept of the problemFailure to generate plausible hypothesisInadequate testing of hypothesisPremature acceptance of the hypothesisFailure to attend to features that are missingOver-emphasis on features which support the “favorite” hypothesisFraming errors
45Confirmation BiasTendency to look for, notice, and remember information that fits with our pre-existing expectations.Competing hypothesis aren’t tested
46Outcome BiasOverreliance on outcome information to indicate the accuracy or quality of the clinical reasoning that occurred when the interventions were chosenGood outcome = good clinical reasoningPoor outcome = ?, situation outside PT control
47Ways to Overcome Errors -Klein, J Ways to Overcome Errors -Klein, J. Five pitfalls in decisions about diagnosis and prescribing. BMJ. 2005;330-7:Develop an awareness of cognitive processer or reasoning used to come to clinical decisionsUnderstand common clinical reasoning errorsTry to understand why your reasoning might be wrongAlways include in the exam questions, physical screening and tests and measures that would disprove your hypothesisDevelop a knowledge of prevalence and incidence of various conditions, make sure you don’t jump to pattern recognition too soon.