Clinical Reasoning: Skills for Decision Making

Objectives Be able to define clinical reasoning Understand the complementary roles of deductive and inductive clinical reasoning strategy models 3. Understand and be able to explain the clinical reasoning of expert clinicians compared to novice clinicians Understand and identify errors in clinical reasoning strategies

Common 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?

Clinical 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 1987 Cognitive 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

A process of reflective inquiry in collaboration with a patient or family seeks to promote a deep and contextually relevant understanding of the clinical problem to provide a sound basis for clinical interventions

Clinical 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 problem Is patient centered and situated within a biopsychosocial model of health Involves both deductive and inductive reasoning Is complex, nonlinear, and cyclical in nature Plays a critical role in reflective learning from practice experiences and in the development of clinical expertise Deductive: 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)

Clinical Reasoning Models Hypothesis Generation Hypothesis are generated from patient history, signs and symptoms and tested in the examination process Utilizes Pattern Recognition Can be the greatest source of error in thinking-jump to conclusion, ignore needed tests to confirm/counter-dict. Narrative Reasoning Hypothesis regarding patients’ interpretation of their experiences are validated through consensus between therapist and patient Not so much what happens to people but how they interpret it

Model of Clinical Reasoning

Development of Clinical Reasoning Dependent upon experience Clinical Personal Didactic Hypothesis formation and testing Confirm or refute hypothesis

Clinical Reasoning: Reflection/Re-evaluation Hypothesis Oriented Algorithm for Clinicians HOAC method provides a good algorithm to use for reflection of clinical practice.

HOAC Conceptual Scheme Guide for evaluation and interventions, and modification of interventions Logical sequence of activities Independent of treatment philosophies Assists therapists in seeking consultations Means of using evidence in decision making Means to document nature and extent of evidence used

Evaluation Scheme Ideally not linked to an intervention scheme Intervention Schemes: Lack ability to be generalized Deal only with information important to that scheme Contain inherent assumptions of cause based on those schemes but not mechanism for testing outside the scheme

Clinical 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 alone Using both of these processes together should help to collect and analyze the patient data and tests and measures.

Physical Therapy Functions – APTA Guide Examination Evaluation Diagnosis Prognosis Intervention

Physical Therapy Responsibilities PT must determine the patient goals PT must generate hypotheses concerning cause of dysfunctions PT must determine if the goals have been met PT must determine modifications if goals haven’t been achieved

1. Collect Initial Data Interview History Chart review Subjective information What are the patient’s reasons for seeking physical therapy?

The initial steps of Part 1 of the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II). Rothstein J M et al. PHYS THER 2003;83:455-470 ©2003 by American Physical Therapy Association

Case History 51 year old male employed as an electrician Work is mainly installing ceiling light fixtures for several stores in his area Has difficulty working at present Pain in in the right anterior shoulder especially with movement into elevation and depression of GH joint PMH: shoulder impingement and ? Tear of right supraspinatus several years ago; generalized arthritis, bouts of gout since age 28, no exacerbation at present PSH: right rotator cuff surgery one year ago Medications: None

2. Generate a Problem Statement Before doing the actual examination, you would already be establishing goals for the patient Must be functional and measurable Guides the development of goals, put into the problem oriented format What can your patient not do? What would your goals be for this patient? How would you make them functional and measurable?

Not for diagnostic terms and clinical impressions Anticipated problems could be listed here (NPIP) Problems Identified by the Patient (PIP) Functional limitations and disabilities What would be some anticipated problems if this patient didn’t undergo treatment successfully?

The final steps of Part 1 of the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II). Rothstein J M et al. PHYS THER 2003;83:455-470 ©2003 by American Physical Therapy Association

Two Types of Problems PIP’s: patient identified problems Functional limitations Disabilities Therapist needs to generate hypotheses as to problem cause and establish testing criteria NPIP’s: non patient identified problems Problems not identified by the patient May be seen by therapist or reported by family member

3. Examination Testing criteria established before exam begins Critical values for measurements What will your testing criteria be? Can you list three working hypothesis for this patient?

Independent from treatment goals Collection of objective data Why would you test this? What do you need to know more about?

The algorithm for reassessment of existing problems in Part 2 of the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II). The algorithm for reassessment of existing problems in Part 2 of the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II). Rothstein J M et al. PHYS THER 2003;83:455-470 ©2003 by American Physical Therapy Association

4. Working Hypotheses List three goals for this patient Why goals can or cannot be met at the present time Are goals viable? Measurable? If yes, proceed If no, modify How will you measure these goals?

Written in behavioral terms Include only problems re-mediated through treatment How will you plan treatment for these goals? How will you progress treatment as patient gets better?

The algorithm for reassessment of anticipated problems in Part 2 of the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II). The algorithm for reassessment of anticipated problems in Part 2 of the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II). Rothstein J M et al. PHYS THER 2003;83:455-470 ©2003 by American Physical Therapy Association

5. Plan for Re-evaluation Mechanisms for testing Has the patient met the goals set? What modifications are needed? Schedule for reexamination should occur When will you see this patient again? How often will you re- evaluate the patient?

6. Treatment Strategy Overall approach that will be adopted Only established by the therapist What overall treatment philosophy will you use to treat this patient?

7. Intervention Tactics Specific interventions that will be used to meet the strategies Prescribed for a finite period of time What are the specific techniques that will apply to the goals? How much time will you spend on interventions?

8. Treatment Implementation of program Who will do what when? May be implemented by a number of different people, not just the PT Who will do what when?

9. Reassessment Goals met Criteria for discharge Modification of interventions Did your treatment interventions allow this patient to achieve her goals?

Self 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?

Summary of HOAC Method Conceptual scheme Generate hypothesis prior to seeing the patient Generate testing criteria Develop rational for physical therapy intervention Develop goals, outcomes, prognosis Set Criteria for re-evaluation

Clinical Reasoning The cognitive processes used in the evaluation and management of a patient Application 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 solving 2. clinical reasoning 3. reflective process 4. critical self-evaluation 5. Self directed learning

Schön's model of reflective practice.2. Knowing – in- action: knowledge and skills a professional has and uses within the patient context Surprise: occurs when the unexpected happens to change your thought process Experimentation: occurs when a solution to a problem is attempted, clinician has no idea if the solution will work or not Reflection-in-action: meta-cognition, what is occurring at that time, tends to work with experimentation for a solution to a problem Reflection-on-action: Therapist looks back on the situation and broadens or changes his framework. Wainwright S F et al. PHYS THER 2010;90:75-88 ©2010 by American Physical Therapy Association

Steps taken by a clinician to reach physical therapy diagnosis and management (intervention) decisions HOAC method may be utilized here How does the physical therapy diagnosis used in clinical reasoning differ from the hypothesis development in the HOAC method? Process involves collecting and analyzing information, generating hypotheses concerning the cause or nature of the condition Investigating or testing the hypotheses Determining the optimum diagnostic and treatment decisions based on data obtained

Professional Development of Expert Clinicians Stage One: accumulation of biomedical, basic scientific knowledge Knowledge is linked in a network presented through formal education Clinical reasoning is based on biomedical concepts Students have difficulty differentiating between relevant and irrelevant patient findings – excessive hypothesis develop

Stage Two Development Integration of biomedical knowledge into clinical knowledge Occurs with increase experience with patients Links are formed between patient findings and clinical concepts Hypothesis formation is more refined

Stage Three Development “illness scripts” begin to develop Clinical patterns plus the information on predisposing factors, medical hereditary conditions, patho-physiological process that occurs, presenting signs and symptoms Increases efficiency of knowledge network, search less for information

Stage Four Development Content and structure involved in the storage of clinical encounters as “instant scripts” in memory Stored separately from the clinical knowledge Recognize variations of the “instant scripts” of basic clinical patterns seen in practice Jones M (1994) Clinical Reasoning in Orthopedic Manual Therapy in Physical Therapy of the Cervical and Thoracic Spine, 2nd ed. Churchill Livingston

Clinical Reasoning: Reflection/Re-evaluation Hypothesis Oriented HOAC method provides a good algorithm to use for reflection of clinical practice.

Errors in Clinical Reasoning Framing Errors: Forming a wrong initial concept of the problem Failure to generate plausible hypothesis Inadequate testing of hypothesis Premature acceptance of the hypothesis Failure to attend to features that are missing Over-emphasis on features which support the “favorite” hypothesis Framing errors

Confirmation Bias Tendency to look for, notice, and remember information that fits with our pre-existing expectations. Competing hypothesis aren’t tested

Outcome Bias Overreliance on outcome information to indicate the accuracy or quality of the clinical reasoning that occurred when the interventions were chosen Good outcome = good clinical reasoning Poor outcome = ?, situation outside PT control

Ways to Overcome Errors -Klein, J Ways to Overcome Errors -Klein, J. Five pitfalls in decisions about diagnosis and prescribing. BMJ. 2005;330-7:781-784 Develop an awareness of cognitive processer or reasoning used to come to clinical decisions Understand common clinical reasoning errors Try to understand why your reasoning might be wrong Always include in the exam questions, physical screening and tests and measures that would disprove your hypothesis Develop a knowledge of prevalence and incidence of various conditions, make sure you don’t jump to pattern recognition too soon.