1. Clinical Reasoning: Skills for Decision Making

2. 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

3. 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?

4. 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

5. 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

6. 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)

7. 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

8. Model of Clinical Reasoning

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

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

11. 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

12. 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

13. 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.

14. Physical Therapy Functions – APTA Guide
Examination
Evaluation
Diagnosis
Prognosis
Intervention

15. 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

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

17. 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:
©2003 by American Physical Therapy Association

18. 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

19. 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?

20. 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?

21. 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:
©2003 by American Physical Therapy Association

22. 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

23. 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?

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

25. 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:
©2003 by American Physical Therapy Association

26. 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?

27. 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?

28. 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:
©2003 by American Physical Therapy Association

29. 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?

30. 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?

31. 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?

32. 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?

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

34. 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?

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

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

44. 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

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

46. 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

47. Ways 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 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.