Clinical Reasoning

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invite yves talbot and melissa nutik, from UofT, to review. They presented on this at FMF 2010.

• ask them about anchor prototypes

 

 

 

Introduction

Clinical reasoning is essential to health professionals' competence, and reasoning skills should be taught and evaulated (Bowen, 2006). It is important to develop structured approaches to different chief compaints early in training, and to continue honing these approaches throught the career.

 

What are the most common causes? What are the most serious causes (which do you need to rule out before you go for coffee?)

 

 

reasoning process

memory: expertise and recall

knowledge representation (basic science, ; experiental knowledge)

 

 

 

What is Clinical Reasoning?

Expert reasoning depends on extensive knowledge base, learned early during pre-clinical years, and the ability to organize and reorganize it to reach a diagnosis in a variety of ways, given presentation and context. "Clinicians often unconsiously use multiple, combined strategies to solve clinical problems, suggesting a high degree of mental flexibility and adaptability in clinical reasoning (Bowen, 2006).

 

Clinical reasoning requires extensive practice, and "it is emerging that central to the acquisition of expertise...is the opportunity for deliberate practice with multiple examples and feedback, both to facilitate effective transfer of basic concepts and to ensure an adequate experiental knowledge base (Norman, 2005).

 

The steps of clinical reasoning have been well laid out by Dr Bowen in a NEJM paper. She describesL

 

Chief complaint.

Initial hypothesis to guide the rest of the clinical experience.

history, physical exam, previous charts, investigations

accurate problem representation.

• summarize the cases in 1-2 sentences, often unconsciously
• for new learners, depends on understanding medical terminology
• important to delay this as the story is fleshed out; do not jump prematurely to conclusions
• include patient's own words

generation of hypothesis

• probe for supporting evidence

 

search for and select the illness script

• syndrome, condition, disease in mind: stored, clinicially useful knowledge in ANCHOR PROTOTYPES
• from this point, can return to data acquisition for further analysis

 

diagnosis

• get a commitment
• refined the problem representation, for communication to patient, other health care professionals, charting (similar to the 'assessment' in a SOAP note)

Junior learners are slower and require more deliberate hypothesis testing, while experts are focused and purposeful in searching for, and verifying or refuting, illness scripts during data acquisition.

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Expert Clinical Reasoning

Simple facts, stored and accessed from memory, plays only a limited role. Learners depend extensively on memorized knowledge, while experts use little basic science knowledge. However, knowledge representation can be very helpful.

 

Clinical epidemiology is also critical in clinical reasoning, and a good clinican will consider disease probabilites when attempting to apply an illness scripts.

 

Experiental memory plays an important role in an individual's decisions. Anchor prototypes are critical to form early in training, and a good preceptor will endeavour to ensure this happens.

 

Experience can also lead to idiosyncratic clinical choices, even in the face of evidence. For example, a clinician who catastrophically misdiagnosed a pulmonary embolism may order unnecessary lab tests or imaging on all patients with dysnpea, even though this is clearly inappropriate.

 

** Help early learners create anchor prototypes early during their training. This is important to gain early on.

 

Clinicians often unconsciously use multiple strategies to solve clinical problems, suggesting a high degree of (Bowen, 2006).

 

Come to understand, generally, what an illness script looks like.

 

 

 

Learner Difficulties

As they progress in the capacity, learners can struggle in a variety of ways. It is important for both learner and preceptor to identify and diagnose the specific type(s) of difficulty, in order to improve. The following is modified from Bowen, 2006.

 

skill	symptom	diagnosis	educational strategy
data acquisition and reporting	missing information	difficulty identifying or obtaining information	model
problem representation	disorganized presentation	lack of experience, or lack of approach	elicit or confirm findings; link findings to your representation
problem representation	summary statement only loosely connected	incomplete understanding of case; no problem representation identified	review importance of problem representation. Ask for 1-2 sentence summary, and compare/contrast with yours
hypothesis generation	multiple diagnoses with no prioritization	no problem respresentation; illness scripts not available; limited understanding of prevalence	list important findings, formulate summary, prioritize based on discriminating characteristics for each diagnosis
hypothesis generation	differential diagnosis not linked with case findings	illness scripts not yet developed, or difficulty comparing/contrasting diagnoses	ask to support diagnoses with findings; ask for additional possibilities
knowledge gap	far-fetched diagnosis	poor understanding of cases, disease, or prevalence	ask to describe illness script for the unlikely diagnosis, then contrast. Identify what is required to rule it out
organization of complex information	disorganized presentation	risk of premature closure when more than one problem representation is possible	ask for plausible problem representations
inexperienced learner	performance globally below expected	has not yet committed 'anchor prototype' to memory, or too little experience	assign patients and readings to create anchor prototype

 

 

For Preceptors

Can be helpful to directly observe their history and physical exam in order to validate the findings. Once this happens a few times, trust begins to build.

 

Skilled questioning and demonstration can be very helpful.

OSCEs can be extremely helpful. Simulated patients

 

 

Reasoning Research

 

 

 

Risks

Premature closure

 

 

Resources and References

Bowen JL. 2006. Educational strategies to promote clinical diagnostic reasoning. NEJM. 355:2217-25.

Norman GR. 2005. Research in clinical reasoning: past history and current trends. Med Education. 39:418-427.

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