Clinical Reasoning

Jorge E. Valdez MD,MA.Dean

School of Medicine and Health Sciences

Competencias

Técnicas Competencias

Intelectuales

Competencias

Analíticas y Creativas

Competencias en

Profesionalismo

1. Aplicación de habilidades clínicas.

2. Manejo de recursos diagnósticos3. Manejo terapéutico.4. Promoción de salud yprevención de la enfermedad.5. Habilidades de comunicación.6. Aplicación dehabilidades para el manejode la información.

7. Aplicación del entendimiento de las

Ciencias Básicas, Clínicas y Sociales para

la práctica clínica.

8. Razonamiento, juicio clínico y

toma de decisiones.

9. Desempeño del Médico dentro del sistema de salud.10. Ética y desarrollo personal.

Estructura Curricular Centrada en Competencias

Objectives

• By the end of this lecture, students should be able to: – • Understand the need for clinical reasoning – • Define clinical reasoning – • Understand the clinical reasoning process

Need for clinical reasoning

• People live longer with more chronic and complex problems.

• Health professionals are expected to be more responsible, to work with diverse teams, and to make more independent judgements and decisions.

• There is information overload because of instant access to information through computers.

• Doctors are frequently involved in complex situations, which require an increasing level of responsibility

Definition:

• The thinking and/or decision-making processes that are used in clinical practiceHiggs and Jones 2000, Edwards et al 2004

Goal = “Wise Action”

Clinical Reasoning• Refers to a process in which the therapist,

interacting with the patient, structures meaning, goals & health management strategies based on clinical data, client choices, professional judgment & knowledge (Higgs and Jones 2000)

• –Hypothesis oriented, collaborative and reflective• –Knowledge and organization of knowledge are

important

Process of Clinical Reasoning

Theoretical Models of Reasoning1.Knowledge -Reasoning Integration (Schmidt et al

1990)2.Integrated Patient Centered Model (Higgs and

Jones 1995)3.Hypothetic–Deductive (Elsteinet al 1978)4.Pattern Recognition (Barrows &Feltovich1987)

Knowledge –Reasoning Integration

• CR is not separate skill from knowledge and clinical skills

• Important for knowledge to be domain-specific• With increasing knowledge and reasoning skills

–knowledge structure changes (towards illness scripts)

(Schmidt et al 1990)

Developing Expertise

• Knowledge acquisition and clinical reasoning go hand in hand.

• Occurs in stages• Novice →Intermediate

→Experts

Developing Expertise

Level Knowledge Representation Knowledge structure

Novice Networks Knowledge growth and validation

Interm Networks Encapsulation

Expert Illness Scripts Illness Script formation (instantiated scripts)

BoshuizenH & Schmidt HG (2000)

Developing ExpertiseLevel Clinical Reasoning Control Required Demand (Cogn.)

Novice Long chains of detailed reasoning

Active monitoring each step

High

Interm Reasoning thru’Encapsulated network

Active monitoring each step

Med

Expert Illness script activation and instantiation

Monitoring at level of script

Low

Integrated Patient-Centred Model

• Involves 3 core elements –Knowledge –Cognition –Metacognition

• Incorporates mutual decision making process with the patient

• Contextual interaction (situation/ environment)

Knowledge• Biomedical knowledge• Clinical knowledge• Everyday knowledge• Increase growth of knowledge

needs to be organized to be useful

Cognition

• Perception of relevant from irrelevant information

• Interpretation of information and hypothesis testing

• Inquiry strategies (hypothesis testing)

• Weighting and synthesis of information

Metacognition

• Therapist‘s awareness, self-monitoring and reflective processes

• Thinking about your thinking

Reflection

“To be conscience that you are ignorant is a great step to knowledge”

Benjamin Disraeli (1835-1910)

Narrative Reasoning

• Understanding the patient’sIllness experiences“stories”Meaning perspectivesContextsBeliefs Cultures

Using Narrative Reasoning

• Patient wants to return to his job• Shows up for all clinical appointments and does

everything that is asked of him during appointment

• Does not “get around”to doing the exercises at home

• Without exercises, treatment will not be successful• How do we proceed?

Integrated Patient-Centred Model

The client´s input

Knowledge

Metacognition

Cognition

The clinical problem The enviroment

Integrated Patient-Centred Model

Hypothetico-Deductive Reasoning

• Analytic process of reasoning (Eva 2004)• “Backward Reasoning”• Relation between the signs and symptoms and

diagnosis

Hypothetico-Deductive Reasoning

• Hypothesis generating and testing involves both inductive and deductive reasoning

• –Induction -to generate the hypothesis• –Deductive -to test hypothesis

Hypothetico-Deductive Reasoning

Pros• Thorough• Organized• Appears to be a skill

that can be taught to novice clinicians

Cons• Slow• Too much data can

leave reasoner without a direction.

Collaborative reasoning

• Shared decision making between the therapist and the client

• Client’s opinion actively sought and utilized

Pattern Recognition• Direct automatic retrieval of information from

a well organized knowledge base• Seeing a case that strongly resembles a case

seen in the past

Pattern Recognition

• Direct automatic retrieval of information from a well organized knowledge base

• Seeing a case that strongly resembles a case seen in the past

• Non-analytic process of reasoning• “Forward Reasoning”• Illness Scripts• Intuition• Tends to occur unconsciously

Pattern Recognition

Pattern Recognition

Pros•Fast•Conclusions can be

reached with imprecise data

Cons•Lacks certainty•Need exposure to

pattern in order to recognize

Overview of clinical reasoning process

• This process can be represented by an upward and outward spiral, and is a cyclical (iterative) and developing process. Each loop of the spiral involves: – Data input – Data interpretation (or re-

interpretation) – Problem formulation (or re-formulation) – It aims to achieve a progressively

broader and deeper understanding of the clinical problem, and finally to make decisions and to take actions.

Efficacy of a clinical reasoning process relies on:

• Health care professional’s reasoning proficiency

• client’s participation in clinical decision making

The outcomes of the clinical reasoning process can be affected by:

• Internal factors relating to health professionals, e.g. knowledge base, familiarity and experience with this type of case, reasoning skills

• Factors relating to the client, e.g. needs, communication skills, circumstances, choices

• External factors, e.g. institutional expectations, profession-specific frameworks of operation, complexity of the case

Thank You

Jorge.valdez@itesm.mx