Download Shaping Clinical Reasoning

9/3/2014
Story..
• Take home message—clinical reasoning is the glue in OMPT learning
Shaping Clinical Reasoning:
A Collaborative Approach Using Varied Case Reports and Vignettes for
Entry-level and Fellowship Students.
Carina D Lowry and Carol A Courtney
Objectives
Clinical Reasoning
• By the end of this presentation, the learner will:
• Describe metacognition and explain techniques that the student can use to
develop metacognition.
• Explain several ways to incorporate clinical reasoning case reports into
entry level and fellowship curricula.
• Describe how videotape and interactive learning platforms can be utilized
to give feedback on clinical reasoning processes.
• Recognize the role of clinical instructor, clinical faculty, and small group
facilitators in guiding clinical reasoning.
• Identify pitfalls and errors in student reasoning and what to do to ensure a
helpful learning environment.
• Clinical Reasoning: thinking and decision making associated with clinical
practice that enables therapists to take the best-judged action for
individual patients
• Hypothetico-deductive: Hypothesis testing for diagnosis/management
• Pattern recognition: Associate current problem with pattern for
management
• Narrative: Collaborative reasoning between patient and clinician for
management
Jones and Rivett, 2004
Metacognition
Clinical Reasoning
Novice
“Expert”
• Requires more cues from patient
and environment.
• Broad base of questions
• Many hypotheses to be tested
• Difficulty with pattern
generation and recognition
• Single hypothesis reasoning
• Able to pick up cues more quickly
from patient and environment.
• Narrows focus for questions
• Explores fewer hypotheses more
thoroughly/deeply
• Recognizes patterns easily in their
domain
• Able to reason in different
hypotheses simultaneously
“Being aware of one’s cognitive processes and exerting control over
these processes” (Higgs and Jones, 2000)
The ability to think about one’s clinical reasoning, and being able to
modify one’s behavior based upon this awareness.
Often seen as a progression toward mastery level and indicates that the
student is able to use a hypothetico-deductive model reasoning
process (Rushton, 2009)
Jones and Rivett, 2004
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However, today we want to:
• Explore how to improve clinical reasoning and metacognition through
pattern recognition and the “lowly” case report
• Show that pattern recognition really is more of a mastery level skill
when you reason in different hypotheses categories simultaneously
• Outline how to integrate case reports into Physical Therapy
education—at entry level, residency, and fellowship level.
Hierarchy of Evidence—Why the Case Report?
1. Case reports allow for
individual patient
considerations whereas they
may be excluded from an RCT.
2. Case reports can give more
detail to examination and
treatments.
3. Case reports can explore more
of the “why did I pick this
specific diagnostic test,
treatment procedure, etc.” to
fit the patient case.
4. Case reports can “tell the
patient’s story”.
http://myhome.spu.edu/cfry/ebp.htm
How does your student learn?
Narrative Reasoning
• The patient’s interpretation of his/her unique story
• “Construction of Meaning”
• Choice of what is expressed, what is emphasized, and what is not expressed
• Gains insight into the patient’s experiences of disability, pain, beliefs,
feelings, health behaviors.
• Affects patient’s ability to learn and their learning styles
• Affects treatment choice
• Validated by consensus between patient and therapist.
Howard Gardner’s Theory of
Multiple Intelligences, 1983
Edwards, Physical Therapy, 2004
Another story…..
3 Broad Categories
• Determining irritability is a skill that develops with clinical reasoning
and experience.
• Three categories of mental representation
1. Basic science
2. Formal knowledge of disease probabilities, scripts, and schemas
3. Experiential knowledge: exemplars aka pattern recognition.
• Conclusion: “the more important finding is that focusing instruction
on one processing strategy or another may be less important than
engaging students with many problems, which are carefully
sequenced to optimize learning and transfer.”
Norman, Medical Education, 2005
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Entry Level DPT Years 1-3
“Paper” patients
• Didactic Learning through “paper” or virtual patients
• Designed case based upon a real patient or a well known clinical
pattern or common diagnosis.
• Use of Learning Platform like D2L, Blackboard
• “Learn as you go” format
• Reproducible and low cost
• Limited visual unless videos are incorporated into the case
• Pattern Recognition Notebooks
• Based on didactic material/textbooks/Clinical guidelines
• Additional Pattern Generation during clinical rotations
• Selection of Case Report patient during clinical rotations
• Guided by clinical instructor
• Written case report 2nd year
• Oral defense case report 3rd year
• Use of 2nd year students to simulate paper patients for 1st year
• Refines interview skills with practice
• Transfers to clinical practice with real patients
• Second year students then have more in depth discussions for
examination and management, home setting, etc.
• Meet with expert clinician and peers to discuss case as it progresses.
• Can be interdisciplinary peers
Patient
Initiating the session
Doctor
Initial Rapport
Virtual Patients in Primary Care
• Swedish Qualitative Study of 3rd year medical school students
• Interactive case study on a virtual learning platform
• Videos of standardized patient and primary care MD embedded in case
• 5 sections (see next slide)
• Reflections in each section
• Generally positive learning experience reported
• Intermediate activity between didactic theory and real patients
Gathering information
The student’s strategy,
history taking
Clinical Reasoning
Pattern
Recognition
Physical Examination
Hypothesis
Generation
Patient’s ideas,
concerns and
expectations,
The patient’s
unique
experience of
illness
Doctor’s ideas,
concerns and
expectations.
The doctor’s
agenda
Preliminary diagnosis
Collaboration during the physical exam
Explanation and
planning
Shared understanding and involvement
in decision making
Closing the session
Follow up and farewell
(Salminen, 2014)
(Adapted from Salminen, 2014)
Virtual Patients Key Points cont.
Pattern Recognition Notebooks
1.
2.
3.
4.
5.
6.
• Use of clinical reasoning forms for visualizing pain referral patterns,
reasoning in different hypothesis categories, and management
• Common diagnoses and patterns at first didactic
• Clinical patients when student goes on rotation reflection on
action
• Allows organization of patterns
Preformulated comments based on EBP presented as text for case
Text and video used for learning and collaboration
Hyperlinks embedded in case
Open ended questions allow free text answers by student
Reflective thought guided by a virtual “tutor”.
Student able to visualize and read communication (both verbal and
nonverbal) between patient and health care provider
7. Reflection-in-action emphasized throughout culminating in
reflection-on-action
• Visual learners and mathematical/logical learners
(Salminen, 2014)
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Clinical Pattern Subjective Form
Clinical Pattern Disorder Name
Common Pain Referral Pattern
Subjective Characteristics
Behavior of Symptoms
• Aggravating
• Ease
• 24 hour
• Precautions/Contraindications
• History of Condition
• Contributing/Predisposing Factors
•
•
•
•
Physical Exam
• Observation
• Functional tasks
• Active ROM
• Passive ROM
• Palpation/Joint Play
• Prognosis
• Impairments
• Functional Limitations
• Disabilities
• Pathobiological Mechanism
• Management/Treatment
• Goals
• Supporting Evidence
Used with permission – Mark Jones
The clinical reasoning form can be a way of forcing
the student to analyze the patient presentation
Another Story…..
• Identifying motivation for the patient and psychological factors may
be more important than the impairment itself.
• Draw a “pie chart” on the
diagram that reflects the
proportional involvement of the
pain mechanisms apparent after
completing the subjective
examination.
Hypotheses Categories
Case Report
• Activity and Participation Capabilities/Restrictions
• Patient’s perspectives and beliefs/psychosocial factors
• Physical Impairments and associated structure/tissue sources
• Pathobiological Mechanisms
• Contributing factors
• Precautions and Contraindications
• Management and Treatment
• Prognosis
• Actual writing of case report
• Can fulfill CAPTE requirements (entry level) and also demonstrate
clinical reasoning in clinical setting
• Merging of didactic and clinical education
• Case report selection is critical
• Promote professionalism
• May need to assist student by finishing case and/or data collection
Jones and Rivett, 2004
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Selection of Case Report (cont.)
Writing Case Reports
• What can you do as a clinical educator to ensure student success with
case report selection?
• Break into sections
•
•
•
•
•
•
•
Unique diagnosis or presentation or treatment approach
As complete course of care as possible
Use an outcome measure
Take good notes/records while maintaining HIPAA
Guide selection of tests and treatments with evidence if possible
This is where we shape clinical reasoning
“What makes this case interesting? What is my angle to discuss?”
•
•
•
•
•
•
Lit Review
Case Description, Outcome Measures, Examination, Intervention
Clinical Impression(s)
Background and Purpose
Outcomes, Discussion, and Conclusion
Abstract when case is final/complete
• Mixed media to introduce writing technique/material
• Meet to review with peers and/or faculty facilitator
• Weekly, Biweekly, Monthly
• Writing on a Timetable
Case Defense
• Oral defense of case that is based upon written report
• Case report selection during clinical rotations
• Displays oral communication skills in entry level, residency, and
fellowship trained students
• Presented to peers, clinical faculty, and clinical educators
• Can be poster presentation at conference
Errors in clinical reasoning in entry level and beyond
• Faulty perception or elicitation of cues
• Deficiency in basic clinical skills
• Incomplete factual knowledge about a disease process or clinical
condition
• Deficiency in content knowledge
• Misapplication of known facts to a specific problem
• Incorrect use of heuristics
• ie. Mechanical Diagnosis and Therapy applied to all patients with low back
pain.
A final story
Entry Level to Residency to Fellowship
• Second year student with a patient with low back pain.
• Should demonstrate a progressively deeper body of knowledge
• More ability to reason in different hypothesis categories
• More ability to reason using dual processing
• More ability to treat patient with different theories
• More ability to explain and defend reasoning using different theories
• “I really thought I should extend him. But it worsened his pain and it
stayed worse.”
• “We were taught McKenzie theory as our low back pain framework. It
blew my mind that he would get worse if I extended him.”
• Can use vignettes, clinical patterns, written case report, and case
defense in all three levels of Physical Therapy education
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Errors in Clinical Reasoning
Norman 2009, Mamede 2014
(Not a complete list)
• Availability
• Tendency to judge diagnoses as more likely if they are more easily retrievable from
memory
Processing Strategies
• Base rate neglect
• Tendency to ignore the true rate of disease, and pursue rare but more exotic
diagnoses
Errors in Clinical Reasoning
• Confirmation Bias
Carol A Courtney
• Premature closure
• Tendency to seek data to confirm, not refute the hypothesis.
• Tendency to stop too soon without appropriate consideration of alternative
possibilities
• ‘Salient distracting features’
Diagnostic error (medical)
Graber et al. 2005
Dual processing
• Analyzed 100 diagnostic errors
• Found an average of 5.9 cognitive errors per case
• Found 4 categories:
•
•
•
•
Faulty Knowledge (11 occasions)
Faulty Data Gathering (45)
Faulty Information Processing (159)
Faulty Verification (106)
• Intuitive (fast):
• earlier in evolutionary development, and is
rapid, contextual, holistic, and unavailable to
introspection
• Automatic formation of memories
• Analytical (slow):
• abstract and inductive
Dual Processing
System 1 (Intuitive)
• experience-based and automatic
• consistent with memories of
individual experiences
• access based on similarity between
the present situation and prior
experience
Intuitive Processing – Implicit Learning
System 2 (Analytical)
• conscious, logical, and without
context
• places heavy loads on working
memory, and is energy-intensive
1. Pattern recognition
2. Common-sense understanding:
• Identification of subtle trends;
3. Similarity recognition:
• ability to recognize subtle likenesses to cues found in past episodes
4. Sense of salience:
• Identifying key pieces of information
• Determining relevance versus irrelevance;
5.Deliberative rationality:
• Selective attention to certain aspects or events
6. Skilled know-how:
• Experiential knowledge, where the tools of a practical situation become an extension of one’s
self.
Ken Randall Dissertation 2009
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Analytical Processing
1.
2.
3.
4.
Which is better? Intuitive or Analytical?
Hypothesis generation
Application of clinical prediction rules
Application of evidence based practice
Reflection
Analytical Processing: Reflection in/on Action
Intuitive Processing
• “inherently flawed”
• Solution: slow down
• Valuable in the early stages of learning
• Reflection strategies explicitly mobilize analytical knowledge
Kahneman 2011
• Promotes greater ‘accessibility’ to knowledge base
• Medical decision making may be different
• Dependent on both systems
• diagnoses are not reasoned so much as they are recognized
Monteiro and Norman 2013
What happens when intuition fails us?
Utilizing both Intuitive and Analytical Thinking
• When signs and symptoms of a diagnosis do not fit:
• Response not triggered
• With recognition failure, System 2 (Analytical) will engage
• Alternatively:
• clinician may act against better judgment and behave irrationally
• Clinician rejects System 2, and defaults to System 1 (Intuitive)
• Good decision makers consciously blend their processing styles
• Although System 1 (intuition) operates at an unconscious level, its
output, once seen, can be consciously modulated by adding a
System 2 (analytical) approach
• Engagement of System 2 may occur when it “catches” an error in
System 1
Croskerry and Norman 2008
Risen and Gilovich 2007
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Overconfidence
Questions to ponder…
• Not always a bad thing?
• Leads to definitive action
• However,
• intuitive thinking may be associated with strong emotions such as
excitement and enthusiasm. Such positive feelings, in turn, have been
linked with an enhanced level of confidence in the decision maker's
own judgment
Tiedens and Linton 2001
• A specific number of practice hours are the standard requirement
before undertaking OMPT Fellowship training, meaning:
• Can lead to:
• Better to gain intuitive knowledge before encouraging a analytical monitoring
of intuitive processing?
confirmation bias
References
• Daniel Kahneman (2011). Thinking, Fast and Slow. Farrar, Straus and Giroux, New York.
• Edwards, I, Jones, M, Carr, J, Braunack-Mayer, A, Jensen, G. (2004). Clinical Reasoning strategies in physical therapy. Physical
Therapy. 84(4):312-330.
• Gardner, Howard (1983). Frames of Mind: The Theory of Multiple Intelligences, Basic Books, ISBN 0133306143
• Jones, M. and Rivett, D. (2005). Clinical Reasoning for Manual Therapists. Philadelphia: Elsevier.
• McEwen, I. (Ed) (2009). Writing Case Reports: A How-To Manual for Clinicians. Washington D.C.: American Physical Therapy
Association.
• Miller, P, Rivett,D, Isles, R. (2009). Pattern recognition is a clinical reasoning process in musculoskeletal physiotherapy. ANZAME09
Handbook, Launceston, NSW.
• Monteiro S and Norman G. (2013). Diagnostic Reasoning: Where We’ve Been, Where We’re Going. Teaching and Learning in
Medicine, 25(S1), S26–S32
• Norman, G (2005). Research in clinical reasoning: past history and current trends. Med. Educ. 39:418-427.
• Norman G (2009). Dual processing and diagnostic errors. Adv in Health Sci Educ 14:37–49.
• Rushton, A, Lindsay, G. (2010). Defining the construct of masters level clinical practice in manipulative physiotherapy. Manual
Therapy. 15:93-99.
• Salminen, H. et al. (2014). Virtual patients in primary care: developing a reusable model that fosters reflective practice and clinical
reasoning. J Med Int Research. 16 (1):1438-8871.
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