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Constructing Clinical Reasoning Skills
Using a Problem-Based Learning Prototype
P. Alex Mabe, Ph. D.
Professor
Department of Psychiatry and Health Behavior
Medical College of Georgia
Workshop
Objectives
 Examine the domain of clinical reasoning.
 Provide an overview of Problem-Based
Learning models in teaching clinical
reasoning.
 Present an adaptation of Problem-Based
Learning designed to teach clinical
reasoning to predoctoral interns/residents.
Acknowledgement
Nettie Albrecht, Ph.D.
Co-Creator/Co-Director of the
Diagnostic/Treatment Seminar - PBL
VAMC Training Director for the
MCG-VAMC Psychology Residency Consortium
Staff Psychologist, VAMC of Augusta
Assistant Clinical Professor of Psychiatry, MCG
Disclaimer
Components of Clinical
Expertise
Experts
 “Experts recognize meaningful patterns and
disregard irrelevant information, acquire extensive
knowledge and organize it in ways that reflect a
deep understanding of their domain, organize their
knowledge using functional rather than descriptive
features, retrieve knowledge relevant to the task at
hand fluidly and automatically, adapt to new
situations, self-monitor their knowledge and
performance, know when their knowledge is
inadequate, continue to learn, and generally attain
outcomes commensurate with their expertise.”
(p.276)
APA Presidential Task Force on Evidence Based Practice
(2006) Evidenced-based practice in psychology. American
Psychologist, 61, 271-285.
Components of Clinical
Expertise - continued
 (a) assessment, diagnostic judgment, systematic case
formulation, and treatment planning;
 (b) clinical decision making, treatment implementation,
and monitoring of patient progress;
 (c) interpersonal expertise;
 (d) continual self-reflection and acquisition of skills;
 (e) appropriate evaluation and use of research evidence
in both basic and applied psychological science;
 (f) understanding the influence of individual and cultural
differences on treatment;
 (g) seeking available resources (e.g., consultation,
adjunctive or alternative services) as needed;
 and (h) having a cogent rationale for clinical strategies.
(p. 276)
APA Presidential Task Force on Evidence Based Practice
(2006) Evidenced-based practice in psychology. American
Psychologist, 61, 271-285.
Components of Clinical
Expertise - continued
competence is "the habitual and judicious use of
communication, knowledge, technical skills,
clinical reasoning, emotions, values, and
reflection in daily practice for the benefit of the
individual and community being served"
(Epstein & Hundert, 2000,p. 227). They further
asserted that competence depends on habits of
mind, including attentiveness, critical curiosity,
self-awareness, and presence. (p.775)
As such, competence connotes the capability of
critical thinking and analysis…
Kaslow NJ (2004) Competencies in professional psychology.
American Psychologist, 59, 774-781.
Conclusions:
 Clinical reasoning is a core
competency of professional
psychologists.
 Teaching clinical reasoning
appears to be a complex task.
How Psychologists Think
Thinking like a psychologist is based on a combination of factors
including:
 (a) critical thinking and logical analysis;
 (b) being conversant with and utilizing scientific inquiry and
professional literature;
 (c) being able to conceptualize problems and issues from multiple
perspectives (e.g., biological, pharmacological, intrapsychic,
familial, organizational/systems, social, cultural);
 and (d) being able to access, understand, integrate, and use
resources (e.g., empirical evidence, statistical approaches,
technology, collegial consultation).
(p. 369)
Elman NS, Illfelder-Kaye J, & Robiner WN (2005) Professional development: training for professionalism
as a foundation for competent practice in psychology. Professional Psychology: Research and Practice,
36, 367-375.
Teaching
Psychologists
How to
Think…
It’s a daunting
task!
Critical thinking and Clinical Reasoning
 Critical thinking – actively and skillfully
conceptualizing, applying, synthesizing and
evaluating information…
 Clinical reasoning – all that plus have a
knowledge of “illness”, “illness scripts”, illness
trajectories, etiology as well as description, and
the integration of problem understanding with
problem solution.
Research Regarding Diagnostic Reasoning
 Success in diagnosing one problem has
been shown to be a poor predictor of
success in diagnosing another.
 Content specificity has been critical in
successful diagnostic reasoning.
 Pattern recognition appears to be key to
diagnostic efficiency and accuracy.
Research Regarding Diagnostic Reasoning –
the development of clinical reasoning
 Expertise is not a matter of acquiring some kind of
general, all inclusive reasoning strategy.
 Knowledge counts … no one kind of knowledge
counts more than any other.
 Expertise (in medicine) is derived from both formal
and experiential knowledge.
 The process of pattern recognition so characteristic
of an “expert’s approach appears to be a product of
extensive experience with patients overlaid on formal
knowledge structure.
Geoffrey N (2006) Building on experience – The development of clinical
reasoning. The New England Journal of Medicine, 355, 2251-2252.
General Training Recommendations:
The Development of Clinical Reasoning
 Encourage students to use both analytical rule
knowledge and experiential knowledge.
 Provide clinical reasoning experience. A
critical element of becoming an expert is
accruing the experience that enables experts
to recognize patterns.
 Help students make the connection between
“basic science” and specific clinical
encounters.
Elements of the Clinical Reasoning Process
 Data acquisition.
 Data organization.
 Data abstraction.
– Hypothetico-deductive method – experts
produce better hypotheses.
– Schema development.
– Illness scripts.
Elements of the Clinical Reasoning Processcontinued
 Case formulation
– Comprehensive.
– Precise.
– Integrated.
– Coherent.
– Systematic
– Goodness-of-fit (problem definition and
treatment)
Elements of the Clinical Reasoning Processcontinued
 Self-monitoring skills.
 Effective use of available resources.
– Evidence based practice.
– Information management.
Teaching Clinical Reasoning-
Criticisms of Traditional
Teaching Methods
 Information overload.
 Passive transfer of expert knowledge.
 Emphasis on knowledge as opposed to
skill and attitudes.
Teaching Clinical
Reasoning-
Adult Learning
 Adults have a foundation of life
experiences and knowledge.
 Adults are goal directed.
 Adults are relevancy-oriented.
 Adults must be shown respect.
Problem Based Learning
(PBL)
 Problem-based learning (PBL) is a method
of teaching first adopted in undergraduate
medical education by McMaster University
in the mid-1960s.
 Currently, more than 90 medical schools
worldwide have incorporated some form
of PBL in their undergraduate curricula.
 Studies have shown that PBL can be a
more successful approach compared with
more traditional curricula with regard to:
– intrinsic motivation
– improving problem-solving skills/clinical
reasoning
– long-term retention of learned knowledge
Common Components of
PBL Instruction
 Small group instruction.
 A gradually evolving clinical
problem is presented.
 Think out loud strategies are
employed.
 Discussion and clinical reasoning
are primarily self-directed although
facilitators are present to assist.
 Identification of learning issues.
 Summarizing what has been
learned.
Aims of PBL Instruction
 Activation and elaboration of prior
knowledge.
 Acquisition and integration of
scientific and clinical knowledge.
 Restructuring prior knowledge.
 Developing clinical reasoning in
context.
 Triggering curiosity and habits of
lifelong learning.
PBL Instruction:
Thinking Out Loud





“What do you know?”
What do you need to know?”
“Why do you need to know…?”
“What are your hypotheses?
“What are your learning issues?”
PBL Instruction:
Content Material Selected
 Often part of a core curriculum in
integrating basic and clinical
sciences.
 Paper based scenarios are more
common because of the
consistency of material
presented.
 Levels of difficulty/complexity
often are progressively
introduced.
PBL Instruction:
An Unfolding Case
 Bridget is a 14year-old, biracial adolescent
who initially presents with Major Depressive
Disorder with Psychotic Features, but
subsequently develops a manic episode,
changing her diagnosis to Bipolar Disorder.
She has multiple risk factors for suicide, and
many attempts. She is also very sensitive to
medication, and goes through trials of
multiple antidepressants and mood
stabilizers. She is hospitalized when she
takes an overdose of her mother's triiyclic
antidepressants. (p.150)
Zisook S, Benjamin S, Balon R, Glick R, Louie A, Moutier C, Moyer T, Santos C & Servis M (2005)
Alternative methods of teaching psychopharmacology. Academic Psychiatry, 29, 141-154.
PBL Instruction:
An Unfolding Case- continued
 After obtaining consent from Bridget
and her family, you begin to treat
Bridget with carbamazepine and
haloperidol. The family is actively
involved in family therapy. Five days
later in report, the nursing staff
informs you that Bridget has
developed a pruritic rash. When you
evaluate this, you discover an
erythematous, macutopapular
eruption on the trunk
andextremities. (p.150)
Zisook S, Benjamin S, Balon R, Glick R, Louie A, Moutier C, Moyer T, Santos C & Servis M (2005)
Alternative methods of teaching psychopharmacology. Academic Psychiatry, 29, 141-154.
PBL Instruction:
An Unfolding Case- continued
 Bridget is very upset about the rash and
accuses you of causing it. She subsequently
begins to refuse all scheduled medication
despite your best efforts to address her
concerns. Her behavior and thought
processes remain disorganized and she is
constantly disruptive on the unit. Her
parents are quite worried and ask you why
don't just make her take the medications
since you hove their permission to give
them and since Bridget is an involuntary
patient. (p.150)
Zisook S, Benjamin S, Balon R, Glick R, Louie A, Moutier C, Moyer T, Santos C & Servis M (2005)
Alternative methods of teaching psychopharmacology. Academic Psychiatry, 29, 141-154.
PBL Instruction:
How well has it achieved it’s aims?
 PBL students do as well as
lecture-based learning
counterparts on knowledge
acquisition.
 PBL students tend to perform
better on measures of reasoning
and learning strategies.
 Increased use of learning
resources and more reading for
meaning.
Challenges in Using PBL for
Training Professional Psychologists
 Psychological problems are highly complex.
 Problems are often poorly defined, and
presented in a confusing and contradictory
manner.
 Etiology of problems are multi-determined and
often not well understood.
 Instruction time for the content that needs to
be taught is limited.
Our PBL Prototype for
Internship Training
 Components of traditional PBL that are
maintained:
– Small group instruction.
– A gradually evolving clinical problem is
presented.
– Think out loud strategies are employed.
– Identification of learning issues.
– Summarizing what has been learned.
Our PBL Prototype
Modifications of traditional PBL:
 The unfolding case is presented in the
form of videoed interviews plus
additional case/ psychological
assessment information.
 Guided discovery is emphasized, and in
addition to facilitators the case “expert”
is present and assists in case discussion
and formulation.
Our PBL Prototype
Modifications of traditional: continued
 When learning issues are discovered, the
facilitators guide the students in regard to
sources of “expertise” that might be available.
 Processing of the case discussion is
emphasized each session in order to
encourage an attitude of reflection.
 Case conceptualization is emphasized and
routinely practiced.
Our PBL Prototype
Modifications of traditional: continued
 Expert critiques of the case
conceptualization are provided.
 “PBL” is followed by didactics on the
knowledge base needed to understand
and treat the patient problem(s) at hand.
Case Demonstration
 13 year-old presents with her
mother.
What you know?
 Relevant versus irrelevant data.
 Distinguishing between data versus
inference.
 Organization of the data to facilitate a
biopsychosocial examination of the data at
hand and to facilitate recognition of
schemas and illness scripts.
What you know?
Progression with PBL TrainingFirst Module to the Most Recent Module
 What we know? – first session 15 y.o white male
Lives with mother/father and 12y.o. sister
Problems 1st noted in K.
Previous Meds. Ritalin & Prozac
History of oppositional behavior and low frustration tolerance (crying and kicking the
walls)
Behavior problems seem situationally specific (only with parents)
Dx of ADHD – in special ed.
Emotional problems, dysgraphia
Mom-Pt’s Perceptions skewed, no hallucinations.
Current medication – Abilify
In therapy for 5 years, but not currently.
Participated in the CARE program – intensive otpt intervention.
Father’s belief – pt is “faking” sometimes and has serious “meltdowns.”
Treatment for depression with Prozac
Participates in several activities with church.
Not oppositional in settings where parents are not present.
Avoidance and lack of motivation.
Motivation concerns: minimal efforts on homework, no extra work or chores.
Exhibits kicking.
Interventions (separation) have been successful.
Attention/concentration problems
What you know?
Progression with PBL Training

What we know? – Second session -15 year old white male
Peer / Family Relations
Friends are younger, not intimate, no strong preferences.
Mom and Dad – Pt upset by parental control/structure.
Different parental perceptions – overstimulated versus “getting his way”, try to accommodate to decrease tension.
Sister- pt bullies her, physically rough with her, but is “crazy about her.”
Symptoms
Fixation on specific clothing, rigidity – only will watch certain TV channels.
Avoidance of novel situations, persistent crying to mild stressors.
Low frustration tolerance.
In attention – “inner hyperactivity”; reports difficulty paying attention
Social anxiety – has difficulty speaking in front of groups, gets nervous around others, fearful of embarassing himself, shy with
girls.
Feels sad, tired, fearful of break-ins, Worried that others are mad at him.
Scared of a spooky chapel,
Thinks he is a “weakling”.
Has lots of negative self-perceptions.
Has a hard time enjoying things.
Academic History
Is in the 9th grade.
Retained 1 year.
Improved school performance last year, but decreased performance this year.
Reading and writing difficulties.
In special education because, “I have troubled concentrating.”
What you know?
Progression with PBL Training
 What we know? – 13-year old with Eating Disorder - 1st session
Demographic Info:
13 y.o. cauc female, presents with her mother.
5’3” – 102 lbs.
1 sister 11 y.o.
Symptoms/Presenting Problem
“Mom thinks I throw up too much”. – Made me come.
Current weight – 102 lbs./low adolescent wght = 95-96 lbs.
Binges – 2x/wk, purges – 2x/day, chews/spits foods- occasionally.
Denied laxative /diet pill use. Pt knows her symptoms anger mom.
Restricting diet x2 years – no high fat/high calorie
Body Image – ideal weight is 95 lbs, stomach “too poochy”, satisfied with rest of body.
Irregular menstrual cycles,
Difficulty distinguishing hunger from satiety, eats when bored not when anxious (will get sick)
Wears baggy clothes.
Has a temper – throws tantrums.
Medical/Psychiatric History
Treated at MCG EFAP
Always had “nervous stomach”
Threw up “every day” in 6th grade when going to school
Trauma History
Family/Social History
Developmental/Academic History
Friend died 5 months ago.
Boyfriend broke up with her 2 months ago.
Friend have gone to High School - new friends/peer group.
Substance Use
Smoking (tobacco)
Family Medical/Psychiatric History
Strengths
Mental Status Exam
What you need to know?
Inquiry based on hypotheses,
schemas, and illness scripts
 Emphasis is on inquiry that is data driven
– not just a question that you would
routinely ask.
 Focuses on relevant inquiry guided by
hypothetico-deductive reasoning, schema
development, and/or illness scripts.
 Can develop precision in the questions
that are being asked of the patient.
What you need to know?
Progression with PBL Training
 What you need to know? – first session15 y.o white male
What does mom’s statement that the patient’s
“perceptions are skewed” mean?
Why therapy stopped at age 10?
When was the cognitive testing done and why?
How does he function well in other environments but
not at home?
What you need to know?
Progression with PBL Training
 What you need to know? – second session
15 y.o white male
Is the patient’s disruption because of loss of
friendship versus disruptions in routine?
“Skewed perception” – difficulty with social cues,
interpretation, or poor judgment in general?
Are there weird obsessions? Preoccupation with
restricted focus? Any repetitive or stereotypical
behaviors?
What is “inner hyperactivity” – is it racing thoughts
or obsessional thinking?
What you need to know?
Progression with PBL Training
 What you need to know -13-year old with
Eating Disorder- 1st session
What is the relationship between mood and eating
behavior?
Why is treatment being sought now? (was 95 lbs but
now is 102 lbs)
How is the eating behavior affecting functioning/
interference with life?
What family dynamics were associated with the onset
of symptoms? (conflict resolution style? Is Mom
permissive? Where’s dad? How is parental
involvement/control connecting to the eating
behavior?)
“Why do you need to
know…?”
Think Out Loud Reasoning
 Forces the learner to articulate the
hypothesis or theory underlying
inquiry.
 Sets up the opportunity for analyses
that either confirm or disconfirm the
hypothesis or theory.
Why you need to know…?
Progression with PBL Training
 Why you need to know…? -first session15 y.o white male
What does mom’s statement that the patient’s
“perceptions are skewed” mean? – Could
determine differential diagnoses such as:
psychotic versus anxiety versus cognitive deficits
versus poor judgment.
Why you need to know…?
Progression with PBL Training
 Why you need to know…? -first session13-year old with eating disorder
What is the relationship between mood and eating
behavior? – Could help to identify triggers/
patterns and establish a functional analysis of the
disordered eating behaviors.
“What are your
hypotheses?”
 Functional or etiological theories/models are
encouraged and not just DSM-IV descriptive
diagnoses.
 Requires understanding of the etiological factors
of illness or problem, familiarity with descriptive
diagnosis criteria, knowledge of illness
trajectories and probabilities, and consideration
of treatment options.
What are your hypotheses?
Progression with PBL Training
 What are your hypotheses? -first session15 y.o white male
Differing perspectives between the mom and dad –
“can’t help it versus he can”
Ruleout:
Asperger’s Disorder
OCD
Schizoaffective Disorder
What are your hypotheses?
Progression with PBL Training
 What are your hypotheses? -first session13 year old with eating disorder
Ruleout:
Eating Disorder, N.o.s. versus Bulimia
Anxiety Disorder
Medical Condition (stomach)
Eating Disorder may be attention seeking because of
her sister’s extensive illness
“Learning Issues”
 Learning issues will vary by the case
material.
 Often the facilitators have to push for
greater awareness of “learning
issues.”
“Learning Issues”
 15 y.o white male
– Are the dosing of medication normal?
– What is Abilify and what is it used for?
– What are the implications of dysgraphia?
 13 year old with eating disorder
– How is a growth chart used in the diagnosis of eating disorders
in adolescents?
– What is Total Anomalous Pulmonary Venous Rtn/Connection –
the sisters congenital medical condition – and what would its
implications be for her functioning and prognosis?
– What family system terms would be used to depict this family?
“Processing the Case”
 Reflections on “the case.”
 Reflections on one’s response to
“the case.”
 Reflections on one’s skill in
processing the “case.”
Questions and
Discussion