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At least 19 recordsLinked to original sources
PubMed2003

Understanding our mistakes: a primer on errors in clinical reasoning.

Clinical reasoning allows physicians to move from areas of clinical uncertainty to points where the medical literature offers guidance, and is equally important in deducing whether the results of clinical trials are applicable to an individual patient. However, studies in the field of cognitive psychology indicate that the reasoning skills of clinicians are imperfect. Moreover, clinicians may be aware of their mistakes but often do not understand the cognitive processes underlying their errors. Greater understanding of the reasoning process has the potential to improve patient care but independent study of clinical reasoning can be difficult, as the literature is complex and unfamiliar to most physicians. This article provides an introduction to diagnostic reasoning and highlights some of the cognitive factors that lead to errors in clinical problem solving. Clinical scenarios are used to illustrate key points and place the material in a readily accessible framework.

Clinical Competence↗
PubMed1997

Basic Science Reasoning and Clinical Reasoning Intertwined: Epistemological Analysis and Consequences for Medical Education.

The aim of this paper is to emphasize the distinction between basic medical science (and reasoning) and clinical science (and reasoning) in order to illuminate some basic philosophical and cognitive issues in medical education. The Kunhian concept of exemplar refers to the field of growth of scientific knowledge and in this sense is related to the "anti-theoretical" emphasis on problem solving performance. In cognitive science this (and similar) types of postpositivistic objections to the formalistic excess of the neopositivistic tradition are exploited to stress the relevance of the distinction between theories and their domains of application. This objection is exploited to stress the difference between established bodies of scientific knowledge and their processes of discovery and/or application and, in medical knowledge, between clinical reasoning (situated, concerned with attributes of people) and basic science reasoning (unsituated, concerned with attributes of entities such as organs, bacteria, viruses). Exploiting the theoretical consequences of the previous analysis I will try to answer some questions: What is the role of problem solving in teaching and learning, as different from conventional basic science-centred education? Is it relevant, in medical education, an epistemological and logical awareness of the main methodological topics? Finally, the analysis of the significance of abduction in a unified epistemological model of medical reasoning is exploited to individuate the proper ontological level dealing with the entities and relationships belonging to the dynamism of the underlying domain knowledge (for instance biomedical physics) and the consequences for medical education.

Journal Article↗
PubMed1991

Clinical reasoning in medicine compared with clinical reasoning in occupational therapy.

This article highlights some observations made in the American Occupational Therapy Association/American Occupational Therapy Foundation Clinical Reasoning Study, an ethnographic study of 14 occupational therapists working in a large teaching hospital. Concepts and premises that frequently appear in the clinical reasoning in medicine literature are discussed and compared and contrasted to observations and interpretations made of the practice and reasoning strategies of the occupational therapists who were participants in the Clinical Reasoning Study. It is postulated that similarities in the reasoning strategies of the members of the two professions are a result of use of the scientific model that calls for hypothetical reasoning. Differences, it is proposed, are accounted for by the difference in the particular focus, goals, and tasks of the two professions and the nature of the practice in those arenas. Five hypotheses are proposed as questions for further research in clinical reasoning in occupational therapy.

Clinical Competence↗
PubMed2003

"Clinical reasoning theater": a new approach to clinical reasoning education.

Recently the authors developed and implemented a new approach to clinical reasoning education called clinical reasoning theater (CRT). The purpose of CRT is to demonstrate the process of clinical reasoning to students through the conversation of a doctor with his or her patient. With students as the audience, the doctor's clinical reasoning skills are modeled in CRT when he or she thinks aloud during conversations with the patient, which makes clear why he or she asks particular questions. In CRT the interaction between doctor and patient is analyzed in such a way that the repeated cycles of questions and answers are revealed to the students. CRT's format and the activities of the three "actors,"(the doctor, the patient, and the audience of students) are described. Two "acts" are repeatedly performed. The first act (the communication between the doctor and the patient) deals with the history taking, physical examination, etc. The second act, the time-out period, is the most important component of CRT. In this act, the doctor explains his or her reflections and discusses suggestions from the audience for additional questions. The preliminary results of students' evaluations of the relevance of CRT reveal that they appreciate CRT. Further, the CRT format offers instructors with previous experience as lecturers only sufficient tools to apply the new approach successfully.

Clinical Competence↗
PubMed2005

Consensus methods: a bridge between clinical reasoning and clinical research?

Evidence-Based Practice does head the "hierarchy of evidence" upon which developments in clinical practice should be based. There are, however, situations where evidence is either unavailable, unclear, or results between studies are at variance. Consensus is a reliable contingency, and approaches to reaching consensus have acceptable construct validity (Nominal Group Technique, Delphi, and Consensus Development Conference). Consensus is reached when: (i) the method of investigation tightly controls communication to reduce the obscuring "noise" of divergent discussion; (ii) statistical measures of agreement or dissent screen out the bias that would otherwise be produced by the dictate of vociferous minorities or coalitions that may represent vested interests; (iii) all participants contribute equally to the product of the investigation.

Biomedical Research↗
PubMed2005

Promoting clinical reasoning in undergraduate nursing students: application and evaluation of the Outcome Present State Test (OPT) model of clinical reasoning.

Promoting clinical reasoning in undergraduate nursing students through application of the Outcome Present State Test (OPT) Model of Clinical Reasoning, is a challenge that can be successfully managed through effective teaching-learning strategies. Empirical evidence to support teaching strategies that foster both cognitive and metacognitive skill acquisition is limited. The purpose of this research was to evaluate the development of clinical reasoning skills among nursing students through the application and evaluation of teaching-learning strategies associated with self-regulated learning and the OPT model (Pesut & Herman, 1998; 1999; Pesut, 2004). The model and self-regulated learning prompts were used to structure learning with junior level baccalaureate nursing students during a ten-week, medical-surgical clinical experience in acute care telemetry units. Data analysis revealed students effectively made gains in learning associated with the OPT model. Qualitative analysis of self-regulated learning prompt journal data revealed students made significant gains in self-observation, self-judgment, knowledge work and use of health care personnel resources during clinical experiences. Results indicated the intentional use of guided reflection coupled with structure and learning tools of the OPT model significantly enhanced clinical reasoning skill acquisition, and provided evidence for the effectiveness of structured teaching learning strategies.

Adult↗
PubMed2005

Does the medical college admission test predict clinical reasoning skills? A longitudinal study employing the Medical Council of Canada clinical reasoning examination.

BACKGROUND: To investigate the predictive validity of the Medical College Admission Test (MCAT) for clinical reasoning skills upon completion of medical school. METHOD: A total of 597 students (295 males, 49.4%; 302 females, 50.6%) participated from 1991 to 1999. Stepwise multiple regressions of the MCAT and premedical school GPA (independent variables) on the Part 1(declarative knowledge) and Part 2 (clinical reasoning) of the Medical Council of Canada Examinations (dependent variables) were employed. RESULTS: For Part 1, the multiple regression revealed that three predictors (verbal reasoning, biological sciences, GPA) accounted for 23.3% of the variance, and for Part 2, two predictors (verbal reasoning, GPA) accounted for 11.2%. CONCLUSION: There is both convergent and divergent evidence for the predictive validity of the MCAT for clinical reasoning.

Canada↗
PubMed1999

Heuristics and biases: selected errors in clinical reasoning.

Many clinical decisions are made in uncertainty. When the diagnosis is uncertain, the goal is to establish a diagnosis or to treat even if the diagnosis remains unknown. If the diagnosis is known (e.g., breast cancer or prostate cancer) but the treatment is risky and its outcome uncertain, still a choice must be made. In researching the psychology of clinical judgment and decision making, the major strategy is to compare observed clinical judgments and decisions with the normative model established by statistical decision theory. In this framework, the process of diagnosing is conceptualized as using imperfect information to revise opinions; Bayes' theorem is the formal rule for updating a diagnosis as new data are available. Treatment decisions should be made so as to maximize expected value. This essay uses Bayes' theorem and concepts from decision theory to describe and explain some well-documented errors in clinical reasoning. Heuristics and biases are the cognitive factors that produce these errors.

Bayes Theorem↗
PubMed1992

Clinical reasoning in manual therapy.

Clinical reasoning refers to the cognitive process or thinking used in the evaluation and management of a patient. In this article, clinical reasoning research and expert-novice studies are examined to provide insight into the growing understanding of clinical reasoning and the nature of expertise. Although hypothetico-deductive methods of reasoning are used by clinicians at all levels of experience, experts appear to possess a superior organization of knowledge. Experts often reach a diagnosis based on pure pattern recognition of clinical patterns. With an atypical problem, however, the expert, like the novice, appears to rely more on hypothetico-deductive clinical reasoning. Five categories of hypotheses are proposed for physical therapists using a hypothetico-deductive method of clinical reasoning. A model of the clinical reasoning process for physical therapists is presented to bring attention to the hypothesis generation, testing, and modification that I feel should take place through all aspects of the patient encounter. Examples of common errors in clinical reasoning are highlighted, and suggestions for facilitating clinical reasoning in our students are made.

Bias↗
PubMedDate not supplied

Using a head-mounted video camera to study clinical reasoning.

Studies of clinical reasoning are essential if we are to extend our knowledge of occupational therapy practice, better communicate our work to clients and colleagues, and reveal to our students the nuances of therapy that cannot be gained from texts. However, accessing therapists' clinical reasoning is not an easy task because these cognitive processes can be studied only indirectly. The aim of this article is to promote the study of clinical reasoning by reviewing a new approach to data collection in this field. To achieve this purpose, the article outlines current data collection methods, such as the think-aloud method written notes, free recall, and audio-assisted and video-assisted recall. A novel method involving a head-mounted video camera is described, and details are provided on a modified approach to debriefing using video-assisted recall. Anecdotes from the authors experience of using this technology illustrate the text.

Clinical Competence↗
PubMed2006

The clinical reasoning of pain by experienced musculoskeletal physiotherapists.

There is currently no research within Physiotherapy to explain the extent to which current theories and models of pain influence clinicians' reasoning related to clinical presentations of pain. The purpose of this qualitative study was to investigate the clinical reasoning of experienced musculoskeletal physiotherapists in relation to three different presentations of pain. A qualitative multiple-case studies method was used in this study. A purposive sample of seven experienced musculoskeletal physiotherapists viewed three videotaped patient-therapist clinical interviews describing three different pain presentations. An audio taped, semi-structured interview was carried out with each participant during which the participants were encouraged to verbalize their thoughts regarding aspects of each patient's pain presentation. All interviews were subsequently transcribed, coded and analysed. Results showed a dynamic, multidimensional nature to the therapists' clinical reasoning, which was found to be grounded in a number of established models of pain. Five main categories of pain-based clinical reasoning were identified. These were (i) biomedical, (ii) psychosocial, (iii) pain mechanisms, (iv) chronicity and (v) irritability/severity. Reasoning within these categories influenced therapists' prognostic decision-making as well as the planning of physical assessments and treatment. The clinical reasoning of pain by the participants in this study appeared to reflect the integration of diverse models and theories of pain into current clinical practice. Mechanisms-based clinical reasoning has not been previously observed amongst physiotherapists.

Data Collection↗
PubMed1998

Teaching clinical reasoning as a thinking frame.

OBJECTIVE: Clinical reasoning concepts can be viewed as descriptions of mental operations or as a thinking frame--a structure to organize and support clinical thinking. This study examined an approach for teaching clinical reasoning as a thinking frame to occupational therapy students. METHOD: A quasi-experimental, pretest-posttest design was used with a convenience sample of 10 undergraduate occupational therapy seniors. All participants (a) acquired the thinking frame of clinical reasoning concepts through explicit instruction and (b) practiced that thinking frame with an external aid--the Clinical Reasoning Case Study Format. The accuracy of participants' definitions of clinical reasoning concepts before and after this learning experience were examined to assess their acquisition of the thinking frame. The content of clinical reasoning case studies were examined to assess students' application of the thinking frame to clinical situations. RESULTS: Wilcoxon signed rank tests done on presemester and postsemester definitions ratings indicated that the latter were rated significantly higher than the former for (a) narrative reasoning (p = .008), (b) procedural reasoning (p = .005), (c) interactive reasoning (p = .006), (d) pragmatic reasoning (p = .008), and (e) conditional reasoning (p = .01). The content of participants' clinical reasoning case studies indicated that they were able to apply clinical reasoning concepts. CONCLUSION: The results suggest that using a clinical reasoning thinking frame to organize clinical observations is an effective way to help entry-level occupational therapy students learn and apply clinical reasoning concepts.

Adult↗
PubMed2004

A framework for understanding clinical reasoning in community nursing.

BACKGROUND: Clinical reasoning is employed to develop solutions to health needs. The impact of the clinical environment on the organization of knowledge-guiding practice has received limited attention. This gap in the clinical landscape restricts the sharing of decision-making processes. AIMS: Focusing on the community, and specifically the patient's home as a context for nursing, this paper describes the creation of a collective conceptual map for a group of community nurses. There is a twofold aim of exploring the process of exposing and articulating the clinical framework and enhancing and sharing understanding of the clinical paradigm in this context. DESIGN: An interpretive research approach was utilized. Hermeneutic phenomenology guided the level of meaning accessed and constructivism was used to build an educational picture. METHODS: Multiple methods including focus groups, observation and narrative recordings were utilized to collect and analyse research data. RESULTS: All nurses may engage with the same concepts--health, need, care and partnerships--but organized into particular frames by the guiding practice philosophy and service organization. A four-stage framework for understanding clinical reasoning in the community setting is presented. This acknowledges the multi-faceted nature of health, the lived experience of health deficits, and is located in a participation and negotiated model of care. Practice examples are presented to expose the construction of need and response which often occurs in a triadic decision-making process. CONCLUSIONS: Environment of care has significant implications on need identification and response. RELEVANCE TO CLINICAL PRACTICE: Mechanisms to enhance the sharing of clinical reasoning and decision-making transparency are essential to aid inter- and intra-professional communication. Presentation of a clinical reasoning framework exposes the breath of 'signals' encountered in practice and the range of knowledge employed in understanding and responding to patient need.

Community Health Nursing↗
PubMed2006

Medical students' clinical reasoning skills as a function of basic science achievement and clinical competency measures: a structural equation model.

BACKGROUND: The purpose of this study was to investigate the fit of a hypothesized model of medical students' diagnostic or clinical reasoning skills based on their aptitude for medical school, basic science achievement, and clinical competency measures. METHOD: A total of 589 medical students who received their MD from 1994 to 2002 participated in this study. Confirmatory factor analysis was used to evaluate the fit of theoretical models of clinical reasoning using measures of basic science and clinical knowledge. RESULTS: The results provided support for a three-factor model of medical student performance (Bentler's Comparative Fit Index = .905, standardized root mean squared residual = .054, root mean squared error of approximation = .105). The clinical reasoning skills of medical students were influenced by an independent relationship between latent variables of basic science achievement and clinical competency. CONCLUSION: The findings support a theoretical model of diagnostic or clinical reasoning that treats the basic science and clinical knowledge of medical students as distinct domains.

Aptitude Tests↗
PubMed1995

Clinical reasoning and pain.

Clinical reasoning is reviewed with respect to the historical and continuing need for critical inquiry skills, the hypothetico-deductive basis of sound reasoning, factors influencing therapists' reasoning, and ways of promoting critical yet creative reasoning. The importance of clinicians' organisation of biomedical and clinical knowledge and the inclusion of the patient in the problem solving and decision making processes are emphasised.

Journal Article↗
PubMed1991

What is clinical reasoning?

This paper offers a concept of clinical reasoning that differs from many of the traditional definitions of clinical reasoning in occupational therapy and the health professions in general. Here, clinical reasoning in occupational therapy is described as a largely tacit, highly imagistic, and deeply phenomenological mode of thinking. It is argued that clinical reasoning involves more than the ability to offer explicit reasons that justify clinical decisions because it is also based on tacit understanding and habitual knowledge gained through experience. Clinical reasoning also involves more than a simple application of theory, particularly theory as understood in the natural sciences, because complex clinical tasks often require that the therapist improvise a treatment approach that addresses the unique meaning of disability as it relates to a particular patient.

Clinical Competence↗