How do physical therapists make clinical decisions?

Tami Struessel PT, DPT, OCS, MTC

What is Clinical Reasoning?

Expert practice• What does it mean to be an “expert?”

• What does it mean to be an “experienced non-expert?”

• What makes the expert stand out?

• Does anyone here want to be an “experienced non-expert?”

4 themes that unify philosophy of practice by expert PT’s

(Jensen-from commentary by Laurita Hack)

1. Knowledge-similar to other health professions2. Virtue-similar to other health professions3. Clinical reasoning

– different-PT’s use a more collaborative mode of reasoning that involves patients/families and relies less on a diagnosis of pathology and more on identifying patient goals and function.

4. Movement– different-PT’s show an exquisite sense of movement, both

their own movement as an instrument of patient care and the patient’s movement as a source of information and communication

Professional Development

Virtue Clinical reasoning

KnowledgeMovement

Virtue Clinical reasoning

Knowledge Movement

Clinical reasoning

Virtue Clinical reasoning

MovementKnowledge

Student

Competent

Novice

Expert

Virtue

Knowledge Movement

Philosophy of practice

From Jensen Expertise in Physical Therapy Practice, p.11

For you…What does the thought process of an expert look like?

• And what DOESN’T is look like?

What is Critical Thinking?

• Critical Thinking “typically involves the individual’s ability to do some or all of the following: – Identify central issues and assumptions in an argument

– Recognize important relationships

– Make correct inferences from data

– Deduce conclusions from information or data provided

– Interpret whether conclusions are warranted on the basis of the data given

– Evaluate evidence or authority “ • (Pascarella and Terenzini, 1991)

What is Critical Thinking?• The thought processes used to evaluate information

and the practice of using such conclusions to guide behavior.

• The process of critical thinking is associated with accuracy, logic, depth, fairness, credibility, and intellectual clarity.

• Critical thinking merely means that one must not automatically accept the validity of the information he or she is given.

What does NOT thinking critically look like?

• Blindly thinking that everything you hear is true• Blindly believing everything you read without

criticism• Blindly reproducing old learned reactions• Blindly doing the same thing over and over

• Can you see these in an “experienced, non-expert”?

What is Critical Thinking?• “Some scholars and educators erroneously

assume critical thinking to be higher order thinking or cognitive processing.” (Paul)

• “Critical thinking is best understood as the ability of thinkers to take charge of their own thinking. This requires that they develop sound criteria and standards for analyzing and assessing their own thinking and routinely use those criteria and standards to improve its quality.” – Elder and Paul (1994)

Questions for you• How would you rate yourself on your critical

thinking skills?– Poor, Fair, Good, Very Good, Excellent?

• How would you rate your Critical Thinking skills as you progress through your Physical Therapy education, and practice?

• In CEI, did you feel your CI’s demonstrated critical thinking skills? When you asked, were they able to explain why they made the decisions they made?

What is Clinical Reasoning?• Application of Critical Thinking in a clinical

context.• The process in which the therapist, interacting

with the pt, structures meaning, goals and health management strategies based on clinical data, client choices, professional judgment and knowledge.– Higgs/Jones

• What is Wise Action?• Goal of Clinical Reasoning=Wise Action

– Davies

Reasoning outside a clinical context(van der Vleuten)

• Some times more simple application of knowledge, rules and principles.

• For some problems, all data necessary to solve them are present, goals are clear, and solutions are known. Solution is found by technical rationality.

• Multiple choice questions assess the ability to solve this sort of problem.

What is Clinical Reasoning?

• “Clinical Reasoning is the foundation of professional clinical practice. In the absence of sound clinical reasoning, clinical practice becomes a technical operation requiring direction from a decision maker.” Higgs,Jones

• Independent thinking

What is Clinical Reasoning?

• In clinical encounters, rarely is all information available. More data must be gathered, and the clinician must deal with contradictory, confusing, imperfect and even inaccurate information.

• “The capacity to reason in the context of uncertainty and to solve ill-defined problems is the hallmark of professional competence“ (Johnson, 1988)

Clinical Reasoning by Team?• TEAM: In some contexts, “Clinical Reasoning

occurs within a system comprising numerous participants (client/pt, care givers, clinicians, larger healthcare team) all contributing to an understanding of the clinical problem and seeking to implement collaboratively sound, high quality strategies to achieve problem resolution.”

Clinical Reasoning?

• Clinicians often face ill-defined problems, goals that are complex and outcomes that are difficult to predict clearly.

• Professional judgment and decision-making within the ambiguous or uncertain situations of health care is an inexact science which requires reflective practice and excellent skills in clinical reasoning. Higgs,Jones

The challenge of assessing Clinical Reasoning…

• A difficulty with assessment of ill-defined problems as in case situations, is that in similar situations, professionals do not collect exactly the same data and do not follow the same paths of thoughts. – What are the issues with assessing/testing this?

Multiple systems of describing Clinical Reasoning

• We’ll use one

Dual Process Theory

• Dual process theory based on the interconnectedness of 2 ways the brain reasons:

• Croskerry “Overconfidence in Clinical Decision Making.”

– System 1 (intuitive)– System 2 (analytical/rational)

“The effortless pattern recognition that characterizes the clinical acumen of the expert

physician is made possible by accretion of a vast experience (the repetitive use of a System 2 analytic approach) that eventually allows the process to devolve to an automatic level.”

Norman

• System 1 (intuition) is the default

• Repetitive operations of System 2 (analytical) leads to better System 1 decisions

Dual Process• System 1: Intuitive

– Mostly at the subconscious level/ automatic

– Pattern recognition– Intuition– More developed in

experienced practitioners– Difficult to put into words– Low Scientific Rigor

• System 2: Analytical/Rationale– Exhaustive method– Hypothetico-deductive method– Requires knowledge– Easy to put into words– Repetitive use of System 2 leads

to better understanding and development of System 1

– Largely forms the basis of the Patient Care Seminar process

Dual Process (Croskerry)

• System 1:– Similar to driving a car-no conscious recollection

of exactly what you did to get there, but you got there nonetheless.

Dual System Characteristics (Croskerry)Characteristic System 1 (Intuitive) System 2 (Analytic)

Cognitive Awareness? (high/low)

Cost (high/low)

Automaticity(high/low)

Rate (fast/slow)

Reliability (high/low)

Errors (usually/few)

Effort (high/low)

Predictive Power (high/low)

Emotional Component

Scientific Rigor (high/low)

Context (high/low)

Cognitive Style?

Dual System Characteristics (Croskerry)Characteristic System 1 (Intuitive) System 2 (Analytic)

Cognitive Style Heuristic (experience-based)

Systematic

Cost Low High

Automaticity High Low

Rate Fast Slow

Reliability Low High

Errors Usually Few

Effort Low High

Predictive Power Low High

Emotional Component High Low

Scientific Rigor Low High

Context High Low

Cognitive Awareness Low High

Dueling Books that give us thought…

To Think or to Blink? (Malloy, Monash Univ.)

• “Decisions made very quickly can be every bit as good as decisions made cautiously and deliberately.” Malcolm Gladwell (Blink)

• “That’s all very well if we’re talking about choosing wall paper.” Croskerry 2008 in “Overconfidence in Clinical Decision Making”

• Implications of decision making in the health care context

Which system is best? (Croskerry)

• It is natural to think that System 2 thinking, coldly logical and analytical, likely is superior to System 1– but much depends on context.

• A series of studies have shown that “pure” System 1 or System 2 thinking (either alone) are error prone; a combination of the 2 is optimal.

Certain contexts do not allow System 1…

In contrast, adopting an analytical approach in an emergent/immediate situation, where rapid decision making is called for, may be paradoxically irrational.

Croskerry• Mark of good decision-maker:

• ability to match 2 systems to their respective optimal contexts

• consciously blend them into overall decision making.

Holding onto System 1 too tightly• Sometimes people

automatically override System 2 and automatically revert to System 1, despite good evidence derived from System 2 that would be preferable.

• “Gandhi spoke often of how, at important moments, his “inner voice” would pipe up, with its decisive counsel. His strategy was to make that inner voice “hold its breath” for awhile, to give him time to study the facts. More often than not, the facts bore out what the intuition knew all along.” U-Turn by Grierson

When might bias creep into our decision-making?

• Bias-higher risk for error when stakes are high– Affective– Cognitive

Affective biases

• Emotions• High stress• Financial stresses• Gender/age biases

Cognitive biases-examples• Confirmation bias – the tendency to

search for or interpret information in a way that confirms one's preconceptions

• Irrational escalation – the phenomenon where people justify increased investment in a decision, based on the cumulative prior investment, despite new evidence suggesting that the decision was probably wrong.

PT’s are different, and it’s OK

• Much of clinical reasoning literature is based on the “diagnosis model” based on physicians.

• While we can learn a lot, as PT’s, we think differently…

Specific blended examples of PT decision making using dual approach• Analytical: Hypothetico-deductive approach

– Look for “Initial Hypothesis”

• Intuitive: – Look for “Pattern Recognition”

What we know about how students use these methods

• Analytical (Hypothetico-deducto) and Intuitive (Pattern recognition) have equally poor diagnostic accuracy in novices

• Combined strategies improve the accuracy (Eva 2004)

Teaching/learning tips for you• Maximize exposure to a variety of patient conditions

in context• You are encouraged to ask:

– What is the most likely diagnosis?– What is for and against this diagnosis?– What else could this be?– What is for and against the alternatives?

• Recognize distracting stimuli (noise)• Understand and recognize cognitive and affective bias

Teaching/learning tips for you• Identify and analyze and challenge assumptions in

arguments• Assess credibility of information (evidence quality)• Understand how to systematically work through a

problem• Overtly work on capacity for making effective

decisions using both System 1 and 2• Modeling-Experienced clinicians-see patients, and

have them “Unpack” their reasoning

Methods of teaching clinical reasoning

• Problem/Case based learning• Compare/contrast decision-making in patients

with similar diagnoses• “Consider the opposite” strategies can be an

effective de-biasing strategies (avoids over confidence)– The biased fashion in which evidence is generated

during the development of a particular belief or hypothesis that leads to overconfidence.

Your goal as you learn to care for patients…

• Overtly work on getting better– At the Analytical Process– At Pattern Recognition

PCS

• PCS is VERY analytical System 2

• But as you’ve learned, this will help you with the snap/intuitive decisions that are more likely to occur in the clinic

• Questions?

Purpose of:

• The entire PCS series

• Patient Care Seminar I

Content ObjectiveTo Orient Students To:

• Description of course series, PCS I, nuts/bolts• Key concepts in terminology for clinical

reasoning in PT

On Canvas

• Pairs/instructor assignments– Instructors are faculty and/or clinical colleagues– Communication with instructors

• Case descriptions/nature of cases– One pair per 1/3 lab group

• Syllabus – Step by step outline of expectations– Email addresses of instructors

Design of course

• Primary PCSI product: an outline, one per pair– Submit twice– Facilitation by instructor

• Presentation by pair

Course Logistics• Grade based on:

– Quiz– Homework– Initial outline– Final outline– Power Point– Presentation in pairs (draw for who goes first)– How well you work in pairs

• Grading• Dates

– In Class • Lectures• Group work time

– Meetings with individual instructors

First deadline

• Feb. 13th (this week) to contact instructor and set up time to meet– In person meeting to occur no later than Feb. 21st.

• Get together with partner, find several times that work and email to instructor.

• Remember, many are outside folks, so you might have to meet off-campus

• Should be prepared to talk about case (and course) in an informed manner.

2 preliminary assignments

• 1st: APTA ICF online course – instructions on Canvas for accessing

• Take course• Complete Canvas quiz• Due date Friday Feb. 16th

2nd : Homework

• Due Feb.18th• Directly to your instructors• Assignment:

– After reading your case, list the:• Primary Health Condition• Impairments in body structure/function• Activity Limitations• Limitations to participation• Contextual factors

– Environmental– Personal

– Turn in single copy for your pair

Course Logistics

• References: – Websites – AMA format for referencing in outline – Referencing on slides (Authors last name, year)

• Name and page numbers on outline (Footer) • Typical number of references• EndNote x3 or higher:

– STRONGLY RECOMMENDED as it will save lots of frustration and hundreds of hours of time over the course of the program

– Available for purchase at bookstore/online– Optional orientation available by librarian on Feb. 14th:

everything you need to know to get started

What is plagiarism?

• Part of honor code• Applies to outline, as well as fully written papers and has been an

issue in PCS• Examples:

– Use of someone else’s published work without giving credit (whether or not it is reworded)

– Use of someone else’s published work, citing the work, but using it verbatim without quotation marks.

• Standard (3 or more words together)– Always reword, unless there is some profound meaning in keeping the

wording exactly “as is”. E.g. a poem

• If you aren’t sure, always ask!• Plagiarism.org

Course Logistics

• Google docs http://www.commoncraft.com/google-docs-video-over-million-views-you-tube

• Enables both members of the pair to work on single document:– Outline– Power Point presentation

Important notes

• Greatest emphasis of your cases at this time:– Function & patient centered care – increasing

emphasis as you progress through the curriculum– Health Condition, beginning’s of examination,

diagnosis, and prognosis

• When it comes to the evaluation and Plan of Care, we are looking for thought processes

• This is just the beginning!• You will build on this course/material as you

progress through the 3 year curriculum.• Much of grade in this course is based on

effort, not perfection.

Open your case now