Clinical Problem Solving, Reasoning and Decision Making

What is clinical reasoning?

The process of using a patient’s information, clinical knowledge, and critical thinking to make decisions about their POC

Why is clinical reasoning important?

Improves patient outcomes

What makes an “expert” clinician

One who has well organized clinical knowledge, understands patients needs and values, and incorporates the social context

What encompasses Metacognition?

Problem Recognition
Definition
Representation
Strategy formulations
Resource allocation
Monitoring/evaluation of problem solving

What are “memory slots”

Mental spaces used to temporarily hold and organize information while processing new information

What is working memory?

The mental system that temporarily holds and processes information while you are actively thinking or solving a problem

What is the deliberate practice theory?

Improving a skill through repeated, focused practice with feedback, specifically targeting weaknesses to gradually improve performance

What is the cycle of the “deliberate practice theory”?

Practice > Feedback > Attention Focus → Correction Improvement

What is situated cognition theory?

Learning and thinking are influenced by the specific situation, environment, and context (aka contextual factors) in which they occur

What is the Information Processing Model?

Knowledge organization in memory than generalized problem-solving processes or algorithms
(taking in info, processing/organizing, storing it, then retrieving it when needed)

What is Analytical reasoning?

Slow, logical, step-by-step thinking that uses algorithms, practice guidelines, and clinical information to reach a decision

What is Nonanalytical reasoning?

Fast, automatic, and experience-based thinking that uses pattern recognition and heuristics (mental shortcuts) to make a decision

Cognitive bias has 3 components:

- Premature Anchoring Effects
- Framing Effect
- Availability

What is the Premature Anchoring Effect?

Over-reliance on initial impression fails to consider alternatives

What is the Framing Effect?

Positive or negative framing of questions

What is Availability?

Just learned an intervention and now want to jump to use it

What are the 5 main components of the Clinical Reasoning Model?

Hypothetico-deductive
Pattern recognition
Clinical prediction
Narrative
Collaborative Model

What is Hypothetico-deductive?

Generates initial hypotheses and test through questioning and physical exam (backward reasoning)

What is Pattern Recognition?

Prior clinical experience patterns (forward reasoning)

What is Clinical Prediction?

Identifies clinical variables that together suggest treatment

What is Narrative?

Forms an understanding of the patient story

What is Collaborative Model?

Therapist and patient shared

What are the 4 aspects of the Philosophy of Physical Therapy Practice?

Clinical Reasoning
Virtues
Movement
Knowledge

What is Collaborative Reasoning?

Working together with the patient, family, and healthcare team to share information, perspectives, and decisions when developing a POC

What is Reflective Practice?

The ability to assess one’s own skills, to identify one’s own educational needs, to evaluate one’s own progress, and to determine one’s performance

What are requirements for Self-Assessment?

Areas for improvement, motivational and promotional factors, and activities that facilitate

How many types of learners are there?

3

The comparative differences between novice and experienced PTs are noted about the therapist-patient interaction in:

- how participants used their time with their patients
- impact the environment had
- type of information collected and how it was applied
- degree of responsive interaction

The students’ analytical errors fell into 3 primary categories:

- Jumping to conclusions
- Perseveration
- Disregard

“Taking one piece of info that was necessary but not sufficient to draw a certain conclusion and jumping to the evaluation without considering other findings necessary for drawing that conclusion”

Jumping to Conclusions

Taking a necessary but not sufficient piece of diagnostic info to rule in a particular hypothesis, and then continuing to rationalize that hypothesis as other information was collected, even when it ran counter to the participant’s conclusion

Perseveration

Selecting to ignore unfamiliar information and move on because of uncertainty concerning how to assess the information

Disregard

Lack of connection between any personal information collected about the patient and the impact of the patient’s condition on his/her day-to-day life

Limited Connections

What are the 3 Main Focuses of Clinical reasoning

- Diagnostic Analysis
- Analysis of Movement
- Collaborative reasoning process - gaining an understanding of the patient’s context and perspective on the illness or injury

What is the Primary Biomedical Model?

Biomechanical nature of the patient’s health condition and paid little attention to the patient’s personal goals, values, or life situations that impacted his or her level of participation

What is Biopsychosocial Model?

Focused primarily on the patient’s level of participation and identified areas to educate the patient for self-management

What is Reflection on Action?

Student reflects on prior performance (went well, not well and what to do differently)

What is Reflection In Action?

During performance able to adapt to patient responses and adapt skills to ongoing results of tests and measures and makes spot on corrections in real time

What is the goal of CRT?

Moving from basic clinical reasoning making to systematic reasoning approach

What is Step 1 of Integrating Clinical Reasoning Concepts?

Step 1 > What is the dominant mechanism that is driving the patient’s symptoms?

What are 3 dominant mechanisms that drive patient symptoms?

- Nociplastic (Central Sensitization)
- Peripheral Neuropathic
- Nociceptive

What is Nociplastic pain?

Pain caused by altered pain processing in the nervous system, without clear tissue damage or nerve injury explaining the pain

If a patient has Nociplastic pain, what should we do first?

Education!!!

What should the focus be for individuals with Nociplastic pain?

Increase function without increased symptoms

True or False: Nociplastic pain has a weak association to maladaptive behavior clusters

False

What is Neuropathic pain?

Pain caused by a lesion or disease of the somatosensory nervous system

True or False: Most patients with spinal conditions have Neuropathic pain

True

What is Nociceptive pain?

Pain caused by actual or threatened tissue damage that activates pain receptors (nociceptors)

What are some additional domains of pain?

- Emotional Dysregulation or Pathology
- Maladaptive Cognitions
- Socioenvironmental Context
- Sensorimotor Dys-Integrations

What is Emotional Dysregulation?

Diagnosable psychopathology including depression, anxiety and mood disorders

What is Maladaptive Cognitions?

Inaccurate or irrational beliefs, thoughts or behaviors about or resulting from the experience of pain

What is Socioenvironmental Context?

Cultural beliefs about pain, gender roles, early life adversity, environmental demands and stressors

What is Sensorimotor Dys-Integrations?

Discordance between the perceived self and the actual self; difficulty properly processing and coordinating sensory information with motor responses, which can affect movement, balance, and coordination

What is Step 2 of Integrating Clinical Reasoning Concepts?

Step 2 > What location is driving the symptoms?

What are 3 main locations that drive symptoms?

Local Symptoms
Proximal to Distal Symptoms
Global Symptoms

What is Step 3 of Integrating Clinical Reasoning Concepts?

Step 3 > What mechanical input significantly changes the patient’s primary complaint?

What are some mechanical inputs that significantly change the patient’s primary complaints?

Posture
Tension
Load
Position
Motion
Repetitive Motion

What is Step 4 of Integrating Clinical Reasoning Concepts?

Step 4 > Generate and Modify the Hypothesis

What do we use to generate and modify hypothesis?

Observation
Patient Response
Symptom irritability
Symptom modification
Test and verify the hypothesis

What are some common causes of clinical reasoning errors?

Inadequate knowledge
Recognize faulty data gathering/processing/metacognition
Recognizing fallacious thinking or cognitive bias
Recognize when starting with an answer vs question

How is clinical reasoning developed?

Slowing down to verbalize thinking
Hands on process
Reflective

Name all the steps for Integrating Clinical Reasoning:

Step 1: What is the dominant mechanism that is driving the patient’s symptoms?
Step 2: What location is driving the symptoms?
Step 3: What mechanical input significantly changes the patient’s primary complaint?
Step 4: Generate and Modify the Hypothesis