CLINICAL REASONING in the Health Professions

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CLINICAL REASONING in the Health Professions
Mark A. Jones BS (Psych), MAppSc (Manip Physio)
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AIMS

• Overview of Expertise in general
• Overview of CR in the Health Professions
• Common errors of CR
• Overview of WHO model of Health and Disability
• Overview of contemporary Pain Science and
  Psychosocial theory used in Health Professionals
  CR

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Aspects of Expertise

• Experts excel in their own domains
• Experts possess large repertoire of well
  developed clinical patterns
• Experts solve problems fast with little error
• Experts see problems at a deeper level
• Experts spend more time analysing problems
  qualitatively

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Aspects of Expertise

• Experts have strong self-monitoring skills
• Experts possess the affective dispositions
  necessary to learn from their experiences

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Aspects of Expertise

• Experts value the participation of relevant
  others (patients, family, other heath prof)
• Experts recognise the value of different forms of
  knowledge in their reasoning
• Experts are patient centred
• Patients viewed as active participants in therapy
• A primary goal of care is empowerment of patients
  achieved through collaboration between patient
  and therapist
• Strong moral commitment to beneficence or doing
  what is in the patients best interest
• Willing to serve as a patient advocate or moral
  agent in helping them be successful

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Aspects of Expertise

• Experts use collaborative problem solving to help
  patients learn how to resolve their problems on
  their own, fostering self-efficacy and empowering
  them to take responsibility
• Experts share their expertise to assist others
• Experts communicate their reasoning well
• Experts more sensitive to contextual cues as they
  are aware of their own mental processes, listen
  more attentively, are flexible, recognize bias
  and judgments and therefore act with compassion
  based on insight

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Clinical Reasoning

• The thinking underlying clinical practice
• Facilitates critique and use of popular fad
• Without sound clinical reasoning, therapists
  become technicians
• Reasoning facilitates life long learning
• Incorporates pattern recognition and hypothesis
  testing

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Clinical Patterns Include

• Syndromes (symptoms, context of symptoms,
  physical signs)
• Predisposing physical, psychosocial
  environmental circumstances
• Precautions to examination and Rx
• Associated ifthen management strategies
• Prognosis

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Clinical Patterns in Medical Radiation

• Prototypical features of pathology on different
  imaging procedures plus Exemplar cases
• Image critique
• Image quality
• Best angle
• Other views
• Recognising when further investigation is required

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Inductive or Forward Reasoning

• Problem cues elicit recognition of the solution
  without specific hypothesis testing
• Used by experts when confronting familiar
  problems
• Efficient, fast and dependent on a good knowledge
  base

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Backward Reasoning

• Hypotheses elicit a return to the data for either
  re-interpretation or collection of further
  confirming or negating evidence
• Used by novices, and experts confronted with
  unfamiliar problems

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Cognition

• Thinking processes such as perception of relevant
  information, specific interpretations and higher
  level data analysis and synthesis
• Inquiry strategies such as hypothesis testing
• Cognitive skills and knowledge are interdependent
• Errors in clinical reasoning often errors of
  cognition

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Common Errors in Clinical Reasoning

• Overemphasis on findings which support existing
  hypothesis
• Misinterpreting non-contributory information as
  confirming existing hypothesis
• Ignoring findings which do not support favoured
  hypothesis
• Incorrect interpretations or deductions

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Common Errors in Clinical Reasoning

• Expert and resident radiologists given x-ray
  films and clinical history (normal,
  bronchiolitis) list features, estimate
  probability
• When history biased to positive result both found
  more features and gave higher probability in BOTH
  abnormal and normal films
• Early hypotheses can bias subsequent
  interpretations
• Norman et al (1992a) The correlation of feature
  identification and category judgments in
  diagnostic radiology. Memory and Cognition, 20,
  344-355
• Norman et al (1992b) Expertise in visual
  diagnosis A review of the literature. Academic
  Medicine, 67, S78-S83

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Metacognition

• Awareness and ability to think about your
  thinking
• Ability to think (reflect) on your feet
• Recognising what you know and what you dont know
• Should lead to self-directed learning and life
  long learning

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Knowledge

• Expertise dependent on clinicians knowledge,
  especially their ORGANISATION OF KNOWLEDGE
• Represents breadth and depth of your
  understandings and beliefs held together in
  patterns acquired through academia and personal
  experience
• Three forms of knowledge essential

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Three Forms of Knowledge Essential (Higgs
Titchen 1995)

• Propositional knowledge knowing that
• Biomedical, diagnostic/pathology focused textbook
  and research-based knowledge
• Non-Propositional knowledge
• Professional craft knowledge knowing how allows
  us to use propositional knowledge in practice
• Personal knowledge knowledge acquired through
  life that shapes personal perspectives, beliefs
  and attitudes

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Contemporary Understanding of Health and
Disability

• Influence psychosocial factors have on patients
• Cognitive and sensory perceptions
• Motor programs
• Health behaviours
• Non-diagnostic reasoning critical to obtaining
  psychosocial profile
• Application of learning theory integral to
  promoting change

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WORLD HEALTH ORGANISATION MODEL OF HEALTH AND
DISABILITY (WHO 2001, p.18)
Health Condition (disorder or disease)
Body Functions Structures
Participation
Activities
Personal Factors
Environmental Factors
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Mature Organism Model (Gifford 1998)
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Mature Organism Model (Gifford 1998)

• Like WHO model illustrates interactions between
  patients disorders, their environment and
  personal perspectives
• Depicts interactions of fundamental pathways into
  and out of CNS that are necessary for
• Survival
• Maintenance of health
• Development and continuation of poor health (e.g.
  activity and participation restrictions and
  associated impairments)

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• Tissue health sampled and communicated along with
  contextual information re environment via Input
  Mechanisms
• Brain scrutinises (consciously unconsciously)
  incoming info with engrams of past experiences
  for Processing to the Output Mechanisms
  (somatic motor, autonomic, neuroendocrine,
  neuroimmune, descending pain control)

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• How persons health is manifest via output
  systems (cognitively, emotionally, behaviourally,
  physiologically) depends in part on
• Contextual factors in persons immediate
  circumstances
• Past experiences that contribute to shaping
  beliefs, attitudes, emotions and behaviours
• Even with same extent of tissue injury or illness
  no two people have exactly same presentation as
  how they manifest their pain or illness is shaped
  in part by who they are

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• Input, processing and output mechanisms are
  always operating
• Pinch ? (input) ? (processing where
  interpretation depends on context of pinch and
  past experiences) ? (output) ? pain, withdrawal,
  emotions, autonomic response (e.g. increase heart
  rate), local physiological response (erythema,
  bruise, etc.)
• Clinicians need to learn clinical patterns of
  abnormal or maladaptive pain mechanisms

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Applying a Biopsychosocial Model

• Requires understanding patients individual
  perspectives or pain experiences
• Input, Processing Output mechanisms not always
  dysfunctional
• Even nociceptive dominant problems will co-exist
  with maladaptive psychosocial factors creating
  obstacles to recovery
• Key is to learn clinical features representing
  maladaptive Input, Processing, Output

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Hypothesis Categories

• Activity and Participation capability/restriction
• Patients perspectives on their experience
• Pathobiological mechanisms
• Physical impairments and associated
  structure/tissue sources
• Contributing factors
• Precautions contraindications P/E Rx
• Management treatment
• Prognosis

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Activity and Participation Capability/Restriction

• Activity restriction difficulties in performing
  activities (walking, lifting, etc.)
• Participation restriction problems with
  involvement in life situations (caring for
  family, work, sport, etc.)
• Essential to also recognise Capabilities
• Restrictions often represent goals where
  capabilities provide point where retraining or
  reactivation must commence

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Hypothesis Categories

• Activity and Participation capability/restriction
• Patients perspectives on their experience
• Pathobiological mechanisms
• Physical impairments and associated
  structure/tissue sources
• Contributing factors
• Precautions contraindications P/E Rx
• Management treatment
• Prognosis

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Patients Perspectives on Their Experience

• Understandings, beliefs, feelings, etc.
• Can be barriers to their recovery
• Therapists must develop skills to question and
  explore patients perspectives which they may
  even be unaware of
• Important to know what the perspective is (e.g.
  pain harm therefore reduced activity) and the
  basis for that perspective (previous medical or
  family advice, past medical experiences, etc.)

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Adapted From Main et al 2000

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Blue Flags

• Perceived features of work associated with
  higher rates of symptoms, ill-health, work loss
• High demand and low control
• Unhelpful management style
• Poor social support from colleagues
• Perceived time pressure
• Lack of job satisfaction

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Black Flags

• National Policy
• Rates of pay
• Negotiated entitlements
• Employer Policy
• Sickness policy
• Restricted duties policy
• Management style
• Organization size and structure
• Trade union support
• Content-specific aspects of work
• Ergonomics
• Hours, shift work

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Hypothesis Categories

• Activity and Participation capability/restriction
• Patients perspectives on their experience
• Pathobiological mechanisms
• Physical impairments and associated
  structure/tissue sources
• Contributing factors
• Precautions contraindications P/E Rx
• Management treatment
• Prognosis

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Pathobiological Mechanisms Tissue and Pain
Mechanisms

• Tissue mechanisms tissue health and stages of
  tissue healing (inflammatory, proliferative,
  remodelling)
• Pain mechanisms input, processing and output
  mechanisms underlying patients activity and
  participation restrictions, unhelpful
  perspectives and physical impariments

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Input Mechanisms

• Nociceptive Pain chemical and mechanical
  activation of nociceptors in local somatic
  tissues (ligaments/fascia, muscles, bone, etc.)
• Peripherally Evoked Neurogenic Pain symptoms
  that originate from neural tissue outside the
  dorsal horn or cervicotrigeminal nucleus (nerve
  root pain, peripheral nerve entrapment)
• Both have a predictable pattern (history,
  behaviour and progression)

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Maladaptive Central Processing

• Symptoms provoked from past injury can be
  maintained even after original injury healed
• Symptoms no longer follow predictable nociceptive
  pattern
• Symptoms out of proportion to impairment
• Activity/participation restrictions out of
  proportion to symptoms and impairment
• Symptom behaviour not consistent with
  psychosocial triggers common
• Problem does not follow typical course of
  recovery or response to physical management

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Maladaptive Output Mechanisms

• Motor, Autonomic, Neuroendocrine, Immune
• Maladaptive motor patterns from injury (pain
  inhibition) learning (through lifestyle)
• Excessive sympathetic nervous system activity
  common in many chronic pain problems
• Neuroendocrine system affected by stress with
  decreased healing increased sensitivity
• Chronic pain, deconditioning stress interfere
  with immune system function

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Hypothesis Categories

• Activity and Participation capability/restriction
• Patients perspectives on their experience
• Pathobiological mechanisms
• Physical impairments and associated
  structure/tissue sources
• Contributing factors
• Precautions contraindications P/E Rx
• Management treatment
• Prognosis

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Physical Impairments Associated
Structures/Tissue Sources

• Physical impairments specific regional
  neuromusculoskeletal abnormalities detected
  through physical examination (active and passive
  movements, soft tissue, motor control)
• The associated structure/tissue sources refers to
  the actual structure/tissue the symptoms and
  signs are from
• Clues available from Area, Behaviour, History
  with confirmation from Phys Exam Treatment

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Physical Impairments Associated
Structures/Tissue Sources

• Interpretations about specific sources must be
  made with reference to the dominant pain
  mechanism
• Local tissue impairment accurate reflection of
  structures involved with Nociceptive and
  Peripheral Neurogenic patterns
• False positives common with maladaptive central
  processing
• Often not possible to diagnose exact
  structure/source (imaging may not correlate, not
  all pathology symptomatic)

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Hypothesis Categories

• Activity and Participation capability/restriction
• Patients perspectives on their experience
• Pathobiological mechanisms
• Physical impairments and associated
  structure/tissue sources
• Contributing factors
• Precautions contraindications P/E Rx
• Management treatment
• Prognosis

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Contributing Factors

• Any predisposing or associated factors involved
  in the development or maintenance of the
  patients problem
• Environmental
• Psychosocial
• Behavioural
• Physical/biomechanical
• Hereditary

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Contributing Factors

• Source
• Inflamed subacromial bursa
• Contributing Factor
• Tight posterior capsule
• Ineffective scapular rotators
• Poor sporting technique, etc.
• Source
• Central nervous system (central pain)
• Contributing Factor
• Psychosocial factors

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Hypothesis Categories

• Activity and Participation capability/restriction
• Patients perspectives on their experience
• Pathobiological mechanisms
• Physical impairments and associated
  structure/tissue sources
• Contributing factors
• Precautions contraindications P/E Rx
• Management treatment
• Prognosis

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Precautions Contraindications to Physical
Examination Treatment

• Determine extent of P/E and Treatment that may be
  undertaken safely
• Determined by
• Dominant pain mechanism
• Stage of healing/recovery (local tissue)
• Patients perspectives and expectations
• Severity and irritability of the symptoms
• Progression of the problem
• Known pathology (RA, osteoporosis, cardio, etc.)
• General health/medical status, age

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Hypothesis Categories

• Activity and Participation capability/restriction
• Patients perspectives on their experience
• Pathobiological mechanisms
• Physical impairments and associated
  structure/tissue sources
• Contributing factors
• Precautions contraindications P/E Rx
• Management treatment
• Prognosis

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Management Treatment

• No recipes!
• Specific treatment procedures and overall
  management must be based on
• Clinical reasoning through subjective and
  physical
• Ongoing reassessment of interventions
• Management of contributing factors critical to
  minimise risk of reoccurrence
• Patient understanding and active involvement
  critical to long term success

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Hypothesis Categories

• Activity and Participation capability/restriction
• Patients perspectives on their experience
• Pathobiological mechanisms
• Physical impairments and associated
  structure/tissue sources
• Contributing factors
• Precautions contraindications P/E Rx
• Management treatment
• Prognosis

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Prognosis

• Determined by
• Nature and extent of patients problem
• Ability and willingness to make necessary changes
  to facilitate recovery (lifestyle, psychosocial,
  physical)
• Clues available from
• Patients perspectives and expectations
• Extent of activity/participation restrictions
• Extent of physical impairments
• Social, occupational and economic status

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Prognosis

• Clues available from
• Dominant pain mechanisms present
• Stage of tissue healing
• Irritability of the disorder
• Length of history and progression of disorder
• Patients general health, age and pre-existing
  disorders
• Useful to consider list of Positives and
  Negatives
• Helpful to review decision every few appointments

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Diagnostic versus Narrative Reasoning
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Acquisition of Expertise is a Long Process

• Master chess player estimated to have 50,000
  configurations of chess stored in memory
• How many clinical patterns to expert
  physiotherapists have?
• Estimated to take 10 years professional
  experience to become an expert but not all
  physiotherapists become experts in 10 years
• No short cut to expertise, but improving your
  clinical reasoning will help!