How do physical therapists make clinical decisions? - PowerPoint PPT Presentation


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How do physical therapists make clinical decisions?


How do physical therapists make clinical decisions? Tami Struessel PT, DPT, OCS, MTC When might bias creep into our decision-making? Bias-higher risk for error when ... – PowerPoint PPT presentation

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Title: How do physical therapists make clinical decisions?

How do physical therapists make clinical
  • 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
  • What makes the expert stand out?
  • Does anyone here want to be an experienced

4 themes that unify philosophy of practice by
expert PTs (Jensen-from commentary by Laurita
  • Knowledge-similar to other health professions
  • Virtue-similar to other health professions
  • Clinical reasoning
  • different-PTs 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.
  • Movement
  • different-PTs show an exquisite sense of
    movement, both their own movement as an
    instrument of patient care and the patients
    movement as a source of information and

Clinical reasoning
From Jensen Expertise in Physical Therapy
Practice, p.11
For youWhat does the thought process of an
expert look like?
  • And what DOESNT is look like?

What is Critical Thinking?
  • Critical Thinking typically involves the
    individuals ability to do some or all of the
  • Identify central issues and assumptions in an
  • Recognize important relationships
  • Make correct inferences from data
  • Deduce conclusions from information or data
  • 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
  • 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
  • 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 CIs 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
  • 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
  • Higgs/Jones
  • What is Wise Action?
  • Goal of Clinical ReasoningWise Action
  • Davies

Reasoning outside a clinical context(van der
  • 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
  • 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
  • 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
  • Well use one

Dual Process Theory
  • Dual process theory based on the
    interconnectedness of 2 ways the brain reasons
  • Croskerry Overconfidence in Clinical Decision
  • 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.
  • 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)
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)
  • Thats all very well if were 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.
  • Mark of good decision-maker
  • ability to match 2 systems to their respective
    optimal contexts
  • consciously blend them into overall decision

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

  • 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.

(No Transcript)
PTs are different, and its OK?
  • Much of clinical reasoning literature is based on
    the diagnosis model based on physicians.
  • While we can learn a lot, as PTs, we think

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

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

Teaching/learning tips for you
  • Identify and analyze and challenge assumptions in
  • Assess credibility of information (evidence
  • Understand how to systematically work through a
  • 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
  • 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 is VERY analytical System 2
  • But as youve 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
  • 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.
  • 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

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 elses published work without
    giving credit (whether or not it is reworded)
  • Use of someone elses published work, citing the
    work, but using it verbatim without quotation
  • 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 arent sure, always ask!

Course Logistics
  • Google docs http//
  • 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, beginnings 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