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Clinical Reasoning

Presentation · June 2016

DOI: 10.13140/RG.2.2.14596.94080

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Lecturer notes:
• Sit the students in groups to facilitate group discussions.

1
Lecturer notes:
• Explain the learning objectives

2
Lecturer notes:
• Outline the contents of the day.

3
Lecturer notes:
• Ask students in groups to discuss what they think it means and why it is important.

4
Lecturer notes:
• Firstly, explain briefly the biopsychosocial model from the slide.
• Ask students in groups to list at least three items of each component and one
member from each group will summarize their answers.
• Add some of the description content that is written below and some points that may
be missed by students.

Description:

Biomedical components:
This is a traditional and obvious component that requires patient examination, to think
in terms of a physical diagnosis and the value of prompt medical attention. This
focuses on those patients with structural, pathological, physical disorders/diseases or
who require further investigation and medical management. However, psychosocial
factors are still important even in these patients. The biopsychosocial model is not
telling us to stop ‘diagnosing’ but is saying, be very careful to see that what you
diagnose is very much a hypothesis rather than a fact.

5
Psychological components:
This is how the patient feels and thinks in response to their pain, injury or disease.
Psychological factors have been shown to have a significant impact on how patients
deal with the situation and how they respond to it. Considering psychological factors
will help us to identify some patients’ problems that are related to musculoskeletal
pain.

• Fear of pain, fear of being injured again and avoidance of activity (fear avoidance).
• Negative or passive coping: patients doing little to help themselves, expecting
treatment to fix the problem, keen to rest and avoid activity.
• Stress or anxiety and misunderstandings about the nature of the condition.
• Depressed mood.

Many of these are not fixed in stone and can be dealt with and changed in a positive
direction by good interventions that are given by physiotherapists through using
communication skills, education and reactivation.

Social components:
• Dissatisfaction and unhappy with current job/work.
• Worries about safety at work.
• No support or encouragement from family and friends.
• Work load.
• Low education level and substance abuse.

Reference:
• Gifford L. (2001) Perspectives on the Biopsychosocial Model - part 1: Some issues
that need to be accepted? The Journal of the Organisation of Chartered
Physiotherapists in Private Practice 97: pp.3-9.

5
Lecturer notes:
• Read this slide or pick one student to read the slide.
• Ask students to identify the possible causes of Ahmed’s pain.
• Ask students in groups to discuss the case through the biopsychosocial model.
• Distribute a paper copy of the case study.
• Distribute a concept map form in order to help them to make connections between
biomedical and psychosocial components or encourage students to create their own
concept map form.
• Listen to the students’ discussion and focus on the way they are thinking.
• Check the students’ concept map and see how they make connections between
multiple components.
• Ask at least two groups to give summary of their results.
• Comment on their results and confirm the importance of considering psychosocial
factors.

6
Lecturer notes:
Ask students in groups to discuss what they think it means and why it is important.
Ask at least 2 student representatives from two different groups to comment on what
they think about this terminology.

Description:

• Clinical reasoning is cognitive thinking through the different components of patient

care to arrive at a considerable judgment regarding the diagnosis and the treatment
of a clinical problem in a particular patient.
• Kassirer (2010) defined clinical reasoning as ‘The range of strategies that clinicians
use to generate, test, and verify diagnoses, to assess the benefits and risks of tests
and treatments, and to judge the prognostic significance of the outcomes of these
cognitive achievements.
• The process in which the therapist, interacting with the patient and others (such as
family members or others providing care), structures meaning, goals and health
management strategies based on clinical data, patient choices, professional
judgment and knowledge (Higgs and Jones, 2000).

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• Therefore, clinical reasoning should be one of the important skills that
physiotherapist should use in order to provide better outcomes in terms of patient
care.
• Biomedical knowledge, clinical experience, ability to collect and interpret data and
critical thinking skills are necessary to understand and implement clinical
reasoning effectively in physiotherapy practice.
• Clinicians often face ill-defined problems, goals that are complex and outcomes
that are difficult to predict clearly.

References:
• Kassirer, J. P. (2010) Teaching clinical Reasoning: Case-based and Coached.
Academic Medicine 85(7): pp.1118-1124.
• Higgs, J. and Jones, M.A. (2000) Clinical Reasoning in the Health Professions.
2nd ed. Mass: Butterworth-Heinemann, Boston.

7
Lecturer notes:
• Let students see and read the slide content which clearly sends a direct message
about the importance of clinical reasoning.

8
Lecturer notes:
Discuss the following:
• Explain the core dimensions of clinical reasoning.
• Explain why we should not considered ourselves as experts but that their expertise
will develop over time

Description:
Knowledge: Can be built through research and experiences.
Cognition: Cognition can simply be defined as all mental processes and abilities that
help to generate new knowledge.

Critical thinking skills: These include the individual’s ability to do (Pascarella and
Terenzini, 1991, p.118):
• 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.

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

Metacognition: This is a cognitive process of an individual’s thinking about thinking

for themselves and most researchers divide it into metacognition knowledge or
regulation which is not similar to Flavell’s work in the late 1970s (Hochberg, 2014).
Although there are some differences between these two components, they are strongly
connected to each other. Therefore, it is simply considered as a method of
introspection in which one contemplates or reflects on one’s own thinking; i.e.
thinking about thinking.

Effective metacognition involves:

• Awareness of the learning process: knowing when a piece of information is
important enough to commit to memory.
• Recognition of the limitations of memory.
• Ability to step back from the immediate problem at hand and appreciate the
broader picture.
• Capacity for realistic self-critique and self-monitoring.
• Ability to actively select a strategy to deal with problems in decision-making: a
deliberate cognitive intervention in the thinking process.

Reference:
• Higgs, J. and Jones, M. (2000) Clinical Reasoning in the Health Professions. In:
Higgs, J., Jones, M. (eds.), Clinical Reasoning in the Health Professions.
Butterworth Heinemann, Edinburgh.
• Hochberg, L. (2014) Metacognition and Decision-Making Style in Clinical
Narratives. MSc dissertation. Rochester Institute of Technology
• Pascarella, E.T. and Terenzini, P.T. (1991) How College Affects Students:
Findings and Insights from Twenty Years of Research. San Francisco, CA:
Jossey-Bass.

9
Lecturer notes:
• Emphasise the importance of critical thinking
• Explain what does not constitute critical thinking
• Ask student groups to consider and discuss their experience about their own
practice and what they usually do

10
Lecturer notes:
• Firstly, explain to students the strategies and models of clinical reasoning.
• Ask students in groups to give an example of non-analytic and analytic reasoning in
physiotherapy practice.
• Ask each group to give their examples in front of other groups.
• Comment and give feedback on student answers.

Description:

Diagnostic clinical reasoning (Croskerry, 2009; Kassirer, 2010):

Intuitive components (Non-analytic):

• The intuitive components, thought to be a holdover from our evolutionary origins
in our primitive past, are instinctual and reflexive, require no input from the
analytic system, and respond to domain relevant stimuli.
• They are characterized by first impressions, quick pattern recognition, and rapid
responses to information. They seem to be effortless and autonomous, require little
or no awareness or active thought, can be influenced by affect and emotions and are
activated in conditions of considerable uncertainty.

11
• Some aspects of diagnosis, such as hypothesis generation, are presumably an
intuitive function. Though intuitive, this heuristic part of the process is also primed
to recognize new situations or patterns in its rapid recall fashion after repeated
exposure to the same stimuli or set of events. These components are sometimes
prone to error.
• Evidence suggests that more complicated cases cannot be easily solved by pattern
recognition compared to easy cases. However, analytic strategies are more
appropriate to use to solve complicated cases.

Analytic components:
• The analytic components are deliberate, studied problem-solving processes that
consciously and mindfully consider alternatives and options.
• They are thought to require considerable cognitive work, are slower than the
intuitive component, and are solidly based on science, logic, inference, causality,
probabilistic associations and decision making.
• These components are activated when a pattern is not clear, for example, when a
patient’s clinical or laboratory findings do not fit an easily recognized clinical
picture.
• Parts of the diagnostic process subsumed by these components include hypothesis
testing, differential diagnosis, diagnostic verification, and maintaining a coherent
clinical story that explains all the findings.
• The analytic system creates and manipulates models of reality in working memory
and maintains a coherent story, thus facilitating diagnostic reasoning and
hypothesis testing.

Clinical reasoning strategies (Edwards, Jones, Carr et al., 2007):

Diagnostic reasoning: The formation of a diagnosis is related to physical disability
and impairment with consideration of associated pain mechanisms, tissue pathology,
and the broad scope of potential contributing factors.

Narrative reasoning: This involves the apprehension and understanding of patients’

“stories”, illness experiences, meaning perspectives, contexts, beliefs and cultures.

Interactive reasoning: This is the purposeful establishment and ongoing management

of the therapist-patient rapport.

Teaching as reasoning: Reasoning is directed to the content, method, and amount of

teaching in clinical practice, which is then assessed as to whether it has been
effectively understood.

Predictive reasoning: This is the active envisioning of future scenarios with patients,
including the exploration of their choices and their implications.

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Ethical reasoning: This is the apprehension of ethical and practical dilemmas that
impinge on the conduct of the intervention and its desired goals.

Collaborative reasoning: This is the nurturing of a consensual approach toward the

interpretation of examination findings, the setting of goals and priorities, and the
implementation and progression of interventions.

Procedural reasoning: This is the decision-making in determining and performing

treatment and examination procedures.

Reference:
• Edwards, I. and Jones, M. (2007) Clinical Reasoning and Expert Practice. In G.
Jensen, J. Gwyer, L.M. Hack and K.F. Shepard (Eds.), Expertise in Physical
Therapy Practice (2nd ed., pp.192-213). St Louis: Saunders Elsevier.
• Edwards, I., Jones, M., Carr, J., Braunack-Mayer, A. and Jensen, G.M. (2004)
Clinical Reasoning Strategies in Physical Therapy. Physical therapy 84(4):
pp.312-330.
• Kassirer, J.P. (2010) Teaching Clinical Reasoning: Case-based and Coached.
Academic Medicine 85(7): pp.1118-1124.

11
Lecturer notes:
• Ask students to discuss the differences between system 1 and 2
• Distribute a hard copy of this table without answers
• Once they have done so, ask students to compare and contrast their responses to the
one on this slide, highlighting any differences and similarities

12
Lecturer notes:
• Comment on student answers before showing this slide, adding further information
that may assist their understanding

Description:
Dual process theory based on the interconnectedness of 2 ways the brain reasons
(Croskerry, 2009):
System 1:
• System 1 is an intuitive approach that proves effective most of the time.
Importantly, it is highly context-bound, with the potential for ambient conditions to
exert a powerful influence.
• In forming their early diagnostic impressions, clinicians may be consciously or
subconsciously influenced by a variety of factors, including patient (appearance,
degree of discomfort, communication issues, past experience with the patient),
characteristics of the illness (severity, past experience with the presenting
complaints), immediate issues in the medical environment (other patients’ needs,
workload, priority setting, interruptions,), resource issues (availability of specific
tests, consultants, hospital beds), overarching issues (ethical, medico legal).

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• System 1 is characterized by heuristics and other mental shortcuts. Many diagnostic
decisions in medicine are based on this type of pattern recognition, which is
strongly related to how fully manifest the disease is (i.e. how characteristic and
pathognomic the presentation is for a particular illness).
• The system is fast, frugal, requires little effort, and frequently gets the right answer
but occasionally it fails, sometimes catastrophically. Predictably, it misses the
patient who presents atypically, or when the pattern is mistaken for something else.

System 2:
• System 2 takes place under more ideal conditions, where there are fewer
boundaries and greater availability of resources, resulting in less uncertainty;
decisions made under these circumstances approach normative reasoning and
rationality more closely.
• System 2 is engaged when the patient’s signs and symptoms are not readily
recognized as belonging to a specific illness category, or do not follow a particular
script.
• The analytic reasoning mode is classically Popperian, with hypothesis testing and
deductive reasoning; it is analytical, involves critical thinking, and is logically
sound. Arborization, or multiple branching, is an algorithmic approach using a
series of unambiguous branching points and is particularly useful for delegated
decision making.
• It characterizes the approach of novices, but it may also be employed when
diagnoses are rare and esoteric, as well as under conditions of sleep deprivation and
fatigue. Robust decision making is more analytical than intuitive. It adopts a
systematic approach to remove uncertainty within the resources available to make
safe and effective decisions.

Reference:
Croskerry, P. (2009) A Universal Model of Diagnostic Reasoning. Academic
Medicine, 84(8): pp.1022-1028.

13
Lecturer notes:
• Explain to students the interaction between the two systems
• Give an example of where one system may be better due to the specific context

Description:
Which system is best? (Croskerry, 2009):
• It is natural to think that System 2 thinking, coldly logical and analytical, is likely
to be superior to System 1 but much depends on context.
• 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.
• Analytic mode can override the intuitive mode, and vice versa.
• Repeated presentations to the analytic mode will eventually result in pattern
recognition default to the intuitive mode.
• A series of studies have shown that System 1 or System 2 thinking (either alone)
are error prone; a combination of the 2 is optimal.

Reference:
• Croskerry, P. (2009) A Universal Model of Diagnostic Reasoning. Academic
Medicine, 84(8): pp.1022-1028.

14
• Eva, K.W. (2005) What every teacher needs to know about clinical reasoning.
Medical Education 39(1): pp.98-106.

14
Lecturer notes:
• Summarize what has said before the break time
• Clarify the meaning of hypothetico-deducto and pattern recognition

Description:
Analytical (hypothetico-deducto) and Intuitive (pattern recognition) have equally poor
diagnostic accuracy in novices. However, combined strategies improve the accuracy
(Eva, 2004).

Hypothetico-deductive clinical reasoning:

Source of the symptoms or dysfunction: What is the actual structure/source that
causes the dysfunction?

Contributing factors: What are predisposing and associated factors included in the
development or maintenance of the patient's problem, whether environmental,
behavioral, emotional, physical, or biomechanical?

Precautions and contraindications: What are the precautions and contraindications

to physical examination and treatment?

15
Management: Does this problem need a physical therapy intervention? Should the
treatment focus on the source of the problem or the predisposing factors?

Prognosis: What is the expected prognosis for this type of patient based on the current
data and evidence?

Reference:
• Eva, K.W. (2005). What Every Teacher Needs to Know About Clinical Reasoning.
Medical Education 39(1): pp.98-106.
• Jones, M.A. (1992) Clinical Reasoning in Manual Therapy. Physical Therapy
72(12): pp.875-884.

15
Lecturer notes:
• Explain to students the learning tools that may be used to develop clinical
reasoning

Description:
Problem Representation: This is a physio’s evolving sense of the clinical picture; a
way of describing a specific case in abstract terms. It includes Patient demographics,
clinical features from the history and physical examinations. It is considered as a
summary of a case, usually generated at the start of the assessment section. Semantic
qualifiers: These are paired opposing descriptors that can be used systematically to
compare and contrast diagnostic considerations: sharp/dull, acute/chronic, tender/non-
tender, proximal vs. distal etc.

Illness Script: This is a mental representation of the important elements of an illness.

The same illness script may be linked to more than one problem representation (i.e.
different clinical presentations of the same disease). They are developed by medical
knowledge and refined through clinical experience.

16
Illness script includes:
How the disease happens (pathophysiology).
Who gets it (demographics, risk factors, exposures)?
Key signs and symptoms.
Natural history (duration/pattern of symptoms).

Horizontal reading: This is a very useful way to understand and compare multiple
hypotheses. This will help to compare the illness script with other diagnoses.

Metacognition questions: Metacognition questions are a list of questions that are

characterized by a high level of critical questions that are used to make the learners
think deeply about their answers and choices.

Concept Mapping: This is a type of graphic organizer used to help make connections
between different components and represent the knowledge of a subject in a creative
way. Concept maps begin with a main idea (or concept) and then branch out to show
how that main idea can be broken down into specific topics.

The IDEA method was developed to address the lack of diagnostic reasoning
documented in patient write-ups. The IDEA method asks students to organize the
assessment section of their write-ups in a simple paragraph form (Baker, Connell,
Bordage et al., 1999).
I: Interpretive summary
D: Differential diagnosis with commitment to the most likely diagnosis
E: Explanation of reasoning in choosing the most likely diagnosis
A: Alternative diagnoses with explanation of reasoning

In the interpretive summary, students summarize the most important findings and
transform the patient’s findings into semantic qualifiers to interpret and represent the
problem. The two or three most likely diagnostic possibilities are then listed and
students commit to one diagnosis as most likely. The data from the interpretive
summary as well as knowledge about the disease are then used to defend the choice of
the most likely diagnosis, with alternative diagnoses being compared to the most
likely diagnosis (Baker, 2003).

Reference:
• Hochberg, L. (2014). Metacognition and Decision-Making Style in Clinical
Narratives. MSc Dissertation. Rochester Institute of Technology.
• University of Lowa Carver College of Medicine (undated) Clinical and Diagnostic
Reasoning [online]. Available at:
http://www.medicine.uiowa.edu/internalmedicine/education/MasterClinician/Diagn
osticReasoningOverview/ [accessed 20 May 2016].
• Baker, E.A. (2003) Challenging students to expose their thoughts in write-ups: The
IDEA method. Journal of General Internal Medicine 18(1): p.235.

16
• Baker, E.A., Connell, K.J., Bordage, G. and Sinacore J. (1999) Can diagnostic
semantic competence be assessed from the medical record? Academic Medicine
74(10): pp.13-S15.

16
Lecturer notes:
• Explain the stages of the clinical reasoning process

Reference:
Kerry, R. (2010) The theory of clinical reasoning in combined movement therapy. In
McCarthy C. (ed.) Combined movement theory: rational mobilization and
manipulation of the vertebral column. Edinburgh, Elsevier, pp.19-49.

17
Lecturer notes:
• Firstly, ask each student to go back to Ahmed’s case and read the case more
carefully using critical thinking.
• Remind students to use tools that have described in the learning strategies slide.
• Ask students to write an illness script and problem presentation before they
complete their answers based on IDEA method in order to help them to understand
the case
• Ask student groups to formulate at least three possible hypotheses for Ahmed’s
pain, outlining possible subjective, objective examinations and treatment plan for
each hypothesis
• Allow students plenty of time to discuss and complete this activity
• They are permitted to use their mobiles or laptops to search for evidence to support
their hypotheses.
• Facilitate the students’ discussions, encouraging students to participate in the
discussion rather than giving them the answers
• Once they have finished, allow each group to present a summary of their findings
• Comment on their findings, ensuring they understand the importance of using case
studies to develop their clinical reasoning skills, which will improve with practice
over time

18
Lecturer notes:
• Ask student groups to think about the types of errors that may occur during the
clinical reasoning process
• Ask at least two groups to present their feedback to other groups
• Comment on the student responses and distribute a paper that includes a list of
cognitive errors
• Distribute a hard copy of cognitive errors in physiotherapy

Some example of cognitive Errors in Physiotherapy (Jones, 1992):

Adding pragmatic inferences: Making assumptions is an error of reasoning. For
example, a patient with pain in the supraspinous fossa will often describe this as "pain
in my shoulder." It is a misrepresentation of the facts to assume the patient's "shoulder
pain" is actually within the shoulder itself without specific clarification of the site.

Considering too few hypotheses: By prematurely limiting the hypotheses considered,

discovery of the correct hypothesis may be missed or delayed. This can occur when
inquiries and physical tests are only directed to the local sources of a patient's
symptoms.

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Failure to sample enough information: It is an error to make a generalization based
on limited data. This is seen in judgments regarding the success or failure of a
particular management approach based on only a few experiences. Closely linked to
this error is the failure to sample information in an unbiased way. Although this is
typically controlled for in formal research, the practicing therapist will rely on
memory of previous experiences as the sample on which views are based. The error
occurs when only those cases are recalled that support one view while confounding
evidence is forgotten.

Confirmation bias: Another error of reasoning related to a biased sample of

information occurs when therapists only attend to those features that support their
favorite hypotheses while neglecting the negating features. This can lead to incorrect
clinical decisions and hinder the therapist's opportunity to learn different variations of
clinical patterns.

Reference:
• Jones, M.A. (1992) Clinical reasoning in manual therapy. Physical therapy 72(12):
pp.875-884.
• Croskerry, P. (2003) The importance of cognitive errors in diagnosis and strategies
to minimize them. Academic medicine 78(8: pp.775-780.

19
Lecturer notes:
• Explain the possible strategies that may use to decrease cognitive errors
• Distribute a paper that includes strategies to reduce cognitive errors

Cognitive Debiasing Strategies to Reduce Diagnostic Error (Croskerry, 2003):

• Develop insight/Awareness: Provide detailed descriptions and thorough
characterizations of known cognitive biases, together with multiple clinical
examples illustrating their adverse effects on decision-making and diagnosis
formulation.
• Consider Alternatives: Establish forced consideration of alternative possibilities
e.g., the generation and working through of a differential diagnosis. Encourage
routinely asking the question: What else might this be?
• Metacognition: Train for a reflective approach to problem solving: stepping back
from the immediate problem to examine and reflect on the thinking process.
• Decrease Reliance on Memory: Improve the accuracy of judgments through
cognitive aids: mnemonics, clinical practice guidelines, algorithms, and hand-held
computers.

20
• Specific Training: Identify specific flaws and biases in thinking and provide
directed training to overcome them: e.g., instruction in fundamental rules of
probability, distinguishing correlation from causation, basic Bayesian probability
theory.
• Simulation: Develop mental rehearsal, ‘‘cognitive walkthrough’’ strategies for
specific clinical scenarios to allow cognitive biases to be made and their
consequences to be observed. Construct clinical training videos contrasting
incorrect (biased) approaches with the correct (debiased) approach.
• Cognitive forcing strategies: Develop generic and specific strategies to avoid
predictable bias in particular clinical situations.
• Make task easier: Provide more information about the specific problem to reduce
task difficulty and ambiguity. Make available rapid access to concise, clear, well-
organized information.
• Minimize time pressures: Provide adequate time for quality decision making.
• Accountability: Establish clear accountability and follow-up for decisions made.
• Feedback: Provide as rapid and reliable feedback as possible to decision makers so
that errors are immediately appreciated, understood, and corrected, resulting in
better calibration of decision makers.

Example method:
SEA TOW - Avoiding Errors of Omission:
Second Opinion: Do I need one?
Eureka Moment: Is this a pattern recognition dx?
Anti-evidence: Is there anything refuting the dx?
Thinking over my thinking: Have I done it?
Overconfident: Am I?
What else: could I be missing?

Reference:
• Croskerry, P. (2003) The importance of cognitive errors in diagnosis and strategies
to minimize them. Academic medicine 78(8): pp.775-780.

20
Lecturer notes:
• Explain the figure and send a clear message that is not easy, especially for novice
clinicians, to gain full control and skills to reduce cognitive errors.

Reference:
• Croskerry, P., Singhal, G. and Mamede, S. (2013) Cognitive Debiasing 1: Origins
of Bias and Theory of Debiasing. BMJ Quality and Safety 22(2): pp.58-64.

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 Lecturer notes:
• Encourage students to use learning tools throughout the course
• Distribute the evaluation form for the day and explain the importance of their
feedback for future content and the teaching methods used

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