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 professions
2. Virtue-similar to other health professions
3. 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
Clinical
reasoning
Virtue
Clinical
reasoning
Virtue
Knowledge
Knowledge
Movement
Movement
Student
Novice
Professional Development
Competent
Virtue
Clinical
reasoning
Expert
Clinical
reasoning
Virtue
Philosophy
of practice
Knowledge
Movement
Knowledge
Movement
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, nonexpert”?
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
• System 2: Analytical/Rationale
– Mostly at the
subconscious level/
automatic
– Pattern recognition
– Intuition
– More developed in
experienced practitioners
– Difficult to put into words
– Low Scientific Rigor
–
–
–
–
–
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
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?
System 1 (Intuitive)
System 2 (Analytic)
Dual System Characteristics (Croskerry)
Characteristic
System 1 (Intuitive)
System 2 (Analytic)
Cognitive Style
Heuristic (experiencebased)
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 Objective
To 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-docsvideo-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