Clinical Decision Making in Physiotherapy Practice

Introduction[edit | edit source]

The majority of time spent working in clinical practice involves thinking and decision making.[1][2][3] Because decisions are so commonly made, it is easy to assume that anyone can make effective decisions.[1] Effectiveness in clinical practice depends on the decisions made which stresses the importance of learning how to optically make decisions.[4][5]Clinical or diagnostic reasoning has been proposed to be the most important core skill of any health care practitioner.[6] The dynamic and ever changing realm of health care demands that practitioners provide meaningful improvements in patients and the clinical decision  process is the only path to achieving it.[5][7] The rate at which practitioners however fail at this critical skill is alarmingly high. Not only has large discrepancies (20-40%) been reported between ante and postmortem diagnoses but many of these postmortem examinations would not have been necessary if the correct diagnosis was made.[8][9]. It has been estimated that nearly 18% ($2.7 trillion) of the United States’ GDP is spent on healthcare, yet more than 30% is wasted on inappropriate care.[10] Up to 80 000 deaths occur annually in hospitalised patients in the United States due to incorrect diagnoses and in the outpatient setting, around 5%  of adults (12 million US adults annually) are incorrectly diagnosed. [11]

The majority of these failures are not attributed to system problems or knowledge failure, but to how practitioners think - how they solve problems, reason and ultimately make decisions[5]. To improve healthcare it is of great importance to improve clinical reasoning and hence clinical decision making.

What is Clinical Decision Making?[edit | edit source]

Clinical decision making (CDM) has been defined as a contextual, continuous and evolving process where data is gathered, interpreted and evaluated in order to select an evidence-based choice of action. [12] The CDM process is a highly complex, multi-faceted skill that is developmental in nature and requires a substantial amount of practice with realistic patients to develop.”[7][13] The understanding of CDM is still evolving and largely based on research in psychology, medicine and nursing.[7][14] It involves multiple different types of reasoning [7] and is therefore wrapped up in the  “Great Rationality Debate” about the most optimal course of our reasoning, decision-making and actions. [15] Rationality is proposed to be the foremost characteristic of the accomplished decision-maker.[5]

What is the great rationality debate all about?[edit | edit source]

There are multiple major theories of rationality that could in part be relevant to the medical field.[15] “Rationality is often defined as acting in a way that helps us achieve our goals, which in the clinical setting typically means desire to improve our health.”[15] Most major theories of consequence agree that in order to achieve our goals we need to take into account both the benefits (gains) and harms (losses) of alternative courses of action.[15] Djulbegovic & Elqayam[15] developed a list of “core ingredients” of rationality and its relevance to the medical field (Table 1).

Principle 1

Rational decision-making requires integration of

  • Benefits (gains)
  • Harms (losses)

in order to accomplish our goals like improved health

Principle 2 It generally happens under conditions of uncertainty.
  • The rational approach requires the use of reliable evidence to deal with the intrinsic uncertainties.
  • It depends upon cognitive processes that permit the integration of probabilities/uncertainties.
Principle 3 “Rational thinking should be informed by human cognitive architecture.”
  • Made up of type 1 “old mind” reasoning processes (affect‐based, intuitive, fast, resource‐frugal) and type 2 “new mind” processes (“analytic and deliberative, consequential driven, and effortful”)
Principle 4 Rationality is context dependant and should be aware of environmental, and computational constraints of human brains
Principle 5 Rationality (in medicine) is closely related to ethics and morality of our actions
  • requires consideration of utilitarian (society‐oriented), duty bound (individual‐oriented), and right‐based (autonomy, “no decision about me, without me”) ethics

References[edit | edit source]

  1. ↑ 1.0 1.1 Croskerry P, Nimmo GR. Better clinical decision making and reducing diagnostic error. The journal of the Royal College of Physicians of Edinburgh. 2011 Jun 1;41(2):155-62. Available from:http://www.ajustnhs.com/wp-content/uploads/2012/10/croskerry-better-decision-making-2011.pdf DOI: 10.4997/JRCPE.2011.208
  2. ↑ Smyth O, McCabe C. Think and think again! Clinical decision making by advanced nurse practitioners in the Emergency Department. Int Emerg Nurs. 2017 Mar 1;31:72-4. https://www.researchgate.net/profile/Catherine_Mccabe/publication/307524001_Think_and_think_again_Clinical_decision_making_by_advanced_nurse_practitioners_in_the_Emergency_Department/links/5d15caaea6fdcc2462ab655b/Think-and-think-again-Clinical-decision-making-by-advanced-nurse-practitioners-in-the-Emergency-Department.pdf  DOI: 10.1016/j.ienj.2016.08.001
  3. ↑ Whelehan DF, Conlon KC, Ridgway PF. Medicine and heuristics: cognitive biases and medical decision-making. Irish journal of medical science. 2020 May 14;189:1477-1484.       DOI: 10.1007/s11845-020-02235-1
  4. ↑ Croskerry P. Context is everything or how could I have been that stupid. Healthc q. 2009 Aug 15;12(Spec No Patient):e171-176. Available from:https://www.researchgate.net/profile/Pat_Croskerry/publication/51437685_Context_Is_Everything_or_How_Could_I_Have_Been_That_Stupid/links/5776721908aeb9427e27892f/Context-Is-Everything-or-How-Could-I-Have-Been-That-Stupid.pdf
  5. ↑ 5.0 5.1 5.2 5.3 Croskerry P. A model for clinical decision-making in medicine. Medical Science Educator. 2017 Dec 1;27(1):9-13. Available from:https://www.researchgate.net/profile/Pat_Croskerry/publication/321510386_A_Model_for_Clinical_Decision-Making_in_Medicine/links/5ae70b4c0f7e9b9793c7e527/A-Model-for-Clinical-Decision-Making-in-Medicine.pdf  DOI: 10.1007/s40670-017-0499-9
  6. ↑ Croskerry P. A universal model of diagnostic reasoning. Academic medicine. 2009 Aug 1;84(8):1022-8. Available from: https://static1.squarespace.com/static/57b5e6e0ebbd1ad42af1f8b6/t/5d7e9e8f79d8cf7718ca18af/1568579215659/Croskerry+A+Universal+Model+of+Diagnostic+Reasoning.pdf  DOI:10.1097/ACM.0b013e3181ace703
  7. ↑ 7.0 7.1 7.2 7.3 Huhn K, Black L, Christensen N, Furze J, Vendrely A, Wainwright S. Clinical reasoning: survey of teaching methods and assessment in entry-level physical therapist clinical education. Journal of Physical Therapy Education. 2018 Sep 1;32(3):241-7. Available from: https://journals.lww.com/jopte/Fulltext/2018/09000/Clinical_Reasoning___Survey_of_Teaching_Methods.6.aspx    DOI:10.1097/JTE.0000000000000043
  8. ↑ Gawande A. Final cut. In: Complications: A Surgeon’s Notes on an Imperfect Science. New York: Henry Holt and Company; 2002;197-198
  9. ↑ Graber M. Diagnostic errors in medicine: a case of neglect. The Joint Commission Journal on Quality and Patient Safety. 2005 Feb 1;31(2):106-13. Available from: https://www.researchgate.net/profile/Mark_Graber/publication/7943691_Diagnostic_Errors_in_Medicine_A_Case_of_Neglect/links/5c9a5122299bf11169498a6a/Diagnostic-Errors-in-Medicine-A-Case-of-Neglect.pdf
  10. ↑ Berwick DM, Hackbarth AD. Eliminating waste in US health care. Jama. 2012 Apr 11;307(14):1513-6. Available from: http://files.mccn.edu/media/ds/Berwick%20et%20al%202012.pdf   DOI: 10.1001/jama.2012.362
  11. ↑ Singh H, Meyer AN, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. BMJ quality & safety. 2014 Sep 1;23(9):727-31. Available from: https://qualitysafety.bmj.com/content/qhc/23/9/727.full.pdf   DOI: 10.1136/bmjqs-2013-002627
  12. ↑ Tiffen J, Corbridge SJ, Slimmer L. Enhancing clinical decision making: development of a contiguous definition and conceptual framework. Journal of professional nursing. 2014 Sep 1;30(5):399-405.
  13. ↑ Hussain A, Oestreicher J. Clinical decision-making: heuristics and cognitive biases for the ophthalmologist. Survey of Ophthalmology. 2018 Jan 1;63(1):119-24. Available from: https://www.surveyophthalmol.com/article/S0039-6257(17)30115-7/fulltext   DOI: 10.1016/j.survophthal.2017.08.007
  14. ↑ Chowdhury A, Bjorbækmo WS. Clinical reasoning—embodied meaning-making in physiotherapy. Physiotherapy theory and Practice. 2017 Jul 3;33(7):550-9. Available from: https://www.tandfonline.com/doi/pdf/10.1080/09593985.2017.1323360   DOI: 10.1080/09593985.2017.132336
  15. ↑ 15.0 15.1 15.2 15.3 15.4 Djulbegovic B, Elqayam S. Many faces of rationality: implications of the great rationality debate for clinical decision‐making. Journal of Evaluation in Clinical Practice. 2017 Oct;23(5):915-22. Available from: https://onlinelibrary.wiley.com/doi/pdf/10.1111/jep.12788    DOI:10.111/jep.12788
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