Introduction to Clinical Reasoning

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (2/03/2024)

Original Editor - User Name

Top Contributors - Wanda van Niekerk and Jess Bell  

Introduction

Definitions of Clinical Reasoning

There are multiple different definition of clinical reasoning. Some of these definitions are listed below.

"Clinical reasoning (or practice decision making) is a context-dependent way of thinking and decision making in professional practice to guide practice actions."Chapter 1 Higgs and Jensen in Higgs Clinical Reasoning in Health Professionals

"Clinical reasoning refers to the thinking and decision-making processes that are used in clinical practice." Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen GM. Clinical reasoning strategies in physical therapy. Physical therapy. 2004 Apr 1;84(4):312-30.

Clinical reasoning in physical therapy could be conceptualised as "integrating cognitive, psychomotor, and affective skills. It is contextual in nature and involves both therapist and client perspectives. It is adaptive, iterative, and collaborative with the intended outcome being a biopsychosocial approach to patient/client management." Huhn K, Gilliland SJ, Black LL, Wainwright SF, Christensen N. Clinical reasoning in physical therapy: a concept analysis. Physical therapy. 2019 Apr;99(4):440-56.

In occupational therapy clinically reasoning is defined asda Silva Araujo A, Anne Kinsella E, Thomas A, Demonari Gomes L, Quevedo Marcolino T. Clinical Reasoning in Occupational Therapy Practice: A Scoping Review of Qualitative and Conceptual Peer-Reviewed Literature. The American Journal of Occupational Therapy. 2022 May 1;76(3):7603205070.: (also refer to references within this reference)

"a largely tacit, highly imagistic and deeply phenomenological mode of thinking"

" the process used by practitioners to plan, direct, perform and reflect on client care

"as a mode of thought that involves all the thinking processes of the clinician as s/he moves into, through and out of the therapeutic relationship and therapy process with a client"

Clinical reasoning is "a process in which the therapist, interacting with the patient and others (s8such as family members or others providing care), helps patients structure meaning, goals, and health management strategies based on clinical data, patient choices, and professional judgement and knowledge."Higgs and Jones in Edwards

Clinical reasoning is defined as a complex cognitive process leading to meaningful interpretation of patients' problems and formulation of an effective management plan" Modi JN, Anshu Gupta P and Singh T. Teaching and assessing clinical reasoning skills. Indian Pediatr 2015; 52(9):787–794 in Spaulding SE, Yamane A, McDonald CL, Spaulding SA. A conceptual framework for orthotic and prosthetic education. Prosthetics and Orthotics International. 2019 Aug;43(4):369-81.

Clinical reasoning reflects the thinking or reasoning that a health practitioner engages in to solve and manage a clinical problem. It has been described as a process or an outcome Young ME, Thomas A, Lubarsky S, Gordon D, Gruppen LD, Rencic J, Ballard T, Holmboe E, Da Silva A, Ratcliffe T, Schuwirth L. Mapping clinical reasoning literature across the health professions: a scoping review. BMC Medical Education. 2020 Dec;20:1-1.

Importance of Clinical Reasoning

• Promotes professional autonomy Higgs 2019
• Improves patient outcomesPillay T, Pillay M. Contextualising clinical reasoning within the clinical swallow evaluation: A scoping review and expert consultation. South African Journal of Communication Disorders. 2021;68(1):1-2.

Clinical Reasoning according to Timing

Two systems of thought are described: System 1 is instinctual and fast, whereas System 2 is methodical and deliberate (Kahneman 2011)

System 1	System 2
intuitive reasoning	slow effortful thinking, deliberate
heuristic	useful for intentional thinking
intuition	slow, conscious effortful
pattern recognition	tends to occur in new unfamiliar situations
experience	tend to be reliable
fast, automatic
can have errors and biases

Novice versus Expert Clinical Reasoning

Experienced clinicians use experience to develop scripts for pattern recognition

Recognition primed decision model

Rather than investigating each sign and symptom individually, the chunk information to form a pattern. This allows for a comparison of whether the current situation is similar to previous situation.

Experts rely on fast thinking until they notice that something is different

When they notice that something is different they stop, reflect on how it is different and gather more information

Novice clinicians must rely more on slow thinking because they don't have the experience to build scripts

Rehabilitation professionals need to be aware of biases in automatic thinking. Crosskerry Examples of types of biases include:

• Availability bias - Priority is given to the first thought that comes to mind
• Recency bias - Give more weight to something that is recent
• Confirmation bias - Gather selective information that favours a hypothesis
• Premature closing bias - end the decision making process early and accept a diagnosis that has not been completely verified

Clinical Reasoning in Different Professions

As part of a concept analysis of clinical reasoning in physiotherapy, other healthcare professions were also considered and concept analyses were developed for the different professions. This was done to explore similarities and differences of clinical reasoning between the professions. It is evident that the purpose (area where emphasis is focused) and terminology differ across different professions. Some of these results are shown in the table below. If you'd like to read more about this concept analysis you can read more here: article link

Profession	Area of Emphasis	Related Terminology (Synonyms for Clinical Reasoning)
Physician	Correct diagnosis	Decision-making; diagnostic reasoning
Nursing	Competence; establishing a nursing plan of care	Critical thinking; clinical reasoning
Pharmacy	Thinking skills	Critical thinking; problem solving
Psychology	Identifying cues and key features, hypothesis testing to form a judgement	Clinical decision-making; diagnosis
Physiotherapy	Patient and client management; use of the movement system	Critical thinking; decision-making; professional reasoning (Araujo)
Occupational Therapy	Patient and client management; use of the occupational profile (Araujo)	Critical thinking; decision-making; professional reasoning (Araujo); therapeutic reasoning; theoretical reasoning
Prosthetist and Orthotist	Integration of ICF into decision-making (Spaulding)Spaulding SE, Yamane A, McDonald CL, Spaulding SA. A conceptual framework for orthotic and prosthetic education. Prosthetics and Orthotics International. 2019 Aug;43(4):369-81.
Speech and Language Therapy	Diagnosis; interventionSwallow assessment, Classification for speech disordersDiepeveen S, van Haaften L, Terband H, de Swart B, Maassen B. Clinical reasoning for speech sound disorders: Diagnosis and intervention in speech-language pathologists' daily practice. American journal of speech-language pathology. 2020 Aug 4;29(3):1529-49.	Practice decision making

Organising clinical reasoning according to purpose or goal can help the selection of the process (Young)

Clinical Reasoning around a Purpose

Clinical reasoning strategies can differ depending on the specific theme / purpose / activity the rehabilitation professional needs to perform as well as the behaviours observed in rehabilitation professionals. These themes can include:

• conducting an assessment and classifying, making a diagnosis
• developing a rehabilitation plan which may include: establishing a prognosis, identifying the need for referral, resources allocation
• implementing rehabilitation interventions (management, intervention, patient education) and evaluating progress toward desired outcomes
• purpose to engage and establish a therapeutic alliance. (Edward 2004
• resolving a moral dilemma

Purpose	Clinical Reasoning Strategies Employed and Definition
Identifying diagnosis or classification	Hypothetical deductive reasoning (also known as diagnostic reasoning or data-driven decision making) Within the framework of hypothetical deductive reasoning, patient cues serve as key elements in creating multiple hypotheses. These hypotheses undergo continuous updates and refinement as new information is incorporated. Narrative reasoning Narrative reasoning utilises stories to depict clinical encounters, incorporating conditions, consequences, motivation and interaction (M) This proves beneficial for gaining insights into the patient experience and fostering empathy skills. (C) In an educational context, narrative reasoning involves sharing a story, individual reflection and the collaborative exchange of perspectives.
Identifying diagnosis using ICF	A clinical reasoning framework designed for orthotists and prosthetists emphasised the use of the International Classification of Functioning, Disability and Health along with technical variables and rehabilitation services to ensure patient-centred care. In this framework, the examination should focus on the patient's body structure, function, activities, participation, and personal and environmental factors. Using this framework improves communication in a multidisciplinary team. add links to icf
Developing a rehabilitation plan - creating prognosis, goals and progressions	Predictive reasoning (also called conditional reasoning) Predictive reasoning involves imagining future scenarios based on decisions and their implications. This strategy includes actively envisioning future scenarios with patients, exploring their choices and considering the potential implications of those choices. Collaborative reasoning Collaborative reasoning involves a consensual approach to interpreting findings, setting priorities and advancing intervention. This method, incorporating problem-solving and communication, actively engages patients, families and team members. Rehabilitation professionals adapt reasoning strategies based on patient cues, making it a dynamic process where professionals collaborate to derive meaning, establish goals and formulate rehabilitation plans using data, patient preferences and professional judgment.
Implementing interventions and evaluating progress	Scientific reasoning Scientific reasoning is the integration of evidence-based practice tailored to a specific patient. It entails using evidence to inform decisions for a specific individual within a particular context. Intuitive reasoning Implicit information is used to form a basis for judgement or decision making (Ruth)("gut feeling")
Establishing a therapeutic alliance	Collaborative reasoning Interactive reasoning Interactive reasoning aims to establish rapport between the rehabilitation professional and the patient. This connection is fostered through shared experiences, such as conversation and storytelling, as well as discussions on the patient's perception of the effectiveness of an intervention.
Resolving a moral dilemma	Ethical reasoning Ethical reasoning involves recognising ethical and practical dilemmas that impact both the treatment process and its intended goals, guiding subsequent actions towards their resolution.

Resources

• bulleted list
• x

or

1. numbered list
2. x