Clinical reasoning apao

Clinical Reasoning Jorge E. Valdez MD,MA. DeanSchool of Medicine and Health Sciences

1. Aplicación de habilidades clínicas.2. Manejo de recursos diagnósticos3. Manejo terapéutico. 7. Aplicación del4. Promoción de salud y entendimiento de lasprevención de la enfermedad. Competencias Competencias Ciencias Básicas,5. Habilidades de Técnicas Intelectuales Clínicas y Sociales paracomunicación. la práctica clínica.5. Aplicación dehabilidades para el manejode la información. Competencias Competencias en Profesionalismo Analíticas y Creativas9. Desempeño del Médico 8. Razonamiento,dentro del sistema de salud. juicio clínico y10. Ética y desarrollo toma de decisiones.personal.

Objectives• By the end of this lecture, students should be able to: – • Understand the need for clinical reasoning – • Define clinical reasoning – • Understand the clinical reasoning process

Need for clinical reasoning• People live longer with more chronic and complex problems.• Health professionals are expected to be more responsible, to work with diverse teams, and to make more independent judgements and decisions.• There is information overload because of instant access to information through computers.• Doctors are frequently involved in complex situations, which require an increasing level of responsibility

Definition:• The thinking and/or decision-making processes that are used in clinical practice Higgs and Jones 2000, Edwards et al 2004 Goal = “Wise Action”

Clinical Reasoning• Refers to a process in which the therapist, interacting with the patient, structures meaning, goals & health management strategies based on clinical data, client choices, professional judgment & knowledge (Higgs and Jones 2000)• –Hypothesis oriented, collaborative and reflective• –Knowledge and organization of knowledge are important

Process of Clinical ReasoningTheoretical Models of Reasoning1.Knowledge -Reasoning Integration (Schmidt et al 1990)2.Integrated Patient Centered Model (Higgs and Jones 1995)3.Hypothetic–Deductive (Elsteinet al 1978)4.Pattern Recognition (Barrows &Feltovich1987)

Knowledge –Reasoning Integration• CR is not separate skill from knowledge and clinical skills• Important for knowledge to be domain- specific• With increasing knowledge and reasoning skills –knowledge structure changes (towards illness scripts) (Schmidt et al 1990)

Developing Expertise• Knowledge acquisition and clinical reasoning go hand in hand.• Occurs in stages• Novice →Intermediate →Experts

Developing ExpertiseLevel Knowledge Representation Knowledge structureNovice Networks Knowledge growth and validationInterm Networks Encapsulation Expert Illness Scripts Illness Script formation (instantiated scripts) BoshuizenH & Schmidt HG (2000)

Developing Expertise Level Clinical Reasoning Control Required Demand (Cogn.)Novice Long chains of detailed Active monitoring each High reasoning stepInterm Reasoning thru’Encapsulated Active monitoring each Med network stepExpert Illness script activation and Monitoring at level of Low instantiation script

Integrated Patient-Centred Model• Involves 3 core elements –Knowledge –Cognition –Metacognition• Incorporates mutual decision making process with the patient• Contextual interaction (situation/ environment)

Knowledge• Biomedical knowledge• Clinical knowledge• Everyday knowledge• Increase growth of knowledge needs to be organized to be useful

Cognition• Perception of relevant from irrelevant information• Interpretation of information and hypothesis testing• Inquiry strategies (hypothesis testing)• Weighting and synthesis of information

Metacognition• Therapist‘s awareness, self- monitoring and reflective processes• Thinking about your thinking

Reflection“To be conscience that you are ignorant is a great step to knowledge” Benjamin Disraeli (1835-1910)

Narrative Reasoning• Understanding the patient’s Illness experiences “stories” Meaning perspectives Contexts Beliefs Cultures

Using Narrative Reasoning• Patient wants to return to his job• Shows up for all clinical appointments and does everything that is asked of him during appointment• Does not “get around”to doing the exercises at home• Without exercises, treatment will not be successful• How do we proceed?

Integrated Patient-Centred Model The client´s inputThe clinical problem The enviroment Cognition Knowledge Metacognition

Integrated Patient-Centred Model

Hypothetico-Deductive Reasoning• Analytic process of reasoning (Eva 2004)• “Backward Reasoning”• Relation between the signs and symptoms and diagnosis

Hypothetico-Deductive Reasoning• Hypothesis generating and testing involves both inductive and deductive reasoning• –Induction -to generate the hypothesis• –Deductive -to test hypothesis

Hypothetico-Deductive ReasoningPros Cons• Thorough • Slow• Organized • Too much data can• Appears to be a skill leave reasoner without that can be taught to a direction. novice clinicians

Collaborative reasoning• Shared decision making between the therapist and the client• Client’s opinion actively sought and utilized

Pattern Recognition• Direct automatic retrieval of information from a well organized knowledge base• Seeing a case that strongly resembles a case seen in the past

Pattern Recognition• Non-analytic process of reasoning• “Forward Reasoning”• Illness Scripts• Intuition• Tends to occur unconsciously

Pattern RecognitionPros Cons•Fast •Lacks certainty•Conclusions can be •Need exposure to reached with imprecise pattern in order to data recognize

Overview of clinical reasoning process• This process can be represented by an upward and outward spiral, and is a cyclical (iterative) and developing process. Each loop of the spiral involves: – Data input – Data interpretation (or re- interpretation) – Problem formulation (or re- formulation) – It aims to achieve a progressively broader and deeper understanding of the clinical problem, and finally to make decisions and to take actions.

Efficacy of a clinical reasoning process relies on:• Health care professional’s reasoning proficiency• client’s participation in clinical decision making

The outcomes of the clinicalreasoning process can be affected by: • Internal factors relating to health professionals, e.g. knowledge base, familiarity and experience with this type of case, reasoning skills • Factors relating to the client, e.g. needs, communication skills, circumstances, choices • External factors, e.g. institutional expectations, profession-specific frameworks of operation, complexity of the case

Thank YouJorge.valdez@itesm.mx

Clinical reasoning apao

by Jorge E. Valdez on Sep 05, 2012

Accessibility

Categories

Upload Details

Usage Rights

Statistics

Clinical reasoning apao Presentation Transcript