This document discusses clinical reasoning, which refers to the thinking and decision-making processes used in clinical practice. It defines clinical reasoning as a process where clinicians structure meaning, goals, and health strategies based on clinical data, patient choices, professional judgment, and knowledge. The document then outlines several models of clinical reasoning, including knowledge-reasoning integration, integrated patient-centered reasoning, hypothetico-deductive reasoning, and pattern recognition. It also discusses how clinical reasoning skills develop from novice to expert and the importance of knowledge, cognition, metacognition, narrative reasoning, and collaboration in clinical decision making.

1. Clinical Reasoning
Jorge E. Valdez MD,MA.
Dean
School of Medicine and Health Sciences

2. 1. Aplicación de habilidades
clínicas.
2. Manejo de recursos diagnósticos
3. Manejo terapéutico.
7. Aplicación del
4. Promoción de salud y
entendimiento de las
prevención de la enfermedad. Competencias Competencias Ciencias Básicas,
5. Habilidades de Técnicas Intelectuales
Clínicas y Sociales para
comunicación.
la práctica clínica.
5. Aplicación de
habilidades para el manejo
de la información.
Competencias
Competencias en
Profesionalismo Analíticas y
Creativas
9. Desempeño del Médico 8. Razonamiento,
dentro del sistema de salud. juicio clínico y
10. Ética y desarrollo toma de decisiones.
personal.

3. 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

4. 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

5. 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”

6. 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

7. Process of Clinical Reasoning
Theoretical Models of Reasoning
1.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)

8. 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)

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

10. Developing Expertise
Level Knowledge Representation Knowledge structure
Novice Networks Knowledge growth and validation
Interm Networks Encapsulation
Expert Illness Scripts Illness Script formation (instantiated
scripts)
BoshuizenH & Schmidt HG (2000)

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

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

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

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

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

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

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

18. 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?

19. Integrated Patient-Centred
Model
The client´s input
The clinical problem The enviroment
Cognition Knowledge
Metacognition

20. Integrated Patient-Centred
Model

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

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

23. Hypothetico-Deductive
Reasoning
Pros 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

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

25. 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

26. 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

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

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

29. 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.

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

31. The outcomes of the clinical
reasoning 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

32. Thank You
Jorge.valdez@itesm.mx