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Definition of Clinical Reasoning:
During clinical encounters with patients, experienced physicians engage in numerous clinical tasks, including listening to the patient's story, reviewing the patient's past records, performing a physical examination, choosing the appropriate investigations, providing advice or prescribing medications, and/or ordering a consultation. These behaviors which provide the basis of clinical reasoning are influenced and driven by "what" physicians think about and "how" they think.
Clinical Reasoning Principle:
New knowledge is best acquired in the context of application of that knowledge in the cases (case based learning and longitudinal mentorships). Along with factual information stored in long-term memory, the learner continues to develop memory schemes for representing and relating the clinical problems in reasoning strategies.
Two-Process Model of Clinical Reasoning
Obtain and filter information.
Formulate an initial set of hypotheses.
Obtain additional information as directed by initial hypotheses.
Use a reasoning strategy: Hypothetical- Deductive reasoning (deductive v. inductive) to process the information in the clinical context of the case.
The human body is very complex, and we cannot obtain all information we want, so that regardless of the reasoning process utilized, we can never absolutely prove or disprove most hypotheses in many cases. We derive the 'most likely' diagnosis, but we may need to eventually consider others if more information becomes available or the outcome is different than expected.
Perform an analysis of hypotheses by probabilistic and cause-effect means.
Formulate a final diagnosis/hypothesis (Based on the above mentioned steps) and test the final diagnosis/hypothesis.
Consider other possible diagnoses.
Evaluate the process. (Stop, Think, Act, Review): Diagnostic time out
1. Patient’s story:
2. Data acquisition:
3. Accurate problem representation:
4. Illness scripts:
5. Hypothesis generation, prioritization and evaluation:
1. Hypothetical- Deductive Reasoning:
2. Compare and Contrast (Pattern recognition) ( as you advance from novice to expert you will be using this type of reasoning more often)
Prioritize the Hypothesis or Differential: Based on the most likely hypothesis prioritize your differential diagnosis:
1. Compare and contrast two plausible hypotheses and prioritize among the competing options.
2. Compare/contrast different illness scripts with the patient’s problem representation looking for best match
Test the final diagnosis/hypothesis (Hypothesis Evaluation): Perform an analysis of hypotheses by probabilistic and cause-effect means. Hypotheses are refined by cause-effect analysis to apply principles of pathophysiology (such as biomedical knowledge and knowledge about basic science concepts) and determine if a hypothesis is based upon a sound scientific basis.
Synopsis: The above detailed steps may not be immediately recognizable or flow in the same sequence in the context of actual clinical reasoning. Experts apply pattern recognition with non-analytic cognitive processing during the initial phases of considering a novel clinical case, and then apply analytic processing in hypothesis testing. Novices may work the other way round. However, these two forms of reasoning can be interactive and not sequential. They are complementary contributors to the overall accuracy of the clinical reasoning process, each one influencing the other. Persons who use both perform better than persons using either non-analytic or analytic approaches alone.
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