Clinical reasoning En

The answers…Clinical reasoning is knownas the physician’s mostcritical competence!CHARLIN et al, 2000HIGGS & JONES, 2008NORMAN, 2005SCHWARTZ & ELSTEIN, 2008…

Teachingclinical reasoning

What isclinical reasoning?

Clinical reasoning processesYou are all health professionalsYou are all actors in clinical situationsYou are all human beingsAs a resultyou use reasoning processesconstantly in your everyday life!

Intuitive processesEVA, 2005 | HOGARTH, 2005 | PELACCIA et al, 2011Most common form = pattern recognitionPrinciplesMaking unconsciously a link between a given clinicalsituation and patterns stored in the long-term memory,through the automated identification and treatment ofclinical and contextual information.GoalFormulate diagnostic hypotheses very fast when meetinga patient for the first time.

Intuitive processesCROSKERRY, 2009 | EVA, 2005 | HOGARTH, 2005Features• unconscious• very fast• irrepressible• similarity judgment based on a few clinical andcontextual data• source of errors• efficacy based on clinical experience• decisive

Analytical processesEVA, 2005 | NENDAZ et al, 2005Most common form = hypothetico-deductionPrinciplesTesting analytically the diagnostic hypotheses that havebeen raised intuitively (by questioning the patient, makinga clinical examination, etc.)ObjectiveTo confirm or invalidate solutions that have beengenerated intuitively

2 examples of reasoning in E.M.The triage nurse tells you…• an ambulance is coming from a caraccident scene with an unconscious patientImmediately, you think about…• severe cranial traumaContextual andclinical dataIntuitivereasoningWhen meeting the patient, you look for…• scalp wound,• anisocoria,• etc.Analyticalreasoning(hypothetico-deductive)

2 examples of reasoning in E.M.The triage nurse tells you…• you should see the young womanroom 2. She has a severe headacheContextual andclinical dataImmediately, you think about…• subarachnoid hemorrhage• meningitisIntuitivereasoningWhen meeting the patient, you look for…• nuchal rigidity,• fever,• etc.Analyticalreasoning(hypothetico-deductive)

Clinical reasoningINTERMEDIATE SUMMARYWhen meeting a patient, a physician:• formulates diagnostic hypotheses within the firstseconds or minutes, based on immediatelyavailable contextual and clinical data= intuitive reasoning• performs patient’s questioning, clinicalexamination and complementary investigations toconfirm or invalidate hypotheses that have beenraised intuitively= analytical (hypothetico-deductive) reasoning

OK, but…Anyone can reasonintuitively andanalytically whenmeeting a patient!

The experts…CHAMBERLAND, 2005 | NORMAN, 2005Use reasoning processesUse knowledge that has beenspecifically organized toreason in the clinical practice

Knowledge used to reasonCHAMBERLAND, 2005 | NORMAN, 2005Size is not important…Organizationis the main!

Knowledge used to reasonCHAMBERLAND, 2005 | NORMAN, 2005In experts, knowledgeis commonly organized into3 cognitive models• instances• prototypes• illness scripts

Knowledge used to reasonInstancesPast cases stored in the long-term memoryCHARLIN et al, 2007 | GRUPPEN et al, 2002 | NENDAZ et al, 2005PrototypesTransformation and abstraction of past cases stored in thelong-term memory. The disease is represented by a typicalassociation of signs (with several variants)Prototype myocardial infarct = mature man – retrosternal chest pain –sweatingVariant #1 = mature man – epigastric pain – sweating

Knowledge used to reasonIllness scriptCHARLIN et al, 2007 | GRUPPEN et al, 2002 | NORMAN, 2005Story-like narration of a typical case of the conditionScript « pizzeria » = I enter the restaurant – An Italian waiter will bewelcoming me – He will take me to the table I booked – He will give me themenu and suggest the day menu – He will ask if I want to drink something,etc.Script « multiple injured patient » = I will first assess vital signs – I will asksome information about what happened – I will auscultate his lung to lookfor a pleural effusion – I will palpate the abdomen to see if it is painful – Iwill palpate limbs to seek for pain, etc.Illness scripts are dedicated to a specific task (diagnostic,therapeutic, etc.)

The links between processes and knowledgePELACCIA et al, 2011Instances and prototypesare at the basis ofintuitive reasoningIllness scriptsare at the basis ofhypothetico-deductive reasoning

Clinical reasoningINTERMEDIATE SUMMARYPhysicians’ clinical reasoning rests upon:• general processes of reasoning: intuitive andanalytical (hypothetico-deductive)• specifically organized knowledge: instances,prototypes, illness scriptsCognitive models of knowledge organization are atthe basis of reasoning processesClinical experience plays a major role in organizingknowledge

How to teachclinical reasoning?

How to teach clinical reasoning?Teachingclinical reasoningrequires to follow• the general principles of learning• some specific principles related to thisfield of expertise

The specific principlesARK et al, 2006 | CHAMBERLAND et al, 2005 | NENDAZ et al, 2005The learning of processesshould not be separated fromthe learning of knowledgeThe learning of processesshould take into account the2 dimensions of clinical reasoning(intuitive and analytical)

5 principles to teach clinical reasoningTeachers and learners should know what is clinical reasoning to talkabout clinical reasoning• plan a short teaching sequence on thistopic• give learners short reviews about thesubject• use the « words » of clinical reasoningwhen speaking of clinical reasoning

5 principles to teach clinical reasoningGet the learner involved in the learning process• training periods should be more than makingtechnical and administrative tasks, and followingexperienced practitioners when visiting patients• clinical case presentations should not be turnedinto expert conferences• the audience should be involved in caseresolution from the beginning of thepresentation

5 principles to teach clinical reasoningGive learners the opportunity to reason in a realistic context• do not give the solution before the learnerstarts to reason• do not reveal all data at one time• choose adequately the order in which datawill be given to the learners• give relevant and non-relevant data

5 principles to teach clinical reasoningLearners should be encouraged to use both intuitive and analyticalprocesses• ask explicitly learners to adopt a multiprocessingapproach• give students the opportunity to formulatediagnostic hypotheses from the first seconds orminutes of encountering the patient• ask students to adopt a targeted approach whencollecting information, to confront diagnostichypotheses and to reduce the field of hypotheses

5 principles to teach clinical reasoningHelp learners to organize their knowledge according to cognitive modelsthat are useful for reasoning• confront learners with multiples cases, in a widerange of contexts and presentations• to start with, confront novice learners with typicalpresentations of a given disease and,subsequently, with more atypical situations• ask students to generalize or discriminatebetween the situations

Programs dedicated to clinical reasoning• Clinical reasoning learning (CRL)• Metaplan method• Problem solving clinical seminars• Clinical problem solving conference• The scheme approach• Principles of clinical reasoning• Clinical reasoning theaterCHAMBERLAND, 1998NENDAZ et al, 1998STRUYF et al, 2005DHALIWAL et al, 2009MANDIN et al, 1997WINDISH, 2000BORLEFFS et al, 2003

Clinical reasoningFINAL SUMMARY• clinical reasoning is a core medical competency clinical reasoning should be taught and learned• in order to teach clinical reasoning:- teachers and learners should speak the language ofclinical reasoning- learners should be actively involved in the learningprocess- learners should have the opportunity to reason in acontext close to the clinical reality- learners should be trained to use both intuitive andanalytical processes- learners should have the opportunity to organize theirknowledge adequately

Thank you for your attention!thierry.pelaccia@wanadoo.fr