Facilitating the Development of Clinical Reasoning

Outline
I What is clinical reasoning? II
Why is it important?
III Reflective exercise
IV Strategies to develop reasoning

Clinical reasoning

“the cognitive process that underlies diagnosis and management of a patient’s

presenting problems.” (Linn, Khaw, Kildea, & Tonkin, 2012, p. 18)

“an ability to integrate and apply different types of knowledge, to weigh evidence,
critically think about arguments and to reflect upon the process used to arrive at a
diagnosis.” (Linn, et al., 2012, p. 18)

“expert clinical reasoning is a consequence of an extensive and multidimensional

knowledge base.” (Norman, 2005, p. 423)

“expertise in medicine, as in any craft, derives from both formal and experiential
knowledge.” (Norman, 2006, p. 2252)

Two views of professional practice (Fish, 1995)

Technical rational
• follows rules and laws
• aims for efficient systems
• views knowledge and permanent
• theory is applied to practice
• technical expertise is all
• quality = quantity
• training
Professional artistry
• starts were rules fade
• wants creativity
• views knowledge as dynamic
• theory can emerge from practice
• values professional judgments
• embraces uncertainty
• education

Experts (Benner, 1984; Higgs & Jones, 1996)

• use past experience rather than abstract knowledge
• perceive large meaningful patterns
• view events as complete wholes of which only some elements are relevant
• perceive problems at a deep level
• understanding of situation includes client perspective
 Strands of reflection (Fish, Twinn, & Purr, 1991)

factual strand
 reconstructing the experience, drawing mainly on procedural knowledge of it



retrospective strand

developing a wholist theory about, and a critique of, the entire experience, drawing mainly on procedural knowledge of it



sub-stratum strand
uncovering and exploring critically the personal theory which underlies the experience, and considering how it relates and might be helped
by formal theory



connective strand
considering how the experience might relate to future experiences
Strategies to develop clinical reasoning

1. Use a shared language.

2. Ensure there is dedicated time.

3. Model making your reasoning explicit.

4. Vary expectations depending on stage of student.

5. Use a variety of techniques

a. reflection

b. articulation

c. problem list prioritization

d. provide feedback

e. read widely
 References
Bannigan, K., & Moores, A. (2009). A model of professional thinking: integrating reflective
practice and evidence based practice. Canadian Journal of Occupational Therapy,
76(5), 342-350.
Banning, M. (2008a). Clinical reasoning and its application to nursing: concepts and
research studies. Nurse Education in Practice, 8(3), 177-183.
Banning, M. (2008b). The think aloud approach as an educational tool to develop and
assess clinical reasoning in undergraduate students. Nurse Education Today, 28(1),
8-14.
Bender, H. S., & Danielson, J. A. (2011). A novel educational tool for teaching diagnostic
reasoning and laboratory data interpretation to veterinary (and medical) students.
Clinics in Laboratory Medicine, 31(1), 201-215. doi: 10.1016/j.cll.2010.10.007
Benner, P. (1984). From Novice to Expert: Excellence and Power in Clinical Nursing
Practice. Menlo Park: Addison-Wesley.
Bland, A. R., Rossen, E. K., Bartlett, R., Kautz, D. D., Carnevale, T., & Benfield, S. (2009).
Implementation and testing of the OPT Model as a teaching strategy in an
undergraduate psychiatric nursing course... Outcome-Present State-Test. Nursing
Education Perspectives, 30(1), 14-21.
Bowen, J. L. (2006). Educational strategies to promote clinical diagnostic reasoning. New
England Journal of Medicine, 355(21), 2217-2225.
Boyd, G. W. (2011). Education debate: clinical diagnostic reasoning. Internal Medicine
Journal, 41(7), 573-576. doi: 10.1111/j.1445-5994.2011.02529.x
Claessen, J. (2004). A 2:1 clinical practicum, incorporating reciprocal peer coaching, clinical
reasoning, and self-and-peer evaluation. Journal of Speech-Language Pathology &
Audiology, 28(4), 156-165.
Coppard, B. M., Jensen, G. M., & Custard, C. L. (1997). Teaching reflection: integrating
clinical reasoning with narrative cases. OT Practice, 2(12), 30-35.
Dequeker, J., & Jaspaert, R. (1998). Teaching problem-solving and clinical reasoning: 20
years experience with video-supported small-group learning. Medical Education,
32(4), 384-389.
Ernstzen, D. V., Bitzer, E., & Grimmer-Somers, K. (2010). Physiotherapy students' and
clinical teachers' perspectives on best clinical teaching and learning practices: a
qualitative study. South African Journal of Physiotherapy, 66(3), 25-31.
Eva, K. W. (2004). What every teacher needs to know about clinical reasoning. Medical
Education, 39(1), 98-106.
Fish, D. (1991). Developing a theoretical framework. In D. Fish, S. Twinn & B. Purr (Eds.),
Promoting Reflection: Improving the Supervision of Practice in Health Visiting and
Initial Teacher Training (pp. 17-31). London: West London Institute of Higher
Education.
Fish, D. (1995). Quality Mentoring for Student Teachers: A Principled Approach to Practice.
London: David Fulton.
Fish, D., Twinn, S., & Purr, B. (1991). Promoting Reflection: Improving the Supervision of
Practice in Health Visiting and Initial Teacher Training. London: West London Institute
of Higher Education.
Gardin, F. A. (2010). The "think-aloud" method to promote student modeling of expert
thinking. Athletic Therapy Today, 15(4), 18-21.
Gierach, M., & Evenson, C. (2010). Teaching Strategies. Clinical Reasoning in the
Classroom: A Triage Simulation. Nurse Educator, 35(6), 228-230. doi:
10.1097/NNE.0b013e3181f7e806
Groves, M. (2011). Fostering clinical reasoning in medical students. Medical Education,
45(5), 518-519. doi: 10.1111/j.1365-2923.2011.03962.x
Hanson, D., Larsen, J. K., & Nielsen, S. (2011). Reflective writing in level II fieldwork: a tool
to promote clinical reasoning. OT Practice, 16(7), 11-14.
Higgs, J., & Jones, M. (1996). Clinical Reasoning in the Health Professions. Oxford:
Butterworth-Heinemann.
Jacobson, K., Fisher, D. L., Hoffman, K., & Tsoulas, K. D. (2010). Integrated Cases Section:
A Course Designed to Promote Clinical Reasoning in Year 2 Medical Students.
Teaching & Learning in Medicine, 22(4), 312-316. doi:
10.1080/10401334.2010.512835
Kaldjian, L. C. (2010). Teaching practical wisdom in medicine through clinical judgement,
goals of care, and ethical reasoning. Journal of Medical Ethics, 36(9), 558-562.
Kautz, D. D., Kuiper, R., Pesut, D. J., Knight-Brown, P., & Daneker, D. (2005). Promoting
clinical reasoning in undergraduate nursing students: application and evaluation of the
Outcome Present State Test (OPT) model of clinical reasoning. International Journal
of Nursing Education Scholarship, 2(1), 21p.
Kuiper, R. A., Heinrich, C., Matthias, A., Graham, M. J., & Bell-Kotwall, L. (2008). Debriefing
with the OPT Model of Clinical Reasoning during high fidelity patient simulation.
International Journal of Nursing Education Scholarship, 5(1), 1-13.
Lee, J. E. M., & Ryan-Wenger, N. (1997). The "think aloud" seminar for teaching clinical
reasoning: a case study of a child with pharyngitis. Journal of Pediatric Healthcare,
11(3), 101-110.
Lim, F. A. (2011). Questioning: A Teaching Strategy to Foster Clinical Thinking and
Reasoning. Nurse Educator, 36(2), 52-53. doi: 10.1097/NNE.0b013e31820b4dd8
Linn, A., Khaw, C., Kildea, H., & Tonkin, A. (2012). Clinical reasoning - A guide to improving
teaching and practice. Australian Family Physician, 41(1-2), 18-20.
Lysaght, R., & Bent, M. (2005). A comparative analysis of case presentation modalities used
in clinical reasoning coursework in occupational therapy. American Journal of
Occupational Therapy, 59(3), 314-324.
Mookherjee, S., & Chou, C. L. (2011). Bedside teaching of clinical reasoning and
evidencebased physical examination. Medical Education, 45(5), 519-519. doi:
10.1111/j.13652923.2011.03977.x
Murphy, J. I. (2004). Using focused reflection and articulation to promote clinical reasoning:
an evidence-based teaching strategy. Nursing Education Perspectives, 25(5),
226231.
Neistadt, M. E. (1996). Teaching strategies for the development of clinical reasoning
[corrected] [published erratum appears in AJOT 1997 Feb; 51(2): 118]. American
Journal of Occupational Therapy, 50(8), 676-684.
Neistadt, M. E. (1998). Teaching clinical reasoning as a thinking frame. American Journal of
Occupational Therapy, 52(3), 221-229.
Neistadt, M. E., & Smith, R. E. (1997). Teaching diagnostic reasoning: using a classroom-
asclinic methodology with videotapes. American Journal of Occupational Therapy,
51(5), 360-368.
Neistadt, M. E., Wight, J., & Mulligan, S. E. (1998). Clinical reasoning case studies as
teaching tools. American Journal of Occupational Therapy, 52(2), 125-132.
Norman, G. (2005). Research in clinical reasoning: past history and current trends. Medical
Education, 39(4), 418-427.
Norman, G. (2006). Building on experience -- the development of clinical reasoning. New
England Journal of Medicine, 355(21), 2251-2252.
O'Dell, B., Mai, J., Thiele, A., Priest, A., & Salamon, K. T. (2009). The Hot Seat: challenging
critical thinking and problem solving skills in physical therapist students. Internet
Journal of Allied Health Sciences & Practice, 7(1), 10p.
Palese, A., Saiani, L., Brugnolli, A., & Regattin, L. (2008). The impact of tutorial strategies on
student nurses' accuracy in diagnostic reasoning in different educational settings: a
double pragmatic trial in Italy. International Journal of Nursing Studies, 45(9),
12851298.
Rochmawati, E., & Wiechula, R. (2010). Education strategies to foster health professional
students' clinical reasoning skills. Nursing & Health Sciences, 12(2), 244-250. doi:
10.1111/j.1442-2018.2009.00512.x
Su, W. M., Osisek, P. J., & Starnes, B. (2005). Using the Revised Bloom's Taxonomy in the
clinical laboratory: thinking skills involved in diagnostic reasoning. Nurse Educator,
30(3), 117-122.
Torcivia, E. M., & Gupta, J. (2008). Designing learning experiences that lead to critical
thinking and enhanced clinical reasoning. OT Practice, 13(15), CE-1-CE-8, 2p.
Zunkel, G. M., Cesarotti, E. L., Rosdahl, D., & McGrath, J. M. (2004). Enhancing diagnostic
reasoning skills in nurse practitioner students: a teaching tool. Nurse Educator, 29(4),
161-165.