Model Of Clinical Reasoning Research Articles

Integrated Cases Section: A Course Designed to Promote Clinical Reasoning in Year 2 Medical Students

Background: Medical students often have difficulty applying basic science knowledge within clinical contexts as they transition into clerkships. Description: To enhance clinical reasoning skills in 2nd-year medical students, we developed a 7-week transition course called the Integrated Cases Section. Curricular instruction incorporated analytic and nonanalytic clinical reasoning models. Practice with variable case scenarios enhanced students’ application of basic science knowledge to clinical problem solving. Evaluation: We evaluated curricular design and objectives by measuring student perceptions during the course and following completion of 2 clerkship rotations. To obtain measurement of students’ clinical reasoning ability we administered a script concordance test immediately before and after the course. Conclusions: Students reported increased confidence in their diagnostic reasoning ability during the course and after completion of 2 clerkships. Students’ clinical reasoning showed a significant gain after the Integrated Cases Section on a script concordance test. Student support has solidified Integrated Cases Section in the curriculum.

Cushing’s syndrome: Why is diagnosis so difficult?

Practicing and perfecting the art of medicine demands recognition that uncertainty permeates all clinical decisions. When delivering clinical care, clinicians face a multiplicity of potential diagnoses, limitations in diagnostic capacity, and "sub-clinical" disease identified by tests rather than by clinical manifestations. In addition, clinicians must recognize the rapid changes in scientific knowledge needed to guide decisions. Cushing's syndrome is one of several disorders in which there may be considerable difficulty and delay in diagnosis. This article describes a current model of clinical reasoning, some of its challenges, and the application of the principles of clinical epidemiology to meet some of those challenges.

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The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients

Acute care settings are characterised by patients with complex health problems who are more likely to be or become seriously ill during their hospital stay. Although warning signs often precede serious adverse events there is consistent evidence that 'at risk' patients are not always identified or managed appropriately. 'Failure to rescue', with rescue being the ability to recognise deteriorating patients and to intervene appropriately, is related to poor clinical reasoning skills. These factors provided the impetus for the development of an educational model that has the potential to enhance nursing students' clinical reasoning skills and consequently their ability to manage 'at risk' patients. Clinical reasoning is the process by which nurses collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process. Effective clinical reasoning depends upon the nurse's ability to collect the right cues and to take the right action for the right patient at the right time and for the right reason. This paper provides an overview of a clinical reasoning model and the literature underpinning the 'five rights' of clinical reasoning.

Promoting the Self-Regulation of Clinical Reasoning Skills in Nursing Students

Aim:The purpose of this paper is to describe the research surrounding the theories and models the authors united to describe the essential components of clinical reasoning in nursing practice education. The research was conducted with nursing students in health care settings through the application of teaching and learning strategies with the Self-Regulated Learning Model (SRL) and the Outcome-Present-State-Test (OPT) Model of Reflective Clinical Reasoning. Standardized nursing languages provided the content and clinical vocabulary for the clinical reasoning task. Materials and Methods:This descriptive study described the application of the OPT model of clinical reasoning, use of nursing language content, and reflective journals based on the SRL model with 66 undergraduate nursing students over an 8 month period of time. The study tested the idea that self-regulation of clinical reasoning skills can be developed using self-regulation theory and the OPT model.Results:This research supports a framework for effective teaching and learning methods to promote and document learner progress in mastering clinical reasoning skills. Self-regulated Learning strategies coupled with the OPT model suggest benefits of self-observation and self-monitoring during clinical reasoning activities, and pinpoints where guidance is needed for the development of cognitive and metacognitive awareness.Recommendations and Conclusions:Thinking and reasoning about the complexities of patient care needs requires attention to the content, processes and outcomes that make a nursing care difference. These principles and concepts are valuable to clinical decision making for nurses globally as they deal with local, regional, national and international health care issues.

Pregnancy-Associated Breast Cancer: Significance of Early Detection

Pregnancy-associated breast cancer (PABC) is defined as cancer of the breast diagnosed during pregnancy and up to 1 year postpartum. Delays in diagnosis are frequently associated with increased morbidity and mortality. The aim of this article is to determine the significance of early detection of PABC and to alert health care providers to include PABC in the differential diagnosis when evaluating a breast mass in the perinatal period. This integrative literature review evaluated 15 research studies by using the hypothetical deductive model of clinical reasoning to determine factors related to diagnosis of PABC. As women delay childbearing, the incidence of PABC increases with age. In the reviewed studies, breast cancer was diagnosed with greater frequency in the postpartum period than during any trimester in pregnancy. Delay in diagnosis is complicated by axillary lymph node metastasis, high-grade tumors at diagnosis, and poor outcomes. Early detection is a significant predictor of improved outcomes. Diagnostic modalities such as ultrasound, mammography, and biopsy can be safely used for diagnostic purposes in the evaluation of potential cases of PABC during pregnancy.

Clinical intuition versus statistics: different modes of tacit knowledge in clinical epidemiology and evidence-based medicine

Despite its phenomenal success since its inception in the early nineteen-nineties, the evidence-based medicine movement has not succeeded in shaking off an epistemological critique derived from the experiential or tacit dimensions of clinical reasoning about particular individuals. This critique claims that the evidence-based medicine model does not take account of tacit knowing as developed by the philosopher Michael Polanyi. However, the epistemology of evidence-based medicine is premised on the elimination of the tacit dimension from clinical judgment. This is demonstrated through analyzing the dichotomy between clinical and statistical intuition in evidence-based medicine's epistemology of clinical reasoning. I argue that clinical epidemiology presents a more nuanced epistemological model for the application of statistical epidemiology to the clinical context. Polanyi's theory of tacit knowing is compatible with the model of clinical reasoning associated with clinical epidemiology, but not evidence-based medicine.

Dilemmas in Surgery: Medical Ethics Education in Surgery Rotation

Mount Sinai School of Medicine, New York, NYMount Sinai School of Medicine provides its studentswith a 4-year curriculum in medical ethics that ishorizontally and vertically integrated into the educa-tional program. In the first 2 years, as part of the Artsand Science of Medicine (ASM) course (ASM 1 andASM 2), students participate in 6 ethics modules, thefirst 5 of which are designed to provide them withan understanding of the basic concepts of medicalethics. Sessions focus on professionalism, fiduciaryresponsibility, truth telling and informed consent,autonomy, surrogate decision making, justice, andresearch ethics. Through readings, minilectures, pan-els, sample cases, and small group discussions, thesessions provide students with the vocabulary andunderstanding to enable them to navigate the ethicalissues of clinical practice. The final module of thesecond year presents students with a model of clin-ical moral reasoning to be used in the resolution ofethical dilemmas.

Clinical Reasoning in Athletic Training Education: Modeling Expert Thinking

Objective: To address the need for a more definitive approach to critical thinking during athletic training educational experiences by introducing the clinical reasoning model for critical thinking. Background: Educators are aware of the need to teach students how to think critically. The multiple domains of athletic training are comprehensive and complex. Thinking is the fundamental connection between didactic and experiential components. Therefore, clinical thinking must be viewed as a critical part of experiential education in athletic training. Description: Research from educational journals in medicine, physical therapy and athletic training, as well as relevant texts, were searched to investigate the theoretical and practical underpinnings of clinical thinking models. Definitions, applications, and the historical underpinnings of the clinical thinking processes in allied health were reviewed and presented to highlight the need for athletic training educators to better appreciate the thinking processes of students and practitioners. Practical suggestions for the implementation of clinical reasoning in athletic training are presented. Application: Athletic training requires clinically based decision-making and problem solving skills. Medical educators recognize differences between the thinking of novice and expert practitioners, and have investigated the nature of clinical cognition as part of their formal curriculum. As AT's professional scope and credibility expand, the process of teaching, fostering, and evaluating clinical reasoning is paramount for AT educators.

The Nursing Outcomes Classification

The research to develop the Nursing Outcomes Classification (NOC) began with the formation of the outcomesresearch team in 1991. This work grew from previous language development focused on patient problems ornursing diagnoses by the North American Nursing Diagnosis Association and the development of nursing interventionsby the Nursing Interventions Classification (NIC) research team at Iowa. Outcome terminology was needed tocomplete the clinical reasoning model identified as part of the NIC research

Physical Therapist Management of Acute and Chronic Low Back Pain Using the World Health Organization's International Classification of Functioning, Disability and Health

The World Health Organization's Classification of Functioning, Disability and Health (WHO-ICF) model was developed to describe, classify, and measure function in health care practice and research. Recently, this model has been promoted as a successor to the Nagi model by some authors in the physical therapy literature. However, conceptual work in demonstrating use of the WHO-ICF model in physical therapist management of individual patients remains sparse. The purpose of this case report series is to demonstrate the application of the WHO-ICF model in clinical reasoning and physical therapist management of acute and chronic low back pain. Two patients, 1 with acute low back pain and 1 with chronic low back pain, were treated pragmatically using the WHO-ICF model and other applicable models of clinical reasoning. Manual therapy, exercise, and education interventions were directed toward relevant body structure and function impairments, activity limitations, and contextual factors based on their hypothesized contribution to functioning and disability. Both patients demonstrated clinically significant improvements in measures of pain, disability, and psychosocial factors after 3 weeks and 10 weeks of intervention, respectively. The WHO-ICF model appears to provide an effective framework for physical therapists to better understand each person's experience with his or her disablement and assists in prioritizing treatment selection. The explicit acknowledgment of personal and environmental factors aids in addressing potential barriers. The WHO-ICF model integrates well with other models of practice such as Sackett's principles of evidence-based practice, the rehabilitation cycle, and Edwards and colleagues' clinical reasoning model. Future research should examine outcomes associated with the use of the WHO-ICF model using adequately designed clinical trials.

Evaluation of the Outcome-Present State Test Model as a Way to Teach Clinical Reasoning

The Outcome-Present State Test (OPT) Model of Clinical Reasoning is a nursing process model designed to help students develop clinical reasoning skills. Although many nurse educators are using the OPT model as a teaching strategy, few are formally evaluating its use as a method. We used the OPT model as a teaching tool in an undergraduate psychiatric and mental health clinical nursing course and evaluated how quickly students became adept at using it. Most students mastered the use of the model; 29 of 43 students achieved the criterion score (a score greater than 65 on 3 or more models completed over 4 weeks). Not only did the students gain clinical reasoning skills, but they also used and learned more about the North American Nursing Diagnosis Association, Nursing Interventions Classification, and Nursing Outcomes Classification languages. Recommendations for future use of the model include adding client strengths and increasing focus on the quality of students' responses.

Debriefing with the OPT Model of Clinical Reasoning during High Fidelity Patient Simulation

Evidenced-based educational practices propose simulation as a valuable teaching and learning strategy to promote situated cognition and clinical reasoning to teach nursing students how to solve problems. A project that uses a structured debriefing activity, the Outcome Present State-Test Model of clinical reasoning following high fidelity patient simulation, is described in this paper. The results of this project challenge faculty to create and manage patient simulation scenarios that coordinate with didactic content and clinical experiences to direct student learning for the best reinforcement of clinical reasoning outcomes. Considerations for the future include incorporating patient simulation activities as part of student evaluation and curriculum development. The arguments for using high fidelity patient simulation in the current educational environment has obvious short term benefits, however, the long term benefit of developing clinical expertise remains to be discovered.

Non-analytical models of clinical reasoning: the role of experience

This paper aims to summarise the evidence supporting the role of experience-based, non-analytic reasoning (NAR) or pattern recognition as a central feature of expert medical diagnosis. The authors examine a series of studies, primarily from their own research programme at McMaster University, that demonstrate that expert and novice diagnostic problem solving is based, to some degree, on similarity to a prior specific exemplar in the memory. The studies reviewed have shown NAR to be a component of diagnostic reasoning at all levels from novice to subspecialist, and in dermatology, electrocardiography and psychiatry. The retrieval process is rapid and is not available to retrospect. It may be based on visual similarity, but can also be present in verbal descriptions. Some evidence exists that the process is unlikely to be available to introspection. Further, early hypotheses based on NAR can result in the re-interpretation of critical clinical findings. Non-analytic reasoning is a central component of diagnostic expertise at all levels. Clinical teaching should recognise the centrality of this process, and aim to both enhance the process through the learning of multiple examples and to supplement the process with analytical de-biasing strategies.

Difficult Decisions in the Intensive Care Unit: An Illustrative Case

Difficult clinical decision-making is a common experience in intensive care units. There is often considerable pressure on time and decisions may have to be made in a stressful environment. Patients in the intensive care unit not infrequently present with extreme or rare manifestations of a disease process. Clinical evidence to guide management of such patients may be incomplete, non-existent, or its relevance to the problem at hand may be questionable. In this context, formal decision-making analytical tools are often impractical. Unconscious cognitive biases have been shown to play an important role in medical decision-making, particularly in these settings. While mostly these contribute to doctors making appropriate and timely decisions, occasionally they lead to errors. Despite 30 years of research into models of clinical reasoning, most doctors are unaware of how biases affect their thinking and are unfamiliar with techniques of detecting and neutralising bias in clinical practice. We present the case of a patient with Wegener's granulomatosis, which highlights many of the difficulties outlined above. We review the clinical evidence for our decisions at each stage and explain the rationale for our choices, highlighting the many situations for which high quality evidence was lacking. Examples of cognitive bias are identified and techniques of metacognition (thinking about thinking) that can be useful in limiting the effects of bias on complex decision-making are reviewed. The intensivist's evaluation of management alternatives has an important role in steering medical management towards optimal patient outcomes.

The effect of causal knowledge on judgments of the likelihood of unknown features.

People frequently infer unknown aspects of anentity based on their knowledge about that entity. The current study reports a novel phenomenon, an inductive bias people have in making such inferences. Up on learning that one symptom causes another in a person, both undergraduate students (Experiment 1) and clinicians (Experiment 2) judged that an unknown feature associated with the cause-symptom was more likely to be present in that person than an unknown feature associated with the effect-symptom. Thus, these findings suggest a specific mechanism in which causal explanations influence one's representation of and inferences about an entity. Implications for clinical reasoning and associative models of conceptual knowledge are discussed.

COMET: A Collaborative Tutoring System for Medical Problem-Based Learning

This paper discussed about the developed collaborative intelligent tutoring system for medical PBL called Comet (collaborative medical tutor). Comet uses Bayesian networks to model the knowledge and activity of individual students as well as small groups. It applies generic tutoring algorithms to these models and generates tutorial hints that guide problem solving. An early laboratory study shows a high degree of agreement between the hints generated by Comet and those of experienced human tutors. Evaluations of Comet's clinical-reasoning model and the group reasoning path provide encouraging support for the general framework.

A systematic approach to clinical moral reasoning

Because the process of moving from moral principles and facts to action-guiding moral conclusions has not been articulated clearly enough to be useful in a practical way, we designed a systematic approach to aid learners and clinicians in their application of ethical principles to the resolution of clinical dilemmas. Our model for clinical moral reasoning is intended to provide a clear and replicable structure that makes the thought process involved in reasoning about clinical cases explicit. In this paper we present the model and demonstrate how it can be used in three clinical cases.

Use Of The Clinical Reasoning Model For The Development Of Interventions For Mechanical Tissue Tension-Induced Pain

Use Of The Clinical Reasoning Model For The Development Of Interventions For Mechanical Tissue Tension-Induced Pain

A new integrated model of clinical reasoning: Development, description and preliminary assessment in patients with stroke

Purpose. The main objective was the development and collection of preliminary data on the application of a new integrated clinical reasoning model (Anadysis) with patients suffering a stroke or Transient Ischemic Attack (TIA).Method. Twelve healthcare professionals working in the neurological and the Accident and Emergency (A&E) units of an acute general hospital participated and experimental control was achieved by employing a pre-test post-test control group experimental design. Members of the control group used the current reasoning model of their discipline whereas the new integrated model was used by the members of the experimental group irrespective of their professions. Outcomes were measured by scoring on a protocol derived from the UK National Clinical Guidelines for Stroke divided into the three main clinical reasoning processes.Results. Collectively, data from 186 protocols based on the medical records of 49 patients showed that median percentages of correct responses in clinical reasoning were substantially higher for the experimental group by using the new integrated model.Conclusions. This study will inform the healthcare professionals about a new effective integrated clinical reasoning model which incorporates the complex processes of diagnosis, planning and treatment as a whole. This study may also become an important consideration in the further development of clinical decision support systems within the scientific area of health informatics.