Lecturer in Medical Education, Faculty of Medicine, University of Kelaniya
Clinical reasoning is at the heart of delivering effective and safe patient care. Yet, it is a complex construct, challenging the research community to unravel its complexity, despite continued efforts for nearly four decades.
Novice medical graduates, immediately after graduation is a special cohort reflecting qualities of undergraduate training and as well as its application during clinical practice. It is also a critical period of training as it marks the beginning of a professional career towards patient care. However, consequent to numerous work challenges encountered by trainees, educational focus during internship is often questioned by many. Yet, considering the contribution to patient care by interns, internship training demands opportunities to facilitate their learning clinical reasoning during training. This becomes critical especially in resource poor contexts where interns work in wards overloaded with patients.
Therefore, exploring how novice medical graduates learn and apply clinical reasoning during patient care may give rise to renewed understanding of how they experience this complex construct during practice. It can also shed light on remedial measures to enhance undergraduate training in clinical reasoning as well as to recognize how internship can be facilitated to derive maximum benefits as a placement of training. Therefore, this study was conducted to explore how novice medical graduates learn and apply clinical reasoning at workplace, expecting to bridge the gap in literature and to identify measures to improve their practice towards better patient care. A qualitative study was conducted among novice medical graduates working in a metropolitan hospital in Sri Lanka. Study participants were recruited to represent the four main clinical specialties. During phase-1 of the study in depth interviews were conducted with 18 study participants to explore how they learn clinical reasoning during practice. Phase -2 consisted of post consultation discussion based on 48 patient encounters. Audio recordings were transcribed verbatim and a coding framework developed and employed to thematically analyze data using Atlas.ti software. Multitude of factors facilitating, driving and challenging learning clinical reasoning during the internship was identified and remedial measures recognized. Furthermore, diversity of approaches employed by interns in applying clinical reasoning was recognized.
Abstract: Homeopathy is a major modality in complementary and alternative medicine. Significant tensions exist between homeopathic practice and education, evident in the diversity of practice styles and pedagogic models. Utilizing clinical reasoning knowledge in conventional medicine and allied health sciences, this article seeks to identify and critique existing research in this important area.A literature search utilizing MEDLINE,(®) Allied and Complementary Medicine (AMED), and CINAHL(®) (Cumulative Index to Nursing and Allied Health Literature) was conducted. Key terms including clinical thinking, clinical reasoning, decision-making, homeopathy, and complementary medicine were utilized. A critical appraisal of the evidence was undertaken.Four (4) studies have examined homeopathic clinical reasoning. Two (2) studies sought to measure and quantify homeopathic reasoning. One (1) study proposed a reasoning model, based on pattern recognition, hypothetico-deductive reasoning, intuition, and remedy-matching (PHIR-M), resembling much that has been previously mapped in conventional medical reasoning research. The fourth closely investigated the meaning and use of intuition in homeopathic decision-making.Taken together, these four studies provide valuable insight into what is currently known about homeopathic clinical reasoning. However, despite the history and breadth of practice, little is known about homeopathic clinical reasoning and decision-making. Building on the research would require viewing clinical reasoning not only as a cognitive phenomenon but also as a situated and interactive one. Further research into homeopathic clinical reasoning is indicated.
Pub.: 01 Dec '10, Pinned: 02 Oct '17
Abstract: Clinical reasoning requires knowledge, cognition and metacognition, and is contextually bound. Clinical teachers can and should play a key role in explicitly promoting clinical reasoning.The aim of this article is to relate the clinical reasoning literature to the general practice or family medicine context, and to provide clinical teachers with strategies to promote clinical reasoning.It is important that the clinical teacher teaches trainees the specific skills sets of the expert general practitioner (e.g. synthesising skills, recognising prototypes, focusing on cues and clues, using community resources and dealing with uncertainty) in order to promote clinical reasoning in the context of general practice or family medicine. Clinical teachers need to understand their own reasoning processes as well as be able to convey that knowledge to their trainees. They also need to understand the developmental stages of clinical reasoning and be able to nurture each trainee's own expertise. Strategies for facilitating effective clinical reasoning in trainees include adequate exposure to patients, offering the trainees opportunity for reflection and feedback, and coaching on the techniques of reasoning in the general practice context.The journey to expertise in clinical reasoning is unique to each clinician, with different skills developing at different rates, depending on content, context and past experience. Doctors enter into general practice training with the building blocks of biomedical and clinical knowledge and a desire to learn how to be a general practitioner. Clinical teachers are integral in the process of helping trainees learn how to 'think like a general practitioner'.
Pub.: 20 Aug '11, Pinned: 02 Oct '17
Abstract: Clinical judgment is a critical aspect of physician performance in medicine. It is essential in the formulation of a diagnosis and key to the effective and safe management of patients. Yet, the overall diagnostic error rate remains unacceptably high. In more than four decades of research, a variety of approaches have been taken, but a consensus approach toward diagnostic decision making has not emerged. In the last 20 years, important gains have been made in psychological research on human judgment. Dual-process theory has emerged as the predominant approach, positing two systems of decision making, System 1 (heuristic, intuitive) and System 2 (systematic, analytical). The author proposes a schematic model that uses the theory to develop a universal approach toward clinical decision making. Properties of the model explain many of the observed characteristics of physicians' performance. Yet the author cautions that not all medical reasoning and decision making falls neatly into one or the other of the model's systems, even though they provide a basic framework incorporating the recognized diverse approaches. He also emphasizes the complexity of decision making in actual clinical situations and the urgent need for more research to help clinicians gain additional insight and understanding regarding their decision making.
Pub.: 30 Jul '09, Pinned: 27 Sep '17
Abstract: A major amount of our time working in clinical practice involves thinking and decision making. Perhaps it is because decision making is such a commonplace activity that it is assumed we can all make effective decisions. However, this is not the case and the example of diagnostic error supports this assertion. Until quite recently there has been a general nihilism about the ability to change the way that we think, but it is now becoming accepted that if we can think about, and understand, our thinking processes we can improve our decision making, including diagnosis. In this paper we review the dual process model of decision making and highlight ways in which decision making can be improved through the application of this model to our day-to-day practice and by the adoption of de-biasing strategies and critical thinking.
Pub.: 17 Jun '11, Pinned: 27 Sep '17