“Why?”: The Question of all Questions to Promote Clinical Reasoning Amongst Students and Clinicians
Purpose
The complexity of health care delivery in the 21st century requires clinicians to quickly and efficiently make difficult clinical decisions. For expert clinicians, clinical reasoning appears automatic given a refined ability to recognize patterns and quickly integrate didactic knowledge and prior experiences. Students and novice clinicians, on the other hand, often struggle when situations deviate from those typically expected or routinely encountered. Evidence well supports that under the guidance of a skilled mentor, the clinical environment provides an optimal venue to develop competent and proficient clinicians who can critically reason through complex scenarios. However, possession of content knowledge alone does not guarantee seasoned clinicians will effectively promote clinical reasoning in their mentees. Recognizing the need for greater development on mechanisms to best teach and promote problem-solving, clinical instructors (CIs) and clinician mentors requested guidance and training from a partner University. This presentation will highlight the methods undertaken by one University in helping clinicians transform their natural and tacit problem-solving abilities into overt and interactive processes for their learners.
Methods and/or Description of Project
CIs and residency directors were provided opportunity to observe seasoned educators interact with students in a manner designed to promote the development of clinical reasoning. University educators modeled how to guide learners in self-determining the data points necessary to solve clinical problems while simultaneously ensuring student responses were of significant depth to truly reflect comprehensive understanding of all information at hand. Clinicians were asked to break clinical scenarios into small components to allow for probing of the student’s rationale. By asking students “why” particular actions and decisions were made, greater insight is obtained on the accuracy of the clinical patterns they are beginning to formulate and recognize. Clinicians also received guidance in techniques to promote within students an ongoing self-reflective process wherein the consequences of their decisions can be analyzed. To receive feedback on their ability to facilitate and promote clinical reasoning skills, University faculty observed clinician interactions with students during simulations occurring in the classroom laboratory environment. Finally, through modeling and mentoring, University faculty helped transform the clinical teaching platform for residents and/or new clinicians in the authentic hospital environment.
Results/Outcomes
Clinicians who have undergone this training report increased confidence in their ability to truly ascertain the thought process underlying clinical decisions in their students and mentees. For students, guided and directed assistance with the formulation of solid clinical reasoning skills has enabled stronger clinical performance and outcome ratings throughout the remainder of their didactic and clinical education curriculum. This is further evidenced by improved ability for students to “reflect in action,” thereby enabling in-the-moment modifications. Physical therapist residents have also acquired more efficient, accurate, and automatic responses when encountering complex scenarios after being challenged to comprehensively articulate the rationale underlying their clinical decisions and to routinely engage in reflective analysis.
Conclusions/Relevance to the conference theme: The Pursuit of Excellence in Physical Therapy Education
Experts often find it difficult to teach clinical reasoning as they engage in critical analysis of situations in an ongoing and automatic manner. Breaking the scenario or clinical question into components, while appropriately guiding a student or novice clinician through the decision-making process, takes skill, time, and practice. Without incorporating appropriate strategies to promote clinical reasoning, the advancement of clinician skills is less certain and complete. While it is imperative that DPT academic faculty provide students with an initial framework for problem-solving, it is incumbent upon CIs to probe the thought process underlying student decisions to ascertain rationale and to foster reflection in and on actions. With appropriate questioning of students and novice clinicians, valuable information is gained on areas of difficulty so specific remediation efforts might occur. Therefore, to achieve the desired standards of excellence in PT education, time and resources must be devoted to the training of clinical mentors on how to best promote clinical reasoning.
References
Atkinson H, Nixon-Cave K. A Tool for Clinical Reasoning and Reflection Using the International
Classification of Functioning, Disability and Health (ICF) Framework and Patient Management Model. Phys Ther. 2011; 91: 416-430.
Furze J, Kenyon L, Jenson G. Connecting Classroom, Clinic and Context: Clinical Reasoning Strategies for Clinical Instructors and Academic Faculty. Pediatr Phys Ther. 2015, 368-375.
Greenfield, B, Jensen, G, Delany, C, Mostrom, E, Knab, M., Jampel, A. Power and Promise of Narrative for advancing Physical Therapist Education and Practice. Phys. Ther. 2015; 95:924-933
Greenfield, B, Bridges, P, Phillips, T, Drill, A, Gaydosik,C, Krishnan, A, & Yandziak, H. Exploring the Differences of Novice Clinical Instructors in Physical Therapy Clinical Education: A Phenomenological Study. Physiotherapy. 2014; 1--: 349-355
Irby, D. Excellence in Clinical Teaching: Knowledge Transformation and Development Required. Medical Education. 2014; 48: 776-784
Jenson GM, Gwyer J, Shepard K. Expert Practice in Physical Therapy. Phys Ther. 2000; 80:28-43.
Musolino, G, van Duijn, J, Noonan, A, Eargle, L, & Gray, D. Reasons Identified for Seeking the American Physical Therapy Association-Credentialed Clinical Instructor Program (CCIP) in Florida. Journal of Allied Health. 2013; 42: 351-e60
Course Objectives
Upon completion of this presentation the audience will be able to:
1. Identify how clinical reasoning develops
2. Evaluate one mechanism use by a University to teach clinicians the art and science to facilitating clinical reasoning
3. Apply principles of Socratic questioning in order to promote clinical reasoning with students and/or novice clinicians.
4. Design clinical and classroom experiences to promote and assess clinical reasoning amongst student, clinicians, and residents
Instructional Methods
Lecture
Tentative Outline/Schedule
I.Overview of development of clinical reasoning -20 min
A. Expert vs novice
II. Promoting clinical reasoning skills in learners- 45 min
A. Options suggested in the evidence
B. University –based training program
i. Process
ii. Outcomes
III. Questions – 25 min