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Have a read post your thoughts on how these tools can help with your goals for residency this year.
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After reading this article, I’m really excited, and a little scared, to get started using the clinical reasoning form. So often I find myself fumbling around trying to decide the best interventions and basing it on past patient patterns instead of searching the literature. This leads to occasionally over or under aggressive treatment and patients not getting better nearly as fast as they could be. I’m excited to streamline the process to start being better equipped to answer questions of “where do I go from here” and “what should I do first.”
The main thought I had while reading this article is “how do you train someone to think” – which is what all of us, I think, want to get out of this residency program. Be better – better thinkers, better clinicians. The clinical reasoning process is subconscious in many ways, as the article pointed out, however, the key is to bring it to the conscious level so it can be discussed. “Reasoning must be exercised consciously to facilitate self-reflection, change professional behaviors and thought processes, and improve diagnostic accuracy.” I think it’s important to be able to articulate your thought process with patient care and that there’s a direct translation into patient education. If you can explain (to yourself and the patient) why you’re doing what you’re doing, the patient will trust you and outcomes will be better.
I really love the emphasis on the subjective exam. I honestly thought I was taking too much time on the subjective part of my evaluations, but I think it’s important to let your patient’s responses tailor your objective exam. After all, they know their body the best, so we can be more specific with our exam and treatment if we listen to them first. I think there’s an art to gathering a subjective exam, but it is also very patient dependent – some want to tell you their entire life story and your job is to guide them and pick out the important pieces of information, and for others it’s like pulling teeth to get them to tell you anything. It will be interesting to assess the effect that the patient’s personality has on the ease of use of the clinical reasoning form. I also like the attention to irritability of symptoms – I often think I need to assess everything fully, but, as the article discussed, if the symptoms are highly irritable, we may need to back off on our exam. I also like that the article mentions going to the research after the first visit and then continuing the assessment during the next visit. I think this helps calm our desire to get it all done during the initial evaluation, and makes the obvious point that clinical reasoning is a continuous process.
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Helen:
“I often think I need to assess everything fully, but, as the article discussed, if the symptoms are highly irritable, we may need to back off on our exam. ”
This quote resonated with me. I feel DPT school does a great job of teaching us how to collect all pertinent information, reproduce symptoms, and come to a diagnosis. However, depending on the irritability of the patient, we may have to focus the examination on alleviating the patient’s symptoms instead of provoking them. Very glad you captured this idea.
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I really like how these two tools assist in organizing your thoughts, but more importantly, help you look back and see where you could have done better. By committing to paper your thoughts in the moment, you have a history of what you were thinking for better recall and reflection later. That way after the whirlwind of the patient interaction is over, you can have more brain power to see where things went well or didn’t. I find myself lamenting questions unasked or measures untestested. This way of thinking should be very beneficial for those instances.
To Helen’s point, the subjective is such an important piece of all this at it seems like these two resources speak to it: a good subjective is what sets you up for success. I just did an eval yesterday for someone with multiple complaints, and I did a poor job of delineating the subjective to ask questions about each complaint and skimped out on details about the foot. I couldn’t find a darn thing wrong with it later on or recreate her symptoms.
And then it came to me after thinking about the rest of her history: “have you ever had shin splints before?” “Oh yea, that’s exactly what it is.”
That would have saved some time.
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I feel utilizing the SCRIPT tool or VOMPTI clinical reasoning form to be incredibly useful. As a new graduate and novice clinician, I have found myself relying entirely on Systems 2 (analytic) thinking. This has also led me to perform very drawn out initial evaluations in fear of missing relevant information. This abundance of information has, at times, made it hard to achieve a clear diagnosis.
After my examinations, I have found it difficult to know what I should reflect on first. Instead, I have found myself going down unproductive rabbit holes, knowing I could have done better but unsure where to start. I believe the clinical reasoning form will be beneficial as it provides a structured reflection. I feel us novice clinicians will benefit greatly by being guided to reflect on areas that we may neglect, be ignorant toward, or uncomfortable confronting.
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This article really highlighted the importance of self-reflection in building clinical reasoning for me. I think that both these tools provide a great structure to frame our clinical decision making, but it also creates a more streamlined “path” for us to follow with more complex cases or unfamiliar diagnoses. It definitely makes it easier to create and then follow your train of thought, rather than jumping around and pulling from different thoughts and ideas that pop up during an evaluation. To me, these tools can help improve efficiency, and I feel like this is an area where I definitely want to improve with this residency. I think that having to actually take the time to write down thoughts and ideas will help me get better with identifying impairments and then being more specific with treatments to get better outcomes. I think this is probably the most intimidating part of the process to me, but it’s also the most exciting because I know this will be an area that I have a lot of room for growth in. I also really like how both of these tools take into consideration tissue irritability and psychosocial factors that can play a big role in the patient’s success, and it keeps the clinician aware of other factors that might be important in the presentation of symptoms.
To Barrett and Helen, I completely agree that the subjective portion is the most important part of the evaluation. I know sometimes it’s a struggle to keep some patients on track, but the information really does direct the rest of the evaluation. I always feel like the toughest part of the subjective part is knowing when to let a patient keep going and when to redirect them back because I don’t want to miss an important piece of the puzzle.
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This article absolutely reinforced the importance of a guide, such as a clinical reasoning form, in early clinical practice. In my first year of practice I had difficulties organizing my clinical exam. When I would reflect on my interactions during documentation I would find things that I had glossed over that I realized I should have examined further. That is one thing that the SCRIPT and VOMPTI’s clinical reasoning tool seeks to minimize.
This type of tool reminds me of a pilot’s checklist. Things that are understood, practiced, and routine, but very necessary to ensuring quality and safety. Each patient experience will bring new and unique challenges, but if we can learn to systematically evaluate and educate we can eliminate much of the common error in our practice.
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So often during evaluations I find myself starting off with a game plan that, on a smaller scale, mirrors these forms- a running list of differentials, a general idea of red flags I need to dive deeper into, what might be some objective findings I expect, etc. But then, all too often, the subjective gets into full swing and that game plan is quickly pushed to the back of my mind, and I revert back to “auto-pilot” of just checking off the steps of asking questions without truly processing and thinking about piecing everything together. This then leads to a lack of attention to detail during my objective examination because I lost sight of the “game plan” and don’t have a clear path to follow. In the end I get enough information to mediocrely come up with a diagnosis, prognosis, and treatment plan, but when reflecting afterwards I come back to that same place of I know I can do better but I am just not sure how to slow myself down in the moment to do so.
This article reinforced the benefits and importance of residency. It is so valuable to have a system in place to learn from more experienced clinicians so that I can become a better clinician myself. There are many things that as a new clinician I can be better at, but at the root of it all is my clinical reasoning and critical thinking. Like Barrett said, using forms like these that commit your thoughts to paper, will greatly help to start making reflection in action a natural process. These clinical reasoning forms are helpful to record and spur thought processes and keep you on track during your examination, but, for me, will also help to remind me to slow down and think about what I am asking and doing in the moment rather than afterwards.
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Have a read post your thoughts on how these tools can help with your goals for residency this year.
All throughout my internships and even now during my first year in the clinic, I have always been focusing on having an efficient flow to my evaluations that allow me to gather the information necessary to better access the patient but to also focus on the patients symptoms and irritability in order not to flare up their symptoms. In school we were provided with a evaluation template that covered all the areas to cover and focused on the SINSS concept but was rather overwhelming and seemed impossible to cover in a realistic time frame during an evaluation in the clinic.
While reading and rereading this case report, I loved the fact that the SCRIPT tool was focused on all parties involved in the evaluation: the patient, the mentee, and the mentor. It is a very systematic tool, allowing for a framework to hypothesize, assess, evaluate, reevaluate, and reflect on subjective and objective findings all while focusing on the patient and their symptoms and impairments and how they conflict with their previous level of function.
Throughout this residency, I believe that this tool, SCRIPT, will provide for a structural sound foundation or framework for evaluations and follow-up visits. With this foundation, I believe that I will be able to better organize and communicate my thought process and clinical reasoning to myself and my mentor. I believe that it will also allow me to better self-reflect and learn from my mistakes or shortcomings to allow me to become a better clinician. Having the foundation written out and organized on paper, more explicit, will allow for facilitation of improved discussion between my mentor and myself and therefore a better learning experience. Overall, I believe this tool will better myself as a clinician to become more organized, better identify differential diagnoses and potential red flags, and provide a more thorough evaluation and overall improved experience for the patients.
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