Clinical Reasoning – 1st post 2018 Residency

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    • #6564
      Eric Magrum

      Have a read – post some thoughts/reflection on how this residency year can help you achieve your professional growth goals.

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    • #6567

      After reading this article one of the first statements that stood out to me immediately was “This greater understanding (sound clinical reasoning) reduces the risk of diagnostic error, overly aggressive, and poorly tolerated physical therapy sessions.” After just 3 days of patient care I have walked away from a few patients having very similar concerns. Am I missing something? Am I progressing them appropriately to optimize recovery? Am I being patient-centered enough? I almost feel like this bull in a china shop. Eager, all over the place and possibly a little reckless. No I’m kidding, but the concerns are note-worthy.

      On a more serious note, reading this article was extremely reassuring and confirms everything I seek to achieve through this residency program. “Sound clinical reasoning, to include using a systematic patient tailored approach to data gathering and forming early prioritized diagnostic hypotheses, followed by a carefully selected interactive patient history taking and examination to test hypotheses.” This is my goal. I’d like to be more effective, efficient and successful evaluating and treating patients. I enjoy and feel confident evaluating and assessing patients for impairments and functional limitations but often times feel I’m just left with a laundry list of dysfunctions, faulty mechanics, etc. and I’m at a crossroads. Where do I go from here? What should I prioritize from this list? Is this the most effective skilled intervention? I mean seriously the list goes on and on. I’m seeking professional growth by building confidence and advancing my clinical reasoning skills. Feel more like a stealth lion, less like a bull.

    • #6570

      This article reinforces why I decided to participate in an orthopedic residency.

      The SCRIPT tool that the article presents, similar to VOMPTI’s clinical reasoning form, is geared towards an initial evaluation, however can help guide follow-up treatments. Having a systematic approach to an initial evaluation is helpful for numerous reasons. It ensures that all relevant hypotheses are considered, and helps guide the subjective and objective exam to assist in ruling in and out diagnoses. This is something that I can benefit from, as it makes me feel as though I am considering all possibilities while focusing on the most likely ones.

      Especially as a new grad and novice clinician, every patient encounter I have is an opportunity for self-reflection and growth. I have limited experience with meta-cognition, or “thinking about your thinking” as the article puts it. Having a mentor ask questions about why I performed a certain objective measure, or why I chose a specific intervention, helps facilitate this idea. With a full year of mentorship, I hope that I begin to think like this on my own and that it becomes more automatic, as well as in the moment (reflection-in-action rather than reflection-on-action). The article states that this is a defining characteristic of an expert clinician. I also feel as though this lays the groundwork for lifelong growth and self-challenge.

      Casey, your bull in a china shop analogy is hilariously accurate to how I am feeling as well. Something that this article helped me remember is that a patient’s SINSS is extremely important to understand in order to have good patient outcomes. Every time I have completed an initial evaluation and seen my patient the next visit, they have told me that they were in increased pain and/or soreness afterwards. As this is somewhat expected, I think I have a tendency to be overly-eager and aggressive with my evaluations, in an attempt to collect a ton of information. I do this hoping that the more information I have, the more accurate my diagnosis will be, and I will have more impairments to address. I like that in the case example in the article, the mentee compiled a list of objective asterisks, so that the mentee could provide intervention and know how it affected the patient’s pain. If I can identify an intervention to decrease the patient’s pain (or reduce whatever issue they have), I have a starting point to my treatment, as well as increased patient buy-in.

    • #6599
      Matt Fung

      As Casey and Jeff stated, this article reinforced why I decided to pursue continuing mentorship thorough a residency program. As a recent grad and novice clinician there were many point made in this article that I could really relate too.

      One patient case in particular came to mind – during my first week I failed to recognize the SINNS my patients presenting symptoms (specifically the severity and irritability), more concerned with making sure I was collecting enough objective information for my initial evaluation. Like Jeff mentioned I was over-eager and aggressive and asked them to do too much. Unfortunately this person left in more pain then they came in with and neglected to return to follow up visits. As I reflect on this encounter I recognize that this particular patient would have benefited more from educational interventions as compared to movement based ones simply due to the irritability of the presenting symptoms.

      As this year of residency begins I look forward to utilizing the VOMPTI clinical reasoning form much like the SCRPIT tool described in the article to improve my history taking and to formulate sound prioritized hypotheses. This will allow me to best determine most appropriate interventions for my patients.

    • #6606
      Cameron Holshouser

      Improving my clinical reasoning is one of the reasons why I wanted to pursue an orthopedic residency – like most of you all. The case example in this article demonstrates how using a form like the SCRIPT can assist with clinical reasoning with a complex patient. The form provides a framework that you can refer back to during or after an evaluation to breakdown the complex patient. This seems especially helpful for those patients with many impairments/complaints that can fog your evaluation findings. The clinical reasoning form also provides a pathway to choosing specific interventions for your patient rather than choosing interventions that are general so that you can hopefully provide faster outcomes. I really liked how the clinical reasoning form shows the importance of test and re-test. Either with testing hypotheses to reach a specific diagnosis or with interventions so that you are using interventions that are showing change. Using a tool like the SCRIPT in combination with the clinical knowledge of a mentor should improve our clinical reasoning by the end of our residency.

      Haha yes, I can definitely relate to you Casey. I feel like sometimes with patients who have so many impairments, I find myself wanting to fix them all at once. This results in an unorganized POC which can be sporadic and exhausting for the PT and the patient. Hopefully using a clinical reasoning form will guide our treatment approaches.

    • #6619
      Erik Kreil

      I loved the common themes used across everyone’s responses to the SCRIPT article, and how we organically use synonyms to some descriptive terms that stood out to me in the article.

      In being here, I think we all recognized the importance of embodying not only our role as a clinician but also one in “patient management.” As Direct Access and the scope of our practice grows, Doctors of Physical Therapy need to respect the duty to ensure comprehensive care that often reaches outside the window of the patient’s visit. A thoughtful practitioner knows when it’s appropriate to call a doctor’s office, alter a treatment frequency, or rule-in a pathology that may be outside the scope of the practice.

      We aim to improve our clinical reasoning, which a novice practitioner may not respect as an ongoing process; a notion that doesn’t end in the initial evaluation. The SCRIPT provides an opportunity to gain an effective, efficient system that isn’t utilized as a blanket examination to the patient rather it becomes “applied” to the individual in front of you. A great example from the text is the mention of patient history transitioning from essentially a checklist of questions to an “interactive” process.

      I know I initially became interested in engaging in a residence program when it became apparent that I was proving my initial hypotheses, rather than “testing” them. My logic may have been adequate, but my approach was not. I hope to genuinely use evidence to guide my practice rather than dart throwing. I hope to respect the value of a pause, so that every action is intentional and fruitful. I hope to develop my skills with you all and deserve the title of Doctor of Physical Therapy.

    • #6620

      Reading these posts and reflecting on the common themes reminds me of an APTA slogan that I personally love, “The Science of Healing. The Art of Caring.” It reflects to the unique patient care we can provide and clinicians we can become.

      Utilizing the SCRIPT tool I can improve my “science of healing” and drive improvement in hypothetico-deductive reasoning which is what I feel is most lacking in my professional experience and where I have the most room for growth. It will also help remediate my similar tendency to want to prove initial hypotheses rather then test them and avoid mindless pattern recognition during patient care. However, what I’m also seeking through this residency is how both the science and the art of the physical therapy practice meet. The science to utilize the evidence available and the art of providing patient centered care. In our profession where some of our interventions, diagnostic tests, etc. aren’t backed with profound evidence I seek knowledge and skills from those who are expert clinicians, with years of applying their “art” under their belt.

    • #6622
      Jon Lester

      I think this was a great article to read and analyze, especially at this point in the program. I can appreciate the comparison of conscious and subconscious processing during clinical reasoning application. I’ve had a discussion with old classmates about this concept, believe it or not. I agree that clinical reasoning (and its application to patient care) is developed over a lifetime. However, I have always been of the mindset that it’s more beneficial to be proactive in your learning process and consciously be working towards improving these clinical reasoning skills. I believe that the SCRIPT tool does just that – with the added benefit of being able to discuss our thoughts with our mentors. I strive to develop these skills as the year progresses. As Erik said above, I believe the SCRIPT tool will improve our ability to see the whole patient in front of us – not the diagnosis or its “typical presentation”.

      I plan on taking the opportunity to become vulnerable and share my thoughts with my mentor in the hopes to develop clinical reasoning skills that will benefit every patient that I will work with throughout my career. I believe that the SCRIPT tool is a great way to develop and discuss these skills in particular.

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