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As someone who wouldn’t normally be classified as “well-organized”, I believe the clinical reasoning form will be beneficial in helping me organize my thoughts when evaluating more complex patients. Additionally, it provides a great framework for metacognitive thought, which will be imperative in helping us develop our clinical reasoning throughout the next year. I believe this will also provide us with excellent opportunities to reflect on the information that we gather during the subjective portion of an examination to ensure that we are screening everything that needs to be screened and also being appropriate with the intensity of our physical exam. After all, it is imperative that we do not flare up patients so badly that they do not return to our clinics.
While reading the article, I was fascinated by the thought of taking multiple 5-10 minute breaks away from the patient to fill out the form. Most settings do not allow 90 minutes for evaluations like the clinic from the article. I personally tend to use the full allotted time for an evaluation in order to begin a treatment program with my patients and to build rapport. I was curious if you all thought of any other potential barriers to implementation of the clinical reasoning form.
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Tyler, I agree about the organization factor of VOMPTI’s CRF. I have used it several times with more challenging patients and I am always glad to have put all of my exam findings and thoughts down in one place. Every time I use it, I find myself thinking about what I “could’ve/would’ve/should’ve” done or asked in my initial evaluation. I find this exceptionally useful when planning my follow up treatments, it helps me prioritize what I want to assess in order to clear up any remaining questions or unclear areas, but also helps me plan what I would like to re-assess as my asterisks. I also think the PICO portion helps me gather my thoughts in order to focus on what interventions and impairments I really would like to address with my treatments and the literature pertaining to it.
While I agree that it is not feasible to assume 90-minute evaluations are always an option, I definitely do see the merit of taking several breaks with a mentor throughout the evaluation to discuss findings. Throughout my clinical rotations in PT school, I have seen several evaluation techniques, and by far my favorite is the technique that I have utilized with my VOMPTI resident CI’s. Discussing differential diagnoses prior to the subjective, taking a break after the subjective exam in order to re-order/add/eliminate differentials and plan the objective exam, then taking another break after the objective exam to discuss findings was the most successful way for me to organize my thoughts and stay on track. So, yes, while it is time-consuming and takes away from immediate patient care, I think the benefits of taking time to analyze and synthesize the information gathered in the initial evaluation in real-time is essential for development of clinical reasoning.
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Katie, I would agree that my most beneficial clinical rotations provided opportunities during evaluations to step out to reflect and organize my thoughts. During more complex evals or evals where you are pressed for time, it would be beneficial to use a portion of this reflection time to discuss what components of the exam must be conducted that visit and which ones would be appropriate to test at the first follow-up visit.
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Tyler and Katie-
I completely agree with your points of how the CRF should help with organizing one’s thoughts and prioritizing examination and treatment. I would agree that stepping aside to discuss sections of the eval with my CI in real time was extremely beneficial during clinical rotations.I like the way the authors describe the SCRIPT form as a way for residents to “show their math” and make their thinking explicit. I imagine this is how the CRF form will help me/force me to grow as a clinician. So much of my thought process during an eval has become automatic. I suspect that showing the math behind my decisions in a clear and organized fashion on paper will be challenging at times. The discussion that comes with filling out the CRF will hopefully improve my decision making and the ability to articulate those decisions.
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Justin, I also really liked their description of utilizing the reasoning form to “show their math”, I feel that so often I may (or may not) do something in an evaluation for a specific reason, and unless it is explicitly stated, that reasoning may go unnoticed or overlooked. I think it is an excellent way to facilitate thought and discussion between us and our mentors. I also agree with your point about utilizing these discussions with our mentors to articulate our decisions, I think it forces me to be concise and make a decision, which I find myself having trouble with when presented with more challenging patient cases.
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I agree that having this tool is a great way to hold yourself accountable and make sure you are thinking critically about each case. I like the discussion in the article about what makes an “expert” clinician, citing their “ability and willingness to consider, document, and test alternative hypothesis”. I have found in practice (through my own mistakes) that the source of one part of the pain is not always linked to the other. It’s easy to get caught in my own biases and not dig deeper. I believe that this tool will help to facilitate a more thoughtful examination and make treatments more efficient.
I also agree with Justin, I hope this tool will improve my decision making and my ability to articulate and fully understand those decisions. I think the PICO section and article review will be helpful to lay out and reinforce my thought process as well. I think the incorporation of article review with each patient will help me learn how to better analyze and relate current research and help make more informed decisions along with my own clinical reasoning.
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Everyone has made excellent points that I truly agree with. I think that this tool is essential in order to help myself as a new graduate eliminate my potential for bias thinking and look at the entire case being presented by the patient. As Justin stated, “showing our math” to our mentors is a critical aspect of the residency program that will allow us to further our clinical reasoning with a great tool to help structure our way of thinking. As the article stated, the ability to hone in on a clinicians clinical reasoning is a very challenging skill to develop, however, this tool is a way to expedite this process. Because it is best applied to working with patient encounters and getting feedback in the moment it is important to take the breaks during this process in order to get the most out of the experience and make sure my thought process is where it needs to be. With that being said, I do believe that the breaks taken during this process may disturb the flow of an evaluation but it is worth the clinical experience gained throughout the process.
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