Comparative Theories in Clinical Reasoning and Their Application to Practice - Essay Example

Academic Assignment: Discussing Comparative Theories in Clinical Reasoning and their Application to Practice Introduction Clinical practice is known to have three key dimensions. These are clinical reasoning, practice specific domain knowledge, and evidence-based practice. All practitioners in the present day are expected to provide best possible practice within the legal and ethical framework. Therefore clinical reasoning in any particular case must also support and credibility from evidence. For a practitioner, clinical reasoning has been defined as the cognitive processes and intelligent strategies used to comprehend the significance of patient information (Edwards et al., 2004). This is used to identify and diagnose potential or actual patient problems, so in order to achieve positive patient outcomes, the practitioner is able to make clinical decisions that can arrive at resolution of problems. However, these definitions do not always apply accurately, and that is the reason the skills of clinical reasoning become important. Practitioners make decisions in contexts where there are no right or wrong solutions or actions, since healthcare sciences are not exact sciences (Toth-Cohen, 2008). The education and experience of the practitioners load them with clinical reasoning skills which generate the capacity to make clinical decisions in the face of certainty or clarity (Charlin et al., 2000). Although the arguments regarding clinical decision making follow different such courses, in clinical practice the use of experiential knowledge is high with the intent of delivering quality care to the patients. In fact in many cases, it has been found that there is spontaneous use of knowledge derived from a variety of sources by the practitioners which they think have been subjected to testing in practice and is credible. From this point of view clinical reasoning and decision making become intrinsic to the provision of practice (Meterissian, 2006). Therefore, knowledge about clinical reasoning and other factors that lead to and influence clinical decision making is important for a deep understanding of clinical practice. As an example, the area of critical care can be sited where several different interacting factors may lead to similar or identical clinical manifestations. Moreover, adequate treatment of one particular parameter may adversely affect another clinical parameter (Simmons et al., 2003). In such situations, a high level of independent clinical reasoning is expected from the practitioners in order to make a clinical decision in practice. Sound reasoning and decision making skills have been thought to be essential for provision of quality care that aims to achieve positive clinical outcome and physical and psychosocial wellbeing of the patient and sometimes of the family. There are many examples where faulty reasoning may lead to errors in decision making that may prove ultimately to be culminating into costly and tragic errors in the practice setting (Hershey and Baron, 1987). There are certain practice scenarios where there is a high possibility of such consequences and hence, there is a demand for high quality clinical reasoning skills. Research that examine the practitioners' clinical reasoning focus on patient outcomes and the relationship between these outcomes and clinical reasoning are therefore extremely significant to demonstrate the roles of the practitioners in care delivery processes, and it has been argued that such research can enhance clinical reasoning of the practitioners and optimise patient outcomes (Kuiper et al., 2009). These concepts appear to be true if examples from different clinical practices are sought. For example, there is evidence that in association with clinical reasoning, available evidence should be used to guide critical thinking, judgment, common sense and intuition. Other studies have argued against this, and they have found that the clinical reasoning process among practitioners do not permit such generalisations (Stempsey, 2009). In case of physicians particularly apart from clinical reasoning, evidently, the physicians consistently develop multiple diagnostic hypotheses early in the encounter with the patient. These could be done in order to guide the inquiry so as to choose the appropriate hypothesis. It may appear that this is a process of gathering a comprehensive body of data as the basis of making subsequent diagnostic decisions; however, upon closer examination the prior approach primarily was problem oriented. While the traditional model of diagnosis holds that initial collection of information in the history and examination that leads to deductive steps is the essence of clinical reasoning, there has been suggestion of more realistic models (Smart and Doody, 2007). The hypothetico-deductive model proposed by Elstein and Schwarz suggests that the initial process is practice is generation of some hypothesis in relation to the presenting problem. This may occur through recognition of some patterns from prior experience. Thus this does not follow the traditional collection of information and then step by step deductive reasoning, rather it becomes as heuristic iterative technique. Although this may sound to be a fault, often this process proves to correct as far as outcome is concerned (Lykkeslet & Gjengedal, 2006). It has been suggested by some researchers that exhaustive data collection without any directive hypothesis may make the reasoning process worse. Current research, however, contends that in the practitioner, both analytic and non-analytical processes operate simultaneously. The practitioner most commonly takes the approach of problem solving (Kunzman & Baltes, 2003). It is experiential learning which makes the practitioner make the appropriate mix of both approaches, and these are guided by duration of experience, familiarity with the problem, and stage which the diagnosis process is accessed. A mechanistic physiological model of clinical reasoning in the traditional way, however, acts as the last resort for the clinician when they encounter a difficult problem, where experiential pattern recognition does not work (Coles, 2002). The question still remains why clinical reasoning is important in practice. According to the practice concerned, the definition of clinical reasoning will vary slightly, but ultimately, the process or model remains the same in almost all practices. As a learning module, clinical reasoning is important since this provides the pathway for development of a profession. Independent and responsible decision making in practice is now considered as an important characteristic of all autonomous professions (Scheckel & Ironside, 2006). Moreover, any practitioner has to make a wide variety of clinical decisions in daily practice. If a practitioner desires to improve the quality of his decision making, he would need to practice a sound reasoning process which may prove to be an important source of learning in practice where meaning, goals, management strategies can be aligned more accurately to clinical data, choices of patients, professional knowledge and judgment through more organised thinking and decision making process in clinical practice, where clinical reasoning skills can be the key (Higgs and Jones, 2000, 3-14). However, as it may appear that clinical reasoning is only necessary to arrive at a diagnosis through the deductive process, it is not entirely so. Although the hypothetico-deductive model is the most durable clinical reasoning model derived from the basic principles of human cognition, this perspective may fail in certain critical situations where the bare logic may fail to deliver (Rothstein et al., 2003). In practice, the practitioners often embrace hypothetico-deductive model of clinical reasoning since initial information about the patient serve to generate some hypothesis. These tentative hypotheses continues in parallel to the ongoing analysis of further patient information where the process involves collection and interpretation of further data. During even the phases of examination and management, there is ongoing creation of hypothesis, evaluation, and negation through which one of fewer hypotheses are confirmed (Higgs and Titchen, 2000, 23-32). Therefore, this model of clinical reasoning is not purely cognitive, and there is an element of empirico-analytical reasoning. This derives from scientific and positivist paradigm, which bases on the premise that truth, knowledge, or reality should be measurable and is objective. Thus results may be accomplished through observation and experiment to produce a result and thus prediction. Therefore, it can be stated that in clinical practice, hypothetico-deductive reasoning targets to validate information and data within the limitation of available standards through measurements based on reasoning in a reliable fashion (Junnola et al., 2002). High-quality clinical practice needs multiple thinking strategies. These thinking strategies are necessary for clinical reasoning and judgment. In this context, thus, critical thinking becomes an essential component of practice and clinical deductive reasoning. It has been defined as a purposeful and self-directed judgment using cognitive acumen such as interpretation, analysis, evaluation, inference, and explanation of findings and information of matters related to evidence, concepts, methods, criteria, and context of the clinical judgment (Hurlock-Chorostecki, 2002). However, in any practice, it is important to remember that there is no accurate or correct model of clinical reasoning. It has often been found that clinical reasoning to the intent of clinical problem solving is bound by context and sometimes specific for particular domain. This means it has an idiosyncratic element imbibed in it where different practitioners even in the same domain will follow different routes to arrive at the same solution to a clinical problem (Claxton et al., 2002). This element of practitioner individuality increases with increasing expertise, since accuracy and skill are known to increase with experience and ability to critically reflect on practice experiences. The development of clinical reasoning acumen, in turn, is fostered by a sound basis of knowledge, practical skills, and clinical experience (Byrnes & West, 2000). The sound basis of knowledge, skills acquired from previous practice, and clinical experience construe what is termed as clinical wisdom. This wisdom helps the practitioners to recognise a pattern. From the cognitive science perspectives, this is not much related to the process of clinical reasoning, but essentially a byproduct of organisation and accessibility of the knowledge derived from practice that has been stored in the memory of the clinician (Fonteyn and Ritter, 2000, 107-116). The neuropsychological mechanism of this phenomenon is interesting in that with experience the practitioner may recognise the patient by merely his presentation, and within the practitioner's memory-knowledge network, other relevant information are synthesized with the help of a series of "if-then" rules of production. This is a different form of reasoning which leads to a pattern generalization and is known as forward reasoning (Burn and Higgs, 2000, 298-304). As is evident, this stands in sharp contrast to hypothetico-deductive reasoning in which multiple hypotheses or generalization is utilised to reach a specific diagnostic conclusion. In practice, however, it has been agreed that practitioners use both forms of clinical reasoning based on the difficulty level of the case. In some cases, both the processes may be parallel, but the extent of application of both these forms of clinical reasoning base coherently on the level of experience and expertise of the practitioner, which has been known otherwise as clinical wisdom (Vertue and Haig, 2008). The concept of clinical wisdom bases heavily on analysis of experience in the light of clinical reasoning skills. Clinical reasoning has both formal and informal components. Although it may appear that different models of clinical reasoning are very strict in premise, actually just due to the fact those deductions are rarely strict and evidences are quite often inconclusive, the practice demands that adequate decisions must be made in practice. In practice, it is quite often the case that expert knowledge or everyday knowledge may not provide a solution (Smith, 2008). In such cases there is necessity of wise decisions to bridge the gap between knowledge and uncertainty, and professional or clinical wisdom provides clue to action through vital insight. Wisdom can facilitate basic clinical reasoning since in this context it can be defined to be a cognitive synthesis of experiential, intellectual, ethical, emotional, and practical capacities. Wisdom has been stated to actively operate on many facets of informal reasoning (Haig, 2008). On the contrary, clinical reasoning that brings about clinical decisions in everyday practice seems to centrally build on and are justified by more formal forms of scientific inferences. Reasoning and its contribution to clinical decisions are realities in practice since many components of reasoning contribute to medical judgment. Much of this informal reasoning is now being recognised to be really a part of interactive and extended reasoning process with complex characteristics (Murphy, 2004). In contrast to the simplicity in presentation, the clinical reasoning process and the associated thinking actually is complex and do not follow the theoretical rigidity. Therefore, there may be interaction between a complex and multiple array of factors in the cognitive framework of the clinician while he is engaged in clinical reasoning. The context-specific demands and pressures is contemplated to be the major driver of this process (Hendrick et al., 2009). This means that this thinking process would ultimately culminate into a professional judgment which would lead to a series of best course of actions in the interest of the particular patient, which has been termed by Aristotle as praxis or wise action (Greenwood, 1998). In this way any clinical reasoning activity is an interactive summation of the practitioner's views, abilities, vision, knowledge and the requirements and possibilities of the patient. Psychologically, however, the practitioner engages himself in the process of identification of the salient features in a particular scenario, weighing of the significance and implications of various elements, and interpretation of the meaning of the most scientific evidence. In no way, these are rigid, since these factors involve human conditions. Most human situations are dynamic, and they naturally would evolve continuously. Therefore, the practitioner must align himself to these so they can respond effectively to these developments. The reasoning must be aware of these changes so the conclusion can be reviewed, refined, and reconsidered (Norman, 2005). It is needless to say that there is an element of exercise of personal professional judgment always interacts with the reasoning skills at all points along the pathway. It is important to remember that a part of this is informal in that important decisions are influenced by information that quite frequently reaches the practitioner in substandard levels. Therefore, the reasoners must have the ability to appropriately analyse and interpret information in order to make the best of such situations. It has been argued that inferring from informal reasoning in order to reach wise reasoning is a function of extra-cognitive aspects of argument. This can address the uncertainty in any clinical situation where there may be dependence on available knowledge on the contexts encountered in practice (ONeill et al., 2005). In reality many clinicians do not have access to all the necessary information, and hardly ever they can exhaust all reasoning to reach a solid conclusion. These can have extraordinary consequences in terms of clinical management, since to complicate matters further, while reasoning, the practitioner often may face more than one solution for a given problem due to paucity of information (Downing and Hunter, 2003). These would lead to contending choices and considerations that must be weighed and interpreted with wisdom, evidence, and logic and other intellectual virtues of the reasoner. It is an impressive concept in that the practitioner is thus enabled to deal with complexity, the competing demands of clashing options, and consequent ambiguities resulting from evolving patient conditions. In this way the personal professional clinical judgment is a result of clinical reasoning and the ability to weigh up elements, ideas, and actions that may be competing in order to bring about a balance between equal but conflicting priorities (Greenwood et al., 2000). The influence of such factors in healthcare practice is enormous since the core of clinical practice in this area may sometimes base heavily on personal professional judgment which is otherwise known as clinical or professional wisdom in comparison to pure clinical reasoning. Critical reflection on prior experiences plays a major role in shaping both professional wisdom and clinical reasoning. Although it is crucial for a practitioner, it is in no way the only reasoning skill that a clinician require, It has been indicated by several researchers that critical thinking needs a process of reflection, induction, deduction, analysis, ability to challenge assumptions, and evaluation of data and information so clinical decision making may be guided. Clinical reasoning on the other hand is the culmination of processes involving knowledge and experience that lead to clinical wisdom that can be effectively applied to a patient's clinical situation through consideration and review of multiple possibilities to reach the most probable and best possible clinical decision in the context of the whole of the person that a patient is (Woods, 2007). Psychologically, this is a synthesis of deductive and inductive cognitive skills which sometimes take the forms of evaluation of scientific knowledge and reasoning in the scientific framework. This means critical thinking is an important parameter clinical reasoning. In any given instance this means a situated form of reasoning that draws heavily on practice in the background of scientific, technological, and research-based knowledge. The relationship with practice is important since the practical ability to discern the relevance of evidence in scientific and technical knowledge to a particular patient or clinical scenario can only be known through practice (Magnani, 1997). Any suitable clinical example will demonstrate that the clinical must blend his reasoning, experience, and evidence to the consideration of the patient's clinical trajectory with its innate dynamics and tendency to evolve, social concerns and other concerns, preferences, choices, sensitivities to care interventions , and particular vulnerabilities such as multiple coexisting morbidities in order to derive a conclusion (Childs et al., 2003). It has further been argued that in the practice setting, the clinical reasoning is more of a social reasoning that involves the interrelationships involving patient, community, family, and collaborative team of practitioners. For a given clinical situation, thus exists a nexus of relationships that is dictated by the clinical scenario. Therefore expert clinical reasoning would need to be engaged socially with the relationships and concerns of the involved. In that sense, it would also mean emotional reasoning since only the clinicians have an access to the emotional realm of the patients and their families and the understanding of the care needs. This may be the pathway to achieve an optimal grasp on the appropriate perception of the clinical scenario which is two-dimensional, expert clinical knowledge based and attuned emotional engagement based .( Groves et al., 2003). Conclusion Although clinical reasoning literature indicates different reasoning processes for different clinical tasks, actually there is an interplay between different reasoning processes in practice. While the scale, extent, complexity and scope of such processes vary between individual practitioners and scenarios, it also indicates that other forms of clinical reasoning activities may exist which are hitherto unknown. Although it may appear that hypothetico-deductive reasoning is a separate entity from interactive and meaning based forms of clinical reasoning, this discussion indicates that in the cognitive realm of the clinical reasoner, there remains an intrinsic relationship between two forms which ultimately is synthesized into clinical decision through both formal and informal reasoning imbibed with professional wisdom that is a direct derivative of experience. This may lead to several hypothesis in the mind of the practitioner, but ultimately, other considerations such as emotional, ethical, critical, and evidence-based reasoning lead to a decision that can lead to an acceptable outcome for the patient, families, and other clinical peers. The understanding of this process for a practitioner may highlight the need for this acumen, and the practitioner may end up knowing his deficits in this very important area of knowledge which needs to be fostered for his professional competence. To suumarise, this discourse indicates that the skill of clinical reasoning is crucial to develop competence in clinical healthcare practice. The hypothetico-deductive model indicates that the practitioners tend to generate several diagnostic hypothesis, and then in the course of the clinical encounter, they collect and critically analyze information to narrow down the hypothesis to a final list. Although this a general method which even the inexperienced can apply, in most cases, the accuracy of diagnosis can be a derivative of expertise and wisdom than the method itself. The recent theory is that of mental representation, which the practitioners create in their mind with regards to the basic pathophysiologic mechanism of the disease encountered in clinical practice, the illness scripts, and experience leading to inferences from different cases, their presentations, and their diagnoses. These approaches have been advanced mainly due to the reason that in most scenarios, the clinical practitioners encounter problems which are basically ill-defined. The clinical experience and wisdom lead to mental probability matrices which can be weighed against these illness scripts, which may explain the clinical reasoning capabilities of these experienced practitioners. It is to be remembered that the basic utility of clinical reasoning is in clinical decision making. This is a process that involves recognition of the clinical problem, probability assessment, and analysis of the value. 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