Clinical Reasoning: Dual Processing in Healthcare

• Clinical reasoning and communication are key components of healthcare.

Dual Processing Theory

• Involves two systems: System 1 and System 2.
• Reasoning acts as an intermediary between System 1 and System 2.

System 1 Thinking

• Non-analytical and fast.
• Characterized by automatic and involuntary processes.
• Relies on pattern recognition and inductive reasoning.

System 2 Thinking

• Analytical and slow.
• Involves conscious and effortful processing.
• Uses logical and deductive reasoning.

Dual Processing Theory in Physical Therapy

• The Dual Processing Theory is utilized in physical therapy.
• This happens in the examination process, from referral and evaluation to intervention and outcomes, all within the Patient Client Management Model and considering factors like the patients history and presentation. This is also framed in the International Classification of Functioning, Disability, and Health (ICF).

The Examination Process

• Comprises a medical intake form review, subjective examination, and objective examination.
• The subjective examination includes history taking and patient interviews.
• The objective examination involves tests and measures.

Clinical Reasoning and Communication

• Clinical reasoning and communication are intertwined during the examination process.
• They involve both System 1 and System 2 thinking.
• They take into account communication roles, communication with special groups, narrative reasoning, communication roles, motivational interviewing, etc.

Cognitive Paradigms in Clinical Reasoning

• It involves cognitive paradigms.

Terminology

• A paradigm is a mental conceptualization, a set of assumptions, a way of thinking, or a methodology.
• A framework is a basic structure underlying a system or concept.

Cognitive Paradigms: Positivism

• All genuine knowledge should be true by definition.
• Facts should be derived from reason and logic.
• Truth should be objective and measurable.

Diagnostic Reasoning

• Diagnostic reasoning involves placing information into a mental classification system.
• It includes grouping relative information together and separating confounding information into its own class.
• Clinicians compare mental sets of information from a patient's presentation to known facts and experiences.
• The end goal is to provide a prognosis, plan a treatment session, or continue investigating the patient's case.

Hypothetico-Deductive Reasoning

• It's a method of approaching an unstructured problem.
• The method structures the problem to produce a small, efficient set of possible solutions for diagnosing problems.
• The steps involve gathering information, formulating questions (hypotheses), and testing hypotheses.
• Inductive reasoning is associated with System 1; deductive reasoning, with System 2.

Pattern Recognition

• The clinician recognizes certain features of a case almost instantly.
• Recognition prompts the use of other relevant information, including "if-then" rules stored in the clinician's knowledge network, such as illness scripts.

Intuitive Reasoning

• Compares a patient's current presentation to one experienced previously.
• It is a pattern formed from a previous instance, known as instance scripts.

Four Major Roles of the Physical Therapist in Communication

• These include confidant, coach, communicative detective, and teacher.
• Each role has its own patient request, communication style, skills, and expertise.

Communicative Detective

• The physical therapist acts as a detective.
• The patient is the victim, hypotheses are suspects, and test results provide clues.
• Environmental factors define the crime scene, and contextual factors relate to timing.
• Treating means arresting the perpetrator, and a successful treatment means the PT diagnosis works.

Hypothetico-Deductive Reasoning

• It is predominantly used for analyzing, researching, and teaching clinical reasoning.
• It facilitates a process where one question leads to another.
• One answer generates the next test.
• It seeks to maximize cognitive efficiency by confirming or negating presented information.
• It relies on reliable measurement and testing.

Examination Process

• Inductive Reasoning (System 1) generates hypotheses.
• Deductive Reasoning (System 2) performs tests and measures to confirm or refute these hypotheses.

Hypothetico-Deductive Reasoning and System 2 Thinking

• Advantages: accuracy and foundational knowledge.
• Disadvantages: lack of accuracy, can be slow, and impersonal.

Hypothetico-Deductive Reasoning Summary

• It leads to informed decision-making and demands System 2 thinking.
• Utilizes role of communicative detective.

Subjective Examination

• Also known as the patient interview.
• It provides the patient with an opportunity to provide their own story describing their current health condition for which they are seeking physical therapy.

Utilizating the Subjective Examination

• The physical therapist asks questions for clarification, to understand personal experiences, to confirm or to refute hypotheses.

Roles of the Physical Therapist During the Subjective Examination

• Communication roles include communicative detective and confidant.
• Therapeutic alliance roles involve fostering trust, mutual goals, and agreement on tasks.

Important Findings from History

• Demographics, occupation/role in society, and social history.
• Includes mechanism of injury and history of current condition and date of onset.
• Features chief complaint and 24-hour symptom pattern.
• Addresses stated functional impairments concerning current medications, historic diagnostic testing, prior treatments, and level of function.
• Incorporates past medical and surgical history, yellow flags and psychosocial remarks, and overall contextual factors, plus patient stated goals.

Important Baseline Symptom Findings

• Outcome measure scores.
• Current and prior level of function.
• Symptom presentation (pain intensity, aggravating and easing factors, time to onset, time to worst, time to ease, and time to best).

System 2 Thinking

• Analytical thinking should be implemented during the subjective examination.
• Deductive reasoning helps determine next questions.
• All methods should be performed consciously and effortfully.

Types of Initial Interview Questions

• Open-ended vs. close-ended questions.
• Physical therapists should use a funneling strategy.

Interview Question Buckets

• Current situation, patient medical history, and symptom description.
• Includes social, family, and social/occupational dynamics and goals.

Example Interview Questions: Current Situation

• "Tell me what brings you in today?"
• "How can I help you?"
• "Can you describe that for me in a little more detail?"
• "What do you mean by [example]?"

Example Interview Questions: Patient Medical History

• "Has this issue ever happened before?"
• "Have you felt these symptoms in the past?"
• "Did you seek out any treatment for this issue?"
• "What did you do to resolve this issue in the past?"
• "Are you taking any medications?"
• "Have you had any imaging?"
• "Are there any other medical issues that you are dealing with?"
• Complete a Review of Systems. "

Example Interview Questions: Symptoms Description

• "Can you show me exactly where your symptoms are?"
• "What do your symptoms feel like?"
• "What is it that seems to aggravate your symptoms?"
• "When you do aggravating factor, at what intensity do you feel your symptoms?"
• "How long does it take to reach that level of intensity?"
• "What is it that seems to ease your symptoms?"
• "When you do easing factor, at what intensity do you feel your symptoms?"
• "How long does it take to reach that level of intensity?"

Example Interview Questions: Social/Family/Occupational Dynamics

• "Are your symptoms currently preventing you from doing anything you enjoy?"
• "Can you tell me more about this?"
• "Can you tell me more about your living situation?"
• "What does a typical day look like for you?"
• "Do you currently work?"
• "Are your current symptoms affecting your ability to work?"
• "Can you describe to me your typical work duties?"

Example Interview Questions: Goals

• "What goals do you have for physical therapy?"
• "If you weren't affected by your current health condition, what types of activities would you like to return to doing?"
• "How do you think your life would change if you didn't have this pain?"

Summary of Subjective Interview

• It is an integral part of the examination process.
• Questions help promote the Hypothetico-Deductive Reasoning process.
• Provides an opportunity to act as a confidant and build a positive Therapeutic Alliance.
• Organizing questions in Buckets helps streamline the patient interview.

Communication Strategies

• These impact the subjective exam.

Terminology of Communication Strategies

• Open-ended questions: stimulate the patient to dig deeper. Ex: "What else can you tell me about your shoulder?"
• Closed-ended questions: seek specific information. Ex: "Does your shoulder hurt when you reach overhead?"
• Parallel questioning: align questions with the patient's story and thought processes and allow them to finish their train of thought when possible.
• Directive questioning: purposefully formulate questions to influence the conversation. Ex: "When do you think you are overloading your shoulder?"
• Firmly Direct the conversation due to time constraints for efficiency.

Question Funneling

• Involves progressing from open to directive to closed questions.

Providing Structure

• Choose a logical structure, summaries, paraphrase, mark transitions in the conversation and link up with the patients comments. Deviate from the intended steps where necessary, and provide anatomical models where appropriate. Communicate if the patient struggles and think out loud.

Verbal and Non-Verbal Communication

• Use active listening through verbal and non-verbal signals.
• Paraphrase a patient's response and nod along with their descriptions.
• Use open body language.
• Mirror part of their body movement, maintain eye contact, and show understanding by humming and smiling periodically.
• Imitate their facial expressions to show alignment
• Adjust voice aspects such as speed, volume, pitch, and intonation to mirror the patient's emotion.

Involving the Patient

• Involve, Listen Understand, Join the team, tune into the patient's story and then respond to their complaints.

Summary of Communication

• It is important to provide structure and involve the patient throughout their care.
• Use open, directive, and closed questioning to influence the conversation.
• Be aware and intentional when selecting verbal and non-verbal communication strategies.