Chapter 10: Clinical Decision-Making

INTRODUCTION

CLINICAL DECISION-MAKING

Clinical problem solving (CPS), clinical reasoning (CR), and clinical decision-making (CDM) and are interconnected terms¹ describing the cognitive process through which physical therapists approach patient care. CDM and CR are important in effective patient and client management to develop an organized process for evaluation and intervention planning. CR is a process whereby knowledge and experience are applied in considering multiple possibilities to achieve the desired goals, while considering the patient’s situation.² The process involves interacting with patients and others to develop mutually agreed-upon goals, establish prognoses, and develop an appropriate plan of care.³ CDM is the outcome of the CR process and guides the physical therapist to effectively manage their patients and clients throughout the course of service.⁴ Effective CDM is the hallmark of an autonomous professional.⁵ A key component of effective documentation is to communicate both the CR and CDM processes.

Reflection will help improve clinical decision making. Schon describes 3 areas of reflection.⁶

1. Reflection on-action: following an event and thinking back upon the encounter

2. Reflection in-action: during the event making changes in behavior in response to the situation.

3. Reflection for-action: making changes for the future based upon previous.

NOVICE VERSUS EXPERT CLINICAL REASONING AND CLINICAL DECISION-MAKING

Early research into CPS processes originated out of medical education and focused on the processes used by novice clinicians.¹ The hypothetical deductive reasoning process involves collecting a multitude of data from the patient and formulating hypotheses based on this available data. The clinician subsequently tests these hypotheses against prior and new data and formulates the most likely solution to the clinical problem. This process has also been labeled backward reasoning and is especially useful for novice clinicians, as it provides a structured problem-solving approach and requires the clinician to examine the breadth of the data, thereby decreasing errors of omission.

Research into expert reasoning indicates that experts, when solving uncomplicated problems in their field of expertise, do not employ a hypothetical-deductive approach, but instead use rapid pattern recognition approaches, also referred to as forward reasoning.¹ These patterns are based on prior similar clinical experiences that these clinicians have encountered. However, when these experts encounter unfamiliar or complex problems, they ...