Clinical Decision Making

Clinical Decision Making

Clinical Decision Making Development Where does EBM fit in? Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.

Clinical Decision MakingClinical Presentations CS uncommon uncommon Common CS

Clinical Decision MakingPrevalence of Clinical Presentations Common Clinical Syndromes Uncommon A Uncommon B Uncommon C Uncommon D

Clinical Decision MakingPrevalence of Clinical Presentations Common ClinicalSyndromes Uncommon A Uncommon B Uncommon D Uncommon C

Clinical Decision Making Factors • Age • Gender • Height/weight • Social habits • Profession/job • Medications • Psychosocial history • Environment • Motivation • Resources • $ • Insurance • Family/friends

Clinical Decision Making Factors • Current, evidence-informed, and patient-centered, clinical practice in OMT requires the clinician to provide care based on an integration of current best research evidence, clinician expertise, and patient preference and values.

Clinical Decision Making CPRs • Clinical predication rules “CPRs” are decision making tools that can contain predictor variables gathered from the history, physical examination, and diagnostic tests • CPRs can assist in making a diagnosis, establishing prognosis, and are used in in patient plan of care strategies

Clinical Decision Making TICs • Test item clusters are decision making tools that can contain predictor variables gathered from the history, physical examination, and diagnostic tests • TICs can assist in making a diagnosis, establishing prognosis

Clinical Decision Making Development • Prior Professional Experience • Sources of Information • Reflection • Personal Experience

Clinical Decision Making DevelopmentPrior Professional Experience • Academic experience: content and faculty mentorship • Academic experience: critical thinking • Clinical experience • Clinical mentorship behaviors • Clinical mentorship skills • Clinical teaching of others • Continuing Education

Clinical Decision Making DevelopmentSources of Information • Medical record • Anticipated patient performance • Literature • Observation of patient’s movement behavior & problem solving • Observation of patient’s psycho-emotional & cognitive perceptual abilities • Protocols

Clinical Decision Making DevelopmentReflection • Reflection in action • Reflection on specific action • Reflection on professional experience

Clinical Decision Making DevelopmentPersonal Experience Exposure of self, family member, or friend to physical therapy

Clinical Decision Making Development

Clinical Decision Making Development prescription

Clinical Decision Making Development Protocols Orders MD thoughts School of thought TBC EBM Favorite Dx

Clinical Decision Making Development Evaluation & Treatment

Clinical Decision Making Development Deductive Reasoning TBC--EBM

Clinical Decision Making Development H. Fearon F. Fearon C. Hodges B. Smith L. Shafer M. Moore D. Torrey B. Boissonnault S. Paris O. Evjenth

Clinical Decision Making Development ---- --- --- ---

Clinical Decision Making DevelopmentSlow Cures & Bad PhilosophersEssays on Wittgenstein,Medicine & Bioethics • Phronesis- Practical wisdom The ability to discern the best course of action in a given instance of choice. It is decidedly not a mastery of algorithmic decision procedures, although a person of practical wisdom will have to know a great many general things both about the world & it’s value. Aristotlle

Clinical Decision Making DevelopmentSlow Cures & Bad PhilosophersEssays on Wittgenstein,Medicine & Bioethics Knowledge requirements -Rules & principles -How to draw valid inferences -Seeing right action between extremes -not conclusions from premises Judgment

Clinical Decision Making DevelopmentSlow Cures & Bad PhilosophersEssays on Wittgenstein,Medicine & Bioethics • Expert judgment diverges from skill at using calculating rules

Clinical Decision Making DevelopmentSlow Cures & Bad PhilosophersEssays on Wittgenstein,Medicine & Bioethics • Philosophers see the methods of science and are tempted to ask & answer questions the way science does. • Philosophy is not intended to add knowledge but to resolve confusion caused by the misunderstandings of the way that we represent the world in language. • Philosophers: Artists/ Musicians/Historians/Therapists

Clinical Decision Making DevelopmentSlow Cures & Bad PhilosophersEssays on Wittgenstein,Medicine & Bioethics • If physicians are trained to practice a medicine of the aggregate, they may loose habits of perception, that allow them to see how disease manifests itself in the lives and bodies of the particular people. • Wittgenstein

Clinical Decision Making DevelopmentSlow Cures & Bad PhilosophersEssays on Wittgenstein,Medicine & Bioethics • ..practice that encourages any kind of cavalier spirit toward the specifics of the case at hand would seem to be bad news for physicians and their patients, too. • JL Nelson

Clinical Decision Making DevelopmentSlow Cures & Bad PhilosophersEssays on Wittgenstein,Medicine & Bioethics • Freed from the thought that any form of scientific reasoning must be superior to any reasoning that operates differently. We can then get a better grasp of those on the relative bona fides of contending approaches. • JL Nelson

Clinical Decision Making DevelopmentSlow Cures & Bad PhilosophersEssays on Wittgenstein,Medicine & Bioethics • Expert Judgment “ Can one learn this knowledge.” Yes some can. Not however from taking a course in it but through experience. …..There are also rules but they do not form a system, & only experienced people can apply them right. Unlike calculating rules.

Clinical Decision Making DevelopmentSlow Cures & Bad PhilosophersEssays on Wittgenstein,Medicine & Bioethics • ..a particular case, even in areas where good guidelines exist, will toss up important features in ways for which formula evidenced-based techniques provide no precedent. The person of good judgment will be able to make sense of the novel.

Clinical Decision Making DevelopmentSlow Cures & Bad PhilosophersEssays on Wittgenstein,Medicine & Bioethics • Evidence model..to enhance, rather than replace, clinical judgment. • If guidelines can hold a number of relationships between Sx & Rx constant. Clinicians will have a less cluttered perceptual field with which to deal. • More subtle clinically relevant indications stand out more sharply if there are fewer unruly phenomenon.

Clinical Decision Making DevelopmentSlow Cures & Bad PhilosophersEssays on Wittgenstein,Medicine & Bioethics • In possession of a rule that allows you to identify a smile., you may be in a better place to distinguish a grin from a smirk.

Clinical Decision Making Development Physical Therapy Practice Educators Researchers Clinicians

Clinical Decision Making Development • Integrating physical skill & thinking

Clinical Decision Making Development • Advancing skill

Clinical Decision Making DevelopmentCreative application of skill

Mastering skill

Clinical Decision Making Development • Unconscious competence How do we develop it? How do we pass it on?

Clinical Decision Making Development • "Conscious competence of unconscious competence". This would describe a person's ability to recognize and develop unconscious competence in others. • 'reflective competence’: Conscious of my own unconscious competence, and additionally looking at my unconscious competence from the outside,

Clinical Expertise Development Theoretical Knowledge Basic Sciences EBM TBC TIC CPR Impairment Based Assessment Functional Restoration Clinical Evidence Patient Presentation Patient Response • Assessment techniques • Treatment techniques

Clinical Expertise Development

Clinical Decision Making Development • The end THANK YOU !

Clinical Decision Making