Reinforced reasoning in medicine

Some philosophers have argued that evidence of underlying mechanisms does not provide evidence for the effectiveness of a medical intervention. One such argument appeals to the unreliability of mechanistic reasoning. However, mechanistic reasoning is not the only way that evidence of mechanisms might provide evidence of effectiveness. A more reliable type of reasoning may be distinguished by appealing to recent work on evidential pluralism in the epistemology of medicine. A case study from virology provides an example of this so‐called reinforced reasoning in medicine. It is argued that in this case study, the available evidence of underlying mechanisms did in fact play a role in providing evidence in favour of a medical intervention. This paper therefore adds a novel and recent case study to the literature in support of evidential pluralism in medicine.     

Simulating Rescue Strategies From Procedural Sedation: One Aspect of Competency Validation

Quality and Safety in Nursing Education identifies both teamwork and patient safety as key domains in which competencies are required. An example that makes these competencies necessary in day-to-day clinical safety is procedural sedation. Procedural sedation is a key area of risk in an acute-care facility. Safety in this area requires teamwork. The Joint Commission requires that risk management also examine the process of procedural sedation outside the operating room. This assures equity of care and oversight by the anesthesia department. Procedural sedation is not within the current National Council Licensure Examination blueprint (NCSBN, 2019). It is up to employers to validate the hired registered nurse has the skills, knowledge, and attitude to safely administer these high-risk medications. Working as a taskforce, five disciplines from ten areas that administered procedural sedation in our acute care facility created a three-component competency validation approach. The novel component was the development of a high-fidelity simulation validating the ability of the registered nurse to rescue a patient from loss of protective reflexes. The outcome of the simulation process included a clinical reasoning evaluation by the clinical educator. This article is a discussion of the development and clinical usefulness of this simulation tool as a competency adjunct.     

“基于案例”教学法在口腔种植学教学中的实践体会

目的:探讨"基于案例"教学法(CBL)在口腔种植学教学中的应用效果及体会。方法 :遴选临床真实病例资料,设计并编写CBL教学案例,通过课前导入、课中讨论、教师评价总结等课堂形式,激发学生学习的主动性,培养其独立分析、思考及解决问题的能力,帮助学生达到对理论知识的深刻理解和融会贯通。结果:超过90%的学生认为CBL教学模式能够调动学生的学习积极性,锻炼逻辑思维,提高综合运用能力。结论:高质量的教学案例是获得理想教学效果的重要保证,如何更好地运用该教学模式,仍需进行深入探讨。     

Development and initial evaluation of an instrument to assess physiotherapists’ clinical reasoning focused on clients’ behavior change

Background and Aim: A systematically developed and evaluated instrument is needed to support investigations of physiotherapists’ clinical reasoning integrated with the process of clients’ behavior change. This study’s aim was to develop an instrument to assess physiotherapy students’ and physiotherapists’ clinical reasoning focused on clients’ activity-related behavior and behavior change, and initiate its evaluation, including feasibility and content validity. Methods: The study was conducted in three phases: 1) determination of instrument structure and item generation, based on a model, guidelines for assessing clinical reasoning, and existing measures; 2) cognitive interviews with five physiotherapy students to evaluate item understanding and feasibility; and 3) a Delphi process with 18 experts to evaluate content relevance. Results: Phase 1 resulted in an instrument with four domains: Physiotherapist; Input from client; Functional behavioral analysis; and Strategies for behavior change. The instrument consists of case scenarios followed by items in which key features are identified, prioritized, or interpreted. Phase 2 resulted in revisions of problems and approval of feasibility. Phase 3 demonstrated high level of consensus regarding the instrument’s content relevance. Conclusions: This feasible and content-validated instrument shows potential for use in investigations of physiotherapy students’ and physiotherapists’ clinical reasoning, however continued development and testing are needed.     

A qualitative study of clinical reasoning in physiotherapy with preterm infants and their parents: Action and interaction

Background: Physiotherapists (PTs) in primary health care provide services to preterm infants and their parents after hospital discharge. The service should be collaborative and individualized to meet the family’s needs. In this study, we analyze pediatric PTs’ collaborative work in the clinical setting and investigate the PTs’ emerging clinical reasoning (CR) in interaction with the infant and parent(s).

Methods: The study is based on observations of 20 physical therapy sessions and 20 interviews with PTs. We performed a systematic content analysis informed by enactive theory regarding the interactions and co-creation of meaning.

Results and Discussion: CR emerged in reciprocity with the PTs’ interaction with the infant and parent(s). Based on the sensitivity to the infant’s motor abilities and signs of engagement as well as the parents’ need of support and education, the PTs individualized and reasoned about their therapeutic approach. This interactional CR was vulnerable: infant disengagement, parent expectations, and PT preoccupations could obfuscate interactions and hamper CR.

Conclusion: Through mutuality and engagement with the infant and parent(s), the PTs allow the autonomy of interaction to emerge and shape the translation of CR into successful therapeutic actions and learning together with the infant and parent(s).     

Establishing assessment criteria for clinical reasoning in orthopedic manual physical therapy: a consensus-building study

Objectives:

Clinical reasoning (CR) represents one of the core components of clinical competence in Orthopaedic Manual Physical Therapy (OMPT). While education standards have been developed to guide curricular design, assessment of CR has not yet been standardized. Without theory-informed and rigorously developed measures, the certification of OMPTs lacks credibility and is less defensible. The purpose of this study was to use a theory-informed approach to generate assessment criteria for developing new assessment tools to evaluate CR in OMPT.

Methods:

A list of assessment criteria was generated based on international education standards and multiple theoretical perspectives. A modified Delphi method was used to gain expert consensus on the importance of these assessment criteria for the assessment of CR in OMPT. The OMPTs from 22 countries with experience in assessing CR were invited to participate in three rounds of online questionnaires to rate their level of agreement with these criteria. Responses were tabulated to analyze degree of consensus and internal consistency.

Results:

Representatives from almost half of the OMPT member organizations (MO) participated in three rounds of the Delphi. High levels of agreement were found among respondents regarding the importance and feasibility of most assessment criteria. There was high internal consistency among items within the proposed item subgroupings.

Discussion:

A list of assessment criteria has been established that will serve as a framework for developing new assessment tools for CR assessment in OMPT. These criteria will be important for guiding the design of certification processes in OMPT as well as other episodes of CR assessment throughout OMPT training.