Assessing Clinical Evaluation: Its Process and Effectiveness
Clinical assessment and diagnostic reasoning skill is vital in medicine. It plays a significant role in formulating a diagnosis that provides effective holistic management for patients presenting to the emergency department. For health care professionals, it is also considered to be a crucial measure of clinical competence. Clinician uses several diagnostic processes to develop strong diagnostic abilities and reasoning skills. This paper is an evaluative report of the clinical assessment and diagnostic processes utilised by the author in the submitted case study presentation. Discussed in this paper are the two major theories on clinical decision making: Hermeneutical theory and information processing model theory. Diagnostic processes used in the case study by the author is compared and contrasted in relation to these two theories along with recognition of their strengths and limitations. Other models of diagnostic reasoning utilised by clinicians and nurse practitioners in the emergency department is also presented. Finally, this paper discusses appropriate management strategies and consultation that is essential for the patient to achieve the best health outcome.
An important aspect of ensuring patient safety in the emergency department is making an accurate diagnosis in a timely manner. Clinicians in the emergency department are required to constantly make critical decisions in a time-constrained, high turn over environment. To achieve optimum patient outcome, clinicians generally require to integrate information obtained from detailed history taking, physical examinations and diagnostic investigations. Formulating a clinical diagnosis can be complex and challenging, especially in the emergency department where a lot of distraction is present. According to Patel et al. (2015), there is a limit to the amount of information that a clinician can process at any given time, limiting their reasoning and diagnosis ability. Also, diagnoses made in the emergency department with limited and pending results can lead to misdiagnosis and error. According to McDonal et al. (2013), the process of clinical decision making and diagnosis in primary as well as secondary care is complicated and linked to a frequent cause of error. Missed, delayed and incorrect diagnoses is related to poor patient management, health outcome and increased cost. Correct diagnosis, on the other hand, helps to initiate appropriate treatment plan for patients ensuring the provision of safe patient care.
Scott (2009) states that clinical judgement is a series of a process occurring in different stages, starting from gathering information from patients, formulating possible diagnoses and confirming or rejecting these hypothesised diagnoses by utilising diagnostic investigations to finally confirm a diagnosis. This process then leads to a management plan that helps to achieve positive patient 1 of 8 outcome. The first and foremost step in diagnosing deep vein thrombosis required the author to take a complete history of the patient. This important step was followed by a thorough physical examination. Proceeding this vital step the author then utilised diagnostic investigations. Information gained from the blood test result strengthened the impression gained from history and physical assessment of the patient which further aided in making a final most likely diagnoses of DVT.
Information processing theory describes human reasoning within two premises which involve problem-solving ability and the environment in which this occurs. It describes reasoning based on access to information from short term or long term memory. The information stored in long-term memory can be harder to access compared to the information stored in short-term memory. Diagnosis of deep vein thrombosis made by the author in the presented case study is based on information accessed from short-term memory. According to Banning (2008) clinicians with a lot of experience have shown to use short-term memory for reasoning and diagnosis purpose. Long-term memory, however, stores information gained throughout life and expert clinicians tend to access long-term memory by associating it with relevant related information. Ability to do this is linked to their excellent clinical reasoning and diagnosis ability.
Information processing model uses a hypothetico-deductive approach for reasoning and medical diagnosis where a hypothesised diagnosis is generated using cue acquisition and interpretation. This hypothesised diagnosis then goes through a series of hypothesis testing which either supports the hypothesised diagnosis or helps rule out differential diagnoses. The author has used this approach in generating a diagnosis of DVT. The patient had presented with left lower calf swelling with a previous history of deep vein thrombosis on the same leg. This vital piece of information from triage alone has initiated a thought process in the author. After accumulating all the required information from history taking a hypothesised diagnosis of DVT is made. This hypothesised diagnosis is then put into testing by conducting a physical assessment which has assisted the author in ruling out differential diagnoses. To confirm the diagnosis of DVT a specific blood marker d-dimer was added to the blood test. Positive d-dimer result assisted in ascertaining the hypothesised diagnosis of DVT.
The hypothetico-deductive approach is considered to be the most popular, and widely used approach in healthcare. In this model, clinicians tend to use linear thinking, structured approach and 2 of 8 forward reasoning to form a clinical diagnosis. However, the limitation of this model is that it is completely reliant on the generated hypothesis. An inaccurate hypothesis may lead to a series of unnecessary investigations and wrong treatment pathway leading to misdiagnosis and ineffective treatment. Furthermore, this model of clinical decision making has been questioned by many researchers with concerns over its simplistic approach used in assessment, diagnosis and treatment.
Hermeneutical model in medical practice is based on the process of interpretation. This approach proposes that clinicians are at the centre of interpreting the meaning of the data acquired from history taking. In other words, the interpreter participates in narrating meaning hence, the data that is being interpreted is not only based on story relayed by patients but also on the norms, values and interpretive skills of the attending clinician. This model also believes that intuition is a vital aspect of clinical judgment and intuitive judgment is what makes the expert nurses decision superior to that of a novice or a machine. In this model, expert nurses are believed to use Dreyfus’s six key elements to information processing which includes pattern recognition, similarity recognition, common-sense understanding, skilled know-how, sense of salience, deliberative rationality, gather data related to the hypothesis, and deciding cue meaning. This decision process is intrinsic in nature and forms a part of complex judgment. Left lower leg swelling was evident on the assessment of the patient in the presented case study. The author has been exposed to multiple similar presentations in the past. This means that the author has, to some extent, used this thought processing system by utilising similarity and pattern recognition skills along with skilled know-how to form a clinical judgment and make a diagnosis of DVT.
Intuitive judgment is a process that is acquired over time. It only comes with experience and forms a part of judgment skills of an experienced nurse. Hence, the limitation of this model is that only experienced nurses is able to make an intuitive judgment. However, a novice learner has to use analytical reasoning skills in order to make a clinical judgment. This is supported by Banning (2008) who argues that novice nurses clinical judgment is based on analytical thinking while expert nurses judgment is based on intuition. Also, similarity and pattern recognition without considering the whole situation may lead to faulty decision and conclusion.
There are many other proposed theory on clinical decision making. Some of these models utilised by emergency clinicians and nurses for clinical decision making are mentioned below. These include the heuristic approach, dual information processing theory and clinical decision-making model. Heuristics approach is an important information processing model frequently utilised in the emergency department. Heuristic or pattern recognition approach is mental rules that are applied by clinicians for clinical reasoning. This skill is acquired over a period of time through exposure to a similar situation in the past. This approach is relevant in an emergency setting as this area receives high volume of patients who present with similar signs and symptoms. In this approach, sound decisions are made by clinicians based on limited relevant predictors. This approach also forms the basis of many protocols and pathway in the emergency department like the chest pain pathway, and the sepsis pathway which essentially makes the decision-making process easy and predictable. However, only focusing on certain predictors and ignoring other relevant parameters may have a detrimental effect on patients health and outcome.
Dual information processing theory uses both analytical and non-analytical reasoning skills. Analytical thinking allows clinicians to use the mental rule to make a diagnosis based on presenting complaint and symptoms of the patient. It also allows clinicians to use the process of deduction and use of mnemonics to retrieve knowledge from clinical memory, thereby minimising the likelihood of error. This is a slower process compared to the non-analytical thinking process. This dual process of thinking is used by the author to process the information provided by the patient. Collating this information with the outcome of physical examination and blood test result has helped the author to make a final diagnosis of DVT. According to Patel et al. (2015) expert clinicians tend to use non-analytical skills more often and make decisions rapidly based on these skills. This model helps to understand the intuitive and rational cognitive process used by clinicians in decision making.
In clinical decision-making model, nurses utilises hypothetico-deductive reasoning and pattern recognition skills. Both of these skills form the basis of clinical decision making. This is a multidimensional hybrid model that is based on a computerised decision support systems. Because this model utilises the benefit of both of these skills, experienced nurses tend to use this thinking process to make important clinical decisions while caring for a patient. Experience help nurses make decisions based on situational context and gain a sense of saliency. This model of information processing is used widely by experienced nurses working in an emergency setting.
Based on the most likely diagnosis of DVT, a management plan was formulated for the patient. After receiving a consent for anticoagulation, the patient was explained in details about the risk and benefits of this therapy. In accordance with the outpatient management of DVT protocol of the hospital, the patient was then commenced on rivaroxaban anticoagulation therapy. An outpatient referral form for ultrasound was provided to the patient along with instructions of following it up with the general practitioner (GP). The patient was also advised to purchase a compression stocking and use it in the affected limb. A discharge referral letter was provided with instructions for the GP. If the ultrasound was positive for DVT, the GP was advised to organise a thrombolytic screen along with referral to a haematologist due to an unprovoked DVT on the patient. If US report was negative for DVT, the GP was advised to stop rivaroxaban, re-review symptoms and consider other management strategies for the patient.
To conclude, the ultimate goal of emergency clinicians and nurse practitioners are to provide high- quality care for all patients presenting to the emergency department. The provision of high-quality care depends on the accuracy and efficacy of the clinical judgment and decisions made by clinicians. Diagnostic reasoning, clinical judgment and clinical decision skills are necessary attributes that define the clinical performance of clinicians and nurse practitioners. Many different models and theories on clinical reasoning have been proposed, some of which has been discussed in this paper, however, a well-defined and well-functioning model is yet to be discovered.
