Enhancing the “What” and “Why” of the Pharmacists’ Patient Care Process With the “How” of Clinical Reasoning

DISCUSSION

Most definitions of clinical reasoning begin with a description of a mental process and use terms like non-analytic and analytic.³ Non-analytic processes are fast, instinct-like processes, such as intuitive knowing or pattern recognition. Analytic processes are more time-intensive and involve intentional investigation, such as hypothesis testing or assessment of likelihood. Many definitions also identify specific practitioner behaviors, such as data collection,^3,4,8 information synthesis,^2,5,8 identification of patient preferences,⁸ or collaboration.⁵ Some definitions identify unique factors (ie, a practitioner’s reflection) that may impact these cognitive processes and behavior. Marcum proposes a cyclical model in which metacognition provides a link between non-analytic reasoning, analytic reasoning, and clinical decision-making.⁴ Christensen also includes a metacognitive component noting “reflective” behavior. Christensen, Trowbridge, and Durning reference external factors, such as the context, setting, or patient-specific factors, that influence clinical reasoning.^2,5,8 Interestingly, Christensen⁵ and Eva³ both use directional language such as “recursive, non-linear” and “proceed[ing] in both directions,” respectively, to describe clinical reasoning. Finally, many definitions name the outcome or goal of reasoning, such as identification of a diagnosis, therapy, or management plan.^9,10 Many definitions utilize diagnostic-based language as much of the research and characterization of clinical reasoning pertains to medical education. However, extrapolation to the profession of pharmacy is not only helpful but necessary to enhance the clinical reasoning skills of student pharmacists.

Many of the skills and behaviors described in clinical reasoning definitions correspond with those attributed to critical thinking,^11,12 such as skills associated with interpretation, assessment, and evaluation of information.¹³ As with clinical reasoning, critical thinking is not well-defined in the literature due in part to the heterogeneous characterization of critical thinking by various disciplines and the complexity of skills, actions, goals, and outcomes of critical thinking.^13-15 Both are context, setting, and knowledge dependent.^2,8,13 Additionally, both critical thinking and clinical reasoning require self-regulation and metacognitive skills for success.^4,5,13 However, clinical reasoning builds upon critical thinking with its emphasis on integration of clinical evidence, previous experience, and collaboration with others. These additional skills and behaviors are unique to healthcare professionals because of the provision of patient-centered care.¹⁶ Thus, further elucidation of clinical reasoning skills is valuable for the teaching and training of student pharmacists.

To describe the associations between clinical reasoning and the work of the pharmacist, clinical reasoning definitions were identified from the health professions education literature and health professions clinical reasoning texts. The definitions in Table 1 were selected to represent the breadth of concepts articulated by health professions educators. Key elements of the PPCP were identified in each definition. The Collect phase was explicitly acknowledged in most definitions, recognizing that data collection allows the practitioner to obtain appropriate information to inform their thinking. All definitions also included elements of the Assess and either the Plan or Implement phases of the PPCP, emphasizing that cognition results in a behavior or action. However, only one definition included the Follow Up step.⁵ While Durning² and Christensen⁵ explicitly identified the need for collaboration, the communication or documentation components were not included in any of the selected definitions.

The PPCP incorporates some components of clinical reasoning as is evident in Table 1. In general, the PPCP framework includes the “what” and “why” of the pharmacist’s work but not the “how” of clinical reasoning during patient care. The PPCP does not describe the cognitive processes and behaviors necessary for clinical reasoning in application of collect, assess, plan, implement, and follow up. Additional characteristics of clinical reasoning that impact application of the PPCP are listed in Table 2. The PPCP’s circular, stepwise model suggests a linear direction. However, this process likely recurs repetitively and proceeds in both directions as student pharmacists reason. For example, when identifying and prioritizing medication therapy problems (MTPs), student pharmacists must simultaneously collect and assess patient-specific information. Additionally, new information, unexpected events, or a change in a patient’s health-related goals may require a student pharmacist to move from the planning phase back to information collection prior to plan development and implementation. Thus, a student pharmacist who is reasoning clinically may move fluidly back and forth between multiple phases of the PPCP. Rigid adherence to the stepwise process of the PPCP may hinder effective clinical reasoning.

The nuances identified in Table 2 have implications for teaching the PPCP and for fostering clinical reasoning skills. Concepts from the clinical reasoning literature that can inform discussion, modeling, and teaching of clinical reasoning within the context of the PPCP are presented in Table 3. The clinical reasoning literature supports use of multiple types of reasoning, including analytical reasoning and the use of preliminary hypotheses in data collection and assessment. A student pharmacist should think critically about the information they are collecting and work to generate preliminary hypotheses about a patient’s MTPs.³ There is also a role for non-analytic reasoning as educators talk-aloud about the impact of their personal experience, intuition, and the recognition of patterns in the care of patients.^3,4,8 Self-reflection and self-assessment of one’s own clinical reasoning skills should occur frequently to promote self-awareness and to identify strengths, opportunities for learning, and personal biases. Student pharmacists must also acknowledge the impact of their environment and of others on clinical reasoning as the reasoning process occurs.^2,5 For example, a student pharmacist’s clinical reasoning process would incorporate different variables when encountering a patient in a community pharmacy as compared to encountering a patient in the emergency department. Finally, student pharmacists should discuss their reasoning with peers, educators, and practitioners.¹⁷ Dialogue and inquiry from others can enhance clinical reasoning in the academic and clinical setting. This collaboration can be especially helpful when student pharmacists are working within the gray areas of patient care.¹⁹ As there may be more than one viable approach in the assessment and treatment of MTPs, student pharmacists must be comfortable using their clinical reasoning skills to identify an appropriate course of action in a given context. The concepts identified in Table 2 and Table 3 are likely best understood when seen in action. Figure 1 provides an illustrative example of clinical reasoning with important considerations highlighted.

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Figure 1.

Example of clinical reasoning through application of the Pharmacists’ Patient Care Process. Boxes with shading include concepts from Table 2. Boxes without shading include concepts from Table 3.

Clinical reasoning is vital to wise action, professional autonomy, competence, and the capacity to reason during uncertainty and with ill-defined problems.⁵ Definitions, theories, models, and frameworks can provide insight into the process of clinical reasoning. They help to define clinical reasoning, the variables involved, the interplay between the variables, and how the process works. However, no single theory seems to account for all aspects of clinical reasoning.²⁰ To better appreciate the complexities and evolution of clinical reasoning in students, it can be helpful to consider clinical reasoning as a threshold skill.²⁰ A threshold skill is integrative (ie, bringing together different aspects of the subject, including declarative and procedural knowledge), troublesome (ie, there is a foreign nature to the knowledge needed and unfamiliarity with the skill), transformative (ie, as students acquire further contextual knowledge they start to perform the skill more effectively and efficiently), associated with practice (ie, learned and sustained through repeated practice), and irreversible (ie, difficult to unlearn). Pinnock and colleagues aimed to investigate the nature of clinical reasoning from a student’s perspective and whether there was explanatory power in considering clinical reasoning as a threshold skill. In their study, medical students discussed clinical reasoning as an “exercise in integration” and reported the value of their previously acquired knowledge in a variety of basic science and clinical science areas, including the psychological and social aspects of the patient’s situation. They indicated that learning clinical reasoning can be troublesome as they begin to understand the knowledge they have yet to acquire and the reality of the need to make patient care plans despite uncertainties. Medical students have described the transformation involved in learning clinical reasoning and how their reasoning changed slowly and almost imperceptibly. In discussing the transformation, they reported the differences in their reasoning over time and in relation to junior colleagues. Clinical reasoning’s tight alignment with practice was also recognized. Supervised, repeated practice was reported as fundamental to developing their skills. Medical students also noted issues with transferability of clinical reasoning skills, given that the reasoning was often specific to the situation and environment. As educators debate, design, and sequence the activities needed to support the development of clinical reasoning abilities, its nature as integrative, troublesome, transformative, and associated with practice are important considerations. While learning to reason clinically is difficult, educators must also recognize the adjustment students are making to learn a different way. In the past, a student’s answers may have been prized and rewarded, along with their confidence in those answers. Yet, in clinical reasoning the questions that they ask become important (ie, questions about the patient, the situation, their peers, and themselves). Clinical reasoning is facilitated by student’s curiosity, open-ended thinking, and dialogue with their clinical teachers.¹⁹ This process may reveal knowledge or skill deficits²¹ and induce feelings of vulnerability. Educators should encourage curiosity, questioning, and dialogue,¹⁹ while also being prepared to diagnose the student’s clinical reasoning errors.²¹

While cultivating clinical reasoning skills in student pharmacists may seem like a daunting task, the clinical reasoning literature proposes useful strategies (Table 4). These teaching strategies can help educators to highlight skills or steps associated with clinical reasoning, facilitate deliberate practice of these skills, and provide feedback regarding performance and competence. Real-world cases or situational activities can introduce students to the ambiguity, uncertainty, and complexity of clinical practice.^3,21,23 Consider using cases or situations that slowly progress from simple to complex.^2,20 This will allow student pharmacists to generate and integrate knowledge, practice cognitive processes related to clinical reasoning, and develop experience. A specific strategy may be selected by considering learner level and learning activity. The serial-cue approach²⁵ involves providing basic case information to the student and follow-up information only after the student asks the appropriate questions or demonstrates a certain level of clinical reasoning. The whole-case approach²⁵ provides the entire case and associated information to the student at the beginning of the simulation. Clinical reasoning scholars have hypothesized that lower-level learners or students with minimal clinical reasoning experience may benefit from the serial-cue approach²⁰ to promote script development and better question-seeking behaviors in these students.

Educators should watch for and verbally recognize signs that students’ questions are changing from taught or rote questions to questions related to the problem or hypothesis. Educators should also watch for and interpret indirect signs related to the student’s clinical reasoning, such as focused or unfocused patient interviewing and ability to identify discriminating features.²⁴ Students and their teachers may benefit from adding clinical reasoning concepts into a familiar process, such as the assessment of indication, effectiveness, safety, and adherence (IESA). Regardless of the approach used, teaching strategies should introduce students to and require them to use different types of cognitive processes. In addition to these teaching strategies, educators should also model clinical reasoning with students^23,26 by discussing their own clinical reasoning and thought processes. For example, an educator could first discuss the risk-benefit assessments of multiple evidence-based strategies (ie, gray areas or ambiguity) and then identify personal biases that may impact clinical reasoning (ie, metacognitive factors) or describe how other members of the interdisciplinary care team may provide information imperative for the management of a specific MTP (ie, collaboration). Finally, educators can encourage students to practice deliberately^20,21 and request feedback on their performance to maximize learning from each experience and allow for reflection on errors that occurred.

It is vital for clinical reasoning to be taught, practiced, and assessed in the didactic curriculum in order to prepare students for experiential education.^21,23,24 Yet, there are currently no definitive best practices for teaching and assessing clinical reasoning. Assessments should include real-world cases and settings to align with situations students will see in practice. Assessments could use multiple “correct” pathways or answers based on the student’s reasoning. Additionally, as clinical reasoning can be considered a threshold skill, clinical reasoning could be included in progression assessments for each academic year or prior to APPEs. Both workplace-based assessments (eg, direct observations, global performance ratings) and non-workplace-based assessments (eg, multiple choice questions, essay-based questions) have been outlined.^{7,21,24,26-29}

As educators consider methods for addressing clinical reasoning and situating it within curricula, the relationships between clinical reasoning and various developmental processes and learning approaches should be considered. For example, for those interested in implicit theories of ability (or “mindset”^30,31), it could be useful to discuss and/or monitor a student’s mindset toward improving clinical reasoning. In addition, it may be helpful to aim instructional support at encouraging effort and maintaining a growth mindset through clinical reasoning-related challenges. As another example, as students move through clinical reasoning thresholds and become more proficient, educators may observe clinical reasoning’s influence on self-authorship³² (eg, trusting their internal voice) or elements of socialization and professional identity formation³³ (eg, doubts of competence leading to anxiety, learning to live with ambiguity). Educators are encouraged to examine clinical reasoning’s associations and intersections with familiar educational theories, concepts, and approaches.