Clinical Reasoning

Irfannuddin

UPEP FK Unsri

Case
Mad Mpul MD is in trouble. He got claim by patient because of wrong diagnosis that cause him gave wrong treatment. Now, the patient has physical defect. The patient prosecute him to pay half million dollar.

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Another Real Case

Mr D come to dr K with skin problem. He feels his skin itchy and redness.
After short 2 minutes interview, dr K ask him to follow the complete blood and scan skin. The cost of tests around 500.000 rupiahs

Based on the test, dr.K just give 5 kind of drugs for Mr D. Mr D spent around 400.000 rupiahs for the drugs
One year later, when he come home to his town (Palembang), Mr D got same problem. He come to a good general doctor.

After 20 minutes interview, the generic doctor conclude that Mr D got allergic problem with some tools. The doctor just give him 1 drug price 15.000 rupiahs and some good advice.
After visiting the doctor and use the drug. Mr D never got the same problem anymore.
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Another Real Case

R 8 th. Selalu merasa lemah dan mudah mengantuk Orang tuanya telah membawa R ke beberapa spesialis dan beberapa rumah sakit ternama di Jakarta. Mereka menetapkan diagnosis dan terapi yang bervariasi, mulai dari gangguan genetik, sindrom metabolik, gangguan defisiensi enzim sampai ke gejala kanker.

Karena kehabisan uang, R dibawa orang tuanya ke Palembang untuk ditipkan ke nenek R. Di Palembang R dirawat di RSMH.
Dokter RSMH melakukan pemeriksaan sederhana terhadap R berupa pemeriksaan feses.

Dari pemeriksaan feses diketahui R menderita cacingan Ascaris Lumbricoides. R kemudian di beri obat cacing dan terapi cairan.
Setelah beberapa minggu, kondisi R menunjukkan perbaikan. R sekarang menjadi anak yang ceria dengan prestasi belajar yang cemerlang.
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Why does clinical reasoning ?

American Medical Association:

> 12.000 malpractice reports/year

Causes:
Misdiagnosis (>>>) Miscommunication Mismanagement

Indonesia : most of them

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Causes of Misdiagnosis

1. Errors in taking decision

2. Insensitive with patients data

3. Less knowledge
4. Not thinking reasonable

Low ability of clinical reasoning

Becker, 2008
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Doctor must think reasoning, why ?

The doctor treat patient base on data

Data about: Patients problem
Sign & symptom

The data/problem always:

Imcomplete

Unclear
Contradictive Befuddling

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The main characteristic of professionalism in Medicine is:

Thinking reasoning in unclear condition to solve the unconfirmed problem

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Medical Competencies

Clinical Reasoning (the most important)

Appraise, priorities, find alternatives, evaluation etc.

Clinical skills
Anamnesis, diagnosis, management

Interpersonal skills
Communication, attitude

Basic medical knowledge Sibert, et al. (2000)

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What is Clinical Reasoning ?

Cognitive process
Synthetize and integrate clinical cases with knowledge and experiences Utiliize to diagnose and treat patients problem
Washington University, 2005

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Ennis, 2000

Clinical Reasoning
A healthy thinking to conduct clinical practice
Central component of medical professionalism

Process : firts contact with patient report

Keyword of Clinical Reasoning Probability analysis Priority Determination

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Kasus
Data & Informasi

Masalah
Hipotesis

Clinical Reasoning
Refleksi

Analisis Basic Clinical

Keputusan
Santoso, Priyadi, Rizki, Irfannuddin, 2007
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Informasi Tambahan
Sintesis

How is building the Clinical Reasoning ?

Clinical reasoning is a skill that could be trained

How ?:

Practice in critical thinking

Practice in logical thiking

Building the knowledge Have a lot experience

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Step in practicing in clinical reasoning

Component of Clinical Reasoning Collect, organize & interpretate data (problem)

Formulate the hypothesis Analyzed the hypothesis Evaluation and make alternative diagnosis Treatment strategy & priority Case presentation
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Step in PBL
Term clarfication Identify problem Analyzed problem Formulate the hypothesis hypothesis Evaluation hypothesis and determine limited knowledge Self learning Synthesis and evaluation Presentation in plenary

Irfannuddin, 2008

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Good Skills in Clinical Reasoning :

Able to:

1.
2. 3. 4.

Generating prioritized problem list

Identifying tha main patient problem Accurately describing the patient problem in a detailed chronological manner Identifying pertinent positives and negatives for the patients problem

5.
6.

Gathering information from other parts of the medical database that supports the most likely diagnosis and refutes alternative explanations
Identifying and accurately reporting the part of the physical examination that are importsnt to understand the patients problem

7.
8. 9.

Summarizing the relevant hystory and the physical finding

Generating and appropiately detailed branching diagram that reflects an organized approach to the patients problem Generating a brief differential diagnosis of the patients problem

10. Explaining how likely each item on differential diagnosis is or is not and why
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Thats all for today

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