Clinical reasoning development has been shown to be a key component of post-graduate education and has been associated with expert practice. Although it is theoretically accepted that residency education will contribute to the advancement of clinical reasoning, limited studies have investigated the influence of residency training on the clinical reasoning development of physical therapists [3,4].
This article explores the influence of an orthopaedic residency program on the clinical reasoning of participating physical therapists. It focuses on a study conducted in Nairobi, Kenya, to determine a hypothetical diagnosis and associated treatment plan.
The Kenya Medical Training College Higher Diploma Program offered the first post-graduate orthopaedic residency program administered by the Jackson Clinics Foundation in 2012 [1]. The Jackson Clinics Foundation is a non-governmental organization in the United States formed for the purpose of funding humanitarian efforts in Africa [2].
Methodology
A mixed-methods research design was utilized to explore the influence of an orthopaedic residency program on the clinical reasoning of participating physical therapists to determine a hypothetical diagnosis and associated treatment plan. This study utilized a convenience sample of residents in the third cohort of an orthopaedic manual therapy residency program in Nairobi, Kenya. All residents were over 18 years old and could speak and read English.
The residency program was chosen based on the unique characteristics of the participants, which limited the introduction of covariates into the study. A total of 14 residents in the third cohort of the residency program agreed to participate in the study. These residents completed live patient examinations at the initiation and completion of the residency program. Three residents initiated the program with the third cohort but had not completed all modules in order to sit for the final live patient exam.
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Participant Demographics
The age of the residents in the third cohort ranged from 26 to 38 years, with a mean age of 32.3 years. Clinical experience ranged from 4 to 16 years, with a mean of 9.0 years.
Program Structure
Physical therapists in the residency program complete six onsite modules over 18 months. Each module consists of ten days of onsite education provided by physical therapy instructors from the United States. The online didactic portion of the program utilizes the Clinical Practice Guidelines and Current Concepts in Orthopedics, 3rd edition (American Physical Therapy Association) as background reading and preparation for participation in onsite modules [2]. The emphasis of the onsite modules is development of clinical reasoning and advancement of skills in participants, with a focus on manual therapy clinical practice and evidence-based practice.
Assessment Tools
Participant clinical reasoning was assessed prior to entering and at completion of the residency program through a live patient examination. To assess the observable components of clinical reasoning used in the live patient examination, a clinical performance evaluation tool based on the Description of Specialty Practice (DSP) in Orthopaedic Physical Therapy was utilized [10]. The tool assesses the physical therapist’s ability to collect key information, integrate the information into a previous knowledge framework to develop a diagnosis and prognosis, and select appropriate interventions based on this assessment [11].
The assessment is divided into five categories: examination, evaluation, diagnosis, prognosis, and intervention. Each category is further divided into multiple skills to allow for a measurable assessment of each component [11]. The assessment form contains a total of 64 items or skills. The tool was chosen for this study because it incorporates context or environment as well as interaction with the patient through a live patient examination. The incorporation of the environment allows for the assessment of narrative reasoning in addition to utilization of hypothetical-deductive and pattern recognition models. Furthermore, initial studies with the tool suggest that it is valid and reliable for the assessment of clinical reasoning in orthopaedic practice [11].
To determine internal consistency, Cronbach’s alpha for the five categories measured by the tool was assessed; examination .86, evaluation .83, diagnosis .84, prognosis .51 and intervention .80 [11]. Cohen’s kappa coefficient was determined for interrater reliability of each of the 64 items. Sixty items demonstrated a Kappa greater than .61 and percent agreement greater than 75% [11].
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Examiners
The assessment of the baseline and final live practical examinations was performed by two examiners. The examiners were current instructors in a United States residency program. Each examiner had over 20 years of clinical experience and was a Board-Certified Clinical Specialist in Orthopaedic Physical Therapy. Both examiners provided significant input during the development of the tool and had extensive experience with the assessment tool in United States Residency programs. Neither of the examiners instructed nor provided mentoring to the cohort of residents in the Kenya program.
Interviews
Immediately following the final practical examination, residents participated in individual, one-on-one interviews onsite with the primary investigator. Contact between the residents and primary investigator was limited to the initial process of informed consent, and there was no further interaction prior to the interviews. The primary investigator used open-ended questions to probe the perspectives of participants and guide the interviews. The participants were asked to share their hypothetical physical therapy diagnosis for the patient and describe the process they utilized to determine the diagnosis.
Data Analysis
For the live patient assessment, baseline and completion scores were compared with a McNemar’s test, after removing ‘not applicable’ scores to create a dichotomous outcome variable. ‘Not applicable’ scores implied that the item would provide no additional information based on patient presentation, or would be contraindicated. Resident scores for each of the five overall categories of examination, evaluation, diagnosis, prognosis, and intervention were also determined. The category scores for each resident at baseline and completion were then compared. The change in score for each category was assessed using the McNemar’s test, with removal of ‘not applicable’ scores. The significance level with Bonferroni correction was set at .01.
A phenomenological approach was utilized to understand the clinical reasoning process from participant’s perspectives. Interviews were audio recorded and transcribed by an independent transcriptionist to ensure accuracy. Information from the semi-structured interviews was coded using NVivo for Mac to arrange codes. Thick, rich narratives of the participants have been provided to inform the clinical reasoning models identified. To ensure credibility, a member of the research study team, with extensive qualitative research expertise, confirmed the themes through peer review. Furthermore, peer review of the data was used to identify potential bias on the part of the primary investigator. Member checks (respondent validation) were performed with 10 of the residents.
Results
Baseline scores on the assessment were obtained in 2014, and scores at program completion were obtained in 2016. Residents’ scores for six of the 64 items at baseline or completion were consistently ‘not applicable’ for the skill based on the patient presentation. Each of the 58 remaining items were analyzed for significant differences between the baseline and completion scores. Detailed results are presented in the supplemental material.
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Participants demonstrated a significant improvement on the live patient examination from baseline to completion on 17 of the items, in the categories of evaluation, diagnosis, and prognosis. One item in the category of intervention regarding joint mobilization demonstrated a statistically significant change. Forty items on the assessment tool did not demonstrate a statistically significant change in scores. Three of these clinical skills, related to patient interview, demonstrated satisfactory performance at time of entry to the program. These three items included communication with the patient, building rapport, and localizing the area of symptoms. Three items on the tool remained not applicable at entry and at completion for the majority of residents based on the patient presentation.
Category Score Changes
Resident scores for each of the five overall categories of examination, evaluation, diagnosis, prognosis, and intervention were compared at baseline and completion. The categories of examination and diagnosis demonstrated a statistically significant change. The category of prognosis approached significance at .015.
In addition, the exam pass rate (minimum score 75%) improved overall from 0% to 100%. Percentage scores on the baseline examination ranged from 11.7% to 61.5%, whereas final percentage scores ranged from 75% to 98.1%. Figure 1 provides a visual representation of the change in percentage scores on the practical examination from baseline to completion for each subject, demonstrating that all subjects improved their individual performance.
The median change in score for the group was 45.5%, with an interquartile range of 20.7%. The 95% confidence interval for the median change in score was (40.0%, 66.0%), indicating considerable gains in skills as a group.
An Introduction to Clinical Reasoning (Strong Diagnosis)
Clinical Reasoning Processes
Following the practical examination, the residents were interviewed and asked to describe the hypothetical physical therapy diagnosis and the process they used to arrive at that conclusion. Residents discussed using the hypothetical-deductive reasoning process and narrative reasoning process throughout the examination of the patient, and in some instances, they integrated both processes to develop a physical therapy diagnosis. Residents also discussed the need to perform a thorough individualized examination and the utilization of key findings to form a hypothetical diagnosis.
The acquisition of cues from the patient’s narrative and examination to develop and reexamine the hypothetical diagnosis followed the four steps outlined in the hypothetical- deductive reasoning process: cue acquisition, hypothesis generation, cue interpretation, and hypothesis evaluation [7].
Residents also discussed the development of non-patient identified problems (NPIPs) as described in the HOAC II algorithm developed by Rothstein, Echternach, and Riddle [12]. Rather than focusing on the local area of symptoms in isolation, residents considered the underlying cause or contributing factors for the development of the symptoms.
In addition to using objective measurements to support the patient’s physical therapy diagnosis, residents expressed the importance of listening to the patient’s story to develop a shared meaning for the patient’s symptoms. These descriptions support the integration of the narrative reasoning process in the evaluation of patients.
Some residents described a combination of sources to determine a hypothetical diagnosis for the patient, integrating two clinical reasoning processes: hypothetical-deductive reasoning and narrative reasoning. It was through the integration of objective data and the patient’s subjective comments that many of the residents discovered the underlying condition.
In addition to the development of a hypothetical physical therapy diagnosis, screening for non-musculoskeletal pathology and making timely referrals were highlighted as key components of the examination. Residents discussed the need to examine the patient from a systemic perspective versus looking at the area of somatic symptoms in isolation. They noted the need to recognize both medical and psychological issues present and considered this as a component of the clinical reasoning process. The determination of appropriateness of the patient for physical therapy was performed throughout the assessment.
Key Findings
Residents (n = 14) demonstrated a statistically significant improvement in their ability to perform an examination of a patient and determine a hypothetical diagnosis. The clinical reasoning process described by the participants included the hypothetical deductive and narrative reasoning models.
Similar to studies on novice and expert practice in physical therapy, residents demonstrated an improvement in cue acquisition, the ability to verify and refute a hypothetical diagnosis, and the ability to match interventions to patients impairments.
| Category | Statistical Significance |
|---|---|
| Examination | Significant Change |
| Diagnosis | Significant Change |
| Prognosis | Approached Significance (0.015) |
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tags: #Kenya
