Enhancing clinical judgement in virtual care for complex chronic disease

Abstract

The COVID-19 pandemic has transformed traditional in-person care into a new reality of virtual care for patients with complex chronic disease (CCD), but how has this transformation impacted clinical judgement? I argue that virtual specialist-patient interaction challenges clinical reasoning and clinical judgement (clinical reasoning combined with statistical reasoning). However, clinical reasoning can improve by recognising the abductive, deductive, and inductive methods that the clinician employs. Abductive reasoning leading to an inference to the best explanation or invention of an explanatory hypothesis is the default response to unfamiliar or confusing situations. Deductive reasoning supports a previously established goal, but deductive accuracy requires sound premises leading to a valid conclusion. Inductive reasoning uses efficient data sorting, data interpretation, and plan creation without a previously established goal, and allows assessing inferential accuracy over time. In all cases, communication remains the backbone of the clinical encounter. Virtual care for CCD challenges clinical judgement by reducing available information, so even experienced specialists who use induction might default to deduction or abduction.The visit might shorten, decreasing narrative competence and in-turn management quality. Clinical judgement in virtual encounters can be enhanced by allowing sufficient time, employing allied health staff, using an advance script, avoiding dogmatic commitment to either virtual or in-person encounters, special training in virtual care, and conscious awareness of abductive, deductive, and inductive reasoning processes.Clinical judgement in virtual encounters especially calls for Gestalt cognition to assess a situational pattern irreducible to its parts and independent of its particulars, so that efficient data interpretation and self-reflection are enabled. Gestalt cognition integrates abduction, deduction, and induction, appropriately divides the time and effort spent on each, and can compensate for reduced available information. Evaluating one's clinical judgement for those components especially vulnerable to compromise can help optimize the delivery of virtual care for patients with CCD.

Virtual care post-pandemic: Why user engagement is critical to create and optimise future models of care

“… 3 , 4 Notably, both groups report that gains are not universal, with particular populations or health condition groups receiving poorer quality of care along with inequitable access due to virtual working. 1 , 5 , 6 The diverse impacts of virtual care on healthcare experiences and outcomes contribute to varied perspectives among clinicians and consumers about the virtual models that should be sustained or halted, and the technologies that best support practice. Healthcare leaders, therefore, need to provide strong rationale for decisions about sustaining, expanding or disbanding virtual services, both to justify their budgets and to ensure virtual models are successfully embedded into existing systems, processes and healthcare infrastructure.…”

“…Clinicians must learn new skills to use and integrate information from different sources and technologies, adopt new ways of working and approaches to patient care in response to novel care processes and greater opportunities for multidisciplinary team meeting and communication in virtual contexts. 5 , 9…”

“…Clinicians must learn new skills to use and integrate information from different sources and technologies, adopt new ways of working and approaches to patient care in response to novel care processes and greater opportunities for multidisciplinary team meeting and communication in virtual contexts. 5,9 Despite the centrality of consumer and clinician involvement in realising the opportunities of virtual care for improved health services and outcomes, there has been limited opportunity for these primary service users to contribute to decision-making about the virtual care models and technologies being deployed during the pandemic. In our survey of physician engagement, well-being and organisational culture among members of the Ontario Hospital Association in Canada, 488 physicians reported an absence of opportunity and mechanisms to take part and collaborate in the process of decision-making about the use of virtual care in their organisation.…”

Humans, machines and decisions: Clinical reasoning in the age of artificial intelligence, evidence‐based medicine and Covid‐19

“…The section includes papers on EBM but extends beyond EBM to broader philosophical discussions concerning clinical knowledge, causal reasoning, research and consent-discussing issues of person-centred care and the purpose of medicine, and challenges to clinical judgement presented by the need for virtual care, a need generated by the global pandemic. [17][18][19][20][21][22][23][24][25][26][27] The first three papers in the section [17][18][19] take up the issues that were the topic of the concluding papers in the preceding 'Humanities' section, 15,16 though in this case the author outlines the history of the EBM debate from the perspective of medical philosophy and the history of ideas. The papers provide an extremely helpful account and critical analysis of the debate over the last 30 years, concluding with arguments concerning the possibilities for future development and the relationship between EBM and complexity theory, providerpatient decision making and person-centred care.…”

“…26 The section concludes with a discussion of the transition from 'traditional in-person care into a new reality of virtual care for patients with complex chronic disease' precipitated by the Covid-19 pandemic, and the specific challenges to clinical judgement this transition presents. 27 This paper sets the scene for the series of papers in the final section.…”