Therapeutic reasoning: from hiatus to hypothetical model

Abstract

Rationale Extensive research has been conducted on clinical reasoning to gain better understanding of this process. Clinical reasoning has been defined as the process of thinking critically about the diagnosis and patient management. However, most research has focused on the process of diagnostic reasoning. Because of the lack of understanding regarding therapeutic reasoning, education in patient management decisions lacks a solid theoretical basis. Aims and objective To improve medical education, training and refresher courses with regard to therapeutic decision making. Methods A search on the literature about clinical reasoning has been conducted. Based on this literature a hypothetical model of therapeutic reasoning is developed. Results It is assumed on the literature about diagnostic and therapeutic reasoning that after the diagnosis has been formulated, the process of determining the therapy is initiated by a concept called the therapy script. Patient cases unconsciously elicit such scripts and they consist of relevant treatments, knowledge and clinical experiences. Analytical and non-analytical processes determine the final choice of therapy. Subsequently, these processes adapt the therapy script continuously. Conclusions A hypothetical model of therapeutic reasoning has been developed in order to improve medical education, training and refresher courses with regard to therapeutic decision making. Future research should empirically test the validity of this hypothetical model in different phases of the medical education continuum.

How could undergraduate education prepare new graduates to be safer prescribers?

“…We believe that our review of learning theory has gone some way in addressing the need for a consensus on the cognitive skills required for safe prescribing, whilst our theoretical model of prescribing expertise provides a suitable background on which to consider the design and evaluation of future developments in prescribing education. Similar theoretical models have proved to be informative when considering specific aspects of prescribing, such as decision making [30] and therapeutic reasoning [31] Medical decision making within clinical practice is certainly relevant to our work [32] but we have concentrated solely on prescribing expertise, in order to explore the whole task in as much depth as possible.…”

What’s in the bottle? Prescriptions formulated by medical herbalists in a clinical trial of treatment during the menopause

“…Whilst common language within herbal practice, this "shorthand" may not be explicit to a wider audience, and further research to explore the practitioner's clinical reasoning would benefit from articulating tacit knowledge, in particular to explore the role of traditional knowledge and vitalist philosophy in the practice of herbal medicine (Evans 2008). It is a limitation of this study that the underling rationale for the prescribing has not been adequately described as it would be useful to understand more about the linkage between the clinical history and the process of composing the prescription (Bissessur et al, 2009). In a future study, it would be important to ensure that the clinical reasoning underlying the prescriptions was recorded at the time.…”

“…As the original study showed treatment of menopausal symptoms by herbal practitioners to be effective (Green et al 2007), closer examination of usual care in this instance is of interest. By reporting not only the prescriptions but the practitioners' rationale for selecting herbs in the context of treating women with menopausal symptoms, we begin to explore their clinical reasoning (Bissessur et al 2009) which is a neglected area of practice research (Higgs et al 2008).…”

Students and Doctors are Unaware of the Cost of Drugs they Frequently Prescribe

“…In clinical practice, taking drug costs into account is part of the therapeutic reasoning paradigm [7] and has been described as the result of a non-conscious reasoning process of pattern recognition that takes place rapidly and at an automatic level in experts [21,22]. While prescribing, an expert would thus automatically take the incorrect drug price into consideration.…”