Tip of the Week: View Clinical Reasoning as a Practice Mindset

Pharmacists in every setting encounter many patients with varying conditions and varying degrees of severity and comorbidities. For example, in the ambulatory sector, patients have been given greater access to more medications through reclassification of drugs to OTC status. Thus, there are increasing numbers of patients who seek advice for a wide range of illnesses.

Facilitation of self-care by pharmacists has the potential to relieve and reshape primary care physician workload and promote cost-effective care in optimizing patient outcomes. The use of protocols has allowed the profession to embrace a greater role in facilitating patient self-care; pharmacists are being asked to help patients manage a broader range of conditions, and pharmacists are in the midst of greater triage responsibilities. However, community pharmacy personnel might find it difficult to consistently interpret signs and symptoms to arrive at a potential diagnosis through appropriate questioning.

As such, researchers Paul M. Rutter, PhD, FRPharmS, FFRPS, SFHEA, and Tim Harrison, BSPharm, propose that the profession move toward the adoption of clinical reasoning as a focal point of practice.1 Clinical reasoning is an evidence-based, dynamic process in which the health professional combines scientific knowledge, clinical experience, and clinical thinking with existing and newly gathered information about the patient against a backdrop of clinical uncertainty.

This begins with asking not only a more thorough set of questions to presenting patients, but the right set of questions framed the right way, employing use of comparative analysis based on experience to actuate the triage process more effectively. This involves the greater use of deductive rather than inductive techniques. Inductive techniques focus on fast, automatic, subconscious, intuitive processes more vulnerable to error; whereas deductive processes are more deliberate and systematic, yet less prone to error.

This framework gets at the most relevant patient histories, including medical, medication, and relevant social histories. As the pharmacist explores additional information, directed by initial consideration of diagnoses, the offering of likelihood of diagnoses can take place, including alternative diagnoses when an initial diagnosis might not fit the additional data acquired. This precludes the “short cuts” often prevalent with inductive reasoning and when use of heuristics and pattern recognition are overly employed. No type of reasoning is foolproof, though, and the likelihood of error must continue to be minimized with continued use of deduction to rule out sinister pathologies.

Although the vast majority of community pharmacy presentations will be self-limiting and non-serious, the volume of patients seen means that pharmacists even in the community will encounter serious conditions. Pharmacists should follow up with patients who are triaged to other health professionals not only to be part of the health care team, but to demonstrate responsibility for the patient and to continuously learn and develop their clinical reasoning skills through experience in working with other professionals.

Pharmacists must strive to be better each and every day they practice. Effective use of clinical reasoning might indeed be one of the major driving forces behind practice change toward more patient-centric care and might help demonstrate pharmacists’ roles as valuable team members who merit recognition and alternative reimbursement structures for their services. All pharmacists are managers, at least in some sense. Pharmacists must role model behaviors and adapt a mindset conducive to future practice rather than merely hope that practice change will simply happen. This requires not only political advocacy, but also the adoption of clinical reasoning and other effective decision-making frameworks as a matter of routine.

Additional information about Ethical Decision-Making, Problem-Solving, and Delegating Authority and Ensuring Quality in Pharmacy Operations can be found in Pharmacy Management: Essentials for All Practice Settings, 5e.

Reference

Rutter PM, Harrison T. Differential diagnosis in pharmacy practice: Time to adopt clinical reasoning and decision making. Res Social Adm Pharm. 2020;16(10):1483-1486.

About the Author

Shane P. Desselle, RPh, PhD, FAPhA, is a professor of social and behavioral pharmacy at Touro University California College of Pharmacy