Abstract: Rationale and Objectives: Diagnostic momentum refers to ruling in a particular diagnosis without adequate evidence. As the field of physical therapy continues to transition more towards autonomous practitioners with direct access, there is a need to identify the effect of a physician diagnosis on a therapist's examination and treatment. The purpose of this study was to identify if diagnostic momentum exists in physical therapy and whether this phenomenon could affect the ability of the therapist to identify clinical red flags.
Methods: An online survey with randomized case scenarios was completed by 75 licensed practicing physical therapists. Participants received one of two scenarios: a case vignette where the patient was referred to physical therapy for left shoulder pain and presented with 'red flags' indicative of myocardial infarction, or a similar vignette with additional results from an exercise stress test that ruled out myocardial infarction. The subjects were asked if they would 'treat' or 'refer' to another healthcare provider and the reason behind their decision. Independent t-tests and χ 2 analyses were conducted to understand the differences between the groups. A thematic analysis was used to explore the therapists' responses regarding the reasoning for their decision.
Results: There was no significant difference in clinical decision making based on age, gender, years of experience, advanced certification, primary caseload or primary practice setting. Among those who received the case without the stress test, 31.4% of participants indicated that they would refer, compared to 12.5% of the participants that had the additional stress test result included within their case. The presence of the negative stress test was indicated as the main reason for choosing to treat without referral by 65.7% of the subjects that received the additional stress test result.
Conclusion: This study suggests that practicing physical therapists may be influenced by diagnostic decisions made by other clinicians, causing them to overlook signs and symptoms of possible myocardial infarction.
(© 2023 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons Ltd.)
References: Ball JR, Balogh E. Improving diagnosis in health care: highlights of a report from the National Academies of Sciences, Engineering, and Medicine. Ann Intern Med. 2016;164(1):59-61. doi:10.7326/M15-2256.
Graber M, Gordon R, Franklin N. Reducing diagnostic errors in medicine: what's the goal? Acad Med. 2002;77(10):981-992. doi:10.1097/00001888-200210000-00009.
Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002;9(11):1184-1204. doi:10.1111/j.1553-2712.2002.tb01574.x.
Saber Tehrani AS, Lee H, Mathews SC, et al. 25-year summary of US malpractice claims for diagnostic errors 1986-2010: an analysis from the National Practitioner Data Bank. BMJ Qual Safety. 2013;22(8):672-680. doi:10.1136/bmjqs-2012-001550.
Jette DU, Ardleigh K, Chandler K, McShea L. Decision-making ability of physical therapists: physical therapy intervention or medical referral. Phys Ther. 2006;86(12):1619-1629. doi:10.2522/ptj.20050393.
Jiandani M, Mhatre B. Physical therapy diagnosis: how is it different? J Postgrad Med. 2018;64(2):69-72. doi:10.4103/jpgm.JPGM_691_17.
Goodman CC, Snyder TEK. Differential Diagnosis for Physical Therapists: Screening for Referral. 4th ed. Saunders/Elsevier; 2007: 911.
Wainwright SF, Shepard KF, Harman LB, Stephens J. Factors that influence the clinical decision making of novice and experienced physical therapists. Phys Ther. 2011;91(1):87-101. doi:10.2522/ptj.20100161.
Boissonnault W, Goodman C. Physical therapists as diagnosticians: drawing the line on diagnosing pathology. J Orthopaedic Sports Physical Therapy. 2006;36(6):351-353. doi:10.2519/jospt.2006.0107.
Boissonnault WG. Primary Care for the Physical Therapist: Examination and Triage. 2nd ed. Elsevier/Saunders; 2011:418.
Moon MD. Triangulation: a method to increase validity, reliability, and legitimation in clinical research. J Emerg Nurs. 2019;45(1):103-105. doi:10.1016/j.jen.2018.11.004.
Whelehan DF, Conlon KC, Ridgway PF. Medicine and heuristics: cognitive biases and medical decision-making. Irish J Med Sci. 2020;189(4):1477-1484. doi:10.1007/s11845-020-02235-1.
Ferrario CG. Experienced and less-experienced nurses' diagnostic reasoning: implications for fostering students' critical thinking. Int J Nur Terminologies Classifications: Offi J NANDA Int. 2003;14(2):41-52. doi:10.1111/j.1744-618x.2003.tb00059.x.
Croskerry P, Cosby K, Schenkel S, Wears R. The cognitive autopsy: gaining insight into diagnostic failure. Patient Safety in Emergency Medicine. Lippincott Williams and Wilkins Philadelphia; 2009:302-308.
Butt S, Affleck A. Decision-making in dermatologic surgery. Australas J Dermatol. 2021;62(4):e568-e571. doi:10.1111/ajd.13723.
Hussain A, Oestreicher J. Clinical decision-making: heuristics and cognitive biases for the ophthalmologist. Surv Ophthalmol. 2018;63(1):119-124. doi:10.1016/j.survophthal.2017.08.007.
Richards JB, Schwartzstein RM. Promoting critical thinking in your intensive care unit team. Crit Care Clin. 2022;38(1):113-127. doi:10.1016/j.ccc.2021.08.002.
Fernández-Aguilar C, Martín-Martín JJ, Minué Lorenzo S, Fernández Ajuria A. Use of heuristics during the clinical decision process from family care physicians in real conditions. J Eval Clin Pract. 2022;28(1):135-141. doi:10.1111/jep.13608.
O'Sullivan E, Schofield S. Cognitive bias in clinical medicine. J Royal Coll Phy Edinburgh. 2018;48(3):225-232. doi:10.4997/JRCPE.2018.306.
James FR, Power N, Laha S. Decision-making in intensive care medicine-a review. J Intensive Care Soc. 2018;19(3):247-258. doi:10.1177/1751143717746566.
Muls AC, Klimova K, Andreyev HJN. Clinical decision-making in managing changes in gastrointestinal function following cancer therapies: is experience enough? Eur J Cancer Care. 2018;27(1):e12766. doi:10.1111/ecc.12766.
Thompson C. Clinical experience as evidence in evidence-based practice. J Adv Nurs. 2003;43(3):230-237. doi:10.1046/j.1365-2648.2003.02705.x.
Stinson KJ. Benner's framework and clinical decision-making in the critical care environment. Nurs Sci Q. 2017;30(1):52-57. doi:10.1177/0894318416680536.
Jette DU, Grover L, Keck CP. A qualitative study of clinical decision making in recommending discharge placement from the acute care setting. Phys Ther. 2003;83(3):224-236.
Gojanovic B, Fourchet F, Gremeaux V. Cognitive biases cloud our clinical decisions and patient expectations: a narrative review to help bridge the gap between evidence-based and personalized medicine. Ann Phys Rehab Med. 2022;65(4):101551. doi:10.1016/j.rehab.2021.101551.
Lau B, Skinner EH, Lo K, Bearman M. Experiences of physical therapists working in the acute hospital setting: systematic review. Phys Ther. 2016;96(9):1317-1332. doi:10.2522/ptj.20150261.
Embrey DG, Guthrie MR, White OR, Dietz J. Clinical decision making by experienced and inexperienced pediatric physical therapists for children with diplegic cerebral palsy. Phys Ther. 1996;76(1):20-33. doi:10.1093/ptj/76.1.20.
Processing Request
No Comments.