The Importance of Clinical Reasoning in Optometry

Clinical reasoning is a crucial soft skill in all health professions. As a core competency, it has been suggested that clinical reasoning is possibly even more critical in optometry compared to a profession such as nursing or general medical practice. This is due to the largely autonomous nature of optometry practice, whereas nurses and GPs rely on input from their clinical team or other specialised professionals.¹ Indeed, the ability to demonstrate clinical reasoning is considered a requirement as per the Optometry Australia Entry-Level Competency Standards for Optometry² and the World Council of Optometry standards, A Global Competency-Based Model of Scope of Practice in Optometry.³

What is Clinical Reasoning?

As there is no standardised definition of clinical reasoning,¹ the terminology can differ between publications, with terms such as clinical judgement, diagnostic reasoning or judgement, clinical thinking, or decision-making being used interchangeably.

However, it is generally agreed that clinical reasoning is a complex process involving integrating evidence-based practice, clinical expertise, and the unique patient context to make clinical decisions.¹ As it relates to critical thinking, clinical reasoning has been presented as a type of critical thinking⁴, and critical thinking is considered a separate but facilitating factor to clinical reasoning.⁵

The dual-processing theory of clinical reasoning is just one theoretical exploration of this concept.^1,6 It describes the application of clinical reasoning as being a balance of two processes – type I (non-analytical or intuitive) and type II (analytical).⁶

When it comes to making diagnostic errors in clinical practice, cognitive error is considered to be the causative factor of the vast majority of situations. Events of cognitive error can encompass a lapse in memory, gaps in knowledge, or poor judgement. Out of these three, poor judgement accounts for up to 87% of cases of cognitive error.⁶ However, although all clinicians agree on the importance of clinical reasoning, formulating a standardised method or framework for developing this skill, or even evaluating it, in optometry has been found to be difficult.¹ As a search of the literature demonstrates, more needs to be investigated regarding clinical reasoning in optometry specifically. However, some principles and practices from other professions, such as physical therapy or general practice, can still be applied to optometry.

Clinical reasoning is considered to be a learned skill, though admittedly, some individuals take to it more naturally than others. One way of outlining the basic steps of the clinical reasoning process is to summarise it in a series of questions:^4,7

• What caused you to ask that question or perform that test? Was it necessary or relevant to obtain that piece of information?
• What alternatives (for example, differential diagnoses or alternative tests) could have been considered?
• Why did you choose to reject those alternatives? How does the data you gathered earlier support your decision to discard those alternatives?
• Can your final decision (for example, a diagnosis or management plan) be justified?

Another alternative representation of the clinical reasoning process is to use a cycle model:⁸

• Consider the patient’s situation
• Collect cues and information
• Process information
• Identify problems and issues
• Establish the goal
• Take action
• Evaluate outcomes
• Reflect on the process and any new learnings that emerged from the experience

Assessing and Teaching Clinical Reasoning Skills

The medical field uses a self-reflective questionnaire, the Diagnostic Thinking Inventory, to evaluate clinical reasoning skills among early-career and experienced clinicians. One recent study assessed the validity of this questionnaire’s adapted and condensed version when applied to optometry. The study found that this self-reflective tool, named the Diagnostic Thinking Inventory for Optometry Short (DTI-OS), is valid and reliable when quantifying diagnostic reasoning ability in optometry.¹ The items in the inventory measure self-evaluated clinical reasoning ability and its two subdomains – flexibility in thinking (understanding the appropriate application of processes during diagnostic reasoning) and structured memory (accessing clinical knowledge during diagnostic reasoning). Questions in the final DTI-OS tool required respondents to mark themselves on a scale between two contrasting statements, such as:

• While I am collecting information about a patient: the various items of information usually seem to group themselves together in my mind versus I often have difficulty seeing how the pieces of information relate to each other.
• During the case history: I cannot bring myself to dismiss some information as irrelevant versus I am quite happy to dismiss some information as irrelevant.
• When I reach my diagnostic decisions: There is often left-over information I have just forgotten about versus I usually will have considered all the information.
• In terms of a way I take case history: I usually cover the ground that I need to during the interview versus quite often I do not ask all the questions that I should at the time.

The authors of this study proposed the tool as being useful both for teaching clinical reasoning skills to optometry students and for experienced practitioners during their continuous professional development.

Ultimately, the development of clinical reasoning in a student or early-career optometrist is best honed under the guidance of an experienced clinician in a real-world clinical setting. However, to get the most out of this process, the mentoring optometrist needs to clearly verbalise their thought processes at each step of the patient interaction.⁴ Being involved in this as an experienced clinician also has the added benefit of allowing you to evaluate and refine your clinical reasoning processes.⁷

Do You Need to Improve Your Clinical Reasoning?

As each patient context is unique, it becomes dangerous to apply a one-size-fits-all approach to managing the individual sitting in your chair. It is directly at odds with the concept of sound clinical reasoning. However, it is possible to fall into the trap of running on auto-pilot when it comes to clinical reasoning in order to streamline the consultation, to the detriment of the patient.⁷

There is no one correct way of honing your clinical reasoning. As mentioned earlier, much of it comes with real-world experience and managing actual patients. This being said, also mentioned earlier, was the significant contribution of poor judgement to diagnostic errors in the clinical setting, making it worthwhile to improve your clinical reasoning if you’ve identified it as an area of weakness in your practice.

Consider reflecting on the following aspects of clinical reasoning to identify whether you find any of them challenging when faced with a patient:

• Identifying the key points or cues provided by the patient, whether during history-taking or diagnostic testing and discarding the irrelevant parts
• Appropriately and efficiently directing or prioritising your history-taking and diagnostic testing
• Flexibility in adapting your clinical procedures to the presenting complaint and other cues that arise during the examination
• Formulating a diagnosis or conclusion at the appropriate time while exploring all other relevant alternatives
• Integrating all findings into one whole clinical picture as it relates to the individual in front of you

Summary

Clinical reasoning is a critical skill and a core competency for all optometrists. Though it may be difficult to define, assess, and develop in a structured way, it is possible to hone your clinical reasoning skills through conscious self-reflection.

References

1. Edgar A, Ainge L, Backhouse, S. et al. A cohort study for the development and validation of a reflective inventory to quantify diagnostic reasoning skills in optometry practice. BMC Med Educ. 2022; 22:536.
2. Kiely P, Slater J.Optometry Australia Entry‐level Competency Standards for Optometry. Clinical and Experimental Optometry. 2014; 98:1, 65-89
3. World Council of Optometry. A Global Competency-Based Model of Scope of Practice in Optometry. 2015. Available at: https://worldcouncilofoptometry.info/wp-content/uploads/2017/03/wco_global_competency_model_2015.pdf.
4. Mivision. Clinical Reasoning: What’s it All About? https://mivision.com.au/. 2019. Available at: https://mivision.com.au/2019/09/clinical-reasoning-whats-it-all-about/#:~:text=CLINICAL%20REASONING%20IS%20A%20LEARNED,environment%20with%20a%20clinical%20educator.. (Accessed April 2023).
5. Faucher, C. Differentiating the Elements of Clinical Thinking. Optometric Education. 2011; 36(3):140-145.
6. Prokop T. Use of the Dual-Processing Theory to Develop Expert Clinical Reasoning in Physical Therapy Students. Journal of Physical Therapy Education. 2018; 32(4):355-359.
7. Linn A, Kildea H, Tonkin A, Khaw C. Clinical reasoning: A Guide to improving teaching and practice. AFP. 2012; 41(1).
8. Levett-Jones T, Hoffman K, Dempsey J, Jeong SY, Noble D, Norton CA, Roche J, Hickey N. The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Educ Today. 2010; 30(6):515-20.