Both Alicia and I attended a lecture evening hosted by the MPA of the Australian Physiotherapy Association. The guest speaker was highly respected Mr Andrew Dalwood who is a Specialist Musculoskeletal Physiotherapist and Fellow of the Australian College of Physiotherapy. Andrew shared his thoughts on clinical reasoning of five different complex pain presentations he has seen in his clinical practice.
Whilst listening to Andrew's presentation I reflected on the changes that have occurred in my own clinical reasoning over the past few years. There was a rapid change in both my base of knowledge and critical and reflective thinking during whilst undertaking my masters degree. Many mentors told me that it was only after finishing university and spending more time working with patients that the information would start to click together. And it has.
Andrew presented very interesting and challenging case presentations. In each presentation I made a few guesses early on about what my diagnosis might be of these patients and then waited for that confirmation from Andrew that my thinking was accurate. But not for all of them. Why? Because we can't always rely on pattern-recognition from the subjective history to make our diagnosis, only to develop a list of potential hypotheses. What I learnt from the lecture evening is that maybe my hypothesis-list-generation could be expanded to include the more rare/obscure/unusual conditions.
Andrew spoke about the history of clinical reasoning as a form of clinical enquiry and reflective thinking. During uni I wrote an essay on clinical reasoning (which wasn't as interesting as Andrew's lecture) and here are some of the main points...
Pattern recognition and hypothetico-deductive reasoning are the two most common types of clinical reasoning used by clinicians.
Hypothetico-deductive reasoning stems from scientific empirico-analytical research, in which truth and reality are both objective and measurable. Butler (2000) describes that hypothetico-deductive clinical reasoning process begins with the physiotherapist’s perceptions and interpretation of the initial cues from the patient. Within this early stages of the consultation our first hypotheses are formed, which are further tested throughout the subjective and physical examination.
Once we develop a list of hypotheses, the involvement of an anatomical structure is only supported when a “comparable finding” is revealed in the physical examination. By the end of the objective examination we can prioritise these hypotheses and test the primary hypothesis further with treatment. The hypothesis is only truly accepted when treatment changes the patient’s signs and symptoms.
This process is often referred to as backward reasoning as it describes a process by which problem solving can occur without knowledge of the problem source.
Many people may attribute hypothetic-deductive reasoning to the thinking process of novice physiotherapists, as they more commonly have an insufficient knowledge base of a particular problem/area (Doody & McAteer, 2002). Experts however continue to draw on hypothetico-deductive reasoning when pattern recognition fails to reveal a hypothesis and when as Andrew said when “the pieces don’t fit together”.
Pattern recognition too was derived from the empirico-analytical model and relies on the “organization and accessibility of knowledge stored in the clinician’s memory” (Edwards, et al., 2004, p. 314). Maitland proposed “pattern recognition is a characteristic of all mature thought” (2005, p. 7). It is generally referred to as forward reasoning and described as a faster, more efficient process, where hypotheses are generated through recognition of patterns of a certain condition (Doody & McAteer, 2002; Maitland, Hengeveld, Banks, & English, 2005).
Both pattern recognition and hypothetico-deductive reasoning are forms of diagnostic reasoning which refers to reasoning that is instrumental, objective and measurable. A significant limitation of diagnostic reasoning is that inquiry is driven by the clinicians’ search for meaningful information related to their hypothesis, often not giving the patient an opportunity to describe how the problem is impacting on their life (Jones, 2004).
So thats a summary of the clinical reasoning strategies Andrew referred to in his lecture. Below are the main reflection points I took from this lecture, which were repeated through each case.
1. Putting the pieces together.
Clinical reasoning has been defined throughout the literature as a problem-solving process, in which the therapist uses clinical data, client choices, professional judgment and knowledge to evaluate, diagnose and manage a patient’s problem (Butler, 2000; Jones, Rivett, & Twomey, 2004). We use clinical reasoning every day to assess and manage our patient’s problems.
Firstly Andrew reminded me that we have to be able to make the pieces fit. We often use pattern recognition to put the information gained together to gain an understanding of the problem.
“One of the biggest limitations of pattern recognition is the tendency to focus too much on one’s favourite hypothesis” (Jones, 1995, p.19). And in the case that the pieces don’t fit always have the confidence to ask yourself “what did I misinterpret in the initial/earlier consultations?”
A constant cycle exists of clinical reasoning between diagnosis and management and this cycle continues within and between treatment sessions. If we stop reasoning we stop thinking about the problem and the most appropriate treatment pathway.
2. Always have a goal and a semi-structured plan.
This point is fairly straight forward when put on paper but often easier said than done. Aim to have a goal of what you need to achieve from the initial consultation in order to devise a treatment plan and always try make a prediction of how long it will take to treat the problem. This helps us to reflect on the progress made and evaluate if the patient is following an expected treatment pathway/timeframe.
Sometimes the goals are as simple as don’t flare them up day 1, address their beliefs and discuss a reasonable prognosis. Try set goals that are functionally specific to the patient and reflect the current state of the patient.
3. Use structural differentiation.
Andrew put it so simply “perform a movement and when it reproduces their pain, try tomodify it to see if you can change the pain”. As a starting point identify what is a modifiable impairment from the patient history and use this impairment as a part of the functional assessment and during specific objective tests. This will further support and enhance the clinical reasoning process.
Structural differentiation is an advanced examination process that is used to further support or refute the hypothesis of pain mechanisms and involved structures, and requires an ongoing and adaptable reasoning process (Butler, 2000).
4. Be confident to try new things and make things up as you go along.
The development of expertise continues to be researched and is currently believed to be achieved through the development of advance clinical reasoning, organization of knowledge and personal attributes. There does not appear to be consensus in the literature as to the effect of time on the development of expert clinical reasoning (Doody & McAteer, 2002). Butler suggests, “experience alone will not ensure one’s organization of knowledge will grow” (2000, p. 96).
All therapists have a degree of routine in their examination of a patient, which enhances the consistency of data obtained. Butler (2000) emphasizes that if examination and treatment become a fixed prescription and process, then recognition of new patterns and development of knew knowledge cannot be achieved. It is important therefore that physiotherapists are taught to understand and apply the clinical reasoning process outlined above to their clinical practice. And, when patient presentations deviate away from common clinical patterns try new movements/techniques/exercises and make things up, if it allows you to explore the presentation further and make it more individualised to the patient's needs/problem.
So I'll finish with the some quotes from Albert Einstein, who Andrew also quoted at the conclusion of his lecture...
"The true sign of intelligence is not knowledge but imagination."
"A person who never made a mistake never tried anything new."
"Insanity: doing the same thing over and over again and expecting different results."
Butler, D. S. (2000). The sensitive nervous system (1st ed.). Adelaide: Noigroup Publications.
Doody, C., & McAteer, M. (2002). Clinical Reasoning of Expert and Novice Physiotherapists in an Outpatient Orthopaedic Setting. Physiotherapy, 88(5), 258-268.
Edwards, I., Jones, M., Carr, J., Braunack-Mayer, A., & Jensen, G. M. (2004). Clinical reasoning strategies in physical therapy. Physical Therapy, 84(4), 312-330.
Higgs, J., Burn, A., & Jones, M. (2001). Integrating clinical reasoning and evidence-based practice. AACN clinical issues, 12(4), 482-‐490.
Jones, M. (1995). Clinical reasoning and pain. Manual therapy, 1(1), 17-24.
Jones, M. A., Rivett, D. A., & Twomey, L. T. (2004). Clinical reasoning for manual
therapists: Butterworth Heinemann.
Maitland, G. D., Hengeveld, E., Banks, K., & English, K. (2005). Maitland's vertebral manipulation: Elsevier Butterworth-Heinemann Edinburg.
Rundell, S. D., Davenport, T. E., & Wagner, T. (2009). Physical Therapist Management of Acute and Chronic Low Back Pain Using the World Health Organization's International Classification of Functioning, Disability and Health. Physical Therapy, 89(1), 82-90.