By Brett Windsor, PT, PhDc, MPA, OCS, FAAOMPT
As teachers, do we teach what WE know? Or do we teach what students SHOULD know? Our post today is on the topic of clinical reasoning. Clinical reasoning is a 'hot' term. It has been for a while now. Everyone agrees it is important. Everyone agrees that students need good clinical reasoning skills. There's a lot of academic talk about how it works cognitively. But are we good at teaching it? Do we teach students how to do it? Or do we simply teach them what to do? How do we know that students are getting better at it?
In some ways, clinical reasoning can be equated with clinical decision-making. Every time we see a patient, we consciously and subconsciously make many small decisions. Collectively, these small decisions add up to making larger decisions about the evaluation and management of the patient. The more accurate decisions we make, the better the patient encounter progresses. The key to clinical reasoning education then, could be seen in finding ways to improve a student’s ability to make good decisions.
There are two basic methods that manual therapists use to reason though patient problems. The first is deductive. Here, the therapist develops an early hypothesis about the patient's diagnosis, usually in the presence of minimal information (such as age, gender and a symptom map) and then uses specific questions, tests and measures that are aimed at confirming that hypothesis. The second method is inductive, where judgment is withheld until a relatively complete and thorough examination has been completed.
In deductive reasoning, a 15 yr-old female presents to physical therapy following a recent traumatic knee injury playing basketball. The knee is swollen; the athlete is on crutches, and can bear little weight. A logical, early hypothesis could be applied to this patient - an ACL tear. We would then ask targeted questions: how did the injury occur? Did you hear a pop? Simple tests such as an anterior drawer would tend to confirm the clinical diagnosis. Decisions can be made accurately without an exhaustive examination sequence.
Inductively, physical therapists often evaluate patients with multi-regional, long-term pain and dysfunction with apparent cause. In this case the physical therapist is poorly served by trying to apply an early diagnosis. An inductive approach is perhaps more appropriate - to step back and complete a longer, more complete evaluation. Then it is possible to sift through all the information and develop theories about what might be happening. Management can then proceed on the basis of the assessment findings.
Either way works. Literature supports both methods. Experts use both methods. However, all too often, students are exposed to only one method. Generally the inductive approach is favored; long, rote, predictable evaluation sequences that don't tend to change based on the patients status, complexity, or diagnosis. Acute, irritable and unstable patients are treated the same way as chronic, non-irritable and stable patients. Should it really be this way? Is this thinking? Or following? Is there a place for grey?
How about being eclectic? Showing students both ways? Teach students when to use each method based on individual patients...
In general, the more acute and localized a problem is, the more deductive the evaluation can be. If a 15 yr-old female presents with a painful swollen knee after a twisting basketball injury, let's go with the probabilities, make the diagnosis and get the management started. The more chronic and widespread a patient's presentation is, the more inductive we should be. More information is needed to develop better theories about what is happening.
It's about a continuum...it's about choices...it's about eclecticism.
In the next post, we'll discuss some of the objections to a more aggressive use of the deductive approach to clinical reasoning. In the meantime, what say you?