Clinical reasoning: Linking theory to practice and practice to theory

Neurology Report, Oct 1999 by Jensen, Gail M, Givens, Diane

Exploration of the clinician's clinical reasoning and decision making process is an essential element for fully understanding practice patterns in physical therapy. This paper provides an overview of theoretical approaches to clinical reasoning and decision making. Categorization and synthesis of the literature is done using 2 complimentary approaches to clinical reasoning: (1) a rational or professional-centered approach and (2) contextual or collaborative approach between practitioner and patient. Key elements of these approaches are then applied to a neurological clinical specialist's reflective analysis of her clinical reasoning and decision making process with a patient case. INTRODUCTION Therapists in neurologic physical therapy practice routinely evaluate patients who present with multiple problems or conditions that may affect the therapist's clinical decision making. Clinical cases are often complicated, unpredictable, and uncertain with no single right approach. These kinds of cases offer us the opportunity for reflection and analysis.1 The purposes of this article are to: (1) provide readers with an overview of the theoretical approaches to clinical reasoning and decision making and (2) apply key theoretical elements in the reflective analysis of a clinical case. We begin this paper with a clinical case managed by a board certified neurologic clinical specialist (NCS). Consider this referral: Rita is a 77-year-old female who is referred to physical therapy for vestibular rehabilitation. Vestibular testing was done 4 months ago that included a battery of ENG tests and a negative Dix-Hallpike maneuver. Results indicated a 45% right peripheral vestibular weakness. The patient continues to complain of loss of balance. She comes to the department today in a wheelchair and has a single point cane. She is accompanied by her daughter. Although Rita states she has never fallen, she has a fear of falling that has limited her activity to the point that her daughter placed her in a nursing home 3 weeks ago due to safety issues. How does the clinician involved in this case go about making decisions of what to do? What information or data is gathered? What is the basis for the decision making: habit or experience, consulting journals or books, consulting colleagues, or an intuitive sense of what to do? For what reasons are the decisions being made to: generate revenue, cut costs, satisfy the referring health professional, address the needs of the patient or the daughter, or prevent disability or improve or restore function?2 Will clinical decision making improve for therapists if they consistently use a model of decision making in their practice?

We were invited to write a paper on "clinical decision making models." Consistent with the questions raised in the initial patient case, current clinical practice is complex and often uncertain. Managing patients involves making multiple decisions that are based on many dimensions of knowledge, skillful data gathering, interaction with the patient and family, reasoning, and problem solving. The structure of this paper has evolved through our discussions and will demonstrate the linking of theory to clinical practice. CLINICAL REASONING: WHY AND WHAT? The topics of clinical judgment, problem solving, cognition, and clinical reasoning have long been active areas of research in psychology and the health professions, particularly medicine.3-6 The July 1989 issue of Physical Therapy included the Proceedings of an American Physical Therapy Association Conference on Clinical Decision Making in Physical Therapy.7 A stated purpose of the conference was integration of clinical decision making into physical therapy curricula necessary for educating therapists to assume a more sophisticated and responsible level of practice. Two articles specifically focused on application of models adapted from World Health Organization's International Classification of Impairments, Disabilities, and Handicaps to clinical cases in neurologic and orthopedic dysfunction.8,9 These models were recommended to clinicians in a problem solving strategy to identify underlying causes of dysfunction. The recently published Guide to Physical Therapist Practice' uses the process of disablement as a framework for understanding practice and for optimizing function. The key elements of the framework represent components of patient/client management that include examination, evaluation, diagnosis, prognosis, and intervention, all aimed at maximizing patient outcome. Using conceptual models assists in focusing physical therapy practice on the process of disablement and the impact of conditions on patient function rather than on disease or diagnosis.ll One may speculate that linking the use of a standard conceptual framework (ie, the process of disablement used in the Guide) with concurrent description and verification of practice patterns should help us become more efficient in managing complex clinical cases. A critical component of fully understanding practice patterns in physical therapy must include a focus on clinical reasoning and decision making of the therapist. Uncertainty, bias, error, and differences of opinion, motives, and values have been identified as common variations in professional practice.2-4 Knowing more about the process of clinicians' clinical reasoning will give us further insight into the practice of physical therapy. Clinical reasoning is a multidimensional concept that involves a wide range of cognitive activities that underlie judgements, decisions, and actions made by health professionals.12 Reasoning can be thought of as an internal dialogue that occurs before, during, and after patient care. Reasoning can be formalized into general problem solving strategies as well as an individualized, contextualized, and sometimes even unknown or an unconscious process.13,14 Jones15 describes clinical reasoning in physical therapy as influenced by, "the therapist (eg, needs and goals, values and beliefs, knowledge, cognitive, interpersonal and technical skills), the patient (eg, values and beliefs,

individual physical, psychological, social and cultural presentation), and the environment (eg, resources, time, funding and any externally imposed requirements)." Historically, much of the research on clinical reasoning has focused on the information processing approach, that is, data acquisition, storage, or memory, and the processes used by the professional to represent, analyze, and solve the "real world or practice problem" such as managing a patient.2-4,16,17 These approaches are grounded in work of cognitive psychologists and take a rational approach aimed at identification and resolution of the "real practice" problem. Much of this work has been done in controlled experimental situations, often comparing novice (student) performance to that of clinical specialists (experts).18,19 A recent trend in clinical reasoning and decision making research has been a focus on investigations in the natural environment to further understand the complexities of practice.20-31 This contextual approach to studying clinical reasoning uses qualitative methods and has been used to explore clinical reasoning in several of the health professions. Results of these studies20-31 have identified key factors such as the important interactive role of the patient, the use of multiple sources of knowledge, and the role of intuition. Both of these general approaches offer us important elements and relevant models of clinical reasoning and decision making. We will provide a brief overview of key elements of both the rational and contextual approaches to clinical reasoning. Problem Solving: The Hypothetico-Deductive Approach The concept of"bounded or limited rationality" is an im portant principle basic to understanding clinical reasoning. This principle emphasizes that limits exist for our human capacity for rational thought. We have limited information processing capabilities which, in clinical reasoning, we cannot work efficiently with all we know about the problem. We cannot possibly gather all the data and be efficient in solving the problem. We therefore work to represent the problem in simplified ways and work as rationally as possible to solve the problem.32 Early work in clinical reasoning centered on the conceptualization of a problem solving process. General methods or heuristics for problem solving were proposed for use across fields.52 An expert was someone who was particularly skilled at doing this heuristic search. Investigative work used the method of having experts and novices think aloud or verbalize as a way to explore the thought processes and to assess their problem solving skills. 16,17 Elstein, Shulman and Sprafka's33 well-known research in medical problem solving was based on elements from this early cognitive work in clinical reasoning and problem solving. They used various methods to analyze the subject's reasoning process including the use of simulated patients, recall tasks, and verbalization or thinking aloud. Several

major findings from this work have had a strong influence on education in medicine and other health professions.3,4,16,33,34 A 4-stage general model of medical inquiry, the hypothetico-deductive method, was generated from their research and has been used extensively in health professions education.4,17,33 The 4 stages include: (1) Cue acquisition: gathering cues through observation, history, or physical examination; (2) Hypothesis generation: generating initial hypotheses based on initial cues; (3) Cue interpretation: formulating patterns of cues through weighing positive and negative evidence; and (4) Hypothesis evaluation: applying the cues to the hypotheses and evaluating whether the hypotheses hold. Variations of the hypothetico-deductive model of inquiry have been incorporated into models that represent the clinical reasoning process. The hypothesis-oriented algorithm for clinicians (HOAC) posed by Rothstein and Echternach35 is based on elements of the hypothetico-deductive process. This process of collecting data or cues from the patient and then generating hypotheses is seen as a way to transform an unstructured problem (such as a patient presenting with several co-morbidities or complications) into a structured problem by generating a small possible set of solutions. Knowledge and Experience in Clinical Reasoning: Case Specificity and Pattern Recognition A second major development in clinical reasoning theory was the linking of the reasoning process to the specific knowledge that the clinician held in a certain specialty area, called case specificity."17 Case specificity means that a successful reasoning strategy in one case may not apply in a second case because the practitioner does not "know" enough about the area of the patient's problem. Experts were not only found to have a method of problem solving, but they combined that with specific, organized knowledge in solving the problem. For example, a clinical specialist in orthopedics is likely to have a much more difficult time evaluating our clinical case example, the patient with a vestibular problem, than a neurologic specialist. In addition to the specific knowledge a clinician may have in an area, is the importance of clinical experience as it influences the clinical reasoning process. Research on the clinical reasoning of expert physicians demonstrated that in familiar, nonproblematic situations, experts did not display hypothesis testing but used a pattern recognition process. This process is called forward reasoning which means the clinician sees a pattern from the cues gathered from a patient in the interview or data collection that conforms to a previously learned picture or pattern, also called "illness script." This pattern recognition comes from the expert's well-structured clinical knowledge.16-18,36 Forward reasoning is used by experts in solving routine cases in their own area of speciality. The expert can

make connections or inferences from the data, recognizing patterns and links between clinical findings and a highly structured knowledge base. Students or novices, however, would rely on a hypothetico-deductive process, setting up hypotheses and gathering clinical data to prove or disprove their cues. This process is called backwards reasoning. This same process is also used when experienced clinicians lack specific clinical knowledge when dealing with patients.6,15,22 For example, in our patient case, the orthopedic specialist is likely to use a hypothesis guided or backwards reasoning approach in examining Rita. Increased knowledge in a clinical area is useful to the clinician in sorting out a complex clinical case. It is not merely the quantity of information, however, that the clinicians holds that will enhance his/her clinical reasoning ability, but also the quality of the organization of that knowledge. It is possible that a conceptual framework like the disablement process provides an initial organizing structure for clinicians. The organization of knowledge allows the clinician to process information at a deeper level and problem solve more effectively.6,16,17 In summary, these cognitive-based approaches to clinical reasoning are primarily centered on the reasoning and decision making of the professional. We will now turn to another approach to clinical reasoning that looks at the clinical reasoning process used in the context of practice. These approaches focus more on the interactions between the professional and the patient or client. CONTEXTUAL OR COLLABORATIVE APPROACHES TO CLINICAL REASONING Clinical practice is an important and essential environment to fully understand the clinical reasoning process.37,41 Schon37 argues that some of the most challenging problems in professional practice are characterized by complexity, uniqueness, uncertainty, and conflicting values. These problems require wise action on the part of the practitioner. This wise action involves using specialized or practical knowledge, but also requires practitioner judgment in the specific clinical situation. The wise action that a professional uses involves "practical knowledge:' This practical knowledge is the knowledge of doingknowing how to do something, also called procedural knowledge. Practical knowledge is distinguished from knowing the facts, concepts, principles, or knowing about things, called declarative knowledge. Practical knowledge is best learned through practice and thinking or reflecting on one's practice.37,40,41 Recent research and writing across the health professions has focused on understanding the practical reasoning of the clinician while engaged in practice.21,42,43 Benner, Tanner, and Chesla21suggest using the term clinical judgment in nursing rather than clinical reasoning to represent the multiple ways in which nurses come to understand the problem, issue, and concerns of clients, patients and families.

The study of clinical judgment using cognitive models and methods has limited the possibility of seeing other important aspects of clinical judgment. By highlighting these aspects, we do not mean to say that rationality has no place. Calculated reasoning, consulting research and theoretical literature for possible interventions and solutions does figure prominently in the practice of experienced clinicians. Our claim is that it is not the only form of reasoning, nor necessarily the best. Rather, the reasoning that is a significant part of everyday practice of expert clinicians is one that relies on intuition, including deliberative rationality, on a disposition toward what is good and right, on practice wisdom gained from experience, on involvement in the situation, and on knowing the particular patient through being attuned to his pattern of responses and through hearing narrative accounts of his illness experiences.21 Using a phenomenological approach for investigating clinical judgment, Benner and Tanner43 initially identified these 6 characteristics as components of expert nurse's intuitive judgment: pattern recognition (ability to perceive relationships between concepts in order to identify a relevant pattern in care provision), similarity recognition (ability to recognize resemblances of patient case to past cases), common sense understanding (sees the cultural and emotional meaning of patient illness), skilled know-how (cognitive abilities acquired through clinical experience), sense of salience (ability to distinguish between important and unimportant events), and deliberative rationality (strategy for maximizing judgement by considering several options). More recently, in a 6-year investigation of 130 hospital nurses, Benner, Tanner, and Chelsa examined the nature of clinical knowledge and clinical judgment.21 They found that the clinical judgment of experienced nurses resembles the practical reasoning (knowing how) rather than a more rational, theoretical approach advocated by cognitive psychologists. They identified these interrelated aspects of nurses' clinical judgment. 1. Assessment of what is good and right is not just individual principle-based ethics, but nurses' actions humanize and personalize care particular to the clinical situation. 2. Caring practices reveal that knowing the patient and pre serving personhood are central components. 3. Knowing the patient and the patterns of responses in the context of the clinical episode is essential. This knowledge includes specific, local knowledge about particular patient responses, function, and physical presentation. 4. Nurses use a wealth of practical knowledge that supports their clinical judgment. Mattingly and Flemming's 23,42 ethnographic investigation of clinical reasoning among occupational therapists reveals similar focus on the central importance of the patient. They were interested not only in how therapists think when they treat patients, but what therapists think about their practice as a practice. They discovered that therapists used

different reasoning strategies for different purposes or in response to particular problems. They identified these 3 different reasoning strategies. 1. Procedural reasoning. This reasoning strategy is very similar to the hypotheticodeductive reasoning. This type of reasoning was seen in therapists when treating the patient's physical problem where they could apply knowledge of clinical conditions. 2. Interactitve reasoning. This type of reasoning was applied when the therapist interacted with the patient as a person or social being. The interaction with patients is not just idle conversation but is done with purpose and structure. It is used to assist the therapist in better understanding the person. 3. Conditional reasoning. The third reasoning strategy seen when the therapist moves beyond specific concerns about the patient, physical problems, and thinks about the patient in a broader social and temporal context. This would include the entire condition (person, disease, illness or meanings of the disease for the person, family, and the social and physical context). Oualitative research in Physical therapy has also revealed the importance of the interaction and collaboration between therapist and patient and family in the clinical reasoning process. In addition, movement assessment and observation has a key role in the decision making process.26,31 Embrey and colleagues26-28 developed a conceptual framework from their study of the clinical decision making processes of experienced and inexperienced pediatric physical therapists that can be used to assist pediatric physical therapists' clinical decision making. This framework includes these assessment components: psychosocial sensitivity, movement scripts, considering procedural changes, treatment planning, and self-monitoring. Qualitative case study research on expert practice by Jensen, Gwyer, Hack, and Shepard""31 focused on 12 clinicians across 4 clinical areas including geriatrics, pediatrics, neurology, and orthopedics. A theoretical model of expert practice was developed that included these 4 core dimensions: 1. dynamic, multidimensional knowledge base that is paient-centered and evolves through therapists' reflective process; 2. clinical reasoning process that is embedded in a collabo rative, problem solving venture with the patient; 3. central focus on movement assessment linked to patient function; and 4. consistent evidence of virtues seen in caring and commitment to patients Although the focus of this investigations29-31was on understanding expertise, expert's clinical reasoning skills and knowledge base were key components. While the knowledge they used in practice was multidimensional, the patient was a key source of knowledge.

Specialty knowledge in their area of clinical practice was visible in the evaluative process and intervention and was closely linked with the patient and the patient's presentation. The central focus on the patient assists these therapists in tailoring their assessment process to the needs of the patient and family. In turn, the patient continues to be a primary source of knowledge for these experts as they learn from their experience or reflect-in-action. Clinical reasoning centered on a process of collaborating and problem solving between therapist and patient. The diagnostic process was not emphasized as a central aspect of patient management. What counted was patient function and understanding the context or the social and psychological conditions and events that are central to the patient. This is similar to the interpretive studies in nursing and occupational therapy, that the clinical reasoning process is not as analytical, deductive, and rational as portrayed in many of the clinical reasoning models. Knowing the patient, understanding his or her story, fitting the patient's story with clinical knowledge, and then collaborating with the patient to problem solve were central components of clinical reasoning. REFLECTIVE ANALYSIS OF A CLINICAL CASE Let us return now to the clinical case regarding Rita's diagnosis and complaint of imbalance. The analysis was done through interview and discussion with the NCS regarding her clinical reasoning and decision making process. The specialist (DG) has over 10 years of experience working with patients with vestibular dysfunction. This is not meant to be an exhaustive analysis of the management or the decision making involved in this clinical case, but is selective with an emphasis on key clinical reasoning points. The summary of the clinical case examination findings are in the Appendix. Clinical reasoning point 1: Specialist is questioning whether the diagnosis of right peripheral vestibular weakness is the primary cause of the problem. Neurological certified specialist (NCS): The reason I am suspicious about the diagnosis is the lack of subjective complaints of dizziness from Rita. There is also examination evidence (objective information) that did not support the diagnosis of right vestibular weakness. For example, there were no complaints of dizziness or evidence of nystagmus with positional movements. In addition, Rita has a history of declining functional status and expressed a lack of confidence about being able to care for herself during the examination. In summary, what I heard and observed with this patient did not fit the pattern of this diagnosis. So at this point I am thinking that the initial diagnosis is not the primary cause for her functional status now. Theory link: Here the specialist primarily uses a process of pattern matching or forward reasoning. She is gathering data and seeing that the findings do not fit the profile of this diagnosis. She is gathering data and matching her findings with typical patterns of clinical signs and symptoms that patients have presenting with during her past clinical experience.

Clinical reasoning point 2: Specialist decides to gather a chronological history of the patient's function, followed by specific assessment of patient's and daughter's perceptions of the be problem. NCS: I now need to find out what is contributing to this decline in functional status so I asked the patient and daughter to describe the chronology of the functional changes over time. I also want a better understanding of the patient's perception of the problem. I do this for several reasons. First, I believe I can get to the problem more quickly by asking the patient. This also makes the patient an active participant in the problem solving and assists her in owning her problems and ultimately her goals. I routinely ask the family for confirmation of the patient's perceptions. In this case, I wanted to know if what Rita said was truly observed by her daughter so I asked for the daughter's perception of the problem. Rita thought the problem was her lack of strength in her legs and her daughter thought it was her inactivity and fear of falling. These were 2 slightly different perceptions of what the contributing factors to Rita's function was so I needed to sort that out next. Theory Link: Initially the specialist is still looking for a pattern and using pattern matching in exploring the functional status history and trying to identify a pattern that fits with the diagnosis and secondary impairments from the problem. Collaboration with the patient and problem solving together with the patient and patient's family is a central part of the specialist's reasoning process. She believes she cannot help the patient without actively engaging her in the process. Explicitly involving the family is evidence of conditioning reasoning that is, thinking of the patient in broader terms.23 Clinical reasoning point 3: Specialist decides to assess actual functional performance NCS: My general observation throughout the evaluation, including physical limitations (muscle strength and flexibility), did not match her subjective complaints of declining functional status. That is why I wanted Rita to perform with only verbal commands to demonstrate that she could physically perform these tasks. This also confirmed my suspicions that it was not a strength problem affecting her functional mobility I found she could do functional bed mobility with just verbal guidance. Theory link: Here is evidence of backward reasoning or use of elements of the hypothetico-deductive model.15,17,18 A hypothesis is generated based on cues from the interview and physical findings (even though her physical impairments may be contributing to her function they are not the primary cause of her functional limitations). Then additional information is gathered and integrated with what she knows and the hypothesis is evaluated (tests hypothesis by having patient perform functional activities by only giving the patient verbal commands). Clinical reasoning point 4: Specialist further explores why the patient appears so powerless and helpless.

NCS: I know that Rita's functional performance does not match her perception of her functional status. Subjectively she has difficulty problem solving solutions to adjust her home environment. Then I asked her if she really did want to go home and she stated yes only if she could help herself. What that meant to her was being able to go to the bathroom by herself. This patient had a rapid course of functional loss over the last 6 months without cognitive change but a definite lack of confidence in her abilities and a fear of falling. It appears that it is the fear of falling that is limiting her function and perhaps contributing to her feelings of helplessness. Theory link: Here the specialist appears to be "reflecting-in-action." 37,43 She has evaluated her working hypothesis regarding functional performance and now she needs to explore more fully contributing factors to the patient's rapid functional decline. She has another hunch or working hypothesis about the patient's fear of falling that appears to be based on her clinical knowledge and intuitive judgment. Clinical reasoning point 5: Specialist focuses on identifying goals of patient and daughter and problem solving through present and future management issues. NCS:The daughter was very encouraged by actually seeing her mother's performance.We were then able to revisit realistic goals for the patient and family. I engaged them in problem solving about the physical layout of her house and supervision and support systems needed. We talked about where Rita is now and my recommendations for moving toward long-range goals. I made further recommendations for follow-up done in conjunction with the referring physician. This included recommendations for assistive devices, a home exercise program, home safety assessment, and consultation for mental health evaluation (to rule out depression). Theory link: Here specialist demonstrates evidence of a multidimensional knowledge base that is used to provide a prognosis and plan for the patient. She works collaboratively with the family in problem solving.29-31 Her central focus is function and patient safety Final reflection from NCS on clinical reasoning process: Working with my colleague (GJ) on this paper has been a good exercise in analyzing how I work through patient problems. Working in the clinic, I am so busy problem solving that I do not recognize the process we go through and how efficient or inefficient it may be. It is important to all of us to give the best care, with the best rehabilitation outcome in the most economically feasible way. At first I felt as if my problem solving was very disjointed when working through all the many angles of this particular case. When I was asked questions about how and why I did things, it made me stop and think more deeply about what I did and the reasons why I handled a case in a certain way. As a board certified Neurological Certified Specialist, an educator, and a clinician it was valuable for me to engage in my own reflective process. Although this example describes one certified specialist's approach to the management of this particular patient, there are many ways the same case could be handled with multiple lines of reasoning. It is interesting to postulate how differently a student would have handled the same situation and how the reasoning

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39 Steinberg RJ, Horvath JA. A prototype view of expert teaching. Educational Researcber 1995;24:9-17. 40. Clinical Reasoning. Special Issue. Amer J Occup Ther. 1991;45:969-1053. 41 Jarvis P The Practitioner-Researcher:Developing Theory from Practice. San Francisco, Calif:Jossey-Bass Pub;1999. 42 Fish D, Coles C. Developing Professional Judgment in Health Care. Learning through the Critical Appreciation of Practice. Boston, Mass:Butterworth-Heinemann Pub; 1998. 43. Benner P Tanner C. Clinical judgment: how expert nurses use intuition. Amer f Nurs. 1987;87:23-31. Gail M.Jensen, PhD, PT1 Diane Givens, MS, PT2 1Department of PT and Center for Health Policy and Ethics, Creighton University, Omaha, NE 68178. gjensen@hslpharmacy.creighton.edu 2Department of Physical Therapy, Creighton University and Director of Vestibular Rehabilitation, Boys Town National Research Hospital. Copyright Neurology Report Oct 1999 Provided by ProQuest Information and Learning Company. All rights Reserved