Debates in clinical reasoning

So often we (occupational therapists) are told that reasoning is complex, multifaceted, tacit, etc. While there is some truth in all of this, I believe that suggesting that reasoning can’t possibly be understood and made explicit is an excuse for not explaining what we do. That was a strong statement to begin this topic! However, I had to start somewhere and everytime I read an article about clinical reasoning and OT I notice it invariably talks about the difficulty of explaining our practice because it deals with complex problems and much of our knowledge is implicit so difficult to access and convey to others. My argument is that if this were the case ie. we are constantly dealing with demanding problems we would all be burnt out and unable to carry on. You may feel like this! Is this because of complexity in reasoning or because of inflexibility of work environments, lack of challenge (the other end of the spectrum) lack of support or… I’m sure you can think of more ideas here.

One topic that I have been reading about lately is the ideal of holism and its application to acute care practice. Linda Findlay writes a good article about the notion of ‘holism’ and suggests that it is a elusive fiction that our profession espouses but has never really teased out what is meant by this. Interestingly, she puts forward the idea that it is possible to encompass both reductionistic and holistic approaches in the same practice area. This is at odds with other authors conclusions (McColl; Barnitt). Linda makes the point that individual therapists are different and that some would always be ‘holistic’ despite their surroundings. This to me, is about the complexity of reasoning. Variations are evident because of our individual approaches, the environments we work in as well as such things as our level of experiential knowledge (actually I prefer the idea of ‘craft’ knowledge – it has a nice ring to it!). Anyway, I would be interested in hearing comments about his topic.

6 Responses to “Debates in clinical reasoning”

  1. Cat Swift Says:

    I agree with your statements Linda. I too, often find myself feeling somewhat frustrated by articles which focus on how difficult it is to articulate our practice as occupational therapists, due to the tacit content of our clinical reasoning; to me such articles merely reinforce a negative self image/internalised stigma within the profession. To strengthen the self-image of occupational therapists and promote our positive status within the health profession, I believe we need to look at the complexity of clinical reasoning is an opportunity rather than a problem!
    I suppose my concern is that continued reinforcement that has occupational therapist we can’t articulate our clinical reasoning because it is too complicated, may in fact be overshadowing the skills are being taught to prospective occupational therapy students, as to how to clearly articulate their clinical reasoning.
    I also struggle with the fact that many articles seem to indicate that occupational therapists are the only ones that struggle to articulate their clinical reasoning due to its complexity. Hence, I am now very curious as to what discussions would arise if a group of health professionals, from a range of different disciplines, were gathered together, and asked to articulate difficulties they encountered in their clinical reasoning, and other such questions.

  2. Linda Robertson Says:

    The idea of asking health professionals to talk about their reasoning is interesting. U suspect that those that clearly come form a medical model perspective eg. medicine and physiotherapy would have little problem. Those that are less clear about ther identity eg. nursing (especially in rehab), OT, SW might share common issues. I’m guessing here!

  3. adiemusfree Says:

    Something I’ve heard over the years is that much of what any clinician does is ‘intuitive’. To me, intuition is overlearned skill – skill so well-learned that we are not cognisant of using it.
    If it’s a skill, then it can be learned, and if it can be learned, it can be taught. Something experienced therapists do is forget that they once ‘learned’ to do what comes automatically!

    I haven’t read much occupational therapy specific ‘clinical reasoning’ literature, but I have read a good deal of pain-related clinical reasoning. The internationally-recognised model of pain is a biopsychosocial one – way back when I learned it, we called it ‘holistic’!! It’s a complex model, and one that requires a good deal of broad knowledge of theory, and the ability to synthesise multiple strands of information to come up with plausible explanations for the individual’s presentation. This means doing several things:
    – explicitly assessing over several domains
    – avoiding prematurely drawing a conclusion
    – using triangulation (measures of similar areas using different strategies)
    – spending a fair investment of time on assessment prior to developing a set of preliminary hypotheses

    I’ve taught many different health professionals who take the papers I teach, and the group that find it easiest to adopt this model and use it effectively – well they’re occupational therapists!

    The reason I raise this is that most clinicians find it difficult to describe in words how they ‘do’ clinical reasoning (it’s not just occupational therapists!). With the possible exception of clinical psychologists who explicitly learn (at least in Canterbury Uni) abductive reasoning, I think every profession has difficulty accessing the complex cognitive processes involved in drawing conclusions.

    There isn’t much difference IMHO between the whole process of scientific enquiry and clinical enquiry – in both situations the ‘problem’ or ‘presentation’ is framed in terms of the possible explanations for it. As hypotheses are generated then systematically tested, ultimately the ‘problem’ or ‘presentation’ becomes defined by the most adequate (parsimonious) explanation for it.

  4. Linda Robertson Says:

    But who decides what the most adequate explanation is? Would different therapists come up with different ideas of the ‘problem’? It is interesting to look at what different health professionals know about clinical reasoning. Recently I was discussing student reasoning with a physio – clearly the students were able to describe their ‘diagnostic’ reasoning with the hypothetico deductive stages described. I doubt that OT students could do this. Does this worry me? I’m not sure! Your description of the 4 points about what a holistic therapist should do made me think about a physio I visited. I was so impressed, he was a very good example of an expert in action… spent a long time on assessment before finally developing any hypotheses.

  5. Falito Says:

    I agree with your statements Linda. I too, often find myself feeling somewhat frustrated by articles which focus on how difficult it is to articulate our practice as occupational therapists, due to the tacit content of our clinical reasoning; to me such articles merely reinforce a negative self image/internalised stigma within the profession. To strengthen the self-image of occupational therapists and promote our positive status within the health profession, I believe we need to look at the complexity of clinical reasoning is an opportunity rather than a problem!I suppose my concern is that continued reinforcement that has occupational therapist we can’t articulate our clinical reasoning because it is too complicated, may in fact be overshadowing the skills are being taught to prospective occupational therapy students, as to how to clearly articulate their clinical reasoning.I also struggle with the fact that many articles seem to indicate that occupational therapists are the only ones that struggle to articulate their clinical reasoning due to its complexity. Hence, I am now very curious as to what discussions would arise if a group of health professionals, from a range of different disciplines, were gathered together, and asked to articulate difficulties they encountered in their clinical reasoning, and other such questions.
    +1

  6. Linda Robertson Says:

    Good to hear from you Falito,
    In my experience, nurses are equally certain that no-one understands their contribution to the team. I have just been marking an assignment where Post Grad OT students develop models to articulate their reasoning … they all manage to do this very successfully but also say how useful the clinical reasoning literature is to enable them to get a handle on their decision making. It would seem that using the published frameworks on reasoning is helpful and not necessarily read by the average clinician.


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