teaching clinical reasoning

University Degree Education and Teaching

Table of contents

Abstract………………………………………………………3

Introduction…………………………………………………..4

Clinical Reasoning..………………………………………5

Models of Clinical Reasoning………………………………..6

Clinical Reasoning in the Author’s Clinical Context……… 8-12

Conclusion…………………………………………………13

Reference list………………………………………………14-17

Abstract

The aim of this paper was to illustrate the clinical significance of the Hypothetic-deductive reasoning, pattern recognition and knowledge reasoning integration models of clinical reasoning. These models were researched and discussed explicitly according to the author’s clinical context, supported by evidence from the available literature. The paper was able to bring to light the notion of clinical reasoning as a fundamental constituent of professional practice amongst health care practitioners. It was also found that there is limited clinical reasoning literature in the radiotherapy profession and that radiation therapist were likely to implement more than one model of reasoning, according to the author’s clinical description. The findings also demonstrated strong similarities between health care professionals and how they performed and developed clinical reasoning skills in order to mange the overall treatment care of their patients.

Introduction

In today’s complex and ever-changing health care environment, health care professionals must be prepared to interpret and analyse large amounts of information critically, so that they can effectively make vital decisions, or determine what course of action is appropriate for a particular clinical scenario, with a particular patient. In all professional fields, not just medicine, health care professionals, based on their knowledge and clinical experience make decisions in very different and complex ways, from the very novice to the very experienced. According to the current literature, the process of applying knowledge and experience to a specific clinical situation or patient, in order to develop a possible solution, has been described a tacit and deeply phenomenological form of thinking which translates to the development of clinical reasoning (Fleming & Mattingly, 1994 p. 12). Hence, the notion of clinical reasoning seemed to have emerged as an essential hallmark of professional practice and its nature has been implemented and researched by several professional disciplines (Ajjawi & Higgs, 2008 p.134).

This paper will look at the hypothetic-deductive reasoning (HDR), pattern recognition and knowledge reasoning integration, identified by the author as, relevant clinical reasoning models reflecting his clinical practice. This will consist of a brief description of clinical reasoning and its importance in health care clinical settings; an overview of HDR, pattern recognition and knowledge reasoning integration; and their significance in the author’s clinical context; with a discussion on how these approaches inter-connect and are also used in other professional clinical practices, with supporting evidence from the literature.

Clinical Reasoning

One of the key attributes that all health care professionals tend to develop during their professional practice is the ability to clinically reason in their specific clinical environment. According to some of the previous literature, clinical reasoning has been described as a complex integral component of clinical practice and is a term used interchangeably with an range of synonyms, such as clinical decision-making, clinical problem-solving, clinical judgement and diagnostic-reasoning (Case, Harrison & Roskell, 2000 p. 14).

There has been considerable research across the medical and some of the health allied disciplines focusing at investigating and understanding the process of reasoning, as well as the nature of clinical resoning and its relationship between knowledge and professional clinical expertise (Norman, 2005 p. 419). Subsequently, an assortment of clinical reasoning models/approaches have emerged and each professional discipline seemed to have adopted one or more of these models based on how these reflect and translate to their clinical practice (Higgs and Jones, 2008 p. 6-8). This in turn, triggered each professional discipline to study and synthesize their own definition of clinical reasoning, according to how they performed reasoning in their clinical context (Edwards & Richardson, 2008 p.186).

For instance in medicine, Sefton and Gordon described clinical reasoning as “the process by which health practitioners evaluate and make decisions on the diagnosis and management of a patient”(Sefton, Gordan, & Field, 2008, p.469). In the occupational therapy discipline, clinical reasoning has been described as a tacit, highly complex intellectual process, which involves a phenomenological approach in making sense of the patient’s condition, and evokes the therapist to use a caring perspective in establishing a collaborative relationship with the patient in order to determine an ideal treatment action (Barker-Schwarttz, 1991 p.31). Similarly, in nursing, Fonteyn and Ritter defined clinical reasoning as the strategies used to understand the significance of data, identify potential client problems, and make clinical decisions to resolve problems and achieve outcomes (Baldwin, 2007 p.24).

Although, definitions of clinical reasoning may seen to differ between health care professions on the basis of how therapists clinically reason, common and distinctive features can be observed, such as the ability to make decisions, solve problems, gather and evaluate clinical information, goal directed thinking and the achievement of positive patient outcomes. Successful clinical reasoning is central to professional autonomy and accountability; it allows therapists to employ their gained capabilities in the task of making countless decisions that are embedded in his/her clinical practice (Ajjawi & Higgs, 2008 p.137).

Models of Clinical Reasoning

The study of clinical reasoning stemmed from the work of Elstein et al in 1978, consisting of the traditional medical problem solving approach from a cognitive science perspective, which emphasized the hypothetical deductive method (Fleming & Mattingly, 2008 p. 55). In the hypothetic-deductive model, clinicians attend to initial cues[information] from or about the patient. From these cues, cautious hypotheses are created [based on knowledge/experience]. This is then followed by ongoing analysis of patient information in which further data is collected and interpreted. Continued hypothesis creation and evaluation take place as examination and management are continued and the various hypotheses ...

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The HDR clinical reasoning model has also been adopted by other health allied professions, such as in physiotherapy, where it is implemented as a means of identifying and assessing physical impairment, leading to a diagnosis (Edwards & Richardson, 2008 p. 186). Similarly, this model has also been identified in nursing, speech pathology, occupational therapy and dentistry as well as being a very influential model in guiding the research in clinical reasoning across these health disciplines.

Another, very commonly used model among health care professional is pattern recognition. The notion of pattern recognition has been described as another key component or form of clinical reasoning among health care professionals as it makes practice more efficient (Fleming, 1994 p153). Rumelhart & Ortony (1977) described pattern recognition, as the storage of knowledge [prototypes] of frequently experienced situations that individuals use to recognise and interpret other situations (Jones, 1995 p. 19). In the health care professions, pattern recognition entails the assumption that the fast and efficient retrieval and processing of clinical information is related to the structure of knowledge in a person’s memory (Khatami, MacEntee & Loftus, 2008 p.258). If a problem or condition is recognised quickly with some type of effective analysis or interpretation, the therapist is able to move into deeper levels of analysis more quickly and hence, move to the problem resolution or treatment phase (Fleming, 1994 p154). This model of clinical reasoning seems to use direct knowledge developed from previous clinical experiences, but if an unfamiliar situation or problem arises, then most therapist tend to revert back to the HDR model ((Jones, 1995 p. 19).

Clinical reasoning is also greatly influenced by a therapist’s biomedical and clinical knowledge integration. This brings us to Boshuizen & Schmidt’s (1990) knowledge reasoning integration approach to clinical reasoning, where they emphasized the parallel development of knowledge acquisition and clinical reasoning expertise, as a cognitive maturation process where knowledge structure changes [from biomedical knowledge to real clinical experience knowledge], in turn increasing expertise in clinical reasoning (Higgs & Jones, 2008 p.7). Another way of looking at this is, as practitioner acquires clinical experience, undergraduate/university knowledge is eventually transposed into clinical patterns anchored within memory through real clinical experiences (Jones & Rivett, 2004 p.11).

Clinical Reasoning in the Author’s Clinical Context

Despite, the fact that radiotherapy has been around since 1905 in Australia, radiation therapy still comes cross as a very young profession that is very gradually shaping its professional body. Radiation therapists in the past have been seen as passive technicians, implementing the design of others and following the radiation oncologist’s orders. This medical dominance in radiotherapy has significantly placed a barrier to the radiation therapists’ autonomous practice and professional development (Bolderston, 2005 p. 61). However, in the last two decades radiotherapy technology has rapidly evolved in a way that it has increased the diversity and complexity of treatment modalities (Griffiths, 200 p. 162).

Consequently, the technical advancements, in conjunction with higher entry-level of education, as well as its growing specialisation, are productively changing the profession. According to Trede & Higgs (2008), professional development and maturity formed the basis for becoming more involved with questions of expertise and knowledge growth, as well as serving to structure and refine therapists’ clinical reasoning skills (Trede & Higgs, 2008 p.33). It can therefore be said, as the professional radiotherapy practice continues to grow, the development of clinical reasoning skills amongst radiation therapists should be acknowledged and considered as an integral component of competent clinical practice.

Radiation therapists work with a multitude of patients, which may result in different specific clinical problem situations, many of which defy simple technical solutions. A technician would normally follow an order/protocol and make little adjustments for individualized patient needs and hence not delivering competent optimal treatment (Branch & Paranjape, 2002 p.1187). It is important to remember that, no two patients are alike, and not everyone will have the same treatment parameters or respond the same way to a radiotherapy treatment regime.

The modern radiotherapy practice requires that a radiation therapist not only has a rich relevant biomedical knowledge but also the ability to continuously apply this to clinical practice, indorsing optimal patient care and the delivery of quality radiotherapy treatment to the highest professional standards. An essential element, when delivering optimal patient care is the development of good clinical reasoning skills amongst health care practitioners (Corcoran-Perry & Bungert, 1992 p.64).

Before the author proceeds, it imperative to note that clinical reasoning research in the radiation therapy profession is scarce. Consequently, for the purpose of this paper, the author focused on the available literature of other health disciplines and translated these to his own clinical context.

Currently, graduate radiation therapists are entering the profession with strong radiotherapy background knowledge [biomedical] and general problem-solving skills. Once, exposed to their clinical environment, they are able to learn how the profession reasons and in turn learn how to deal with the specific tasks and challenges of radiotherapy practice. According to the author’s experience and clinical setting, novice radiation therapists [without realizing] tend to apply the HDR model of clinical reasoning when presented with a particular clinical problem, as most clinical situations tend to be unfamiliar during the early stages of the profession.

A common scenario is working in planning, where a therapist requires skills in computerized tomography [CT], such as cross-sectional anatomy to delineate critical radiosensitive structures, optimal positioning of radiation beam arrangement, and correct use of beam intensity modifiers in order to deliver the maximum prescribed dose to the target site and minimum/no dose to the radiosensitive structures around the target. The therapist has a goal, producing the optimal treatment plan. In the process he develops several ideas [cues] on how to achieve this goal, the coalition of these ideas leads to a particular possible path/way of reaching this goal [not necessarily the optimal treatment plan]. He then evaluates the proposed treatment plan [goal] according to dose-limiting structures and optimal target dose coverage limitations. Depending on the plan evaluation or analysis, he proceeds by approving [confirmed] or rejecting [denied] the treatment plan. The rejected treatment plan information can still be utilized to further refine the next potential treatment plan and the next after that, and so on until the optimal treatment plan is achieved.

This process of achieving a patient’s optimal treatment plan is also normally observed amongst very experienced radiation therapists when confronted with unusual and very complex treatment target volumes. It could be said, the therapist will adopt the HDR model of reasoning in order find possible alternative paths or ways which will aid the process of reaching a solution and hence, achieve the desired treatment plan outcome. In the same way, researchers from other disciplines have also found that novice and experienced therapists tend engage in the HDR form of reasoning similar to the author’s clinical context (Doody & McAteer, 2002 p.266), (Jones, 1992 p.883). Similarly, Ladyshewsky’s (2000) view on novice and expert clinical reasoning, also highlighted the fact that novices appear to be able generate different hypotheses when dealing with a particular clinical situation as their more experienced counterparts. However, the hypotheses of novices do not contain the richness of information that is seen in experts (Ladyshewsky, 2000 p. 2).

In radiotherapy, expertise in problem solving and decision-making seems to vary between radiation therapists and is largely dependent on the therapist’s clinical knowledge and mastery of the profession. According to previous literature, clinical reasoning in experts under familiar situations does not normally require explicit hypothesis testing, but instead it becomes more of a rapid, automatic and non-verbal course of action/response (Schwartz & Elstein, 2008 p.225) Consequently, this brings us to the notion of pattern recognition amongst health care practitioners. In medicine and nursing, this is also described as the associations of symptoms and signs generating patterns that experts recognize quickly according to previous clinical experience (Sefton, Gordon & Field, 2008 p. 470). This is particularly evident among expert clinicians such as dermatologists and radiologists, who use visual cues from previews clinical experiences (Elstein & Schwartz 2000). (Khatami, MacEntee & Loftus, 2008 p.258)

Similarly in radiotherapy, therapists tend to develop pattern recognition skills through previous experiential knowledge of similar clinical situations or problems. They tend to learn how to recognize relationships and configurations across patients’ planning and treatment needs. Behind their clinical decision-making and actions, radiation therapists may be instantaneously generating myriad strands of clinical reasoning, knowledge, and experience (Newnham, 1999 p.110). This is where the author agrees with Schön (1987), practitioners from different disciplines possess a stock of knowledge, which is largely tacit or implicit, enabling them to solve everyday problems (Schön, 1987 p. 4). This is seen everyday in a radiotherapy department where an experienced radiation therapist can often intuitively assess and correct a difficult plan or treatment.

According to a nursing study, expert nurses were identified as having greater understanding of clinical situations, by recognizing patterns of patients’ responses, and hence were able to rapidly respond to changes in patients’ condition (Corcoran-Perry & Bungert, 1992 p. 68). Benner described this as pattern recognition by using intuition and informal reasoning strategies where expert nurses recognize familiar patterns through experiences they have with their clients. The expert nurse is able to assess a clinical situation and focus on the most important clinical aspects (Pesut & Herman, 1999 p.13). This closely parallels with some aspects of the radiation therapist clinical practice. For example, when patients are undergoing a course of radiotherapy treatment, sometimes due to disease progression [metastasis] patients may develop spinal cord compression. Since the therapist deals with the patient on daily basis he/she plays an important role in recognizing subtle symptoms indicative of possible cord compression and thus immediate course of action can be established, avoiding permanent cord damage. This also correlates with the research study by Coders et al., where it was found that pattern recognition strategies were beneficial during the practitioners’ decision making process as well as, increasing their diagnostic accuracy (Coderre et al., 2003 p. 695).

On the other hand, there is also evidence from previous studies where expert practitioners confronted with very difficult and completely unfamiliar clinical scenarios were unable to implement pattern recognition strategies alone and reverted back to the HDR model in order to resolve the problem or reach a diagnosis (Doody & McAteer, 2002 p. 267). This can also be observed in the author’s clinical setting when radiation therapist are faced with difficult and complex planning and treatment situations.

Consequently, the knowledge reasoning integration model of clinical reasoning also plays an import role in the author’s clinical context. Just, as other health allied professions, it can be said that in radiotherapy, the backbone of clinical reasoning is largely knowledge based. This knowledge may be biomedical, experiential, or a combination of both. Radiation therapists are continuously learning new technological elements of radiotherapy treatment and applying these to clinical practice. Bolshevize et al. (1992) emphasized that during stage of early professional practice a mix of practical experience and theoretical education is needed and that clinical reasoning must be performed in the context of real patients. They also proposed that with increasing clinical experience, biomedical Knowledge becomes encapsulated in clinical knowledge. This integration of biomedical knowledge into clinical knowledge has been described as the heart of clinical reasoning expertise amongst health care workers (Bolshevize and Schmidt, 2000 p.15).

The author describes the radiation therapist role as very flexible, in that they move between clinical areas, such as simulation[CT, MRI, Ultrasound], planning[dosimetry] and treatment units. However in today’s radiotherapy clinical environment it is difficult to keep all clinical skills sets current, thus any transition from one area to another may involve a certain amount of retraining or upgrading[extra theoretical and biomedical knowledge]. Subsequently, it can be said, the therapist is continuously incorporating theoretical scientific and experiential knowledge into their clinical practice. Eraut 1994 & Schön 1983 also highlighted this notion, professionals continue to build their practical knowledge based on clinical experience and the understanding learned through experience (Jensen, Resnik & Haddad, 2008 p.127). The productive integration of the relevant knowledge[biomedical and clinical] into clinical practice will in turn enable the therapist to implement and develop further clinical reasoning skills successfully. This encapsulated knowledge can also be unfolded numerous times enabling therapist diligently deal with the complexity of their clinical environment ((Boshuizen and Schmidt, 2000 p.16).

Recently, Patel et al (2005) conducted a study on medical students in problem based learning tutorials and concluded that students tended to generate a great deal more inferences, especially from biomedical knowledge. It also showed that clinical knowledge could serve as a consolidating factor for previously acquired biomedical knowledge, effectively aiding the integration of biomedical knowledge into coherent frameworks of clinical knowledge (Patel et al, 2005 p. 1202). These findings, positively correlate with the author’s clinical context where he describes therapists, as continuously incorporating theoretical and experiential knowledge into their clinical practice and thus, enduring their clinical reasoning skills.

Finally, it is also important for the author to acknowledge other studies in the literature, suggesting that health care professionals should not be locked into just a single mode clinical reasoning, but instead utilize multiple forms of reasoning, resulting in effective diagnostic accuracy, better problem solving and decision making clinical expertise (Kevin, et al 2007 p. 1152) (Ark, Brooks, & Eva, 2006 p. 406). In radiotherapy, often there is no one best way through a problem. So, the combination of more than one mode of clinical reasoning, will allow radiation therapist to develop better clinical skills and hence better able to adapt to the rapidly evolving world of the profession. This notion is also supported by the findings of Doody & McAteer (2002), where they concluded that occupational therapists went beyond diagnostic processes[such as HDR] to include reasoning processes focused on the management of the patient’s problems (Doody & McAteer, 2002 p. 260). In the author’s clinical setting, the therapist develops a very strong relationship with his/her patients, which can often be very meaningful to the patients and can lead to a very individualized approach in managing their problems.

Conclusion

In conclusion, the author was able to clearly identify and associate with the HDR, pattern recognition and knowledge reasoning integration models of clinical reasoning within his clinical context. He was also able to identify clinical reasoning as the foundation of professional clinical practice and establish its important role in his discipline as well as in other health care professions. This paper also illustrated that clinical reasoning could provide a safeguard against the risk of having the popular theory and clinical techniques of the day adopted without questions and hence thwarting alternatives theories of clinical practice. (Jones, 1995 p.18). Therefore, it can be said that clinical reasoning in radiotherapy has also become an essential component of professional practice, enabling radiation therapists to simultaneously gather and evaluate information relevant to their patients’ planning and treatment phase. This in turn, provides radiation therapists with competence in their decision-making process within the context of the constant changes occurring in radiotherapy planning and treatment of patients. The author also trusts that his experience in writing this paper will contribute to the limited literature in clinical reasoning amongst radiation therapists by promoting its clinical significance to clinical practice in his radiotherapy department.

References:

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teaching clinical reasoning

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