Developing Excellent Clinical Reasoning in Health Professions Students
Health care practitioners consider many factors when making important decisions about a diagnosis or treatment plan: observations, patient history, lab results, peer-reviewed journals, published research, clinical trial results — and their own judgment. This multifaceted approach toward patient care is referred to as clinical reasoning.
Understanding Evidence-Based Practices and Clinical Reasoning
Clinical reasoning is essential in the health professions, but it’s important also to understand another approach to decision making in the health professions: evidence-based practices, or EBP.
Evidence-based practice relies on data collected from clinical trials and other studies.
The October 2013 edition of Mayo Clinic Proceedings defines EBP as “the process of integrating individual clinical expertise and the best available external clinical evidence from systematic research.” It states that this systematic research includes randomized clinical trials (RCT) and meta-analyses.
Clinical reasoning, on the other hand, is often considered a more intuitive, imaginative approach; however, it’s far more sophisticated than a gut feeling. The same Proceedings article describes clinical reasoning as “the disciplined, analytical, scientific approach that integrates all the relevant information in the search for the best approach to diagnosis and therapy for individual patients.”
Where Clinical Reasoning Fits In
Jean-Michel Brismée, Sc.D., PT, OCS, FAAOMPT, professor in the Sc.D Program in Physical Therapy at Texas Tech University Health Sciences Center School of Health Professions (TTUHSC SHP), says EBP only gives part of the story. Brismée and his counterparts at other research institutions have, for many years, been promoting the importance of using clinical reasoning both in practice and in health professions education.
Brismée explains that much of what future rehabilitation science professionals learn in school, clinical training, and later in continuing education courses, fits the ideal patient. However, Brismée says: “Most people don’t see the ideal patient.”
The same goes for clinical trials with finding ideal subjects. Brismée uses a hypothetical example of a study measuring the effectiveness of physical therapy for lower back pain in a group of adults aged 18 to 65. While the aim of the study is to capture and assess the overall value of the treatment, it can’t ever reflect 100% of cases. He explains some participants might have additional, seemingly unrelated, factors that could impact the outcome of their treatment: a lost job, family issues, responsibilities at home, or preconceived notions about a therapeutic method, to name just a few.
The Mayo Clinic discusses the limitations of clinical trials. For example, an aggregate sample might be the right size, but it also might not reflect an area’s actual population. This is because inclusion criteria, by nature, often exclude individuals who would otherwise qualify. Brismée agrees, citing the inability to take time off work, find transportation, or afford travel accommodations as reasons that could prevent a perfect match from participating in a clinical trial.
The Art of Treatment
Recognizing that there is really no such thing as an “ideal patient,” clinical reasoning fills in the gaps. “That’s where the art of treatment comes in,” says Brismée. He adds that it’s critical for practitioners to master techniques, but it’s also solid reasoning that helps them become good physical therapists.
He uses another example: a patient who presents with an injury to the Achilles tendon that results in difficulty walking. If you were to look at the research, you might find that doing isometric or eccentric exercises over a specific time period proves to be an effective treatment.
“If I tell my patient to do this training two times a day, at 45 reps, and tell them it will be painful for the first few weeks, people in my clinic might not have the motivation to do this,” he says. “My compliance with that type of treatment, then, might be low.”
On the other hand, if that patient is an athlete, Brismée explains how they might be extra motivated: “They want to get back to their sport.”
Clinical reasoning factors in nuances, ethical considerations and other influences that EBP can’t always determine, such as:
●Biopsychosocial factors (emotion, cognition, etc.).
●Goals and current circumstances.
●Socioeconomic factors (work status, class, etc.).
●Sociocultural factors (age, race, gender identity, etc.).
●Comorbidity (having two or more chronic conditions).
●Patient-specific response to interventions.
●Allergies and adverse reactions.
When it comes to determining the right treatment approach for an individual patient, “You have to puzzle all these factors together,” says Brismée.
Clinical Reasoning to Align Treatment and Boost Satisfaction
Clinical reasoning skills can also work to bridge the gap when there are conflicts in expectations. Brismée brings up a common situation: two practitioners treating the same patient, each offering a different treatment plan. He uses a hypothetical example of someone who saw his primary care physician for knee pain and received a prescription for aquatic therapy, which has been deemed an effective treatment.
“That patient could come into the clinic with a bathing suit and towel, ready for aquatic therapy,” says Brismée. However, during the intake exam, the physical therapist might disagree with the original recommendation. That disconnect could cause initial tension between patient and provider.
“Here, the expectation of the therapist and the patient do not match,” he says. Patient satisfaction is crucial, so the next step is to agree on a solution that balances both expectations and delivers the most effective treatment for the patient.
Benefits of Clinical Reasoning in Health Professions
There’s been a healthy debate in recent years over EBP being the end-all, be-all approach to diagnosis versus allowing room for reasoning. Brismée believes there is room for both. “Not every patient will respond the same way,” he says. “That’s why it’s so critical that clinicians listen to their patients.” That balance in diagnostic approach is something he and his TTUHSC colleagues try to instill in their graduate and doctoral students.
The clinical reasoning article from Mayo Clinic mentioned earlier, also cites a few ways this approach can positively impact someone’s practice. They include:
●Providing a diagnosis sooner.
●Reducing unnecessary investigation (and the related costs that incurs).
●Increasing patient satisfaction.
Brismée is one of the authors of Should Evidence or Sound Clinical Reasoning Dictate Patient Care, which was published in the Journal of Manual and Manipulative Therapy in 2016. In this article, he and other researchers stress that EPB was never intended to de-emphasize a clinician’s expertise, but rather that evidence can be part of a bigger picture. With a firm understanding of a patient’s unique situation, using strong reasoning skills might lead a practitioner to conclude that the best solution is not always what the research recommends.
“While a chosen alternative may not be fully supported by presently available evidence and could be considered an outlier, that outlier of today may be the basis for discovering future evidence,” they write. “Thus, choosing that alternative based on sound clinical reasoning places the clinicians in a position to navigate future clinical science discoveries.”
The Challenge of Teaching Clinical Reasoning
In health care, like in many professions, practitioners develop a body of working knowledge throughout the years. This, along with practical experience, informs their decisions, sometimes even at a gut level. This innate ability is one reason clinical reasoning is such a challenge to teach. Health professions educators like Brismée are dedicated to helping students kickstart these skills before they begin their careers in the rehabilitation sciences.
Clinical reasoning is part of the framework in many programs offered by TTUHSC’s School of Health Professions. Brismée says students are introduced to this problem-solving methodology in several ways, including case studies, guest patients, hands-on clinical training, special projects, and involvement with the Center for Rehabilitation Research.
Some classes address clinical reasoning more directly, including the aptly titled Clinical Reasoning 1 and 2. Both classes focus on “assisting students sharpening clinical problem-solving strategies used in the context of clinical cases,” says Brismée. Students learn more about the influences of culture, poverty and ethics.
Brismée says rehabilitation science students at TTUHSC SHP also have a chance to learn about clinical reasoning and meet leading experts in the field at professional conferences. He adds that the Student Orthopedic Manual Physical Therapy Association (SOMPTA) holds various clinics, courses and events to raise money for conference travel. One example is SOMPTA’s annual three-day dry needling course for third- and fourth-year students, as well as local clinicians.
Throughout this event, participants learn history and theory in lecture sessions, and then practice techniques in lab classes. During the final session each day, according to SOMPTA’s blog post about the event, attendees gather “to go over case studies in order to help apply clinical reasoning for patients that either may or may not be appropriate for dry needling.”
The 2018 event drew 50 people and the money raised from registrations allowed SOMPTA to send 21 students to the annual American Academy of Orthopedic Manual Physical Therapists (AAOMPT) conference, held that year in Salt Lake City, Utah, and also four students to the American Physical Therapy Association (APTA)’s Combined Sections Meeting, which took place in New Orleans, Louisiana.
After earning their degree, many rehabilitation science graduates move from the student chapters of professional societies like AAOMPT and APTA into the main parent organization; these memberships give new practitioners access to continuing education opportunities that often tie in clinical reasoning.
Bringing it All Together
Clinical reasoning involves a mix of scientific knowledge and practical experience — and even a bit of intuition. Health professions students at TTUHSC begin to develop these skills through their coursework, hands-on clinical training experiences and extra-curricular activities. As they grow in their careers, so do their clinical reasoning skills.
Brismée sums up the idea that being a good clinician is more than just mastering technique and following the evidence: “You can’t do this work...” he says, gesturing toward his head, “...without this.”
Texas Tech University Health Sciences Center offers a range of graduate degree programs in the rehabilitation sciences, including masters of occupational therapy and athletic training, doctor of physical therapy, as well as post-professional doctor of science in physical therapy and a Ph.D. in rehabilitation science. Explore them all at our health professions programs page.
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