Clinical Reasoning in manual Therapy

Clinical Reasoning in Manual Therapy - Clinical reasoning refers to the cognitiveprocesses or thinking used in the evalua- Mark A Jones tion and management of a patient. In this article, clinical reasoning research and expert-novicestudies are examined to provide insight into the growing un- derstanding of clinical reasoning and the nature of expertise. Although bypothetic~deductivemethod of reasoning are used by cliniciansat all leuels of experience,experts appear to poses a superior otganization of knowledge. Ex- perts oflen reach a diagnosis based on pure pattern recognition of clinicalpat- terns. Witha n atypicalproblem, however, the expert, like the novice, appears to rely more on bypotheticedeductiveclinical reasoning. Five categories of hypothe- ses are pmposed for physical therapistswing a bypothetico-deductivemethod of clinical reasoning.A model of the clinical reasoningproces for physical therapists ispresented to bring attention to the hypothesisgeneration, testing, and modijica- tion that Ifeel should takeplace through all aspects of the patient encounter. Examples of common errors in clinical reasoning are highlighted,and sugges- tionsfor facilitating clinical reasoning in our students are made. [JonesMA. Clinical reasoning in manual therapy. Pbys Ther 1992;72:875-884.] Key Words: Clinical competence, Decision making, Diagnosis, Manual therapy. There is an increasing demand for observations and the hypotheses are are increasing,'-5 research in clinical accountability of physical therapists then tested through subsequent data reasoning within physical therapy is from within the profession as well as collection and modified as a result of still sparse.- Considerable research, outside, including funding agencies, the outcome of the test. Similarly, however, has been conducted in the competing health practitioners, and physical therapists should b e taught to area of thinkingkeasoning and the the increasingly more health con- use clinical reasoning skills in their nature of expertise in such diverse scious consumer. This demand is met examination and management of fields as medicine, nursing, psychol- in part by the profession's ongoing patients. But what reasoning skills ogy, artificial intelligence, program- efforts to teach and conduct scientific should we teach? And how should ming, law, mathematics, engineering, inquiry with the aim of improving this be balanced against the teaching and physics.S13This article will and validating physical therapy prac- of knowledge? Understanding the briefly highlight research findings that tice. Equally important, physical thera- cognitive components of clinical rea- provide insight into the growing un- pists must apply the methods of scien- soning and in particular the differenti- derstanding of clinical reasoning and tific inquiry to the examination and ating features between experts and the nature of expertise relevant to management of patient problems. novices should enable us to critically physical therapy. Although further Accountability sufferswhen therapists evaluate our own reasoning and de- research is needed to clarify the na- unquestioningly follow examination sign educational activities to facilitate ture of clinical reasoning, the majority and treatment routines without con- improved reasoning. of clinical reasoning literature sug- sidering and exploring alternatives. gests that expert clinicians have a Scientific reasoning often includes the Although theoretical discussions and highly developed organization of hypothetico-deductive method, in educational suggestions on aspects of knowledge and use a hypothetico- which hypotheses are generated from clinical reasoning in physical therapy deductive method in their clinical reasoning.14A model of a clinical - reasoning process for physical thera- pists is presented that emphasizes a MA Jones, PT,is Cwrdinator, Post Graduate Manipulative Physiotherapy Programmes, School of hypothesis testing approach to clinical Physiotherapy, University of South Australia, North Terrace, Adelaide, South Australia, Australia reasoning. Clinical reasoning that is 5000. Physical Therapy/Volume 72, Number 12December 1992

hypothetico-deductivewill assist clini- In a review of research in medical rected. This finding of the importance cians in avoiding common errors of clinical reasoning, Feltovich and Bar- of good hypotheses highlights the reasoning and enhance their recogni- rows15described hypotheses and data crucial role the clinician's knowledge tion of clinical patterns and organiza- gathering that were considered in the base has in the clinical reasoning tion of knowledge. clinical reasoning studies. The vari- process. The importance of knowl- ables affecting hypothesis generation edge and its organization are also Cllnkal Reasonlng included the percentage of patient reflected in the seminal work of El- data items or the time it took to cre- stein and colleagues,16in which clini- Clinical reasoning can be defined as ation of the first hypothesis. The total cal reasoning performance was shown the cognitive processes, or thinking number of hypotheses considered to vary greatly across cases. That is, used in the evaluation and manage- and number of hypotheses actively clinical reasoning is specific to one's ment of a patient. Other terms includ- considered at any one time were also area of work (eg, orthopedics, neurol- ing \"clinical decision making,\"l \"clini- studied. There was no difference in ogy, and so forth), dependent on the cal problem solving,\"8and \"clinical any of these variables across different clinician's organization of knowledge judgrnent\"l0 also appear in the litera- specialties or across different levels of in the particular area. ture and frequently are used inter- experience within the same specialty. changeably.Clinical decision making Although these hypothesis-related These early medical studies provide and clinical judgment focus on the variables are common to all clinicians, an overall picture of a clinical reason- diagnostic decision-making aspect of their importance to effective clinical ing process that is hypothetico- the clinical reasoning process, reasoning was unclear, as none were deductive and universally applied by whereas problem solving typically consistently predictive of the quality clinicians at all levels of experience. refers to the steps involved in work- of outcome (eg, correct diagnosis and The process involves collecting and ing toward a problem solution. Prob- management plan). analyzing information, generating lem solving also infers the therapist's hypotheses concerning the cause or aim is to solve the patient's problem. The data-gathering variables centered nature of the patient's condition, in- Some patient problems, however, are on the general themes of thorough- vestigating or testing these hypotheses \"unsolvable.\" Our profession's aim is ness, efficiency (ie, important to non- through further data collection, and to evaluate the patient problem, iden- important information collected), determining the optimal diagnostic tifylng factors amenable to physical activeness (ie, extent to which data and treatment decisions based on the therapy to effectively manage the collected are evaluated in relationship data obtained. problem. The term \"clinical reason- to hypotheses being considered to ing\" has broader connotations and is test appropriateness of hypotheses), The Nature of Expertise used in this article to refer to the and accuracy in interpretation (ie, cognitive processes used in achieving correctness of interpretations as sup- \"Experts\" in the early medical educa- this aim of evaluating and managing porting or not to hypotheses). The tion research were typically those the patient's problem. value of the data-gathering measures selected by peer nomination, whereas to reveal important aspects of clinical \"novices\" were usually students at Cllnlcal Reasonlng In reasoning were also questionable, as varying levels of their education.lb20 Medlclne: A Unhrersal they did not discriminate among Pate1 and Groen21have suggested that Process clinicians from different specialties o r expertise be considered along the clinicians with different levels of expe- dual continuum of both generic and A summary of findings from early rience or peer-judged proficiency. specialized knowledge. They define a medical education research in clinical The importance of these data- novice as an individual who has the reasoning highlights some universal gathering variables to the products of prerequisite knowledge assumed by aspects of clinical reasoning and the the rea5oning process was also ques- the domain. A subexpert, according to significance that the organization of tioned. With the exception of \"accura- Pate1 and Groen, is an individual with one's knowledge has to the differenti- cy in interpretation,\"16no other data- generic knowledge, but inadequate ation of expert clinicians and novices. gathering variable correlated with specialized knowledge of the domain, Early medical education studies ana- quality of diagnosis and management and an expert is defined as an individ- lyzed clinicians' thoughts (eg, percep plan. ual with specialized knowledge of the tions, interpretations, plans), either domain. These definitions provide retrospectively as the clinicians The best indicator of the correctness sufficient distinctions for interpreting thought aloud while being prompted of diagnosis and management plan the expert-novice literature cited in by a video or audio playback of a was the quality (as judged by expert this article. Although I will not suggest patient examination just completed or standards) of hypotheses consid- my own expert-novice distinction for concurrently as the clinicians read a ered.17-20If the appropriate hypothe- physical therapy, I do feel the full patient's unfolding clinical history. ses were not considered from the range of competencies inherent to start, the clinician's subsequent inqui- physical therapy including knowledge, ries would presumably be misdi- interpersonal, manual, and clinical Physical Therapy /Volume 72, Number 12December 1992

reasoning skills should b e incorpo- radiographs.z8This superior ability to zation of knowledge. Experts make rated into any expert-novice see meaningful patterns is not the significantly more inferences about distinction. result of superior perceptual or mem- clinically relevant information and ory skills; rather it reflects a more chunk information into recognizable Expert clinicians have a superior highly organized knowledge base.2\" patterns.32 Novices make more verba- organization of knowledge and use a tim recall of the surface features of a combination of hypothetico-deductive These representations of the problem problem and have less developed and reasoning and pattern recognition o r will in turn influence the subsequent fewer variations of patterns stored in forward reasoning.16J1.22 Support for search for a solution. The expert their memory. For example, a novice the importance of one's organization chess player's conceptualization of the may recall the specific, yet superficial, of knowledge is available from the game into strengths and vulnerabili- detail that the patient's shoulder hurt literature of cognitive psychology.23~24 ties lessens the number of appropri- with attempted elevation in early Experts acquire efficient ways of rep- ate moves to consider. When the activities. Further details such as the resenting information in their work- physicist characterizes a problem as exact site of pain and position of the ing memory. Studies of problem an example of a physics law, the law patient's neck, shoulder, and arm may solving and expert-novice differences itself substantiallydirects the form not have been sought o r attended to in fields other than medicine have and application of equations that will if the clinical patterns implicated by pointed to the importance of an indi- be used. Similarly, the physical thera- this additional information were not vidual's problem representation for pist's representation of the problem known to the student. The novice guiding reasoning and determining (as determined by each individual's must rely on black and white text- successful problem solution. A prob- personal perspective and organization book patterns and lacks information lem representation is the solver's of knowledge) will influence the on the relationships and shared fea- internal model of the problem, con- subsequent reasoning and search for tures across dfierent clinical pat- taining the solver's conception of the a solution. For example, physical terns.3\" This creates difficulty for the problem elements, his or her knowl- therapists who adhere to the concept novice when confronted with irrele- edge of those elements, and the rela- of \"adverse neural tissue tension\" as vant and unrelated information or tionship the different problem ele- described by Elvey29and Butler 30 will patient presentations containing over- ments have to each other.25 The conceptually approach the examina- lapping problems and gray, nontext- depth and organization of knowledge tion and treatment of a patient differ- book variations. between novices and experts has ently than therapists without this par- consistently been found to differ. ticular organization of knowledge. An example of the novice's risk of Recognition of the continuity of the missing overlapping problems is the Chess experts recognize patterns nervous system29,30will influence patient whose lateral elbow pain is reflecting areas of strategic strength therapists' attention and weighting of aggravated by resisted extension of and vulnerability and positions sup- patient clues and their subsequent the wrist. The novice may recognize porting maneuvers of attack and de- search for supporting and negating this typical feature of injury to the fense. Although the chess expert can data. common extensor origin yet fail to replicate a chessboard when viewed exclude (through inquiry and physical Using a method of propositional anal- tests) other potentially coexisting for only 5 seconds, there is a dramatic ysis to determine a clinician's mental disorders that may share o r predis- representation of a case, Pate1 and pose to this clinical presentation (eg, drop-off in this ability below the level colleagues31-3' have found analogous involvement of C5-6 musculoskeletal of chess master. N o differences, how- results when comparing medical structures, adverse neural tissue ten- ever, are found when the chess pieces clinicians at various levels of exper- sion, radiohumeral joint and local are randomly arranged, demonstrating tise. Typically, subjects are presented radial nerve entrapment). the chess master's superior ability to with a written patient description and perceive patterns in chess posi- then asked to recall the facts in writ- Bordage and colleagues39~4h~ave ti0ns.26.~7Expert physics problem ing, followed by their explanation of demonstrated other more qualitative solvers represent problems as in- the patient's underlying pathophysiol- differences in the organization of stances of major laws of physics appli- ogy and lastly their diagnosis. Proposi- novice and expert knowledge. cable to the specific situation in tional analysis is a system of noting Whereas the novice's knowledge is which novices' problem representa- and classifying the clinician's observa- centered purely on disjointed lists of tion are more literal, fragmented, and tions, findings, interpretations, and signs and symptoms, the stronger tied to overt features of the problem inferences derived from the infoma- diagnosticians make use of abstract such as the use of a spring or a pul- tion contained in the text. These stud- relationships such as proximal-distal, ley.25 Similar results demonstrating ies consistently demonstrated differ- deep-superficial, and gradual-sudden, experts' recognition of patterns have ences between experts' and novices' which assist to categorize similar and been replicated in several other do- conceptualization of a problem, with opposing bits of information in mains such as in the game of GO, in experts possessing a superior organi- memory. reading circuit diagrams, in reading architectural plans, and in interpreting Physical Therapy/Volume 72, Number 12Pecember 1992

One's organization of knowledge not lar. That is, in an attempt to under- be directed at the source of the symp- only appears to determine what labels stand and manage the patient's prob- toms or toward contributing factors. If are given to recognizable patterns of lem, I contend that therapists obtain passive movement is used, examples information, but also includes \"pro- information regarding the following of considerations include whether duction rules,\" which specify what five categories of hypotheses: physiological or accessory movements actions should be taken in different (1) source of the symptoms o r are used; whether pain should be situations.23~32.4E1xperts are thought dysfunction, (2) contributing factors, provoked o r avoided; and what direc- to have a large number of such rules tion, amplitude, speed, and duration specific to their area of experience. (3) precautions and contraindications of movement should be applied.44 The end result of the expert's supe- to physical examination and treat- Whereas epidemiological studies rior organization of knowledge is the ment, (4) management, and provide insight into the probable ability to reason inductively in a for- course of different diseases and inju- ward manner from the information (5) prognosis. ries,45 physical therapists should be presented and to achieve superior able to inform patients to what extent diagnostic accuracy. That is, when These hypothesis categories are not their disorder appears amenable to confronting a familiar presentation, peculiar to any particular approach or physical therapy and to give an esti- experts can utilize rules of action philosophy of manual therapy. Any mate of the time frame for which found reliable in their own clinical clinician who uses hypothetico- recovery can be expected. Hypotheses experience to reach a diagnosis based deductive clinical reasoning should regarding \"prognosis\" in this sense on pure pattern recognition. When be considering hypotheses within can only be made on the basis of faced with an atypical problem o r a each of these categories. each patient's individual presentation. problem out of their area of exper- tise, however, experts, like novices, \"Source of the symptoms o r dysfunc- Information leading to the different must rely more on the hypothetico- tion\" refers to the actual structure hypothesis categories is obtained deductive (ie, hypothesis testing) from which symptoms are emanating. throughout the subjective and physi- method of reasoning.22.42~~3 \"Contributing factors\" are any predis- cal examination, with any single piece posing or associated factors involved of information often contributing to The organization of knowledge rele- in the development or maintenance more than one hypothesis category. vant to clinical manual therapy would of the patient's problem, whether A more detailed discussion of what include the facts (eg, anatomy, patho- environmental, behavioral, emotional, information can be considered for the physiology, and so forth), procedures physical, or biomechanical. For exam- different categories of hypotheses is (eg, examination and treatment strate- ple, a subacromial structure may be available in Jones5 and Jones and gies), concepts (eg, instability, adverse the source of the symptoms, whereas Jones.46 neural tissue tension), and patterns of poor force production by the scapular presentation. This knowledge is uti- rotators may b e the contributing fac- Rothstein and Echternachj~h~av~e lized with the assistance of rules or tor responsible for the development proposed a useful hypothesis-oriented principles (eg, selection of the grade or maintenance of an \"impingement\" algorithm for clinicians. In highlight- of passive movement and technique) syndrome. ing the all-too-frequent occurrence of to acquire, interpret, infer, and collate clinicians carrying out routine treat- patient information. Hypotheses regarding \"precautions ment plans that are unrelated to the and contraindications to physical preceding patient examination, these Clinlcal Reasoning in examination and treatment\" serve to authors make a case for the need for Physkal Therapy determine the extent of physical ex- physical therapists to acquire clinical amination (ie, whether specific move- reasoning skills. They provide a clear Whereas research in medical educa- ments are performed or taken up to set of steps that appropriately high- tion has emphasized diagnosis, I be- or into ranges of movement in which light the importance of utilizing data lieve that physical therapists must be pain is provoked and how many from the patient interview to generate concerned with additional categories movements are tested), whether phys- a problem statement and establish of hypotheses in order to deliver ical treatment is indicated, and, if so, measurable goals. The algorithm physical therapy effectively and safely. whether there are constraints to phys- continues with the physical examina- Therapists with different training will ical treatment (eg, the use of passive tion and the generation of hypotheses ask different questions and perform movement without provoking any about the cause(s) of the patient's different tests in accordance with the discomfort versus passive movement problem. They note that testing crite- significance they give to the subjective that provokes the patient's pain). ria for each hypothesis should be and physical information available considered and that all treatments from the patient. I propose, however, Hypotheses regarding \"management\" should relate to the hypotheses made. that despite these differences, the include consideration of whether The second part of their hypothesis- aims of therapists' inquiries are simi- physical therapy is indicated and, if oriented algorithm provides an or- so, what means should be trialed. If manual therapy is warranted, it must be decided whether treatment should Physical Therapy /Volume 72, Number 12December 1992

INFORMATION patient shows obvious difficulty in PERCEPTION removing his o r her arm from a jacket, the therapist will already be and forming initial hypotheses or working INTERPRETATION interpretations regarding the source of the problem and degree of involve- DATA ment. Further information (ie, data collection) is then sought throughout INITIAL CONCEPT ,or@ COLLECTION the subjective and physical examina- and ~nformatlon, ' s ~ b l e c t l v e tion with these working hypotheses in mind. MULTIPLE mdrd Interview HYPOTHESES physlcal Although certain categories of infor- examlnatlon mation (eg, site, behavior, and history of symptoms) are scanned in all pa- EVOLVING 4 tients, the specific questions pursued CONCEPT are tailored to each patient and the of the PROBLEM Information therapist's evolving hypotheses. For (hypotheses example, when the patient with d f i - knowledge base culty removing the jacket describes an cognltlve skllls modlfled) area of ache in the supraspinous fossa metacognltlve and an area of pain in the anterior skllls shoulder just lateral to the coracoid process, the initial hypothesis of a DECISION \"shoulder problem\" is already modi- fied. For me, two different symptoms, dlagnostlc an ache and a pain, are indicated, management each warranting consideration and further inquiry. I would consider both PHYSICAL THERAPY local and spinal structures as potential INTERVENTION sources o r contributing factors. The patient's response to open questions 4 regarding what aggravates and what eases the pain should then be inter- REASSESSMENT preted with these hypotheses in mind. Flgure. Clinical reasoning model for physical therapists. (AdaptedfromBarrows Maitland**~~u9ses the phrase \"make the features fit\" to encourage thera- and T ~ r n b l y n . ~ ~ ) pists to inquire in the mode de- scribed here where information is dered series of steps for reassessing ing management. I have also interpreted for its support or \"fit\" the effects of the treatment imple- attempted to depict the cyclical char- with existing information (ie, working mented. This algorithm is useful in acter of the clinical reasoning process hypotheses). When features do not fit, teaching the hypothetico-deductive and to highlight key factors that influ- or in this terminology your hypothe- method of clinical reasoning and ence the various phases of clinical sis is not supported by the new infor- assisting clinicians in recognizing reasoning. The process begins with mation, further inquiry is needed. For when their actions have not been the therapist's obsavation and inter- example, an impingement of either logically formulated. pretation of initial cues from the contractile o r noncontractile struc- patient. Even in the opening moments tures may be considered in the pa- I have adapted a diagram from Bar- of greeting a patient, the therapist will tient I have described. If further ques- rows and Tamblyn48 to depict the observe specific cues such as the tioning revealed that the patient had clinical reasoning process of physical patient's age, appearance, facial ex- no difficulty lifting any weight below therapists (Figure). This is not a sub- pressions, movement patterns, resting 90 degrees while movements across stitute for the hypothesis-oriented posture, and any spontaneous com- the body into horizontal flexion were algorithm of Rothstein and Echter- ments. These initial cues from the limited by the anterior pain, this nach.3.47 Rather, this model is pre- patient should cause the therapist to would not, in my view, support a sented to bring attention to the hy- develop an iniiial concept of the contractile tissue lesion but would pothesis generation, testing, and problem that includes prelimina y implicate an impingement of noncon- modification that I feel should take working hypotheses for consideration tractile structures or an acromioclavic- place through all aspects of the pa- through the rest of the examination tient encounter including the inter- and throughout ongoing management view, physical examination, and ongo- of the patient. For example, if the Physical Therapy /Volume 72, Number 12iDecember 1992

ular source to this pain. I would ques- additional examination, reanalysis of Errors of Clinlcal Reasonlng tion and reason in this manner to data obtained, referral to another assess the involvement of other struc- health care practitioner). Successful management of a patient's tures in the anterior pain, such as problem requires a multitude of cervical structures and neural tissues, Factors lnfluenclng Cllnlcal skills. Working from the patient's and I would pay equal attention to Reasonlng account of the problem, the therapist the ache. must be able to efficiently observe The clinical reasoning process is influ- and extract information, distinguish Similarly, the physical examination is enced by the therapist's knowledge relevant from irrelevant information, not simply a routine series of tests. base, cognitive skills (eg, data analysis make correct interpretations, weigh There may be specific physical tests and ~ynthesis),~6~an*d~m~e5t~acogni- and collate information, and draw that are used for different areas, but tive skills (ie, awareness and monitor- correct inferences and deductions. these should be seen as an extension ing of thinking processes).5l These Errors of reasoning may occur at any of the data collection and hypothesis factors influence all aspects of the stage of the clinical reasoning process testing performed through the subjec- clinical reasoning process and can including errors of perception, in- tive e ~ a m i n a t i o nF. ~or~example, re- themselves be improved when thera- quiry, interpretation, synthesis, plan- ports of painful \"clicking\" in the pists consciously reflect on the sup- ning, and reflection. Application of shoulder and sensations of apprehen- porting and negating information on hypothesis-oriented clinical reasoning sion indicate the need for instability which their inquiries and clinical as encouraged by the clinical reason- and labral integrity testing, but these decisions are based. For example, ing model portrayed in the Figure tests may not be warranted in the consideration of the features of the and the hypothesis-oriented algorithm next patient who has similar patient's presentation that fit and do described by Rothstein and Echter- symptoms. not fit existing patterns recognized by nach4' should assist clinicians in therapists will enable therapists to avoiding errors of reasoning. This process of data collection contin- learn about different clinical patterns ues as hypotheses are refined and and their variations and to broaden Examples of reasoning errors extrapo- reranked and new ones considered in their knowledge base. I contend that lated from Nickerson et alsl are given the therapist's \"evolving concept\" of therapists with good clinical reason- below with the physical therapy appli- the problem. The clinical reasoning ing skills will reflect as they interact cations derived by this author. through the patient examination con- with the patient, improvising their tinues until sufficient idormation is actions in accordance with the unfold- 1. Adding pragmatic inferences. Mak- obtained to make a \"diagnostic\" and ing patient findings much like a musi- ing assumptions is an error of management decbion. cian adjusts his o r her performance reasoning. For example, a patient when participating in an improvisa- with pain in the supraspinous fossa The clinical reasoning process does tional session with other musicians.52 will often describe this as \"pain in not stop at completion of the patient my shoulder.\" It is a misrepresen- examination. Rather, the therapist will As reasoning is only as good as the tation of the facts to assume the have reached the management deci- information on which it occurs, any patient's \"shoulder pain\" is actually sions of whether to treat o r not treat; factor influencing the reliability and within the shoulder itself without whether to address the source(s) o r validity of information obtained (eg, specific clarification of the site. contributing factor@),or both, ini- communication/interpersonal and tially; which mode of treatment to use manual skills) will also influence the 2. Considering toofa0 hypotheses.By initially; and, if passive movement effectivenessof one's clinical reason- prematurely limiting the hypotheses treatment is to be used, whether to ing. For example, leading questions in considered, discovery of the correct provoke symptoms and the direction a patient interview often elicit re- hypothesis may be missed or de- and grade of movement. Every treat- sponses that support the examiner's layed. This can occur when inqui- ment, whether it is hands-on o r ad- assertion. Other less tangible factors ries and physical tests are only vice, should be a form of hypothesis influencing clinical reasoning include directed to the local sources of a testing. Continual reassessment is environmental contingencies such as patient's symptoms, as with the essential and provides the evidence group norms and time constraints.*l patient reporting \"shoulder pain on which hypotheses are accepted or That is, working environments of with any lifting.\"To interpret this rejected. Reassessmmt should contrib- overextended case loads and peer or automatically as a shoulder problem ute to the therapist's evolving concept self-imposed pressure to exclusively or, worse yet, a \"frozen shoulder\" of the patient's problem. When treat- adopt the latest treatment fad are not without considering other hypothe- ment has not had the expected effect, conducive to clinical reasoning that is ses is an error of reasoning. the therapist's concept of the problem hypothesis oriented. and its management may be altered, 3. Failure to sample enough irzformu- leading to a change in treatment o r tion. It is an error to make a gen- further inquiry (eg, reexamination, eralization based o n limited data. Physical Therapy 'Volume 72, Number 12Pecember 1992

This is seen in judgments regard- time as a central neck pain is insuf- lesions, there will typically be pain ing the success o r failure of a par- ficient to judge the relationship of on resisted isometric testing; how- ticular management approach these symptoms. A full understand- ever, this does not mean that all based on only a few experiences. ing of the relationship between painful resisted isometric tests are Closely linked to this error is the these two symptoms requires in- necessarily intrinsic rotator cuff failure to sample information in an quiry of when both occur together, lesions. unbiased way. Although this is when the neck pain occurs without typically controlled for in formal the scapular pain, when the scapu- A second form of deductive rea- research, the practicing therapist lar pain occurs without the neck soning states: If A, then B; not B, will rely on memory of previous pain, and when neither neck nor therefore not A. For example, if experiences as the sample on scapular pain are occurring. you have shoulder pain referred which views are based. The error from the cervical spine, you will occurs when only those cases are 6. Confusing covariance with causal- have cervical signs; if you do not recalled that support one view ity. When two factors have been have cervical signs, it is not cervical while confounding evidence is found to covary, it is an error to referred shoulder pain. It is a de- forgotten. deduce the factors are necessarily ductive error to reason: If A, then causally related. For example, if the B; not A, therefore not B. For ex- 4. Confirmution bias. Another error scapular pain in the above example ample, if you have shoulder pain of reasoning related to a biased only occurs when the cervical pain referred from the cervical spine, sample of information occurs when is present, this does not prove the you will have cervical signs; if therapists only attend to those two symptoms are from the same there is no cervical referred shoul- features that support their favorite source (eg, cervical disk). Although der pain, there will not be cervical hypotheses while neglecting the this is a reasonable hypothesis, signs. negating features. This can lead to another possibility is that two dif- incorrect clinical decisions and ferent structures (eg, cenical and 8. Premise conversion.It is a deduc- hinder the therapist's opportunity thoracic) are simultaneously tive error of reasoning to reverse a to learn different variations of clini- stressed by the same activity or statement of categorization. That is, cal patterns. For example, a pre- posture. all A are B does not mean all B are sentation of central low back pain A. For example, all shoulder im- aggravated by slouched sitting may 7 . Conjksion between deductive and pingements are subacromial (or be quickly interpreted by some inductive logic. Deductive reason- subcoracoid) does not mean therapists to be a \"diskogenic\" ing involves logical inference. One all subacromial pains are disorder. Further clarification that draws conclusions that are a logi- impingements. the patient's pain provocation was cal, necessary consequence of the not time dependent and that move- premises without going beyond the These examples represent only a ment from a sitting to a standing information contained in the prem- sample of the reasoning errors a position was not hindered, regard- ises. Correct deductive reasoning is therapist can make. Errors in reason- less of the speed at which it was independent of the truth of the ing are also not confined to the less performed, could represent negat- premises o r the conclusion. In experienced, as even \"experts\" have ing features to the \"diskogenic\" contrast, inductive reasoning in- been shown to overemphasize posi- diagnosis. Attention to such varia- volves going beyond the informa- tive findings, ignore or misinterpret tions in presentation will assist tion given. Every time we make a negative findings, deny findings that therapists' recognition of clinical generalization based on specific conflict with a favorite hypothesis, and variations within the same diagno- observations, this is an induction. obtain redundant information.16.52-54 sis, which in turn should lead to A valid form of deductive reason- The As and Bs of logic may appear to recognition of optimal treatment ing states: If A, then B; A, therefore be nothing more than semantics. If strategies for the respective B. For example, if you have an the inductive generalizations preva- presentations. acromioclavicular joint problem, lent in manual therapy are not recog- horizontal flexion is likely to be nized for what they are, however, 5. E m r s in detecting covariance. To symptomatic. It is a deductive error therapists are prone to accept these make a judgment about the rela- to reason: If A, then B; B, therefore generalizations as fact and fail to look tionship of two factors requires A. For example, if you get pain for alternative explanations. understanding of how the two with horizontal flexion you have an factors covary with one another. It acromioclavicular joint problem. Bordage and c o l l e a g ~ e s ~ ~su, 5gg~e5st~ is an error to make this judgment This may be inductively reasonable that most diagnostic errors are not based solely on one combination based on past experience; how- the result of inadequate medical of covariance. For example, know- ever, it is deductively wrong, as knowledge as much as an inability to ing that the patient's medial scapu- other structures may be responsi- retrieve relevant knowledge already lar pain is experienced at the same ble. Similarly,with rotator cuff stored in memory. That is, the Physical Therapy/Volume 72, Number

amount of knowledge appears less physical therapy organization of closely linked to the accessibilityof relevant than the organization of that knowledge necessitates further inves- one's knowledge. Knowledge that is knowledge. When knowledge is not tigation of potential differences in acquired in the context for which it organized in clinically relevant pat- clinical reasoning and associated will be used becomes more accessi- terns, it becomes less accessible in factors. ble.72,73Although clinical knowledge the clinical setting. is typically presented in the context of Facllltating Cllnlcal Reasoning patient problems, this is less com- Having given the impression that in Our Students monly the case with the basic sci- good clinical reasoning will assist ences (eg, pathophysiology). Ap- therapists in recognizing clinical pat- As physical therapists have taken proaches to physical therapy terns, a word of caution regarding greater responsibility in patient man- education in which the acquisition of excessive attention to clinical patterns agement, especially with the increased knowledge is facilitated by teaching is needed. Clinical patterns are at risk autonomy associated with first-contact centered on patient problems pro- of becoming rigidly established when practice, physical therapy education vide, in my opinion, the ideal envi- the patterns themselves control our ha. respbnded with efforts to produce ronment for building an accessible attention. I believe this leads to errors more \"thinking\" therapists. Although organization of knowledge and foster- of limited hypotheses and insufficient attention to clinical reasoning skills ing clinical reasoning ~kills.67~68,7-1 sampling where anything that has any has presumably always been inherent resemblance to a standard pattern will in our physical therapy education, Learning the hypothesis testing ap- be seen as that pattern. For example, there has been a more recent interest proach also enables students to con- the information that a patient has pain in providing more formal and focused tinue to learn beyond their formal in the area of the greater trochanter learning experiences specifically education. Rather than relying on a aggravated by functional movements aimed at facilitating clinical reasoning text or more experienced colleague involving flexion or adduction of the in physical therapy students.*.5aGS69 to learn new clinical patterns, the hip may cause some therapists to therapist who actively reasons hypothesize the existence of a \"hip Facilitating students' clinical reasoning through and reflects on patient prob- joint\" disorder. Limiting one's hypoth- requires making them aware of their lems will continually challenge exist- eses to what may appear to be the own reasoning process and designing ing patterns and in the process ac- most obvious hypothesis without learning experiences that promote all quire new ones. pursuing additional supporting o r aspects of the clinical reasoning pro- negating evidence prevents the thera- cess while exposing the errors in Summary pist from ever learning the pattern of reasoning that occur. This requires other disorders that may share fea- access to students' thoughts and feed- Early research in medical education tures with a disorder of the hip (eg, back on thinking processes. That is, provided a picture of a clinical rea- lumbar spine, sacroiliac joint, adverse students should be taught to think soning process that was hypothetico- neural tissue tension) or the full and to think about their thinking.70 deductive and universally applied by range of presentations a hip joint This can be achieved by promoting clinicians at all levels of experience. disorder can manifest. students' use of reflection to encour- The differentiating feature of expert age awareness and promote integra- diagnosticians and novices appears to Implkatlons for Physkal tion of existing versus new knowl- lie in their organization of knowl- Therapists edge. When combined with a better edge. Experts have a superior organi- awareness of one's own cognitive zation of knowledge that enables Physlcal Therapy Research in processes (ie, metacognition), the them to reason inductively in a form Cllnlcal Reasoning students' processing of information is of pattern recognition. When con- enhanced and clinical reasoning is fronted with unfamiliar problems, the Consideration of the clinical reason- facilitated. Learning experiences to expert, like the novice, will rely on ing literature outside of physical ther- facilitate clinical reasoning using both the more basic hypothesis testing apy assists in developing an under- reflection and metacognition are approach to clinical reasoning. standing of this topic while providing described else~here.5~71 educational and clinical extrapolations Research to better understand the to our profession. Debate continues The process of reasoning should not, clinical reasoning and nature of ex- in the medical literature, however, in my view, be addressed to the ne- pertise in physical therapy can assist regarding the nature of expertise and glect of knowledge. Rather, facilitating us in designing learning experiences the appropriate methodology to use the clinical reasoning process will to facilitate clinical reasoning. Clinical in research.4015-3 Although some assist the students' acquisition of reasoning is now being given specific evidence does exist suggesting that knowledge. In turn, good organiza- attention in some physical therapy medical and physical therapy clinical tion of knowledge leads to better education programs. The aims of reasoning processes are similar,- the clinical reasoning. The importance of these programs should be to increase potential differences in medical and one's organization of knowledge is students' awareness of their clinical Physical Therapy,/Volume 72, Number 12December 1992

reasoning and to foster development Therapy, May 17-22, 1987; Sydney, New South 24 Newell A, Simon HA. Human Problem of both reasoning and knowledge Wales, Australia. 1987:543-551. Solving. Englewood Cliffs, NJ: Prentice-Hall; through learning experiences cen- 1972. tered on patient problems. This re- 8 Thomas-Edding D. Clinical problem solving quires accessing students' thoughts in physical therapy and its implications for 25 Chi MTH, Feltovich PJ, Glaser R. Categori- during and after a patient encounter curriculum development. In: Proceedings of zation and representation of physics problems and providing feedback on errors of the Tenth International Congress of the World by experts and novices. Cognitive Science. reasoning that emerge. Teaching Confederation for Physical Therapy; May 17- 1981;5:121-152. students skills of reflection and meta- 22, 1987; Sydney, N m South Wales, Australia. cognition should improve their clini- 1987:10@104. 26 DeGrcmt AD. Thought a n d Choice in Chess. cal reasoning now and equip them New York, NY Basic Books; 1965. with the: means to continue learning 9 Benner P. From Novice to Expert: Excellence from future patient problems. Thera- a n d Power in Clinical Nursing Practice. 27 Chase WG, Simon HA. Perception in chess. pists can improve their own clinical Menlo Park, Calif: Addison-Wesley; 1984. Cognitive Psychology 1973;4:5541. reasoning by stopping at various points through a patient examination 10 Downie J, Elstein AS, eds. Profesn'onal 28 Glaser R, Chi MTH. Overview. In: Chi and the ongoing management period Judgment: A Reader in Clinical Decision Mak- MTH, Glaser R, Farr MJ, eds. The Nature of to consciously reflect on hypotheses ing. New York, W,Cambridge University Expertise. Hillsdale, NJ: Lawrence Erlbaum As- being considered, implications of Press; 1988. sociates Inc; 1988:xv-xxxvi. those hypotheses, and, in hindsight, where e:rrors of reasoning occurred. 11 Nickerson RS, Perkins DN, Smith EE. The 29 Elvey RL. Treatment of arm pain associated Clinical reasoning that is hypothesis Teaching of Thinking. Hillsdale, NJ: Lawrence with abnormal brachial plexus tension. Austra- directed and open-minded can add to Erlbaum Associates Inc; 1985. lian Journal of ~ b ~ s i o t h k r1a9~8~6;.32:224 our organization of knowledge and 229. enhance the quality and accountability 12 Chi MTH, Glaser R, Farr MJ, eds. The Nu- of our patient care. ture of Expertise. Hillsdale, NJ: Lawrence Ed- 30 Butler DS. Mobilization of the Nervous baum Associates Inc; 1988. System. Melbourne, Victoria,Australia: Church- Acknowledgment ill Livingstone: 1991. 1 3 Thomas SA, Wearing AJ, Bennett MJ. Clini- I would like to thank Dr Joy Higgs, cal Decision Making for Nurses a n d Health 31 Patel VL, Frederiksen CH. Cognitive p r e Head, School of Physiotherapy, Fac- Professionals. Sydney, New South Wales, Aus- cesses in comprehension and knowledge ac- ulty of Health Sciences, University of tralia: Harcourt Brace Jovanovich; 1991. quisition by medical students and physicians. Sydney, for her review and sugges- In: Schmidt HG, DeVolder ML, eds. Tutorials tions in the development of this 14 Elstein AS. Cognitive processes in clinical in Problem-Based Learning. Assen, the Nether- manuscript. inference and decision making. In: Turk DC, lands: Van Gorcum BV; 1984;14>157. Salovey P, eds. Reasoning, Inference, a n d References Judgment in Clinical Psychology. New York, 32 Pate1 VL, Groen GJ. Knowledge-based solu- NY: The Free Press; 1988:17-50. tion strategies in medical reasoning. Cognitive 1 Wolf SL, ed. Clinical Decision Making in Science. 1986;10:91-108. Physical Therapy. Philadelphia, Pa: FA Davis 15 Feltovich PJ, Barrows HS. Issues of general- Co; 1985. ity in medical problem solving. In: Schmidt 33 Patel VL, Groen GJ, Frederiksen CH. Differ- 2 Grant R, Jones MA, Maitland GD. Clinical HG, DeVolder ML, eds. Tutorials in Problem- ences between medical students and doctors decision making in upper quadrant dysfunc- Based Learning Assen, the Netherlands: Van in memory for clinical cases. Med Educ. 1986; tion. In: Grant R, ed. Physical Therapy of the Gorcum BV; 1984:128-141. 20:3-9. Cervical a n d Thoracic Spine. New York, NY: Churchill Livingstone Inc; 1988:51-79. 1 6 Elstein AS, Shulman IS,Sprafka SS. Medi- 34 Coughlan LD, Patel VL. Processing of criti- 3 Echternach JL, Rothstein JM. Hypothesis- cal Problem Solving: An Analysis of Clinical cal information by physicians and medical stu- oriented algorithms. Phys Ther 1989;69:559- Reasoning. Cambridge, Mass; Harvard Univer- dents.J Med Educ. 1987;62:81&828. 564. sity Press; 1978. 4 Shepard KF, Jensen GM. Physical therapist 35 Patel VL, Evans DA, Groen GJ. Biomedical curricula for the 1990s:educating the reflec- 17 Barrows HS, Feightner JW, Neufeld VR, knowledge and clinical reasoning. In: Evans tive pracl.itioner.Phys Ther. 1990;70:566-577. DA, Patel VL, eds. Cognitive Science in Medi- 5 Jones MA. Clinical reasoning process in ma- Norman GR. Analysis of the Clinical Methods cine. London, England: The MIT Press Ltd; nipdative therapy. In: Boyling JD, Palastanga of Medical Students a n d Physicians: Final Re- 1989:53-112. N, eds. Modern Manual Therapy: The Vertebral port. Hamilton, Ontario, Canada: Ontario De- Column. 2nd ed. London, England: Churchill partment of Health; 1978. 36 Patel VL, Evans DA, Kaufman DR. A cogni- Livingstone. In press. tive framework for doctor-patient interaction. 6 Payton OD. ClinicaI reasoning process in 18 Barrows HS, Norman GR, Neufeld VR, In: Evans DA, Patel VL, eds. Cognitive Science physical therapy. Phys T k . 1985;65:92&928. in Medicine. London, England: The MIT Press 7 Dennis JK, May BJ. 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Reading, Mass: Addison-Wesley;1983:275 319. comparison of resident performance on real and simulated patients.J Med Educ. 1982;57: 39 Bordage G, Lemieux MA. Some cognitive 708-715. characteristics of medical students with and without diagnostic reasoning difficulties.In: 21 Patel VL, Groen GJ. The general and spe- Proceedings of the 25th Annual Conference cific nature of medical expertise: a critical o n Research in Medical Education; 1986;New look. In: Ericsson A, Smith J, eds. Toward a Orleans, Louisiana. 1986:185-190. General Theory of Expertise: Prospects a n d Limits. New York, NY: Cambridge University 40 Bordage G, Grant J, Marsden P. Quantita- Press; 1991:93-125. tive assessment of diagnostic ability. Med Educ. 1990;24:413425. 22 Groen GJ, Pate1 VL.A view from medicine. In: Smith M, ed. Toward a UniJied Theory of 41 Patel VL, Groen GJ. Developmental ac- Problem Solving: Viewsfrom Content Do- counts of the transition from medical student mains. 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Evaluation and the Health Profes~ions1. 990; atory study. In: Proceedings of the 21sr Confer- 69 Terry W, Higgs J. Educational programs to 13:>36. ence on Research in Medical Education; 1982; develop clinical reasoning skills.Australian Washington,DC.1982:171-176. Journal of Physiotherapy. In press. 43 Barrows HS, Feltovich PJ. The clinical rea- soning pmess. Med Educ. 1987;21:8691. 56 Bordage G, Zacks R. The structure of medi- 7 0 Schon DA. Educating the Refective Practi- cal knowledge in the memories of medical tioner. San Francisco, Calif:Jossey-Bass Pub- 44 Maitland GD. Peripheral Manipulation. 3rd students and general practitioners: categories lishers; 1990. ed. London, England: Butterwonh & Co (Pub- and prototypes. Med Educ. 1984;18:406416. lishers) Ltd; 1991. 7 1 Higgs J. Developing knowledge: a process 5 7 Bordage G, Lemieux M. Semantic struc- of construction, mapping and review. New 45 Jeffreys E. 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Clinical reasoning process in rationale for a new approach to physiotherapy Professionals Think in Action. New York, NY: manipulative therapy. In: Proceedings of the continuing education ~hysiotherap~19. 87;73: Basic Books; 1983. International Federation of Orthopaedic Ma- 324-327. nipulative Therapists Congress;September 4-9, 53 Lesgold A, Rubinson H, Feltovich P, et al. 1988; Cambridge, England 1988:29-30. 8 0 Burnett CN, Pierson FM. Developing Expenise in a complex skill: diagnosing x-ray problem-solving skills in the classroom. Pbys pictures. In: Chi MTH, Glaser R, Farr M, eds. 66 Jones MA. Clinical Reasoning in Manipula- Ther. 1988;69:441447. The Nature of Expertise. Hillsdale, NJ: tive Therapy Education. Adelaide, South Aus- Lawrence Erlbaum Associates Inc: 1981:311- tralia, Australia: South Australian Institute of 81 Slaughter DS, Brown DS, Garder DL, Per- 342. Technology; 1989. Master's thesis. ritt LJ. Improving physical therapy students' clinical problem-solving skills: an analytical 54 Voytovich AE,Rippey RM, Suffredini A. Pre- 67 Higgs J. Fostering the acquisition of clinical questioning model. Phys Ther 1989;69:441- mature conclusions in diagnostic reasoning. reasoning skills.New Zealand Journal of Phys- 447. J Med Educ. 1985;60:302-307. iotherapy. 1990;18:13-17. 55 Bordage G, Allen T.The etiology of diag- 68 Higgs J. Developing clinical reasoning competencies. Physiotherapy. In press. nostic errors: process or content?An explor- Physical Therapy/Volume 72, Number 12December 1992