12. Clinical Reasoning & Bonus scepticism.

“At the end of every first session with all my patients I state/ask the following: ‘It is important before moving on with treatment/rehabilitation that you feel comfortable that I have listened to all your problems, all your concerns and examined you fully. I need you to feel reassured about what is wrong and the recovery process. Do you have any concerns?’. You simply cannot ask this question if you are not confident if you do not know.”

Electric words like these inspire a dream in me and many others like me who have been touched by the intriguing itch of wondering ‘why and how whatever we do is important?’

It’s a decisive and seminal driving force in my opinion; that brings us to painstakingly (much to my enjoyment) dive into an effort to know more, know better and argue passionately and sensibly for all that we know! not only ‘believe‘; after a lot of questioning.

A joy beyond this lies in the realisation that all that we’ve come to ‘know’ is incomplete.

Now,

With that gloom on your faces, let’s talk some stuff.

Clinical reasoning, Clinical judgement, Clinical decision-making, Clinical problem-solving, Diagnostic Reasoning;

These are all the various names used to define a process all of us are all too familiar with.

But, are we really? What if I asked you to teach a student about what it is and how to work on it?

Would you be comfortable enough?

Probably not, because it is often assumed as a universally understood construct, but no one clearly defines what they mean by ‘clinical reasoning’ explicitly.

As decision-making under conditions of uncertainty, risk and complexity become the norm of professional practice. Without a generally accepted definition, even experienced clinicians often find themselves unable to satisfactorily define it. (to themselves or others)

So, what exactly is it then?

It is but a set of operational definitions that educators come up with to capture one of many subordinate terms and concepts (relevant to them) that are housed under the ‘clinical reasoning’ umbrella. A ‘God term’ as stated by Larry Gruppen.

For the sake of this blog, we’ll stick with Barbara Simmons’ definition:

Works for you? Not much? Me neither.

At least not without breaking the definition down. Let’s do just that…

‘A complex cognitive process’

How is it complex? How complex it can actually be?

The complexity isn’t by the virtue of it being a ‘concept’. But, due to the fact that it relates to decision-making, information gathering in a clinical setting and the (content)context-specific nature of it all.

In simpler words,

We humans aren’t totally logical and linear when it comes to decision making,

We rarely conform to normative models, people (including clinicians) are often irrational, illogical, and badly flawed reasoners.

We regularly violate many of these normative principles and make predictable errors (~biases) and with increasing clinical experience, employ heuristics (informal thinking strategies or cognitive shortcuts) to reason about complex issues.

Context including psychological variables, such as fatigue and stress or immediately preceding patient experiences, social variables, such as team relationships and support, and institutional/environmental factors, such as inpatient vs. outpatient setting are just simple additions to the trouble.

This complexity of decision making is worsened when clinicians feel unprepared to deal with the Psychosocial and emotional aspects of the patients.

(here,here,here)

To keep the discussion simple, we need not dive into the ‘Models of Clinical Reasoning’ rather we can reason by simplifying its core concepts, like:

1. Cognition

2. Metacognition

3. Subject-specific knowledge.

Not an exhaustive list by any means. But, simple enough to understand the fundamentals of reasoning.

In no particular and tidy order let’s begin with Cognition,

The term ‘cognition’ refers to all the activities and processes concerned with the acquisition, storage, retrieval and processing of information — regardless of whether these processes are explicit or conscious. (here)

To escape the rabbit hole of ‘defining cognition’ and explaining its workings, we can simply (for the scope of this blog) understand cognition as an umbrella under which many processes like thinking, knowing, remembering, judging, problem-solving, etc. operate.

Popularly, clinical reasoning is believed to operate with 2 such complex thought processes,

1. Non-Analytical These processes are said to be evolutionarily ancient and intuitive knowledge-based, it’s said to be a sense of ‘knowing-how’ which is difficult to explain and represents practical understanding. These processes provide the background or contextual information required for explicit knowledge.

- Heuristics or ‘mental shortcuts’ that are automatically and unconsciously employed, closely relate to the non-analytical processes.

2. Analytical

These processes are evolutionarily recent and are related to language acquisition by humans. Thus they relate to logical thinking, with its inductive and

deductive inferences. They are also considered to be the foundation of scientific reasoning, with their reliance on hypothesis formation and subsequent capacity to test hypotheses.

Be it ‘Hypothetico-deductive reasoning’ or ‘Pattern recognition’, a rough insight into CR shows that,

‘clinicians – when making diagnoses – compare patterns of diseases from previous experiences and then match the current disease with one they previously encountered’ (here)

Or simply, a bunch of non-specific hypotheses based on patients’ presenting complaints are then filtered through clinical and theoretical experiences, leading to a single hypothesis that explains most.

So, given that you have read all the technical details mentioned so far, how confidently can you assert any observation about Clinical reasoning?

Aah… If only it were that simple.

Anders Ericsson rightly observes;

This brings us to make an attempt to understand Knowledge, Biases and What makes a ‘True Expert’?.

Bias, a simple yet conspicuously infamous term in science.

Or in simpler terms, “a disproportionate weight in favour of or against an idea or thing, usually in a way that is closed-minded, prejudicial, or unfair.”

As we have established earlier, we human beings and our reasoning aren’t ‘as reliable’ as it ideally should be.

*Funnily enough, there are quite a few ‘lists’ of biases to prove that it is so.

Thus unsurprisingly, clinical reasoning isn’t free from the grips of biased intuitions, knowledge or conclusions as well (many of them sadly are the ‘diagnoses’ we make).

A few critical things about biases in clinical decision making I’d like to point out before we move to a more elaborative portion of the blog are:

1. More processing time is generally associated with more errors. (without sufficient knowledge additional processing is pointless)

2. Cognitive biases can lead to errors in clinical reasoning.

3. Knowing about biases and de-biasing techniques doesn’t necessarily make you immune to errors in reasoning.

4. If you are a novice focus on learning, if you are experienced focus on reflection(explained later).(here)

Now,

With that in mind and In light of clinical experience, knowledge and biases, I believe its important to further focus on:

1. When to stop?

But, What/Who is an expert? Someone who has achieved a certain stature? Someone who performs at a higher level? Belongs to a particular occupation? Have many years of experience? Have certain degrees? Or a specialist/sub-specialist?

We consider expertise as an inevitable result of experience, an achievement that then stays with you for life.

Rather, expertise is a process. It’s not a job-related what or who question, it’s an individual’s ability to respond effectively at the moment to the limits of his/her/their automatic resources and to transition effectively to an effortful process when needed.

To clarify further, an expert’s thought/workflow isn’t the ‘expert analytical process’ as we all immediately attribute it to be,

But, it’s the automatism (of non-analytic processes) that comes with experience that makes an expert’s operations seem streamlined.

Like: A Surgeon performing a standard operation while talking about a tennis game, Emergency physicians immediately initiates multiple procedures in a trauma victim, Family doctors recognize a chicken-pox rash instantly.

Humans have become very good at adapting to a constant flux of information through the development of automatic processes that require less intentional capacity and thereby, frees up cognitive resources for additional activities.

And extremes of this process can be appreciated when experts can no longer verbalize the thought process involving a decision, For example, if asked, many of us would stumble and some even fail to explain ‘long division’ to 3rd graders convincingly.

Is that enough though? All it takes to make an expert is time and theoretical knowledge?

No, Bereiter and Scardamalia in their book Surpassing Ourselves,

Describes that an individual who makes exclusive use of non-analytic resources is unlikely to manage novel situations or unusual cases appropriately.

The recognition that not all those who have the title of ‘expert’ are truly functioning as experts is an important demarcation we need to familiarise ourselves with.

“ ‘no one is disturbed by the fact that experienced physicians are better at diagnosis than interns.’ What we might be disturbed by is a practising physician whose expert judgment is inadequate.”

–Points out Bereiter and Scardamalia

They define such individuals as ‘Experienced Non-Experts’,

They are technicians who perform well on routine problems by unreflectively and automatically applying standard theories and techniques. However, they will not display creativity in finding solutions to ill-defined or unusual situations, the problems for which the standard techniques will not work.

An expert on the other hand understands the complexities of the situation and are well prepared to transition from moment to moment between heavier reliance on automatic and heavier reliance on effortful processes to complete the task at hand.

In summary, an expert knows ‘when to stop’. (here)

And, While the majority of cases present to us with non-specific conditions, it begs the question;

Is it possible to be a ‘true expert’ in physiotherapy? or at all?

2. ‘Once a student always a student’.

All of us know something, even the most basic things in our own ways, Like; the way we hold our pens, the way we sometimes tilt our head when we smile, the way we might have tried to make funny faces for a baby.

From walking to reach school/work, reading, writing, and almost everything we do, we have learnt somehow; even if we realise it or not.

Thus, by a very loose definition, we are all students for life.

For quite a few of us who work with patients/clients (in healthcare).

‘Being a student for life’ is more direct than it seems. Learning comes to us in phases and the knowledge ‘sticks’ with us for life (given that we remain responsible, honest and ethical).

Let’s discuss these phases(wherein we were/are students of different aspects of clinical skills and personal growth)

It’s an interplay of these stages that leads to favourable, functional and evidence-based(updated) knowledge, which translates to better clinical skills and us being able to help people better.

A) Students of Biomedical knowledge.

Medical Colleges and universities primarily initiate students in the study of biomedical aspects of physiotherapy/medicine. The so-called basic sciences:

Anatomy, physiology, genetics, biochemistry, biomechanics, etc.

Even a layperson would agree that a trained health professional should have some understanding of these subjects, While most people would find something unsettling about the notion that these disciplines might have little impact on everyday clinical decisions. By contrast, we are all familiar with situations in which information that is important in theory becomes less so in practice.

Especially Biomedical knowledge, which is increasingly challenged in evidence-based practice, and with ever-increasing awareness about Biopsychosocial aspects of clinical skills.

But, there is no harm in recognizing that while we remain sceptical of the biomedical knowledge for the reductionism, dogma and narratives that stem from it, we may simply be expressing a sort of meta-cognitive bias if we fail in recognizing how our knowledge of the basic (biomedical) sciences form the cues, assumptions and background knowledge that shapes the way we organise and interpret clinical information or even build ourselves towards a more holistic and BPS outlook.

B) Students of Reflective thinking.

‘Practical knowledge cannot be taught in the classroom’ almost all of us might be familiar with this statement or at least some or one of its numerous versions. And it must in fact be true, because practical(clinical) knowledge as heavily context-dependent as it is, must be impossible to teach in a limiting environment.

While learning clinical skills we’ve all been through this cycle of what practical knowledge looks like in action:

1. Knowing in action refers to the ‘know how’ we develop (with years of experience) when carrying out daily routines of practice, like introductions, patient interviews, checking vitals, etc.

2. Reflection in action is the ability to improvise on the spot or ‘thinking on our feet’ when we encounter an unusual or surprising event.

Like changing the flow of questioning when an unexpected presentation or a suspected ‘serious red-flag’ is encountered.

1. Reflection on action completes the reflective cycle, it is an effortful process performed sometime after an event that cannot influence the outcome of that particular event.

It is done in an attempt to make sense of previous situations of uncertainty or uniqueness, either out of curiosity or an effort to prepare for future cases.

This metacognitive or reflective cycle is what brings a functional clinician out of us,

And developing automaticity in this metacognitive monitoring. Control of thoughts, continuously generating possibilities, weighing those options, exploring subsets of options, and evaluating the results, might be a crucial step we take towards becoming a; ‘true expert’.

C) Students of scepticism.

Jennifer saul states;

Probably one of the defining and turning moments of a clinician’s journey is when they adopt healthy scepticism.

This healthy and necessary sceptical outlook towards clinical reasoning leads us to:

1. Discover how things and definitions change for the best.

2. Moving on from ill-informed beliefs and practices.

3. Reasonably doubt and analyse reasoning ‘experts’ present to make an informed choice and avoid accidental ‘bandwagon hops’.

4. Necessary self-reflection to avoid burn-out, disillusionment, and complacency.

And to one final question;

Disclaimer: This blog isn’t meant to be offensive to any profession or a set of professionals, it also does not mean to undermine the value of experience and expert judgment in clinical settings.

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