Nicole Christensen, Mark A. Jones, Darren A. Rivett A common observation among clinicians and their educators about clinical reasoning is that they know it when they see it, and they know it when they don’t! The challenge lies in knowing how to facilitate performance improvements when inadequate clinical reasoning is identified. This chapter aims to serve as a resource for all those involved in facilitating the learning of, as well as from, clinical reasoning. Clinician educators are involved in the facilitation of clinical reasoning development at all levels of formal professional education, from the preparation of learners for first entry to practice to mentoring post-professional clinical students in their advancement toward specialty practice. Individual musculoskeletal practitioners who are committed to continual growth and improvement of their own practice abilities also engage in informal opportunities to facilitate clinical reasoning development throughout their careers, both independently and with colleagues in various practice communities. As such, it is important for all clinicians to develop their skills in the facilitation of clinical reasoning as part of their professional development throughout their careers. The facilitation of clinical reasoning development in clinician learners results in both short-term and long-term benefits to the learners themselves, their current patients and all those they will work with in their future practice. This is because improving the quality of clinical reasoning not only affects the decisions made by a learner with today’s patients but also improves the ability of that clinician to learn from today’s experiences and also to apply that new knowledge to clinical reasoning and decision-making with future patients. Clinical reasoning itself and the ability to learn from experiences of reasoning are, in effect, interdependent learning outcomes, with improvement in one enhancing the potential for greater achievement in the other. In this chapter we have grounded our proposed facilitation strategies in current understandings of clinical reasoning in the literature (as presented in Chapter 1) and relevant educational theories. Literature describing research-based models of expert practice and the clinical reasoning of experts has been summarized (Christensen et al., 2011; Chapter 1) previously as follows: Research-based descriptions of novice and less skilled musculoskeletal clinicians’ clinical reasoning have also appeared in the literature. For example, in physiotherapy, the clinical reasoning of novices has been broadly characterized as more therapist centered and lacking in collaboration, with less focus on understanding of the patient as a person in favor of a narrower focus on primarily the physical aspects of a patient’s presentation (Jensen et al., 1990, 1992; Resnik and Jensen, 2003). Beginning practitioners in their first 2 years of practice have been shown to develop from decision-making characterized as standardized and objectively data driven to more individualized clinical reasoning that is inclusive of the patient’s context and narrative (Black et al., 2010; Hayward et al., 2013). Another study of extreme novices in their first year of training described their early clinical reasoning as a rote (checklist-oriented), protocol-driven process, which progressed to more robust reasoning, including both hypothetico-deductive and early pattern-recognition processes, by the time they reached their final year of training when reasoning was being facilitated through case-based decision-making activities in the academic setting (Gilliland, 2014). These descriptions of novice clinical reasoning support the findings of Christensen et al. (2008a, 2008b, Christensen, 2009), who characterized novice students at the time of professional entry as understanding clinical reasoning to be a deductive, linear process. The clinical reasoning of the novices studied was also found to be lacking in an awareness of the role of collaboration in clinical reasoning and of how to use critical self-reflection as a means to learn from their reasoning experiences (Christensen et al., 2008b). This finding is in stark contrast with the summary description of skilled clinical reasoners provided at the beginning of this section. Critical reflection on clinical reasoning experiences is described as the vehicle from which clinicians learn from past clinical encounters and for future encounters and through which they build knowledge and eventual expertise (Brookfield, 1986; Edwards and Jones, 2007; Higgs and Jones, 2008; Jensen et al., 2000; Stephenson, 1998). Transformative learning theory (Cranton, 2006; Mezirow, 2009) is a particular branch of reconstructivist learning theory that can provide a foundation for proposed educational strategies for facilitating the learning of, and from, clinical reasoning. Transformative learning is a process of using a prior understanding to construct a new or revised interpretation to guide future action. This learning transforms the learner by expanding the learner’s understanding, resulting in knowledge that is more ‘inclusive, discriminating, reflective, open and emotionally able to change’ (Mezirow, 2009, p. 22). Particularly relevant to our focus on using critical reflection on clinical reasoning experiences as the stimulus for transformative learning is this description of one of its outcomes: ‘adults learn to reason for themselves – to advance and reassess reasons for making a judgment – rather than act on the assimilated beliefs, values, feelings and judgments of others’ (Mezirow, 2009 p. 23). This type of learning is critical for novice clinicians, who can tend to excessively rely on others’ knowledge and judgement when just starting out in practice, but also to more experienced clinicians who sometimes fall into cognitively lazy habits of practice with insufficient critical reflection and reasoning. Expertise in clinical practice can be viewed as a result of excellence in learning from clinical experiences. The facilitation of critical self-reflection on clinical reasoning creates opportunities for challenging clinical knowledge and any potentially unsubstantiated assumptions underlying that knowledge. This type of challenge allows for growth and transformation of existing frames of reference, including theoretical or research-derived and experience-derived knowledge that, through application and testing with a recent clinical experience, may be revealed to have been inadequate. Informed by an understanding of the key characteristics of the clinical reasoning of experts and the observable gaps between expert reasoning and the clinical reasoning of novices, Christensen and colleagues (2008a, 2009, 2011; Christensen and Nordstrom, 2013; Christensen and Jensen, 2019) have proposed an approach to facilitating the teaching and learning of clinical reasoning focused on the development of key thinking and experiential learning skills identified in the skilled clinical reasoning of experts. The literature clearly presents a consensus of support for the notion that development of practice-based knowledge through the accumulation and critically reflective processing of clinical experiences is necessary for the development of expertise (Edwards and Jones, 2007; Higgs and Jones, 2008; Jensen et al., 2000, 2019). Although novices cannot simply be ‘taught’ to be experts, the concept of clinical reasoning capability is grounded in the idea that clinical reasoning capability can be facilitated in clinicians at any point along the continuum from novice to expert practice (Christensen et al., 2008a; Christensen, 2009; Christensen and Jensen, 2019). It is this capability that is thought to contribute to the development of expertise through accumulated clinical experiences (see Fig. 31.1). The concept of capability in this case is grounded in descriptions in the higher education literature (Stephenson, 1998) in which the term capability has been operationally defined as ‘the justified confidence and ability to interact effectively with other people and tasks in unknown contexts of the future as well as known contexts of today’. Capability is observed through the following characteristics: In addition to the development of confidence in one’s effectiveness as a collaborator and a decision-maker, in both known and unknown contexts, capability is also characterized by a motivation to intentionally develop knowledge through reflective learning in clinical practice (Doncaster and Lester, 2002). These concepts and descriptions of capability can be seen as compatible with characteristics of transformative learners. Building on this more general understanding of capability in the educational literature, Christensen and colleagues (2008b, 2009) described clinical reasoning capability as the integration and effective application of thinking and learning skills to make sense of, and learn collaboratively from, clinical experiences. Their model of clinical reasoning capability proposes four key areas of interdependent thinking and experiential learning skills, directly related to descriptions of the thinking and learning skills inherent in the clinical reasoning of expert physiotherapists, including those in musculoskeletal practice. The skills proposed to be linked to the development of excellence as both a clinical reasoner and an experiential learner are reflective thinking, critical thinking, complexity thinking and dialectical thinking (Christensen et al., 2008a, 2008b; Christensen, 2009; Christensen and Jensen, 2019). Consistent with the literature on capability, which describes it as always evolving as practice contexts that were previously unknown become known (Doncaster and Lester, 2002; Stephenson, 1998), these proposed clinical reasoning capability skills are not intended to represent a comprehensive or definitive list of all aspects of thinking and learning important to developing excellence in clinical reasoning; rather, they include essential, foundational aspects that can be built upon and tailored to all practice contexts. Reflective thinking is thinking about a situation in order to make sense of it, which involves evaluating the influence of all relevant aspects of the situation and individuals involved (e.g. clinician, patient, clinical setting, resources available, time constraints, etc.). Reflection allows for interpretation of experience; as part of reflection, the thinker comes to know the ‘why’ of a situation by subjectively and objectively reconsidering the context in order to bring to light the underlying assumptions used to justify beliefs (Mezirow, 2000). When reflective thinking calls into question the adequacy of the clinician’s knowledge, learning from the clinical reasoning experience is facilitated as prior knowledge is revised and/or expanded. Schön (1987) describes various moments in time when reflection is integral to making sense of, and eventually improving, the quality of practice experiences: reflection on action, reflection for action and reflection in action. As applied to a clinical reasoning encounter, reflection on action occurs after the clinical action is completed and involves cognitive organization of experiences to make sense of what happened. Reflection for action involves planning for future encounters by thinking back on past experiences. This includes reflecting on the adequacy of the knowledge available to the clinical reasoner during those past encounters, identifying and actively seeking to fill any gaps in existing knowledge, and making links between past experiences and anticipated future events. Reflection in action occurs in the midst of an experience and allows for modification of clinical reasoning by ‘thinking on your feet’ in order to best adapt to an emerging understanding of a situation. In order to successfully employ reflection in action to modify decision-making in the moment, a clinician must be able to readily access contextually relevant knowledge from memory. This is also related to metacognition (Higgs et al., 2008; Marcum, 2012; Schön, 1987) – self-awareness and monitoring of one’s own thinking while in action – described in Chapter 1 as integral to the facilitation of learning from clinical experiences. Wainwright and colleagues (2010) describe how reflection at different times in relation to a clinical encounter was used by novice and experienced clinicians. Their research findings include the observation that novices less commonly used reflection in action, and when it was used, it focused mainly on the patient’s performance. More experienced clinicians reflected in action more often and were focused not only on the patient’s performance but also on self-monitoring of their own reasoning in action. These findings highlight the importance of facilitation of reflection and evaluation of one’s reasoning in action as essential to the facilitation of learning from, and developing expertise in, clinical reasoning. In the context of today’s complex practice environment, Jensen (2011) recently reinforced this importance to the community of professional teachers and learners: … It is the reflective ability to understand the context, identify what values may be at risk, and understand the meanings that others see in the situation that is critical. This reflective ability is best learned by moving well beyond reflection on-action to more critical self reflection on students’ thinking about their thinking, their metacognitive skills, and their ability to self-regulate and self-monitor. (pp. 1679–1680) Critical thinking, also described in Chapter 1, is intimately linked to reflective thinking and involves intellectual discipline in the process of actively conceptualizing, synthesizing, analyzing and evaluating information; this information can be gathered or generated from observation, experience, interaction, reasoning and reflection, and it serves as a guide toward action (Paul, 1992; Paul and Elder, 2006). In this context, critical thinking is conceived of as a way of thinking about thinking with the intent of questioning and clarifying erroneous assumptions underlying the thinking, and it is a skill that promotes learning from and about thinking. In this way, similar to reflective thinking, critical thinking is also linked to metacognition. There is some recent evidence that a standardized measure of critical thinking abilities in the context of health care, the Health Science Reasoning Test (HSRT), is able to demonstrate significant differences in the critical thinking abilities of novices as compared to clinical specialist physical therapists (Huhn et al., 2011). This finding supports the proposal that more skilled, experienced practitioners have more sophisticated critical thinking skills, which parallels the observation of more sophisticated clinical reasoning skills in expert clinicians. Thus, this also further supports the proposition that because it is a foundational element of skilled clinical reasoning, critical thinking is a key component of clinical reasoning capability. Huhn and colleagues (2011) also suggest that critical thinking is a skill that can and should be explicitly developed in novices as one way to support the development of clinical reasoning skill. Explicit teaching and assessment of critical thinking skills themselves have also been recognized as an essential curricular element for all health professions by an interprofessional group of educators, as stated in a recently published consensus document (Huang et al., 2014). Hawkins and colleagues (2010) have summarized elements of clinical reasoning linked to interdependent structures present in all thinking, as follows: Whenever we think, we think for a purpose within a point of view based on assumptions leading to implications and consequences. We use concepts, ideas, and theories to interpret data, facts, and experiences in order to answer questions, solve problems, and resolve issues. (p. 5) In the context of clinical reasoning capability, critical thinking applies to both the examination and management of a particular patient’s clinical presentation and to the critical evaluation of one’s own thinking or reasoning used to engage in, interpret and synthesize that patient’s clinical information (Christensen et al., 2008b; Christensen, 2009). Critical thinking also makes it possible to bring to light blind spots or gaps in knowledge that may be adversely affecting a clinician’s clinical reasoning in a given context. The important role of critical thinking in exploring the potential for biases, incorrect assumptions, inadequate knowledge and erroneous unconscious patterns of interpretation is essential to the concept of demonstrating capability in clinical reasoning. Complexity thinking is a way of thinking that is grounded in an acknowledgement of the dynamic interdependencies present in systems at work between the many elements and players influencing a given situation (Plsek and Greenhalgh, 2001; Davis et al., 2000). Therefore, complexity thinking is linked to the recognition and consideration of the relative weighting of all relevant internal (within the person) and external (the context in which the person is functioning) factors influencing a given clinical presentation (Christensen et al., 2008b; Christensen and Nordstrom, 2013; Stephenson, 2004). Skilled clinical reasoning has been shown to be in part characterized by this ability to see and appropriately address all influences (both biological and psychosocial) at play in a particular clinical presentation, leading to a mutually agreed-upon plan of care (Edwards et al., 2004a). Capability in clinical reasoning is also conceived of as being characterized by motivation and skill in learning from clinical experiences (Christensen et al., 2008b; Christensen, 2009). Consistent with a complexity science perspective of learning, clinical experience alone is not enough to cause learning to happen; rather, experience is viewed as a trigger or an opportunity for learning to emerge from interactions with other individuals (Davis and Sumara, 2006). Complexity thinking therefore is also a key element that enables a capable clinician to consider and appreciate the importance and implications of establishing a collaborative relationship with the patient. Collaboration is an essential component of clinical reasoning when conceptualized as a complex, interactive social system through which decisions emerge (Christensen et al., 2008b; Christensen, 2009). This collaborative interaction between participants in clinical reasoning is proposed to be a hallmark of clinical reasoning capability (Christensen et al., 2008b; Christensen, 2009). Development of an understanding of both the physical or biological aspects of a patient’s presentation and the psychosocial and behavioral aspects as being relevant, inseparable and interdependent elements of the health of the complex human beings who are our patients is consistent with clinical reasoning within a biopsychosocial approach to health care and therefore clearly requires complexity thinking. In this way, complexity thinking is also consistent with the dialectical reasoning approach (see Chapter 1) observed in the reasoning of experts (Edwards and Jones, 2007). Interestingly, it has been proposed that facilitating in a learner the recognition of some of the challenges raised by the complexity inherent in a particular situational context (in this case, collaborative clinical reasoning in today’s healthcare climate) can in and of itself become a trigger for transformative learning (Alhadeff-Jones, 2012). Complexity thinking is also necessary to facilitate continuous learning from experiences. Indeed, a complex way of thinking encompasses a perspective that views engaging in reasoning as a potential source of transformative learning, that is, ‘a method of learning involving human error and uncertainty…taking into consideration both the individual and collective experiences grounding any activity’ (Alhadeff-Jones, 2012, p. 190). In this way, complexity thinking is again closely linked to collaborative clinical reasoning and the learning that can emerge for all involved. The clinical reasoning of experts, as described by Edwards and Jones (2007), is characterized by a fluidity of reasoning between deductive thinking and inductive thinking within each of the clinical reasoning strategies (Edwards et al., 2004a). As described in Chapter 1, expert physiotherapists have been shown to dialectically move in their reasoning between contrasting biological and psychosocial poles in a fluid and seemingly effortless manner (Edwards et al., 2004a). This thinking ability is proposed to be necessary for clinicians to develop a holistic understanding of the person who is the patient and the clinical presentation of the patient’s problem(s), consistent with a biopsychosocial approach to clinical reasoning (Edwards and Jones, 2007). Development of dialectical thinking allows for clinicians to achieve a more complex and contextual understanding of situations both impacting and impacted by a patient’s presentation. Recognition of the interdependence of dialectical thinking and complexity thinking is also key to the promotion of capability in clinical reasoning, as capability includes effectiveness in working with others to achieve collaborative and productive working relationships (Doncaster and Lester, 2002; Stephenson, 1998). The ability to simultaneously perceive and interpret information in terms of its implications for different categories of judgements (e.g. ‘hypothesis categories’ as discussed in Chapter 1) and to dialectically shift reasoning from one focus (e.g. physical/biological) to another (e.g. psychosocial) is also an advanced reasoning ability that can be developed through practice and assistance. How can we use our understanding of the ways in which the clinical reasoning of novices differs from that of experts and the notions of transformative learning and capability in clinical reasoning to better facilitate clinical reasoning development in learners of musculoskeletal practice across all professional education settings? As a complex, abstract practice phenomenon, the teaching and facilitation of learning of clinical reasoning is challenging in both the classroom and clinical education contexts. Core elements within which educators should frame a transformative learning approach to teaching have been summarized by Taylor (2009) as follows: promotion of individual experience; engagement in critically reflective dialogue with others; a holistic, contextual awareness; and learning situated in an authentic practice context. These elements are described as interdependent when put into an educational framework and are thus integrated within the suggested educational strategies described in the following sections. The first and arguably most important step in facilitating the development of both the thinking and learning skills underpinning skilled clinical reasoning, in both academic classroom and clinical education settings at all educational levels, is to make visible to the learner what is invisible. This can be seen as a form of promoting a contextual awareness of clinical reasoning in a community of learners. The profession of physiotherapy can be seen as an example of what Wenger (1998) describes as a community of practice. The notion of giving an artificially concrete ‘form’ to abstract, invisible concepts and experiences (such as clinical reasoning) is described by Wenger (1998) as a way in which a community shapes the experiences of its members in order to provide focused attention to experiences in a particular way so as to facilitate new kinds of understanding (i.e. learning). Clinical reasoning is an invisible phenomenon; the actions of those involved (e.g. patient–clinician interactions throughout the examination and ongoing management) provide an external observer (e.g. clinical supervisor or professional colleague) only one perspective from which to infer all of the reasoning happening within and between those individuals. Therefore, clinical reasoning must be able to be made visible in a mutually understood way, dialogue and discussion enabled, critical self-reflection promoted and experiential learning facilitated in order for reasoning development and progression toward expert practice to occur. Indeed, all of the strategies suggested herein build on this fundamental theme of making visible and explicit their links to facilitating clinical reasoning development by way of a common language and framework to enable the development of a mutual understanding within which the learners and facilitators can discuss, critically reflect and promote the development of clinical reasoning capability. Commonly understood and accepted definitions, models and frameworks of clinical reasoning that enable visualization of all of the aspects of clinical reasoning are essential to this strategy. The dialectical model of clinical reasoning (Edwards and Jones, 2007) and associated clinical reasoning strategies model (Edwards et al., 2004) are two such models that have been described in the literature and are grounded in the study of expert physiotherapists’ clinical reasoning, including musculoskeletal clinicians. The ‘hypothesis categories’ framework is more theoretical but has research evidence for its use (Rivett and Higgs, 1997; Miller, 2009). Each of these is described in detail in Chapter 1. By fostering a learner’s awareness of different foci of reasoning (i.e. clinical reasoning strategies) and their interactions, as well as different categories of clinical judgements (i.e. hypothesis categories) and their interactions, while developing the learner’s ability to dialectically move in his or her focus of reasoning and categories of judgements, the learner’s clinical reasoning capability can be more easily and explicitly facilitated. The development of complex understandings and complexity thinking is facilitated when discussing the different foci of reasoning and categories of judgements, with attention given to the basis and validity of judgements or hypotheses formulated, interdependent relationships between aspects of a patient case and how hypotheses can be further tested. Further complexity is appreciated when analysis and discussion include relevance and weighting of examination and re-assessment findings in the broader context of the patient’s life, including the patient’s pain or disability experiences, expectations and goals. The ability for learners and educators/facilitators to have access to a commonly understood language of clinical reasoning, embedded in clinical reasoning models and frameworks such as these, assists in their identification of, description of and critical reflection on their clinical reasoning, enabling assessment of reasoning performance, which is needed to facilitate learning of, and from, clinical reasoning. Once a model of clinical reasoning has been adopted as a ‘visible’ framework within which learners and facilitators can identify and name various foci of reasoning (i.e. clinical reasoning strategies) and categories of clinical judgements (i.e. hypothesis categories), then use these to critique clinical reasoning performance, the teaching and learning of profession-specific technical skills can be embedded or situated within clinical reasoning as a larger umbrella or learning context (Christensen, 2009; Christensen and Nordstrom, 2013). Clinical reasoning then becomes the foundational context within which to add profession-specific technical knowledge, rather than discussions of associated clinical reasoning serving as intermittent teaching points under the larger umbrella of learning technical skills. This type of curricular structure is not typically found in most entry-level or post-professional educational curricula; these curricula are instead typically organized around the development of technical skills. An example of using clinical reasoning as the curricular organizing framework is a situation where the focus of learning is on interventions appropriate for a particular array of impairments and/or activity restrictions. This technical skills content could be situated as one example within a larger context of procedural reasoning strategies/considerations for addressing various examples of patient presentations. Another example, this time focused on inductive thinking, is a curriculum that frames the content related to the effective education of patients about injury prevention or wellness within a larger context of narrative reasoning strategies. In this case, the focus would be on understanding the patient’s perspective on his or her current situation and the patient’s existing attitudes about making health-behavior changes, as well as how this understanding would influence the education of patients in injury prevention and wellness, depending on what the perspective of the individual patient might be. This type of curricular organization might more easily facilitate the building of explicit connections between what students know about how to ‘do’ musculoskeletal practice and the clinical reasoning and experiential learning processes within which the ‘doing’ takes place (Christensen and Nordstrom, 2013).
Strategies to Facilitate Clinical Reasoning Development
Introduction
Describing Clinical Reasoning
Clinical Reasoning and Transformative Learning
Capability as a Learning Outcome
Clinical Reasoning Capability
Reflective Thinking
Critical Thinking
Complexity Thinking
Dialectical Thinking
Making Learning More Likely
Making Visible the Invisible: Use of Common Definitions, Language and Models
Using Clinical Reasoning as a Curricular Framework
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Strategies to Facilitate Clinical Reasoning Development
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Fig. 31.1 Proposed role of clinical reasoning capability in accelerating the development of expertise. Solid line represents the developmental trajectory of a novice clinician with more capability in clinical reasoning thinking and experiential learning skills. Line of Xs represents the development of a novice with less capability.
