Research Report
Clinical Reasoning in Musculoskeletal Practice: Students’ Conceptualizations Paul Hendrick, Carol Bond, Elizabeth Duncan, Leigh Hale P Hendrick, BSc(Hons), GradDipPhty, PGDMPhty, MMPhty, MNZSP, is Professional Practice Fellow, Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, PO Box 56, Dunedin, New Zealand. Address all correspondence to Mr Hendrick at: paul. hendrick@otago.ac.nz or PaulSinead@xtra.co.nz. C Bond, PhD, MCSP, is Academic Director, Student Learning Centre, and Senior Lecturer, The Higher Education Development Centre, University of Otago. E Duncan, PhD, BSc(Hons), is Research Assistant, School of Physiotherapy, University of Otago. L Hale, PhD, MSc(Physio), BSc(Physio), FNZCP, is Senior Lecturer, Centre for Physiotherapy Research, School of Physiotherapy, University of Otago. [Hendrick P, Bond C, Duncan E, Hale L. Clinical reasoning in musculoskeletal practice: students’ conceptualizations. Phys Ther. 2009;89:430 – 442.] © 2009 American Physical Therapy Association
Background. Qualitative research on physical therapist students’ conceptualizations of clinical reasoning (CR) is sparse.
Objectives. The purpose of this study was to explore CR from students’ perspectives.
Design. For this study, a qualitative, cross-sectional design was used. Methods. Thirty-one students were randomly selected from years 2, 3, and 4 of an undergraduate physical therapist program in New Zealand. Students were interviewed about their understanding of CR and how they used it in practice in a recent musculoskeletal placement. Interviews were recorded and transcribed verbatim. A 3-stage analysis included the categorization of students’ conceptualizations on the basis of the meaning and the structure of each experience and the identification of cross-category themes.
Results. Five qualitatively different categories were identified: A—applying knowledge and experience to the problem, patient, or situation; B—analyzing and reanalyzing to deduce the problem and treatment; C—rationalizing or justifying what and why; D— combining knowledge to reach a conclusion; and E—problem solving and pattern building. Cross-category analysis revealed 5 general themes: forms of CR, spatiotemporal aspects, the degree of focus on the patient, attributions of confidence, and the role of clinical experience. Conclusions. Categories formed a continuum of CR from less to more sophistication and complexity. Students were distributed evenly across categories, except for category E, which included only students from years 3 and 4. Each category comprised a logical, coherent experiential field. The general themes as critical dimensions suggest a new way of exploring CR and suggest a possible pathway of development, but further research is required. These findings have implications for teaching and the development of physical therapy curricula.
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linical reasoning (CR) is the thinking and decision-making process used by practitioners.1 Research on CR in the health sciences has evolved over 3 distinct, but overlapping, phases, in which the shifts in focus have been accompanied by differences in how CR was understood and explained.2 The first phase (1950s–1970s), which focused on the psychometric aspects of reasoning and the development of measurement tools, continues to be evident in tools used to assess CR skills.
The second phase was more cognitive and process oriented, concerned with specifying knowledge structures and strategies,3 analyzing behaviors, and eliciting steps in problem solving.4,5 Clinical reasoning was understood predominantly as hypothetical deductive reasoning (HDR), comprising the generation of hypotheses on the basis of prior knowledge and clinical data, inductive reasoning to generate hypotheses, and the deductive reasoning necessary for the testing of hypotheses. Four components of HDR were identified: cue acquisition, hypothesis generation, cue interpretation, and hypothesis evaluation.6 Much of this research originated in occupational therapy7 and was adopted and expanded by recent work in physical therapy.8,9 Research in the third phase was more hermeneutic. It emphasized situated cognition and phenomenological approaches,10 focused on understanding practitioners’ lived experiences, and reflected the emerging movement toward patientcentered care.11 Clinical knowledge and CR were interdependent; effective CR required depth and organization of knowledge.12 Clinical reasoning was understood predominantly as pattern formation and recognition,13,14 a process of perceiving and storing related information to be reMay 2009
called and used as a prototype when a suitable stimulus was presented. Patterns were constantly revised and reformulated,13 making CR a more transformative spiral model15 reflecting a cyclical, developmental process. Each loop of the spiral incorporated data input, interpretation, and problem formulation to achieve a broader and deeper understanding of the clinical problem; this model better matched the definition of CR as a process of integrating knowledge, cognition, and metacognition.16,17 In contrast to CR in previous phases, CR in the third phase was a process that applied throughout the interaction with the patient.7 For this contemporary, multidimensional view of CR18 to be explained and understood, morecomplex integrated models had to be developed.19 Teaching and assessment of CR skills are key objectives of physical therapy education worldwide.20 Currently, a range of tools are used to assess students’ CR skills.21–27 Each tool tests different decisions regarding diagnostic hypotheses, investigative actions, or treatment options, thus focusing on analyzing and measuring the processes used by the students rather than their understanding of CR.21,25,27,28 Missing are studies that focus on the students’ own experiences, that is, the ways in which they conceptualize CR. Knowledge of variations in students’ conceptualizations of subject matter is important for teaching. Marton et al29 argued that teaching becomes a rational activity only when the instructor understands what and how students discern or conceptualize the phenomenon being taught. From a phenomenographic perspective,30 –32 a large body of research shows that students’ conceptions of learning influence the way in which they learn.33 Students who understand learning as repetitive memori-
zation tend to use simple strategies and achieve a limited conceptualization of the topic. In contrast, students who learn in order to understand a topic are likely to engage in activities that promote understanding and achieve a more sophisticated conceptualization. Given this research, it follows that students’ conceptualizations of CR are likely to influence the way in which they reason in the clinical setting. The current study was prompted by musculoskeletal (MS) clinical teachers’ concerns about the extent of variability in physical therapist students’ CR skills across the curriculum and most evident in the fourth year of study. The aim of this research was to explore students’ conceptualizations of CR in the MS component of the physical therapy curriculum across the years to help inform teaching of this complex skill.
Method Study Context The study was located in a physical therapy school at a university in New Zealand. The physical therapist program offered a 4-year undergraduate degree and comprised a curriculum approved by the physical therapy regulatory body in New Zealand—the New Zealand Physiotherapy Board. Year 1 of the program was a common science foundation program for all students intending to enter health professions. Years 2 to 4 were dedicated to physical therapy education.
Available With This Article at www.ptjournal.org • Audio Abstracts Podcast This article was published ahead of print on March 27, 2009, at www.ptjournal.org.
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Clinical Reasoning in Musculoskeletal Practice guage or who had not completed an MS clinical placement were excluded from the groups. A stratified purposeful sampling approach by year of study was used. Although this approach reduced sample size, it allowed sampling to cover a range of characteristics that better defined the phenomenon under study.35 Students were selected randomly from each group at a ratio of women to men reflecting the actual sex distribution of the class. The final sample consisted of 31 students (20 women and 11 men): 11 from year 2 and 10 each from years 3 and 4 (Tab. 1).
Figure 1. Analytical framework for students’ conceptualizations of clinical reasoning (CR).32
Years 2 and 3 focused predominantly on principles and techniques, taught mainly through lectures and practical sessions; CR was embedded as a key objective and learning outcome in each topic of the 3 core disciplines (MS, neurorehabilitation, and cardiorespiratory). In the MS component of the curriculum, CR was specifically taught using HDR and pattern recognition through three 1-hour lectures and 3 practical sessions in year 2 and two 1-hour lectures and 2 practical sessions in year 3. A “problem-based” learning approach was used, with integration of CR models into case-based scenarios throughout the MS practical sessions. In years 2 and 3, students undertook 162 hours of clinical practice, during which clinical instructors facilitated and reinforced the CR process. Year 4 comprised entirely clinical practice, and the teaching of CR was integrated experientially into the students’ clinical training. A qualitative, interpretive approach based on principles of phenomenography, such as a second-order perspective, internal relationship, and the structure of experience,32 was used in this research. In the secondorder perspective, category meanings were defined by students’ expla432
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nations of their conceptualizations of CR rather than being based on definitions derived from previous research (ie, first-order or researchers’ perspectives).32 Each student’s conceptualization of CR was treated as a holistic experiential field in which aspects such as beliefs about physical therapy and patients, learning, reasoning, understanding, and knowledge were understood to both define and internally relate one to the other and define the whole experience.34 Access to the meaning and structure of the students’ conceptualizations was gained through questions about what was understood about each aspect and how it was understood (Fig. 1). Design and Sampling The study population comprised 360 physical therapist students, 120 enrolled in each of years 2, 3, and 4, in order to gain an understanding of students’ CR processes across the curriculum. Students were informed of the research in lectures at the beginning of the teaching year, assured that nonparticipation would have no effect on their assessment results, and asked to volunteer. A total of 56 volunteers were grouped by year of study and sex. Students for whom English was a second lan-
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Procedure Students participated individually in an audiotaped, semistructured, indepth interview at the midpoint of the year, when all lectures and practical sessions involving CR were completed. Interviews were scheduled to take place within 3 weeks of the completion of the participant’s MS clinical placement (range⫽2–18 days). Interviews, ranging from 30 to 60 minutes, were conducted by the first and second authors. The first author taught CR in the MS component of the curriculum but was not involved in the assessment of the study participants. Participants were assured that their responses would have no influence on their grades. The second author was previously a physical therapist educator and coordinator of student learning development at The Higher Education Development Centre and is currently Academic Director of the Student Learning Centre at the University of Otago. The third author was a PhD research student with a background in science. To ensure procedural reliability, the first and second authors shared the task of conducting several interviews at the beginning of and later in the process. Interviews focused on what the students understood and how they went about their practice. ParticiMay 2009
Clinical Reasoning in Musculoskeletal Practice pants were asked to describe examples of their practice and to talk about their understanding of CR, clinical knowledge or information, and learning and how they achieved that understanding (Appendix). The audiotapes were transcribed verbatim. The transcripts were checked against the audiotapes by the third author.
Table 1. Allocation of the 31 Participants to Categories by Age, Sex, and Year in Program Research Pseudonym
Data Analysis The first and second authors undertook analyses separately to ensure unbiased category development. The third author audited the evolving themes and categories by checking them at regular intervals against the raw data to ensure validity. At each stage of analysis (see below), researchers separately explored the data in a search for evidence that would disconfirm evolving themes and categories.36 Regular research meetings in which each author’s assumptions about evolving themes and categories were reported, challenged, debated, and clarified were used as one strategy to ensure trustworthy representation of the data.
Age (y)a
Sex
Year in Program
Conceptualization of Clinical Reasoningb
Lesley
20
Female
2
A
Malcolm
21
Male
2
A
Melvyn
24
Male
2
A
Shauna
22
Female
3
A
Hazel
22
Female
3
A
Patrick
21
Male
3
A
Kaley
21
Female
4
A
Kane
25
Male
4
A
Aiden
21
Male
2
B
Shayla
22
Female
2
B
Reagan
21
Male
3
B
Sinead
27
Female
3
B
Bevan
22
Male
4
B
Danelea
22
Female
4
B
Aeryn
23
Female
2
C
Ailsa
20
Female
2
C
Betha
20
Female
2
C
Maegan
19
Female
2
C
Annie
22
Female
3
C
Enya
23
Female
3
C
Genevieve
24
Female
3
C
Gallagher
25
Female
4
C
Kristen
22
Female
2
D
The base unit of analysis was a student’s whole transcript. Analysis comprised 3 iterative stages:
James
19
Male
2
D
1. A crude initial reading and sorting, in which individual transcripts were read and grouped according to their similarities and differences, provided easier access to the large amount of complex data.
Alana
21
Female
4
D
Monaghan
38
Male
4
D
2. In a refined categorization, transcripts in each group were subjected to a detailed analysis. Different aspects of a student’s conceptual field were noted and compared with other aspects to establish the meanings that the student associated with CR, practice, patient care, learning, and knowledge. This analysis focused on what the student understood May 2009
Norah
23
Female
3
D
Ardara
24
Female
4
D
Sabrina
23
Female
3
E
Callahan
31
Male
4
E
Trevor
24
Male
4
E
a
The average age of the participants was 23 years. The numbers (percentages) for the whole sample were as follows: category A, 8 (26); category B, 6 (19); category C, 8 (26); category D, 6 (19); and category E, 3 (10). b
as CR, that is, the meaning ascribed to both parts and whole; the structure of each aspect, that is, how the experience was described; and the possible rationale or logic for the relationship between aspects, that is, why the student understood the experience in the way in which he or Volume 89
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Clinical Reasoning in Musculoskeletal Practice were prepared. Criteria for allocation to categories were identified, and an individual’s experiences were checked against the category descriptions and criteria. 3. Completed category descriptions were subjected to a meta-analysis to identify general themes that were evident in different forms across categories. Credibility and Verification Several strategies (shared interviews, audit trails, and disconfirmation) were used to ensure the credibility and robustness of the research process and data analyses. Category descriptions were subjected to peer review and audit in 2 seminars, one with 25 physical therapist faculty staff members at the location where the research was conducted and the other with 20 university academic staff members. Feedback was invited from the audiences, noted, and incorporated into the research. In a separate process, the fourth author (not involved in the original research) verified the conceptualizations of CR and the cross-category themes on the basis of her experiences of CR in the physical therapy curriculum. She reviewed the audit trails through regular discussions with the first 2 authors and step-bystep interrogation of the research process and associated documents. Ethics and the Role of the Funding Source This study was approved by the Human Ethics Committee at the University of Otago and was funded by a Research Into University Teaching grant.
Results The results are presented in 2 parts: conceptualizations of CR as descriptive categories and cross-category thematic variations.
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Conceptualizations of CR Analysis of the data in stages 1 and 2 revealed 5 qualitatively different conceptualizations of CR: category A—applying knowledge and experience to the problem, patient, or situation; category B—analyzing and reanalyzing to deduce the problem and treatment; category C—rationalizing or justifying what and why; category D— combining knowledge to reach a conclusion; and category E—problem solving and pattern building. Category descriptions include the meaning (what) participants attributed to CR and how they thought (the structural aspects). Quotations (identified by pseudonyms and the student’s year of enrollment, eg, “Hazel, 3”) illustrate each category. Table 1 shows the distribution of participants by age, sex, year in program, and category. Category A—applying knowledge and experience to the problem, patient, or situation. In this category, participants conceptualized CR in very general terms. Their focus was applying or relating what had been learned (knowledge, experience, evidence from examination of the patient, or a combination of these) to a problem, patient, or situation. Applying was described as follows: “the application of the treatment procedures” or “doing it” (Hazel, 3), “you’ve got to try and . . . relate . . . what you know . . . to your patient” (Shauna, 3), or “. . . everything you’ve learned in the classroom, [seen and] used in the clinical setting, . . . you apply it to the patient (Patrick, 3). A therapist-centered view of both physical therapy and CR was evident throughout the data. The main concern was finding a technique that “worked” and was the “right thing to do” (Hazel, 3). Figure 2A shows a linear experiential structure. The di-
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rection of application of knowledge was from the student to the object of application: the patient or the problem. Feedback from the patient indicated “how effective the treatment has been” (Patrick, 3). However, there was little evidence to show how the feedback was used, hence, the dotted line in Figure 2A. Category B—analyzing and reanalyzing to deduce the problem and treatment. In category A, students conceptualized CR predominantly as a linear trial-and-error process. In contrast, category B was a much more cyclical analytical process (Fig. 2B). Students spoke of analyzing and reanalyzing to deduce the problem and treatment relating to the patient. They used all of the information available to them to determine possible scenarios, which then were continually narrowed down. The focus was on the process rather than the outcome. Clinical reasoning was exemplified as follows: . . . just figuring it out . . . basically, it’s getting all the information . . . and trying to come up, first with a hypothesis, then testing that and . . . , hopefully, determining whether you’re on the right track and narrowing down that hypothesis to try and come to a treatment process. . . . And . . . then every other session doing all that again in a . . . smaller way . . . reanalyzing and reassessing and determining whether . . . for that patient (Sinead, 3).
Clinical reasoning continued to be mainly therapist centered and tended to emphasize diagnosis. However, information about the patient informed hypothesis formation and assessment. The direction of application of knowledge continued to be from the student but focused more specifically on the patient and the condition (Fig. 2B).
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Figure 2. Diagrammatic representation of the structural aspects of students’ experiences with clinical reasoning.
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Clinical Reasoning in Musculoskeletal Practice Category C—rationalizing or justifying what and why. Clinical reasoning was conceptualized as justification: “explaining why” (Annie, 3), “rationalizing what you’re doing . . . using treatments and techniques for a specific purpose based on your knowledge and experience” (Genevieve, 3), “the thinking behind the thinking . . . the reasons for why you do things” (Betha, 2), and: . . . being able to justify [to yourself and to the patient] what you do, what you see, and what you think is going on. . . . You might interpret what’s going on and then apply [a] certain technique for a certain reason. I think it’s taking the information, evaluating it, and then responding to it in an appropriate way . . . it’s the whole process of going through that (Gallagher, 4).
There was a focus for “why you . . . use techniques” (Enya, 3), “to see . . . the underlying cause of injury” (Aeryn, 2), and “using evidence to suggest a certain outcome” (Annie, 3). Structurally, the experience appeared circular (Fig. 2C). Students referred to the importance of recognition and related their growing confidence to bringing together their own knowledge and experience with their knowledge of the patient. They spoke of using their developing experience of reasoning in new situations. Unlike in categories A and B, in category C the patient was more integral to the experience: . . . it’s their goals and their body . . . you might want to fix their ankle, but they want to be able to play basketball or something . . . so it’s combining it . . . [to] try and get that holistic approach. . .you’re treating the whole person rather than a sprained ankle (Gallagher, 4).
Category D— combining knowledge to reach a conclusion. Clinical reasoning emphasized the endpoint of the process (Fig. 2D). 436
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Clinical reasoning was exemplified as combining knowledge to arrive at a conclusion, a decision, or a diagnosis or to solve a problem: “. . . you just combine things and eventually come up with a conclusion” (Alana, 4) and: . . . what you get from the patient, the subjective and objective, . . . you put that together with what you know, what other people tell you, and . . . clinical experience. You use all that together to make a decision . . . using all your resources, putting them together to make a decision about a patient (Norah, 3).
This kind of combining differed from the concept of bringing knowledge together described for category C above. Students were aware of a range of possibilities and used a flexible approach that required an open mind: . . . you’re really trying to keep an open mind and anything they tell you . . . [you’re] trying to decipher if it’s relevant . . . you’re initially trying to arrive at a diagnosis, so you’re trying to think of . . . a list of possible diagnoses, and the more they tell you [the] more you’re trying to narrow it down to 1 or 2 possible suspects (Ardara, 4). I think you’ve just got to keep an open mind and . . . if you decide to do something and you realize that you’re going along the wrong track, then you need to be able to change that and do something else (Norah, 3).
When asked about HDR, students showed a preference for forms of simple pattern recognition: “I don’t go through it [HDR]. . . . I rely on my experience . . . pattern recognition” (Monaghan, 4), “I don’t really go through the whole . . . [HDR process]” (Ardara, 4); rather, conclusions were based on “gut feeling” (Alana, 4) or a “leap of faith” (Monaghan, 4). Alana (4) talked about different cases with similar signs and symptoms:
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. . . as soon as you see them you get a feeling . . . of what it’s most likely going to be . . . I’d say it’s some form of pattern recognition, but I haven’t seen many patients to get a pattern going, but just from cases I heard about recognizing signs and symptoms that are similar. . . . Each person will be slightly different, but there will be 2 or 3 things that come up time and time again.
Category E—problem solving and pattern building. Clinical reasoning was exemplified as problem solving and picture or pattern building (Fig. 2E), interrelated metacognition processes that were not evident in previous conceptions. Problem solving, which tended to focus on the student’s experiences with individual patients, was perceived as a continuous, spiral process of planning, doing, and reflecting. Picture or pattern building was a more temporally extended, visual process concerned with individual patients, previous clinical experience, and the growth of knowledge and expertise. Both processes involved more focus on the patient than previous experiences: . . . it’s problem solving, really . . . each patient . . . gives you a set of clues, and then you . . . look . . . at your objective measures and . . . what they tell you and then try and build a pattern of what’s gone wrong and see how that relates to a structure (Trevor, 4). It’s not so much about the diagnosis . . . [although] it has a part to do with it, it’s how you get there . . . it’s what you’re given, what you see, what you probe for, what you test, . . . you’re . . . thinking, “OK, is this adding to [the] picture?” If it isn’t, get rid of it . . . carry on until you’re happy in your own mind that you have come to a conclusion based on evidence . . . [and] experience (Callahan, 4).
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Clinical Reasoning in Musculoskeletal Practice Is there a fit?” Trevor (4) indicated, “There’s always the possibility that it’s going to be other things, so I still went through all the different tests.” Callahan (4) described his approach to a patient as follows:
can apply a lot of the time. So, the next time someone comes in and says, “I do this and I’ve done that and this hurts,” then you can go, “Well, I think it’s that because of. . . ,” . . . you’ve seen the pattern before in so many different other people (Sabrina, 3).
. . . when a patient says “shoulder pain,” . . . you go through all the possibles . . . [suprascapular nerve damage is] not a very common thing at all . . . [we considered it because] she had weakness. . . . I still went through my structured objective exam, but as I’m going through [it] I’m always thinking what [it] could be, given what the patient was saying; what could be at fault? . . . that’s what I do with every patient, . . . they say something and I think . . . to myself, it could be this, could be this, could be this, but not discount them all until I’ve had a good check (Callahan, 4).
The therapist-patient relationship was a 2-way “linking [of] the theory to the actual” (Sabrina, 3). Students’ reasoning appeared to start with the patient: “Every person’s different, so you link all the different ideas together . . . with the person” (Sabrina, 3). There was evidence that students intentionally set about building their experience, and they emphasized the ongoing improvement of their clinical practice.
Students emphasized process because it allowed them to “know what they need to do next” (Sabrina, 4). Yet, they also “deviate[d] from the process knowing that when you’ve exhausted the deviation . . . you can get back on track again because you know . . . you’ve done it a number of times” (Callahan, 4). Trevor (4) argued:
Cross-Category Themes Cross-category analysis (stage 3) revealed evidence of 5 general themes: (1) focus of CR, (2) spatiotemporal characteristics of CR, (3) differences in the degree of focus on the patient, (4) variations in meaning and attribution of confidence, and (5) role of clinical experience in CR. These general themes are summarized in Table 2.
. . . having a logical sequence that you can stick to each time so that as a pattern develops, you can recognize it . . . you can’t do exactly the same with every patient but . . . in my assessment, I try to make sure that I’ve got clear what I want to work out—a logical sequence so you can build a good picture of the problem.
Sequence appeared to be the key to more general pattern building: . . . the more you deal with . . . patients . . . you actually start to build up ideas of how things happen and you check it out, and after you’ve done about 5 different patients with a similar thing, you actually start to see a pattern forming with . . . their symptoms or their signs or the way things worked, and those patterns actually
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Focus of CR. With the exception of category A, in which a trial-anderror approach predominated, some features of HDR were recognizable across all categories. In category B, there was evidence of analysis, testing of hypotheses, reassessment of the patient’s response, interpretation and evaluation of information, and decision making using an active, albeit simple, feedback loop. However, there was little reflection on the process, and the narrow focus lacked the full breadth and depth of HDR. In category C, CR was a deeper, more-complex process based on the rationalization of evidence. Categories D and E showed more evidence of the stages of HDR,37 including combining and
weighing information to rationalize decision making6 and recognition of the importance of experience in practice.38 Category D was concerned with both process and outcome, and students showed an increased awareness of their limitations and the implications of CR. They talked about combining knowledge to reach a conclusion but also made reference to their use of intuition and the recognition of clinical patterns in the decision-making process. They acknowledged that pattern recognition was gained through experience and practice. They realized that their application of knowledge and skills in the clinical environment had changed and developed, but they quite often struggled to articulate how decision making took place and were aware that reliance on a particular process could sometimes hinder their reasoning. There was evidence of a strong feedback loop for incorporating knowledge and skills from a range of sources to inform practice. Category E differed significantly from the other categories. As with category D, students described pictures and clinical patterns. However, their focus extended beyond simple recognition to an active and intentional development of such patterns by combining and weighing the information against previous knowledge and experience. Clinical information and knowledge were used to build a “mental picture” to inform current management of the patient’s condition and future practice. Students also talked about reflection in action and about action as a means to build experience and inform practice. Spatiotemporal characteristics of CR. The spatiotemporal characteristics of CR changed across categories (Tab. 2). “Spatio” is defined as the boundary of the experience or “the space” it occupies. “Temporal”
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Clinical Reasoning in Musculoskeletal Practice Table 2. Summary of Cross-Category Themes and Variations Associated With Each Category Conceptualization of Clinical Reasoning (CR)
Spatiotemporal Aspects
Forms of CR
Degree of Focus on the Patient
Characteristic to Which Confidence Was Attributed
Role of Clinical Experience in CR
A: Applying knowledge and experience to the problem, patient, or situation
Simple trial and error
Immediate: the problem, the situation, or the effectiveness of a technique
Little or none: therapist centered
The ability to perform a particular technique
Prior experience with the technique or problem
B: Analyzing and reanalyzing to deduce the problem and treatment
Analysis, testing of hypotheses, and reassessment of the patient’s response; use of a simple feedback loop
Immediate: the diagnosis
Therapist centered: you must be able to explain it to the patient
The ability to figure it out
Prior experience with the condition
C: Rationalizing or justifying what and why
More-complex process involving a form of hypothetical deductive reasoning based on the rationalization of evidence
The treatment period and projection to new situations
The patient is a source of information
An awareness of personal ability: how you put it together
Prior experience is required for effective CR
D: Combining knowledge to reach a conclusion
Combining and weighing information to rationalize both process and outcome decisions; acknowledging recognized patterns
The whole treatment program, from decision to conclusion
Focus on the patient’s goals
Experience, practice, and seeing similar situations
Prior experience is crucial for pattern recognition
E: Problem solving and pattern building
Extending recognition of clinical patterns to active involvement in pattern development, including reflection and action
Past experience, current situation, and future practice, with a broad focus on improving practice
Broadly patient focused
The ability to be professional and base decisions on evidence
Prior experience is crucial for pattern recognition
is defined in terms of the student’s focus in time. In each conception, space and time are integrally linked and are described together. In categories A and B, participants dealt only with current time and the immediate task space. In category A, the student’s focus was the immediate problem, situation, or application or effectiveness of a technique, and in category B, it was the immediate diagnosis. In category C, the temporal focus included a single treatment period and possible new situations, and the experiential boundary was extended to include the management of the patient’s condition during treatment. In category D, the temporal focus was the whole treatment period from diagnosis to conclusion, and the experiential boundary was the student’s practice. In category E, the temporal focus was very broad, extending from past experience to the current situation and to future practice, and the experiential boundary was both the stu438
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dent’s practice and the improvement of practice. Differences in the degree of focus on the patient. Students’ conceptualizations of the role of the patient in the clinical encounter changed across categories from therapist centered to a greater focus on the patient (Tab. 2). In category A, there was little or no reference to the patient, and in category B, the reference was limited to the student’s capacity to provide explanations to the patient. In category C, the patient was recognized as an important source of information, and students focused on their ability to provide care to the patient rather than the problem. In category D, the patient was central to the reasoning process, and students focused on the patient’s goals. In category E, there was a broader focus on the patient.
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Variations in meaning and attribution of confidence. Confidence was mentioned in all categories, but its meaning and attribution differed across categories. In category A, having confidence was associated with the effective performance of a technique. In category B, confidence was related to students’ knowledge of a situation and its analysis. In category C, confidence was related to students’ ability to use their current knowledge to rationalize the management of the patient’s condition. In category D, confidence was based on whether students had experience with the condition or had seen the situation before. Students also showed an increased awareness of their limitations and the implications of CR. In category E, confidence assumed a much broader focus on professionalism and decision making on the basis of best practice.
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Clinical Reasoning in Musculoskeletal Practice Role of clinical experience in CR. Conceptions of the role of clinical experience in CR differed across categories. In categories A and B, previous clinical experience was necessary for the successful completion of a technique (A) or effective diagnosis (B). However, in categories C, D, and E, the emphasis changed. In category C, students perceived the accumulation of clinical experience to be an important contributing factor to CR, and in categories D and E, it was crucial to pattern recognition.
Discussion This study was undertaken because of the belief that good teaching depends on an understanding of students’ conceptualizations of the phenomenon being taught.29 Students conceptualized CR in 5 qualitatively different ways across the 3 years of the undergraduate program, and conceptualizations ranged from very simple to more complex. Moreover, students’ conceptualizations and descriptions of their approaches to CR appeared to be internally related in ways that resembled research on conceptions and approaches to subject material.33 Therefore, in category A, a student who understood CR as an application or a way to make something work used simple, linear trial and error in practice, that is, applying a technique or aspect of knowledge to the patient. Educational research on conceptions of learning has often reported categories of conceptions as a hierarchy from simple to increasingly complex sophistication.33 The categories of CR reported above showed a similar pattern. Moreover, across categories, shifts in emphasis from aspects of HDR, task focus, and therapistcentered practice to embryonic forms of pattern recognition, process orientation, and more patientfocused practice resembled those described in research on novices and experts.4,39,40 However, none of the May 2009
category descriptions resembled a particular model of CR described in earlier literature. Rather, the categories represented a continuum from relatively simple to increasingly complex, but mixed, forms of reasoning. The development of a continuum is further supported by the changes within the cross-category themes. Table 2 shows how each theme assumed a particular meaning in association with the other aspects of its respective category. Yet, across categories, each theme increased in breadth, depth, and sophistication from categories A to E. On the basis of these results and previous literature, it may be argued that such themes represent key dimensions of CR development. For example, the shift from therapist- to patientfocused care is well documented,37,41 and the development of patient-focused care is often a concern for clinical teachers. The characteristics and themes of CR suggest a developmental trend that resembles the development of expertise reported in the literature.11–14 In particular, category E showed evidence of a more cyclical and dynamic reasoning process,40 including a much broader focus and critical self-reflection, recognized as part of the evolutionary process toward independent practice42 and expert practitioner status.37,43 The categories showing more development revealed CR to be a combination of problem solving and pattern recognition, and some of the characteristics of the spiral models of thinking and reasoning11,44 were evident in category E. The latter categories showed signs of students’ increasing ability to manipulate knowledge.14 It was also interesting that variations in experiences mirrored, to some extent, the changing views of CR in the literature.
The sample included students from 3 consecutive years of study. With year of study as an indicator, it would be expected that increasing expertise in CR would be evident as students proceeded through their clinical program. However, this was not the case. Although year 4 students were associated with a more sophisticated and holistic experience of CR than year 2 students, two thirds of the sample experienced CR predominantly in terms of categories A to C, in which the focus was immediate practice, that is, diagnosis, treatment, or both (Tab. 1). Application to Teaching Students’ conceptions of and approaches to learning are related to the context (curriculum organization, teaching, and assessment) in which they learn.45,46 The curriculum was organized so that clinical experience was concentrated predominantly in the fourth year. The variations in our results supported the clinical teachers’ observations that students’ capacity for CR varied substantially in year 4. This variation may be attributable to several factors, including the possible influences of other parts of the curriculum, the quality of clinical supervision, the context of the MS clinical placements,47 the clinical and theoretical balance in the curriculum, and the appropriateness of the assessment. The results suggest a need to examine the relationship between the development of CR and clinical exposure as well as the alignment of course objectives and assessment within the curriculum.48 Dimensions of CR could be used to identify where students are located on the continuum and, therefore, could contribute to the development of teaching, learning, and assessment strategies in the curriculum. For instance, students can be located on the continuum by the language they use, their degree of focus on the
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Clinical Reasoning in Musculoskeletal Practice patient, their spatiotemporal characterizations of CR, and the ways in which they attribute confidence to their practice. Students also could make use of such a tool as a reflective device to aid in learning. The results of this study emphasize the need for clinical educators to explore students’ conceptions and understanding of reasoning in teaching and assessment. Teaching strategies focusing on, for example, particular views of CR could be used to help improve student learning, and generic strategies could be used to improve students’ understanding of CR. These generic strategies might include using open-ended questioning to extend students’ boundaries of thinking and focus; encouraging students to think beyond the textbook, for example, to explore their previous experience; enabling students to trust their observations; and using metacognition strategies to help guide critical reflection. Limitations and Further Research These results may inform undergraduate physical therapist programs in Australasia and Europe, but their application to doctoral programs must be made with some caution. However, it is worth noting that 12 of the 31 therapists (39%) in our sample entered the physical therapist program as graduates, yet this cohort exhibited the same variations in conceptualization. Interestingly, all 3 students who conceptualized CR as category E were graduate entrants. Although students’ conceptualizations of CR in graduate programs may differ, arguably the thematic dimensions will remain the same in that they reflect existing literature. The cross-sectional design and constraints imposed by single-school sampling make it impossible to do more than suggest a developmental trend. Clinical reasoning development and its influences can be inves440
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tigated only through longitudinal studies that track individual students’ progression in various physical therapist programs. The generalizability of results to other physical therapy disciplines, such as neurorehabilitation, and to other programs requires further research. It also is acknowledged that volunteer bias (ie, the majority of students did not agree to take part in the research) and student recall bias may have influenced students’ responses to patient-related questions and, therefore, may have influenced the distribution of conceptualizations of CR; however, these factors are unlikely to have changed the range of conceptualizations of CR found in this study.
Conclusion Previously, CR was not explored qualitatively using students’ direct experience as data. Further research of this kind, in particular, longitudinal studies, may provide a new way of exploring CR and an insight into its development, teaching, and assessment. The continuum reported above for CR has the potential to provide a method of assessing students’ understanding at a particular time in their study. Such knowledge would be extremely useful to teachers and students in the advancement of student learning. Mr Hendrick, Dr Bond, and Dr Duncan provided concept/idea/research design, data collection, and consultation (including review of manuscript before submission). All authors provided writing and data analysis. Mr Hendrick and Dr Bond provided project management and fund procurement. Mr Hendrick provided participants, facilities/ equipment, and institutional liaisons. Dr Duncan provided clerical support. Linda Robertson assisted in checking and editing the manuscript before submission. This study was approved by the Human Ethics Committee at the University of Otago. This study was funded by a Research Into University Teaching grant.
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This research was presented at a research seminar series at The Higher Education Development Centre, University of Otago; September 28, 2006; Dunedin, New Zealand. This article was received May 20, 2008, and was accepted February 2, 2009. DOI: 10.2522/ptj.20080150
References 1 Smith M, Ajjawi R, Higgs J. Clinical reasoning in physiotherapy. In: Higgs J, Smith M, Webb G, Skinner M, Crocker A, eds. Contexts of Physiotherapy Practice. Sydney, New South Wales, Australia: Churchill Livingstone; 2009:102–114. 2 Edwards I, Jones M, Carr J, et al. Clinical reasoning strategies in physical therapy. Phys Ther. 2004;84:312–330. 3 Patel VL, Arocha JF, Shortliffe EH. Cognitive models in training health professionals to protect patients’ confidential information. Int J Med Inform. 2000;60: 143–150. 4 Case K, Harrison K, Roskell C. Differences in the clinical reasoning process of expert and novice cardiorespiratory physiotherapists. Physiotherapy. 2000;86:14 –21. 5 James G. Diagnosis in physical therapy: insights from medicine and cognitive science. Phys Ther Rev. 2002;7:17–31. 6 Norman G. Research in clinical reasoning: past history and current trends. Med Educ. 2005;39:418 – 427. 7 Mattingly C, Fleming MH. Clinical Reasoning: Forms of Inquiry in a Therapeutic Practice. Philadelphia, PA: FA Davis Co; 1994. 8 Edwards I, Braunack-Mayer A, Jones M. Ethical reasoning as a clinical-reasoning strategy in physiotherapy. Physiotherapy. 2005;91:229 –236. 9 Edwards I, Jones M, Higgs J, et al. What is collaborative reasoning? Adv Physiother. 2004;6:70 – 83. 10 Ward JD. The nature of clinical reasoning with groups: a phenomenological study of an occupational therapist in community mental health. Am J Occup Ther. 2003;57: 625– 634. 11 Higgs J, Jones MA. Clinical Reasoning in the Health Professions. 2nd ed. Oxford, United Kingdom: ButterworthHeinemann; 2000. 12 Boshuizen HPA, Schmidt HG. The development of clinical reasoning expertise. In: Higgs J, Jones MA, eds. Clinical Reasoning in the Health Professions. 2nd ed. Oxford, United Kingdom: ButterworthHeinemann; 2000. 13 Roberts AE. Clinical reasoning in occupational therapy: idiosyncrasies in content and process. Br J Occup Ther. 1996;59: 372–376. 14 Milidonis MK, Godges JJ, Jensen GM. Nature of clinical practice for specialists in orthopaedic physical therapy. J Orthop Sports Phys Ther. 1999;29:240 –247.
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Clinical Reasoning in Musculoskeletal Practice 15 Higgs J, Jones MA. Clinical reasoning in the health professions. In: Higgs J, Jones MA, eds. Clinical Reasoning in the Health Professions. 2nd ed. Oxford, United Kingdom: Butterworth-Heinemann; 2000. 16 Jones M, Jensen G, Edwards I. Clinical reasoning in physiotherapy. In: Higgs J, Jones MA, eds. Clinical Reasoning in the Health Professions. 2nd ed. Oxford, United Kingdom: Butterworth-Heinemann; 2000. 17 Jones MA. Clinical reasoning in manual therapy. Phys Ther. 1992;72:875– 884. 18 Smart K, Doody C. The clinical reasoning of pain by experienced musculoskeletal physiotherapists. Man Ther. 2007;12: 40 – 49. 19 Nikopoulou-Smyrni P, Nikopoulos CK. A new integrated model of clinical reasoning: development, description and preliminary assessment in patients with stroke. Disabil Rehabil. 2007;29:1129 –1138. 20 Rivett D, Higgs J. Experience and expertise in clinical reasoning. NZ J Physiother. 1995;23:16 –21. 21 Babyar SR, Rosen E, Sliwinski MM, et al. Physical therapy students’ self-reports of development of clinical reasoning: a preliminary study. J Allied Health. 2003;32: 227–239. 22 Groves M, O’Rourke P, Alexander H. The association between student characteristics and the development of clinical reasoning in a graduate-entry, PBL medical programme. Med Teach. 2003;25:626 – 631. 23 Norton BJ, Strube MJ. The influence of experience with a set of simulated patients on diagnosis of simulated patients not previously diagnosed. Phys Ther. 1998;78:375–385. 24 Ladyshewsky RK. A quasi-experimental study of the differences in performance and clinical reasoning using individual learning versus reciprocal peer coaching. Physiother Theory Pract. 2002;18:17–31. 25 Haffer AG, Raingruber BJ. Discovering confidence in clinical reasoning and critical thinking development in baccalaureate nursing students. J Nurs Educ. 1998;37: 61–70.
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26 Chapman JA, Westmorland MG, Norman GR, et al. The structured oral self-directed learning evaluation: one method of evaluating the clinical reasoning skills of occupational therapy and physiotherapy students. Med Teach. 1993;15:223–236. 27 Larin H, Wessel J, Al-Shamlan A. Reflections of physiotherapy students in the United Arab Emirates during their clinical placements: a qualitative study. BMC Med Educ. 2005:20:3. 28 Gadamer HG. Truth and Method. 2nd rev ed. Weinsheimer J, Marshall DG, trans. London, United Kingdom: Sheed & Ward; 1989. 29 Marton F, Runesson U, Tsui ABM. The space of learning. In: Marton F, Tsui ABM, eds. Classroom Discourse and the Space of Learning. Mahwah, NJ: Lawrence Erlbaum Associates; 2004:3– 40. 30 Marton F. Phenomenography: describing conceptions of the world around us. Instrumental Science. 1981;10:177–200. 31 Marton F. Phenomenography: a research approach to investigating different understandings of reality. J Thought. 1986;21: 28 – 49. 32 Marton F, Booth S. Learning and Awareness. Mahwah, NJ: Lawrence Erlbaum Associates; 1997. 33 Prosser M, Trigwell K. Understanding Learning and Teaching: The Experience in Higher Education. Buckingham, United Kingdom: Open University Press; 1999. 34 Bond C, Madill B, Ross E. The development of tertiary teachers’ experiences of teaching. Paper presented at; Annual Conference of Improving University Teaching (IUT); July 3– 6, 2006; Dunedin, New Zealand. http://iutconference.org/2006/ sessionIII.htm. Accessed March 14, 2008. 35 Patton, MQ. Qualitative Research and Evaluation Methods. 2nd ed. Thousand Oaks, CA: Sage Publications; 2001. 36 Creswell JW, Miller DL. Determining validity in qualitative inquiry. Theor Pract. 2000;39:124 –130.
37 Jensen GM, Gwyer J, Shepard KF. Expert practice in physical therapy. Phys Ther. 2000;80:28 – 43. 38 Norman G. The role of experience in the development of clinical reasoning. Int J Ther Rehabil. 2003;10:488. 39 Embrey DG, Guthrie MR, White OR, Dietz J. Clinical decision making by experienced and inexperienced pediatric physical therapists for children with diplegic cerebral palsy. Phys Ther. 1996;76:20 –33. 40 Rivett DA, Higgs J. Hypothesis generation in the clinical reasoning behaviour of manual therapists. J Phys Ther Educ. 1997;11: 40 – 45. 41 Doody C, McAteer M. Clinical reasoning of expert and novice physiotherapists in an outpatient orthopaedic setting. Physiotherapy. 2002;88:258 –268. 42 Jensen GM, Paschal KA. Habits of mind: student transition toward virtuous practice. J Phys Ther Educ. 2000;14:42– 47. 43 Rikers R, Winkel WT, Loyens S, Schmidt H. Clinical case processing by medical experts and subexperts. J Psychol. 2003; 137:213–223. 44 Stockhausen L. The clinical learning spiral: a model to develop reflective practitioners. Nurse Educ Today. 1994;14: 363–371. 45 Ramsden P. Student learning and perceptions of the academic environment. Higher Education. 1979;8:411– 428. 46 Ramsden P. Learning to Teach in Higher Education. 2nd ed. New York, NY: Routledge Falmer; 2003. 47 Ajjawi R, Higgs J. Learning to reason: a journey of professional socialisation. Adv Health Sci Educ. 2008;13:133–150. 48 Anderson LW. Objectives, evaluation, and the improvement of education. Studies in Educational Evaluation. 2005;31:102–113.
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Clinical Reasoning in Musculoskeletal Practice Appendix. Interview Schedule
1. Let’s start with a question about you. Can you tell me a little about yourself? Age? Where you come from? What made you choose to do physical therapy? (For mature students) What did you do before you enrolled? 2. You’ve completed a musculoskeletal module. I’d like you to think about the placement and choose a particular patient with a musculoskeletal problem that you feel comfortable talking about. Possible probes, depending on response: Tell me about them. What was the patient’s problem? Why did you choose this patient to talk about? What did you think when you first saw. . . ? What did you do? Why did you do that? What conclusions did you draw? Why did you come to those conclusions? Can you talk through the process you used to reach those conclusions? 3. What does the term “clinical reasoning” mean to you? Possible probes: Can you tell me more about. . . ? What do you mean by. . . ? Why do you think that? 4. Can you provide another example of your own clinical reasoning in practice? Tell me about the situation; what happened then. . . ? How did that come about? Why did you think that? 5. Where does the patient fit into clinical reasoning? 6. How do you think you have developed this idea of clinical reasoning? Can you tell me more about. . .? What affected that development? What changed it? How has it changed? What was the effect of the physical therapy curriculum? 7. What is clinical information or clinical knowledge? 8. How do you learn in the clinical area? 9. What is learning for you—in the clinical area? More generally? 10. Do you have any other comments or questions?
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