Clinical Reasoning in Care Planning

Original Editor - Ewa Jaraczewska based on the course by Tarina Van Der Stockt

Top Contributors - Ewa Jaraczewska, Jess Bell and Vidya Acharya  

Introduction

Every clinician uses reasoning processes that transform raw clinical data into meaningful action. This often happens unconsciously, yet these processes determine the quality of clinical decisions. Understanding and deliberately applying clinical reasoning strategies can improve outcomes for both the provider and the patient. This page discusses four distinct reasoning strategies that can strengthen clinical decision-making.

Clinical Reasoning Strategies

Clinical reasoning, which forms the basis of clinical decision-making, is a subset of critical thinking that is applied specifically to patient care. It can be defined as “a complex cognitive process that uses formal and informal thinking strategies to gather and analyse patient information, evaluate the significance of this information, and weigh alternative actions.”

Each clinical reasoning strategy serves a distinct function. Predictive reasoning addresses probability and trajectory. Collaborative reasoning focuses on values and meaning. Scientific reasoning relies on evidence and measurement. Intuitive reasoning draws on pattern recognition. Skilled clinicians understand each strategy and know when and how to switch between them.

Clinical reasoning strategies are not separate, sequential steps. Predicting, collaborating, applying evidence, and trusting intuition are interwoven components of clinical reasoning, with each part contributing to overall care planning.

When a clinician meets a patient, their brain simultaneously processes multiple streams of information. They compare a patient's presentation to previously observed patterns while consciously gathering structured data. They listen to the patient’s concerns while mentally accessing relevant research. They formulate hypotheses while building rapport. This process represents the true nature of integrated clinical reasoning.

Developing Clinical Reasoning

Early-career clinicians often struggle to recognise when to use each reasoning strategy. For example, a patient who presents with multiple comorbidities might ask, "Will I get better?" Responding to this question requires the clinician to use at least three reasoning approaches simultaneously: (1) predictive reasoning to analyse prognostic indicators; (2) collaborative reasoning to explore what "better" means to this specific person; and (3) scientific reasoning to frame the response in realistic timelines and measurable outcomes. Ultimately, all three reasoning strategies should inform one response that is honest, realistic, and helpful.

Clinical Encounter

Clinical reasoning strategies are employed throughout every patient encounter, although different strategies may be more prominent at different moments.

Collaborative reasoning is “the shared decision making between patient and therapist (and others), a therapeutic alliance in the interpretation of examination findings, setting of goals and priorities and implementation and progression of treatment.”

Collaborative reasoning often takes centre stage during the opening minutes of a clinical encounter, as the clinician establishes rapport, understands the patient's problems, and identifies what matters most to them. Throughout this process, the clinician gathers essential data that will define subsequent decisions.

Predictive reasoning is the “reasoning utilised in judgements regarding effects of specific interventions and overall prognosis.”

During the assessment, predictive reasoning often begins to blend with collaborative reasoning to interpret measurements within the patient's specific context. For example, a marathon runner in their 40s and an older adult are both recovering from knee surgery. However, they face fundamentally different recovery landscapes—not because the surgery differs, but because their goals, functional demands and life contexts do.

Scientific reasoning is the “reasoning underpinning the selection, implementation and progression of treatment procedures.”

Research evidence provides the boundaries of what is realistic during care planning, while collaborative reasoning ensures these evidence-based targets align with the patient's priorities. The goal is not simply to achieve the mean improvement reported in published trials, but to facilitate changes that restore a function meaningful to this individual.

Intuitive reasoning monitors for inconsistencies, unexpected patterns, or warning signs that demand immediate attention throughout the clinical encounter. Developing reliable intuitive reasoning requires substantial clinical experience and exposure to diverse patient presentations. Novice clinicians rely more heavily on systematic approaches. As expertise grows, intuitive reasoning becomes more sophisticated, though it must never completely replace systematic analysis in non-emergency situations. The key lies in recognising when intuitive reasoning appropriately supersedes other strategies and when it should prompt rather than replace systematic evaluation.

Clinical Reasoning vs Reality

Clinicians should continue to develop the ability to evaluate their clinical reasoning against reality. Reflecting on what is happening requires structured comparison between prediction and outcome, as well as between planned and actual progression. By reflecting on these discrepancies, clinicians can identify and correct weaknesses in their reasoning. The following clinical scenario illustrates this concept.

A physiotherapist assesses a 52-year-old patient who is six weeks post-rotator cuff repair. Based on the surgical notes, timeline, and initial assessment, the clinician predicts that the patient will achieve 90 degrees of passive shoulder flexion by week 8, with minimal pain during gentle range-of-motion exercises.

The Prediction: (1) progressive improvement in passive range of motion, (2) decreasing pain levels with prescribed exercises, (3) patient returning to light functional activities by week 10.

The Reality: At the week 8 review, the patient has only achieved 70 degrees of passive flexion, reports increased pain during exercises (6/10 instead of the predicted 3/10), and shows signs of guarding and fear-avoidance behaviours.

Structured Reflection Process: The clinician compares their prediction against the actual outcome and asks: "Why didn't this patient progress as expected?" Through structured reflection, they identify a flaw in their initial reasoning—they had focused heavily on the tissue healing timeline and biomechanics, but they had underestimated the patient's anxiety about re-injury. The patient had been hesitant during home exercises and had developed increased muscle tension due to fear.

Correcting the Reasoning: The clinician recognises they had weighted biological factors too heavily and psychosocial factors insufficiently. They adjust their clinical reasoning model to include systematic screening for pain-related fear and patient confidence in future assessments. The treatment plan is modified to include more education about safe movement, graded exposure to feared movements, and strategies to build self-efficacy.

This example demonstrates how an incomplete biopsychosocial assessment created a gap between clinical reasoning and reality. Addressing this gap allowed the clinician to refine their approach for this patient and future cases.

Clinical Reasoning in Challenging Cases

Several factors can complicate clinical reasoning, including:

• clinician bias: e.g., consistently underestimating recovery in younger patients due to overemphasising severity factors
• environmental barriers: e.g., overlooking external factors that ultimately hinder a patient's progress
• patient complexity: e.g., multiple comorbidities, social circumstances that create obstacles, or unrealistic patient goals

When faced with uncertainty, many clinicians seek more information, order additional tests, or delay decisions. While these actions are sometimes appropriate, they can also reflect an unwillingness to accept that clinical decisions can be made with incomplete information. Clinicians do not need perfect knowledge, but rather sufficient information to act responsibly.

Research vs Reality

Clinicians must effectively integrate research findings into their practice, but this process is complicated by the nature of evidence itself. Randomised-controlled trials (RCTs) are the best way to evaluate a therapy, yet the evidence from RCTs can be incomplete, conflicting, absent, or of poor quality. Moreover, research provides population-level probabilities, not individual certainties—patients may not conform to group trends, and their responses to an intervention may vary in unpredictable ways. Skilled clinical reasoning must, therefore, draw on experiential evidence when research is limited. To achieve holistic, patient-centred, and evidence-based practice, clinicians need a strong understanding of health, pain, and disability, combined with critical and reflective reasoning and effective management skills.

Gaining Expertise in Clinical Reasoning

"Awareness, critique and practice in all areas of clinical reasoning are important to developing expertise in clinical practice."

"Clinical reasoning expert performance requires prolonged and deliberate effort."

Developing expertise in clinical reasoning requires clinicians to systematically analyse their own performance and regularly reflect on challenging cases.

Consider the following strategies during structured reflection:

• select cases with surprising outcomes where initial reasoning was incomplete or inaccurate
• reconstruct the thinking process by asking the following questions: Which strategy dominated the approach? What information was overlooked or misinterpreted? Were there cues that should have been recognised earlier?
• identify specific areas for development
• seek feedback on your reasoning process, not just the outcomes—this externalisation helps to refine clinical reasoning skills

Conclusion

Clinical reasoning is not a static skill mastered once and applied uniformly. It evolves throughout a clinician's career. Early-career clinicians may rely more heavily on explicit, conscious application of reasoning strategies. With experience, much of this becomes automatic. Yet the fundamentals remain the same: systematically integrating prediction, collaboration, evidence, and intuition to guide each patient toward their optimal outcome.

Predictive reasoning helps clinicians identify probable trajectories and potential complications. Collaborative reasoning ensures patients understand uncertainties and participate in decision-making. Scientific reasoning provides boundaries about what is possible versus what is wishful thinking. Intuitive reasoning alerts clinicians when something doesn't fit the expected pattern, prompting deeper investigation or urgent referral.

The goal is to develop an increasingly sophisticated ability to recognise what each moment demands and to use the reasoning strategy that best serves the patient.

Resources

• Clinical reasoning in physiotherapy
• Interactive virtual scenarios as a technological resource to improve musculoskeletal clinical reasoning skills of undergraduate physiotherapy students
• Developing a framework for teaching clinical reasoning skills to undergraduate physiotherapy students: A Delphi study