Introduction to Clinical Reasoning

Original Editor - Larisa Hoffman Top Contributors - Wanda van Niekerk and Jess Bell

Introduction[edit | edit source]

Clinical reasoning is a vital part of effective rehabilitation. It plays an important role in establishing professional autonomy and improving patient outcomes. Various definitions of clinical reasoning are available in the literature, as well as different clinical reasoning strategies. This page focuses on some definitions of clinical reasoning and strategies employed by different rehabilitation professionals based on factors such as time, profession, and purpose.

Definitions of Clinical Reasoning[edit | edit source]

There are multiple different definitions of clinical reasoning. Some of these definitions are listed below.

  • "Clinical reasoning (or practice decision making) is a context-dependent way of thinking and decision making in professional practice to guide practice actions."[1]
  • "Clinical reasoning refers to the thinking and decision-making processes that are used in clinical practice."[2]
  • Clinical reasoning in physical therapy could be conceptualised as "integrating cognitive, psychomotor, and affective skills. It is contextual in nature and involves both therapist and client perspectives. It is adaptive, iterative, and collaborative with the intended outcome being a biopsychosocial approach to patient/client management."[3]
  • In occupational therapy, clinical reasoning is defined as[4]:
    • "a largely tacit, highly imagistic and deeply phenomenological mode of thinking"
    • "the process used by practitioners to plan, direct, perform and reflect on client care"
    • "as a mode of thought that involves all the thinking processes of the clinician as s/he moves into, through and out of the therapeutic relationship and therapy process with a client"
  • Clinical reasoning is "a process in which the therapist, interacting with the patient and others (such as family members or others providing care), helps patients structure meaning, goals, and health management strategies based on clinical data, patient choices, and professional judgement and knowledge."[1]
  • "Clinical reasoning is defined as a complex cognitive process leading to meaningful interpretation of patients' problems and formulation of an effective management plan"[5] [6]
  • "Clinical reasoning reflects the thinking or reasoning that a health practitioner engages in to solve and manage a clinical problem. It has been described as a process or an outcome."[7]

Importance of Clinical Reasoning[edit | edit source]

  • Promotes professional autonomy[8]
  • Improves patient outcomes[9]

Clinical Reasoning According to Timing[edit | edit source]

Kahneman[10] describes two systems of thought based on the time it takes for clinicians to clinically reason. System 1 is instinctual and fast, whereas System 2 is methodical and deliberate.[10] [11]

Table 1. Comparison between two systems of thought.
System 1 System 2
Automatic, fast thinking[11] Hypothetical deductive[12] (inexperienced clinician or unfamiliar situations)
Intuitive reasoning[13] Slow effortful thinking, deliberate
Heuristic Useful for intentional thinking
Intuition Tends to occur in new, unfamiliar situations
Pattern recognition Tends to be reliable
Experience
Can have errors and biases

[14]

Novice versus Expert Clinical Reasoning[edit | edit source]

Knowledge structures and clinical reasoning skills differ between expert and novice clinicians. Experienced clinicians use experience to develop scripts for pattern recognition. Rather than investigating each sign and symptom individually, they chunk information to form a pattern. This allows them to compare whether the current situation is similar to the previous situation. Experts rely on fast thinking until they notice that something is different. When they notice something is different, they stop, reflect on how it is different, and gather more information.[8]

Novice clinicians must rely more on slow thinking because they don't have the experience to build scripts. They rely on knowledge networks which are not that easily activated. More information is needed before a hypothesis can be created. This is a slower, time-consuming process. A novice clinician's clinical reasoning is "less orderly, less goal-orientated and more time-consuming."[8]

Biases in Automatic Thinking[edit | edit source]

Rehabilitation professionals need to be aware of biases in automatic thinking.[15] Examples of types of biases include[15]:

  • availability bias
    • priority is given to the first thought that comes to mind
  • recency bias
    • give more weight to something recent
  • confirmation bias
    • gather selective information that favours a hypothesis
  • premature closing bias
    • end the decision-making process early and accept a diagnosis that has not been completely verified

Clinical Reasoning in Different Professions[edit | edit source]

In a recent concept analysis, Huhn et al.[3] described clinical reasoning within the context of physical therapy. They also explored similarities and differences in clinical reasoning between different healthcare professions.[3] They found that the purpose (the area where the emphasis is focused) and terminology differ across different professions.[3] Some of their results are shown in Table 2. If you would like to read more about Huhn et al.'s[3] findings, please see: Clinical reasoning in physical therapy: a concept analysis.

Table 2. Clinical Reasoning in Different Professions, Areas of Emphasis and Related Terminology in Literature[3]
Profession Area of Emphasis Related Terminology (Synonyms for Clinical Reasoning)
Physician Correct diagnosis Decision making; diagnostic reasoning
Nursing Competence; establishing a nursing plan of care Critical thinking; clinical reasoning
Pharmacy Thinking skills Critical thinking; problem-solving
Psychology Identifying cues and key features, hypothesis testing to form a judgement Clinical decision-making; diagnosis
Physiotherapy Patient and client management; use of the movement system Critical thinking; decision-making; professional reasoning[4]
Occupational Therapy Patient and client management; use of the occupational profile (Araujo) Critical thinking; decision-making; professional reasoning[4]; therapeutic reasoning; theoretical reasoning
Prosthetist and Orthotist Integration of the International Classification of Functioning, Disability and Health (ICF) into decision-making[6]
Speech and Language Therapy Diagnosis; intervention; swallow assessment, classification for speech disorders[16] Practice decision making

Because the area of emphasis and terminology differ between rehabilitation professions, organising clinical reasoning according to purpose or goal can help to guide the selection of the clinical reasoning process.[7]

Clinical Reasoning According to Purpose[edit | edit source]

Clinical reasoning strategies can differ depending on the specific theme/purpose/activity of the rehabilitation professional, as well as the behaviours observed in rehabilitation professionals. These themes can include[17]:

  • conducting an assessment and classifying, making a diagnosis
  • developing a rehabilitation plan, which may include establishing a prognosis, identifying the need for referral, resource allocation
  • implementing rehabilitation interventions (management, intervention, patient education) and evaluating progress toward desired outcomes
  • aiming to engage and establish a therapeutic alliance
  • resolving a moral dilemma
Table 3. Clinical Reasoning Strategies and Definitions According to Purpose
Purpose Clinical reasoning strategies employed by health professionals and their definition
Identifying diagnosis or classification
  • Hypothetical deductive reasoning[18] (also known as diagnostic reasoning or data-driven decision-making)[19]
    • Within the framework of hypothetical deductive reasoning, patient cues serve as key elements in creating multiple hypotheses. These hypotheses are continuously updated and refined as new information is incorporated.[19][20]
  • Narrative reasoning[21][22][23][24]
    • Narrative reasoning utilises stories to depict clinical encounters, incorporating conditions, consequences, motivation and interaction.[21] This can help clinicians gain insight into the patient experience and foster empathy skills.[25] In an educational context, narrative reasoning involves sharing a story, individual reflection and the collaborative exchange of perspectives.[23]
Identifying diagnosis using the International Classification of Functioning, Disability and Health (ICF) Framework
  • A clinical reasoning framework designed for orthotists and prosthetists emphasised the use of the International Classification of Functioning, Disability and Health (ICF) along with technical variables and rehabilitation services to ensure patient-centred care. In this framework, the examination should focus on the patient's body structure, function, activities, participation, and personal and environmental factors. Using this framework improves communication in a multidisciplinary team.[6]
Developing a rehabilitation plan - creating prognosis, goals and progressions
  • Predictive reasoning (also called conditional reasoning)[26]
    • Predictive reasoning involves imagining future scenarios based on decisions and their implications. This strategy includes actively envisioning future scenarios with patients, exploring their choices and considering the potential implications of those choices.
  • Collaborative reasoning[27]
    • Collaborative reasoning involves a consensual approach to interpreting findings, setting priorities and advancing interventions. This method incorporates problem-solving and communication and actively engages patients, families and team members. Rehabilitation professionals adapt reasoning strategies based on patient cues, making it a dynamic process where professionals collaborate to derive meaning, establish goals and formulate rehabilitation plans using data, patient preferences and professional judgment.[27]
Implementing interventions and evaluating progress
  • Scientific reasoning[28]
    • Scientific reasoning is the integration of evidence-based practice tailored to a specific patient. It involves using evidence to inform decisions for a specific individual within a particular context.[28]
  • Intuitive reasoning[13]
    • Implicit information is used to form a basis for judgement or decision-making ("gut feeling")[13]
Establishing a therapeutic alliance
  • Collaborative reasoning[27]
  • Interactive reasoning
    • Interactive reasoning aims to establish rapport between the rehabilitation professional and the patient. This connection is fostered through shared experiences, such as conversation and storytelling, as well as discussions on the patient's perception of the effectiveness of an intervention.[2]
Resolving a moral dilemma
  • Ethical reasoning[29]
    • Ethical reasoning involves recognising ethical and practical dilemmas that impact both the treatment process and its intended goals, guiding subsequent actions towards their resolution.[29][30]

Improving Clinical Reasoning[edit | edit source]

Instructional strategies that may improve clinical reasoning are[31]:

  • Self-explanation
    • a rehabilitation professional aims to explain to themself their understanding of a clinical problem and its connection to basic biomedical and pathophysiology principles
  • Clinical reasoning mapping exercise
    • a highly organised map used to visually represent knowledge structures. It provides a framework for the building of early illness scripts
  • Deliberate reflection
    • reflection during the diagnosis of a clinical case is encouraged, allowing clinicians to compare and contrast alternative diagnoses for the specific case

References[edit | edit source]

  1. ↑ 1.0 1.1 Higgs J & Jensen GM. Clinical Reasoning: Challenges of Interpretation and Practice in the 21st Century. In: Higgs J, Jensen GM, Loftus S, Christensen N. Clinical Reasoning in the Health Professions. Edinburgh: Elsevier. 2019
  2. ↑ 2.0 2.1 Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen GM. Clinical reasoning strategies in physical therapy. Physical therapy. 2004 Apr 1;84(4):312-30.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Huhn K, Gilliland SJ, Black LL, Wainwright SF, Christensen N. Clinical reasoning in physical therapy: a concept analysis. Physical therapy. 2019 Apr;99(4):440-56.
  4. ↑ 4.0 4.1 4.2 da Silva Araujo A, Anne Kinsella E, Thomas A, Demonari Gomes L, Quevedo Marcolino T. Clinical Reasoning in Occupational Therapy Practice: A Scoping Review of Qualitative and Conceptual Peer-Reviewed Literature. The American Journal of Occupational Therapy. 2022 May 1;76(3):7603205070.
  5. ↑ Modi JN, Anshu Gupta P and Singh T. Teaching and assessing clinical reasoning skills. Indian Pediatr 2015; 52(9):787–794 as cited in Spaulding SE, Yamane A, McDonald CL, Spaulding SA. A conceptual framework for orthotic and prosthetic education. Prosthetics and Orthotics International. 2019 Aug;43(4):369-81.
  6. ↑ 6.0 6.1 6.2 Spaulding SE, Yamane A, McDonald CL, Spaulding SA. A conceptual framework for orthotic and prosthetic education. Prosthetics and Orthotics International. 2019 Aug;43(4):369-81.
  7. ↑ 7.0 7.1 Young ME, Thomas A, Lubarsky S, Gordon D, Gruppen LD, Rencic J, Ballard T, Holmboe E, Da Silva A, Ratcliffe T, Schuwirth L. Mapping clinical reasoning literature across the health professions: a scoping review. BMC Medical Education. 2020 Dec;20:1-1.
  8. ↑ 8.0 8.1 8.2 Higgs J, Jensen GM, Loftus S, Christensen N. Clinical Reasoning in the Health Professions. Edinburgh: Elsevier. 2019
  9. ↑ Pillay T, Pillay M. Contextualising clinical reasoning within the clinical swallow evaluation: A scoping review and expert consultation. South African Journal of Communication Disorders. 2021;68(1):1-2.
  10. ↑ 10.0 10.1 Kahneman D. Thinking, Fast and Slow, Farrar, Straus and Giroux, ISBN 978-0374275631. Reviewed by Freeman Dyson in New York Review of Books. 2011 Dec 22:40-4.
  11. ↑ 11.0 11.1 Peters A, Vanstone M, Monteiro S, Norman G, Sherbino J, Sibbald M. Examining the influence of context and professional culture on clinical reasoning through rhetorical-narrative analysis. Qualitative health research. 2017 May;27(6):866-76.
  12. ↑ Arocha JF, Patel VL, Patel YC. Hypothesis generation and the coordination of theory and evidence in novice diagnostic reasoning. Medical decision making. 1993 Aug;13(3):198-211.
  13. ↑ 13.0 13.1 13.2 Ruth-Sahd LA. What lies within: phenomenology and intuitive self-knowledge. Creative nursing. 2014 Feb;20(1):21-9.
  14. ↑ ACAPT. Clinical Reasoning in Physical Therapy: Fast & Slow Thinking. Available from: https://www.youtube.com/watch?v=LekUj7dlxlw [last accessed 02/03/2024]
  15. ↑ 15.0 15.1 Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Academic medicine. 2003 Aug 1;78(8):775-80.
  16. ↑ Diepeveen S, van Haaften L, Terband H, de Swart B, Maassen B. Clinical reasoning for speech sound disorders: Diagnosis and intervention in speech-language pathologists' daily practice. American journal of speech-language pathology. 2020 Aug 4;29(3):1529-49.
  17. ↑ Hoffman, L. An Introduction to Clinical Reasoning. Course. Plus. 2024.
  18. ↑ Yazdani S, Hosseinzadeh M, Hosseini F. Models of clinical reasoning with a focus on general practice: a critical review. Journal of advances in medical education & professionalism. 2017 Oct;5(4):177.
  19. ↑ 19.0 19.1 Schaaf RC. Creating evidence for practice using data-driven decision-making. The American Journal of Occupational Therapy. 2015 Mar 1;69(2):6902360010p1-6.
  20. ↑ Rothstein JM, Echternach JL, Riddle DL. The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management. Physical Therapy. 2003 May 1;83(5):455-70.
  21. ↑ 21.0 21.1 Mattingly C. The narrative nature of clinical reasoning. The American Journal of Occupational Therapy. 1991 Nov 1;45(11):998-1005.
  22. ↑ Mattingly C. In search of the good: Narrative reasoning in clinical practice. Medical anthropology quarterly. 1998 Sep;12(3):273-97.
  23. ↑ 23.0 23.1 Milota MM, van Thiel GJ, van Delden JJ. Narrative medicine as a medical education tool: a systematic review. Medical teacher. 2019 Jul 3;41(7):802-10.
  24. ↑ Haines D, Wright J. Thinking in stories: Narrative reasoning of an occupational therapist supporting people with profound intellectual disabilities’ engagement in occupation. Occupational Therapy In Health Care. 2023 Jan 3;37(1):177-96.
  25. ↑ Cruz EB, Caeiro C, Pereira C. A narrative reasoning course to promote patient-centred practice in a physiotherapy undergraduate programme: a qualitative study of final year students. Physiotherapy Theory and Practice. 2014 May 1;30(4):254-60.
  26. ↑ Fernbach PM, Darlow A, Sloman SA. Asymmetries in predictive and diagnostic reasoning. Journal of Experimental Psychology: General. 2011 May;140(2):168.
  27. ↑ 27.0 27.1 27.2 Edwards I, Jones M, Higgs J, Trede F, Jensen G. What is collaborative reasoning?. Advances in physiotherapy. 2004 Jun 1;6(2):70-83.
  28. ↑ 28.0 28.1 Barz DL, Achimaş-Cadariu A. The development of scientific reasoning in medical education: a psychological perspective. Clujul medical. 2016;89(1):32.
  29. ↑ 29.0 29.1 Edwards I, Braunack-Mayer A, Jones M. Ethical reasoning as a clinical-reasoning strategy in physiotherapy. Physiotherapy. 2005 Dec 1;91(4):229-36.
  30. ↑ Rhodes R, Alfandre D. A systematic approach to clinical moral reasoning. Clinical Ethics. 2007 Jun 1;2(2):66-70.
  31. ↑ Torre D, Chamberland M, Mamede S. Implementation of three knowledge-oriented instructional strategies to teach clinical reasoning: Self-explanation, a concept mapping exercise, and deliberate reflection: AMEE Guide No. 150. Medical Teacher. 2023 Jul 3;45(7):676-84.
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