MODULE FOUR: Clinical Reasoning

OVERVIEW: Preceptor Education >> Module Four >> Clinical Reasoning

Clinical Reasoning

The easiest way to explain clinical reasoning is to start with moments when you, as a preceptor, had these thoughts pop into your head while working with a student.

You (as the preceptor):

• “…had to explain to a student why you changed your approach in the middle of an exam, when you had a sound rationale for your initial approach?”
• “…noticed that it is far easier to complete an exam on your own then to have to explain to a student why you did what you did.”
• “…noticed how hard it is to answer the question, ‘but how did you know to do that?’”
• “…noticed that sometimes a student requires the same feedback so many times that you begin to question if they are even listening to you?”
• “…noticed that you and your student have very different ideas about what is ‘common sense’.”

If you have answered yes to any of these, then you are familiar with the challenges of understanding and teaching clinical reasoning skills. (If you have answered yes to all of these, please see me after class…I’m starting a support group! J )

Here are some comments from students that have run into clinical reasoning but don’t know it yet.

I (as the student)

• “…watched my preceptor change their mind during an exam and I have no idea why they chose something different!”
• “…finished an exam and came back and reported my findings to my preceptor who asked me the one thing I didn’t think to ask or look for!”
• “…proudly reported my case review ideas to my preceptor for my next session and died when preceptor asked, ‘Why did you choose that?’”
• “…want to yell at my preceptor, ‘How did you know to do that???’”
• “…had been working with a patient and copying exactly what my preceptor just did with another patient and he/she says to me, ‘I never would’ve done that.’”

Two occupational therapist students (Lisa Mendez and Jodene Neufeld) chose to write about clinical reasoning (their paper is titled “Clinical reasoning…What is it and why should I care?”) based on the student’s perspective and through their research, recorded the comments listed above. The information that follows will encompass many different resources in defining clinical reasoning, the preceptor’s role in facilitating clinical reasoning in a student and expand on your own clinical reasoning to consistently demonstrate best practices.

Forms of Clinical Reasoning

Clinical Reasoning is a broad concept to understand. Many researchers define the concept before breaking it down into manageable pieces. The four that are outlined in this module are easily identified in our daily professional practice. These encompass reasoning taught to us in school, practice, discussion, through past experience, observation and our own values.

Reasoning Integration

This is the earliest and concrete stage, where the information is taught through a classroom, textbooks and research. Problem identification, goal setting and intervention planning fall under this type of reasoning. In clinical, student- and technologist-accessible tools available are; patient’s previous images, departmental protocol/projection manual, or quick reference/trouble shooting notes are also included in the this definition. Referencing prior to starting a case can decrease efficiency and timeliness but accuracy in the beginning stage is most important. Routine and experience should decrease the need to reference because the information will have been learned.

Fact-finding questions will stimulate procedural reasoning, some examples are:

• What’s the routine exam for this request?
• What is the patient’s history for the exam request?
• What will be best demonstrated?
• What is the extent of the injury?

Interactive Reasoning

Utilizing interactive reasoning focuses on the patient as a person and increases collaboration between learner and patient. The added information provided by the patient and knowledge gained by the learner will facilitate the appropriate adaptations/actions needed to perform the exam safely and efficiently. The patient condition/ability/habitus plays a role in how we manage the exam, such as; the order of our case, corrective measures, technical factor adjustments, and any other adaptations that are necessary because of present patient variables. The effect is an overall improvement in the patient’s experience and diagnostic product.

Some questions that stimulate this stage are:

• What are the necessary adaptations to complete your exam?
• Was there any exchange of information that would be useful to document?
• Will you require any accessory equipment to perform your case?

Conditional Reasoning

This is understood to have the foundation of the knowledge and skill with the ability to foresee the outcome/product, almost simultaneously, in order to organize the exam/treatment. This requires experience.

To stimulate or assess for this reasoning, broad concept questioning is best.

• How will you manage your procedure?
• How have you produced this diagnostic series?
• What elements qualify this exam as diagnostic?

Pragmatic Reasoning

Pragmatic Reasoning is involved and affects each step of the reasoning process. It reminds us of the concrete issues that we must overcome to complete the examination which includes the impact of resources like language, support staff, and transportation; environment factors like room size, equipment quality/quantity, and privacy; health professionals ability, knowledge, and values; and clients social and mechanical supports.

Developing Clinical Reasoning

When knowledge and clinical experience unite into clinical reasoning, the learner can then progress from novice to expert. This requires the combination of all types of reasoning to develop expertise and thereby produce effective clinical reasoning. The learner will accumulate their own judgments from their own past and present experiences to gain some clinical reasoning.

In order to accumulate a significant amount of clinical reasoning, the preceptor should;

• Incorporate rationales into their daily instruction
• Relate own judgements to facts
• Give the learner the opportunity to learn through repetition and routine

Interaction and communication in the teaching clinical environment is very important. Everyone’s experience is valuable to a learner, even organizing time for student-student interaction. The more people involved in a learner’s day increases their clinical reasoning abilities. Difficult situations need consistent practice to begin but variety heightens skill and reasoning. The more opportunity you have to work with a learner, the greater the likelihood that you will be creating a worker that you would collaborate with in the future.

Helpful Tips for the Preceptor:

• Be aware.
• Give a homogenous caseload.
• Talk out loud.
• Ask your learner to make predictions
• Encourage “What” and “Why”
• Self reflection on your own clinical practice and learning
• Ask your learner to self reflect on their own clinical practice and learning.

Reflective Practice >>