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Research Reports |
Professor and Chair
Department of Physical Therapy
Temple University
Philadelphia, PA 19140
laurita.hack{at}temple.edu
 | Introduction |
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The most frequent mode of thinking described in the clinical reasoning literature is the hypothetico-deductive reasoning model, as is described by Edwards et al in their review of the literature. While the work that explicated this model most commonly explored physician decision making, this is a mode of thinking that feels familiar to any practitioner trained in diagnostic reasoning and can readily be used in teaching decision making to students and in improving decision making among clinicians in many different health care professions.
Understanding the hypothetico-deductive process, however, I believe does not necessarily help distinguish decision-making processes among various professions. Do physical therapists, occupational therapists, and physicians all approach decision making in the same way? Our clinical experience tells us that they do not.
In earlier work in physical therapy, Jensen et al1 identified 4 themes that they contend contribute to a unified philosophy of practice in expert practitioners: knowledge, clinical reasoning, virtue, and movement. I believe that the descriptions of knowledge and virtue based on this work could be applied to practitioners in many health care occupations. For example, experts stressed the need to see the patient as the most important source of knowledge, and they emphasized the need to serve as advocates for patients, sometimes placing their own livelihoods at risk. In the other 2 areas, however, it is possible to see some issues that distinguish physical therapy practitioners from other types of practitioners. Physical therapist experts showed a preference for a collaborative mode of clinical reasoning that involved patients and families and that relied less on a diagnosis of pathology and more on identifying patient goals. The physical therapists whom Jensen et al studied also showed an exquisite sense of movement, both their own movement as an instrument of patient care and the patient's movement as a source of information and communication.
These attributes resonate with physical therapists, who I believe often speak of the differences in their view of patients and patient care as compared with members of other health care occupations. This new work by Edwards et al appears to validate the perception that there is a difference by demonstrating that expert physical therapists move between the 2 worlds of logical and intuitive reasoning as they work with patients. Edwards et al have also made a very important observation in their discussion of these dual modes of thinking related to the concept of a disablement model of understanding health and illness. The premise of defining health and disability through application of a biopsychosocial model has given physical therapists a means to articulate and explicate what I believe we have done with our patients since the outset of our profession. Models of health and disability that show a continuum from pathology through impairments to functional limitations and possible disability have given us the language to describe our care more precisely.2
The work by Edwards et al has given us the basis to fully explore clinical reasoning in the context of this language. There are many different paths this future work can take. For example: When a physical therapist progresses from novice to experienced to expert, does this ability to move between both modes of thinking develop? Can physical therapists describe the purposes of their interventions, distinguishing between reducing activity limitations and improving the ability of the patient to participate fully in life, or are these purposes so entwined as to be indistinguishable? What are the best ways to help students and clinicians gain necessary skills in the use and application of these 2 modes of thinking? What other differences distinguish physical therapists from other practitioners, especially as compared with other practitioners who move comfortably in the realm of health and disability, such as occupational therapists and speech pathologists? Are there ways to structure practice, for example, through recommended patterns of practice or documentation templates, to help physical therapists develop both modes of thinking of their clinical decision-making skills? I look forward to future research, both phenomological and positivistic, that further explores this type of role between health and disability in the context of physical therapists' reasoning.
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Assistant Professor
Department of Physical Therapy
University of Pittsburgh
6035 Forbes Tower
Pittsburgh, PA 15260
jfritz{at}pitt.edu
The practice of health care professionals such as physical therapists is frequently described as consisting of both "art" and "science." Optimally, these concepts are viewed as consonant and complementary in clinical practice. Yet among researchers, art and science often become dichotomized to the point of becoming adversarial. There can be little doubt of the preeminence afforded to the "science" of practice in 20th-century Western medicine. Research standards have been grounded in a positivist epistemology, seeking to discover the truth of the "best" intervention for patients with a particular disorder.1 The emphasis within this paradigm has been on quantitative methods and deductive reasoning, with the researcher testing prespecified hypotheses under highly controlled conditions.
Qualitative research, such as the study by Edwards et al reported in this issue of the Journal, operates within a different paradigm. The principal aim of qualitative research shifts from attempting to uncover a single truth about the best management to acknowledging and understanding the influence of multiple perspectives on clinical care.2 Qualitative research does not propose discrete hypotheses for testing, but instead utilizes inductive reasoning to generate theories about observed phenomena.3 Given the challenges presented by qualitative methods to the sacrosanct principles of the dominant quantitative research paradigm, it is not surprising that qualitative research has generally met with tepid acceptance by the broader scientific community.4
Recent emphasis on evidence-based medicine (EBM) would appear to afford an opportunity for greater integration of qualitative research findings into the professional knowledge base of health care professions such as physical therapy. The initial model of EBM proposed 3 overlapping and interconnected concerns that should inform clinical decision making; research evidence, patient preferences and values, and the expertise of the clinician.5 This model recognizes that clinical decisions are not made strictly on basis of data gleaned from quantitative research. Evidence-based medicine supports the necessity of understanding the interplay among patients, clinicians, and the evidence. Qualitative research methods certainly offer a means for such investigations. As EBM has evolved, however, the balance among patients, clinicians, and the evidence often seems lost. Critics of EBM regularly cite an excessive allegiance to the authority of evidence for the efficacy of various interventions, with little concern for the unique needs of individual patients or the complex interaction between individual patients and clinicians delivering care.6,7 Although not consistent with its philosophical underpinnings, there can be little doubt that the practical reality of EBM is too frequently simplified down to reading the results of a systematic review or practice guideline, without concern for the applicability of the results to the unique situation presented by an individual patient.
The ultimate goal of EBM is to assist clinicians in making more effective decisions about individual patients.8 Edwards et al utilized qualitative research methods to examine clinical reasoning and knowledge used by clinicians identified as experts in 3 different fields of physical therapy. The authors found that these clinicians made decisions based on an interaction between rational, cognitively based reasoning and interactive, narrative reasoning. They labeled this clinical reasoning strategy as a dialectical model, indicating that the task of clinical decision making is to reconcile information obtained from both rational and interactive reasoning paradigms. This finding cautions against any attempt to reduce clinical decision making to a strictly cognitive process of applying statistics to patients without regard to the patients' situation and concerns.
Although the overall findings generated by Edwards and colleagues are certainly consistent with the underlying principles of EBM, if the specific findings of this and other qualitative studies are to have an impact on the evidence base of the profession, then qualitative studies cannot become an end unto themselves.9 The distinctive characteristics that permit qualitative research to develop unique perspectives on clinical phenomena also make it unable to test the hypothesis that the theories it generates are "true" or "better" than competing theories. This is the domain of quantitative designs and deductive research methods. The "problem of induction," a concern for the interpretation of all observational research, must be borne in mind when examining qualitative research. That is, without a control group of some kind, it is not possible to determine that what is observed is actually superior to some alternative. For example, bed rest for individuals with acute back pain appeared to be effective based on observations that most people who received this intervention recovered within a matter of weeks. It was not until controlled studies showed that even more individuals would recover when alternative interventions were used that bed rest was no longer recommended.10 Edwards et al, by selecting clinicians identified as "experts," seem to presume that the dialectical model they have identified is a superior clinical reasoning model. Recent research11 has questioned the traditional ways used by Edwards and colleagues to identify "expert" therapists. Perhaps another group of therapists would use alternative reasoning strategies that would result in better clinical outcomes. Only a comparative study using quantitative methods could ultimately address this hypothesis.
The Guide to Physical Therapist Practice12 makes it clear that end result of the entire clinical reasoning process is the patient/client outcome. Ultimately, this end must be borne in mind. The present study generates some interesting theories regarding the nature of the clinical reasoning process used by therapists presumed to be experts. It is unlikely that traditional quantitative research methods could have identified these theories. Further qualitative work on the topic of clinical reasoning, without doubt, will raise new or modified theories. Quantitative studies are needed along with this process of theory generation if the results of qualitative research are to begin to have an impact on the evidence base of the physical therapy profession.
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