The aim of this paper was to illustrate the clinical significance of the Hypothetic-deductive reasoning, pattern recognition and knowledge reasoning integration models of clinical reasoning. These models were researched and discussed explicitly according to the author’s clinical context, supported by evidence from the available literature. The paper was able to bring to light the notion of clinical reasoning as a fundamental constituent of professional practice amongst health care practitioners.
It was also found that there is limited clinical reasoning literature in the radiotherapy profession and that radiation therapist were likely to implement more than one model of reasoning, according to the author’s clinical description. The findings also demonstrated strong similarities between health care professionals and how they performed and developed clinical reasoning skills in order to mange the overall treatment care of their patients. Introduction
In today’s complex and ever-changing health care environment, health care professionals must be prepared to interpret and analyse large amounts of information critically, so that they can effectively make vital decisions, or determine what course of action is appropriate for a particular clinical scenario, with a particular patient. In all professional fields, not just medicine, health care professionals, based on their knowledge and clinical experience make decisions in very different and complex ways, from the very novice to the very experienced.
According to the current literature, the process of applying knowledge and experience to a specific clinical situation or patient, in order to develop a possible solution, has been described a tacit and deeply phenomenological form of thinking which translates to the development of clinical reasoning (Fleming & Mattingly, 1994 p. 12). Hence, the notion of clinical reasoning seemed to have emerged as an essential hallmark of professional practice and its nature has been implemented and researched by several professional disciplines (Ajjawi & Higgs, 2008 p. 134).
This paper will look at the hypothetic-deductive reasoning (HDR), pattern recognition and knowledge reasoning integration, identified by the author as, relevant clinical reasoning models reflecting his clinical practice. This will consist of a brief description of clinical reasoning and its importance in health care clinical settings; an overview of HDR, pattern recognition and knowledge reasoning integration; and their significance in the author’s clinical context; with a discussion on how these approaches inter-connect and are also used in other professional clinical practices, with supporting evidence from the literature.
Clinical Reasoning One of the key attributes that all health care professionals tend to develop during their professional practice is the ability to clinically reason in their specific clinical environment. According to some of the previous literature, clinical reasoning has been described as a complex integral component of clinical practice and is a term used interchangeably with an range of synonyms, such as clinical decision-making, clinical problem-solving, clinical judgement and diagnostic-reasoning (Case, Harrison & Roskell, 2000 p. 14).
There has been considerable research across the medical and some of the health allied disciplines focusing at investigating and understanding the process of reasoning, as well as the nature of clinical resoning and its relationship between knowledge and professional clinical expertise (Norman, 2005 p. 419). Subsequently, an assortment of clinical reasoning models/approaches have emerged and each professional discipline seemed to have adopted one or more of these models based on how these reflect and translate to their clinical practice (Higgs and Jones, 2008 p.6-8).
This in turn, triggered each professional discipline to study and synthesize their own definition of clinical reasoning, according to how they performed reasoning in their clinical context (Edwards & Richardson, 2008 p. 186). For instance in medicine, Sefton and Gordon described clinical reasoning as “the process by which health practitioners evaluate and make decisions on the diagnosis and management of a patient”(Sefton, Gordan, & Field, 2008, p.469).
In the occupational therapy discipline, clinical reasoning has been described as a tacit, highly complex intellectual process, which involves a phenomenological approach in making sense of the patient’s condition, and evokes the therapist to use a caring perspective in establishing a collaborative relationship with the patient in order to determine an ideal treatment action (Barker-Schwarttz, 1991 p. 31).
Similarly, in nursing, Fonteyn and Ritter defined clinical reasoning as the strategies used to understand the significance of data, identify potential client problems, and make clinical decisions to resolve problems and achieve outcomes (Baldwin, 2007 p. 24). Although, definitions of clinical reasoning may seen to differ between health care professions on the basis of how therapists clinically reason, common and distinctive features can be observed, such as the ability to make decisions, solve problems, gather and evaluate clinical information, goal directed thinking and the achievement of positive patient outcomes.
Successful clinical reasoning is central to professional autonomy and accountability; it allows therapists to employ their gained capabilities in the task of making countless decisions that are embedded in his/her clinical practice (Ajjawi & Higgs, 2008 p. 137). Models of Clinical Reasoning The study of clinical reasoning stemmed from the work of Elstein et al in 1978, consisting of the traditional medical problem solving approach from a cognitive science perspective, which emphasized the hypothetical deductive method (Fleming & Mattingly, 2008 p.
55). In the hypothetic-deductive model, clinicians attend to initial cues[information] from or about the patient. From these cues, cautious hypotheses are created [based on knowledge/experience]. This is then followed by ongoing analysis of patient information in which further data is collected and interpreted. Continued hypothesis creation and evaluation take place as examination and management are continued and the various hypotheses are confirmed or denied (Buckingham, & Adams, 2000 p.
984). In view of this, the hypothetic-deductive model has remained the most influential mode of reasoning and decision making in medicine (Elstein, Shulman & Sprafka, 1990 p. 5). The HDR clinical reasoning model has also been adopted by other health allied professions, such as in physiotherapy, where it is implemented as a means of identifying and assessing physical impairment, leading to a diagnosis (Edwards & Richardson, 2008 p. 186).
Similarly, this model has also been identified in nursing, speech pathology, occupational therapy and dentistry as well as being a very influential model in guiding the research in clinical reasoning across these health disciplines. Another, very commonly used model among health care professional is pattern recognition. The notion of pattern recognition has been described as another key component or form of clinical reasoning among health care professionals as it makes practice more efficient (Fleming, 1994 p153).
Rumelhart & Ortony (1977) described pattern recognition, as the storage of knowledge [prototypes] of frequently experienced situations that individuals use to recognise and interpret other situations (Jones, 1995 p. 19). In the health care professions, pattern recognition entails the assumption that the fast and efficient retrieval and processing of clinical information is related to the structure of knowledge in a person’s memory (Khatami, MacEntee & Loftus, 2008 p. 258).
If a problem or condition is recognised quickly with some type of effective analysis or interpretation, the therapist is able to move into deeper levels of analysis more quickly and hence, move to the problem resolution or treatment phase (Fleming, 1994 p154). This model of clinical reasoning seems to use direct knowledge developed from previous clinical experiences, but if an unfamiliar situation or problem arises, then most therapist tend to revert back to the HDR model ((Jones, 1995 p. 19).
Clinical reasoning is also greatly influenced by a therapist’s biomedical and clinical knowledge integration. This brings us to Boshuizen & Schmidt’s (1990) knowledge reasoning integration approach to clinical reasoning, where they emphasized the parallel development of knowledge acquisition and clinical reasoning expertise, as a cognitive maturation process where knowledge structure changes [from biomedical knowledge to real clinical experience knowledge], in turn increasing expertise in clinical reasoning (Higgs & Jones, 2008 p.7).
Another way of looking at this is, as practitioner acquires clinical experience, undergraduate/university knowledge is eventually transposed into clinical patterns anchored within memory through real clinical experiences (Jones & Rivett, 2004 p. 11). Clinical Reasoning in the Author’s Clinical Context Despite, the fact that radiotherapy has been around since 1905 in Australia, radiation therapy still comes cross as a very young profession that is very gradually shaping its professional body.
Radiation therapists in the past have been seen as passive technicians, implementing the design of others and following the radiation oncologist’s orders. This medical dominance in radiotherapy has significantly placed a barrier to the radiation therapists’ autonomous practice and professional development (Bolderston, 2005 p. 61). However, in the last two decades radiotherapy technology has rapidly evolved in a way that it has increased the diversity and complexity of treatment modalities (Griffiths, 200 p.162).
Consequently, the technical advancements, in conjunction with higher entry-level of education, as well as its growing specialisation, are productively changing the profession. According to Trede & Higgs (2008), professional development and maturity formed the basis for becoming more involved with questions of expertise and knowledge growth, as well as serving to structure and refine therapists’ clinical reasoning skills (Trede & Higgs, 2008 p.33).
It can therefore be said, as the professional radiotherapy practice continues to grow, the development of clinical reasoning skills amongst radiation therapists should be acknowledged and considered as an integral component of competent clinical practice. Radiation therapists work with a multitude of patients, which may result in different specific clinical problem situations, many of which defy simple technical solutions.
A technician would normally follow an order/protocol and make little adjustments for individualized patient needs and hence not delivering competent optimal treatment (Branch & Paranjape, 2002 p. 1187). It is important to remember that, no two patients are alike, and not everyone will have the same treatment parameters or respond the same way to a radiotherapy treatment regime.