The modern radiotherapy practice requires that a radiation therapist not only has a rich relevant biomedical knowledge but also the ability to continuously apply this to clinical practice, indorsing optimal patient care and the delivery of quality radiotherapy treatment to the highest professional standards. An essential element, when delivering optimal patient care is the development of good clinical reasoning skills amongst health care practitioners (Corcoran-Perry & Bungert, 1992 p.64).
Before the author proceeds, it imperative to note that clinical reasoning research in the radiation therapy profession is scarce. Consequently, for the purpose of this paper, the author focused on the available literature of other health disciplines and translated these to his own clinical context. Currently, graduate radiation therapists are entering the profession with strong radiotherapy background knowledge [biomedical] and general problem-solving skills.
Once, exposed to their clinical environment, they are able to learn how the profession reasons and in turn learn how to deal with the specific tasks and challenges of radiotherapy practice. According to the author’s experience and clinical setting, novice radiation therapists [without realizing] tend to apply the HDR model of clinical reasoning when presented with a particular clinical problem, as most clinical situations tend to be unfamiliar during the early stages of the profession.
A common scenario is working in planning, where a therapist requires skills in computerized tomography [CT], such as cross-sectional anatomy to delineate critical radiosensitive structures, optimal positioning of radiation beam arrangement, and correct use of beam intensity modifiers in order to deliver the maximum prescribed dose to the target site and minimum/no dose to the radiosensitive structures around the target. The therapist has a goal, producing the optimal treatment plan.
In the process he develops several ideas [cues] on how to achieve this goal, the coalition of these ideas leads to a particular possible path/way of reaching this goal [not necessarily the optimal treatment plan]. He then evaluates the proposed treatment plan [goal] according to dose-limiting structures and optimal target dose coverage limitations. Depending on the plan evaluation or analysis, he proceeds by approving [confirmed] or rejecting [denied] the treatment plan.
The rejected treatment plan information can still be utilized to further refine the next potential treatment plan and the next after that, and so on until the optimal treatment plan is achieved. This process of achieving a patient’s optimal treatment plan is also normally observed amongst very experienced radiation therapists when confronted with unusual and very complex treatment target volumes. It could be said, the therapist will adopt the HDR model of reasoning in order find possible alternative paths or ways which will aid the process of reaching a solution and hence, achieve the desired treatment plan outcome.
In the same way, researchers from other disciplines have also found that novice and experienced therapists tend engage in the HDR form of reasoning similar to the author’s clinical context (Doody & McAteer, 2002 p. 266), (Jones, 1992 p. 883). Similarly, Ladyshewsky’s (2000) view on novice and expert clinical reasoning, also highlighted the fact that novices appear to be able generate different hypotheses when dealing with a particular clinical situation as their more experienced counterparts. However, the hypotheses of novices do not contain the richness of information that is seen in experts (Ladyshewsky, 2000 p.2).
In radiotherapy, expertise in problem solving and decision-making seems to vary between radiation therapists and is largely dependent on the therapist’s clinical knowledge and mastery of the profession. According to previous literature, clinical reasoning in experts under familiar situations does not normally require explicit hypothesis testing, but instead it becomes more of a rapid, automatic and non-verbal course of action/response (Schwartz & Elstein, 2008 p. 225) Consequently, this brings us to the notion of pattern recognition amongst health care practitioners.
In medicine and nursing, this is also described as the associations of symptoms and signs generating patterns that experts recognize quickly according to previous clinical experience (Sefton, Gordon & Field, 2008 p. 470). This is particularly evident among expert clinicians such as dermatologists and radiologists, who use visual cues from previews clinical experiences (Elstein & Schwartz 2000). (Khatami, MacEntee & Loftus, 2008 p. 258) Similarly in radiotherapy, therapists tend to develop pattern recognition skills through previous experiential knowledge of similar clinical situations or problems.
They tend to learn how to recognize relationships and configurations across patients’ planning and treatment needs. Behind their clinical decision-making and actions, radiation therapists may be instantaneously generating myriad strands of clinical reasoning, knowledge, and experience (Newnham, 1999 p. 110). This is where the author agrees with Schi?? n (1987), practitioners from different disciplines possess a stock of knowledge, which is largely tacit or implicit, enabling them to solve everyday problems (Schi?? n, 1987 p. 4).
This is seen everyday in a radiotherapy department where an experienced radiation therapist can often intuitively assess and correct a difficult plan or treatment. According to a nursing study, expert nurses were identified as having greater understanding of clinical situations, by recognizing patterns of patients’ responses, and hence were able to rapidly respond to changes in patients’ condition (Corcoran-Perry & Bungert, 1992 p. 68). Benner described this as pattern recognition by using intuition and informal reasoning strategies where expert nurses recognize familiar patterns through experiences they have with their clients.
The expert nurse is able to assess a clinical situation and focus on the most important clinical aspects (Pesut & Herman, 1999 p. 13). This closely parallels with some aspects of the radiation therapist clinical practice. For example, when patients are undergoing a course of radiotherapy treatment, sometimes due to disease progression [metastasis] patients may develop spinal cord compression. Since the therapist deals with the patient on daily basis he/she plays an important role in recognizing subtle symptoms indicative of possible cord compression and thus immediate course of action can be established, avoiding permanent cord damage.
This also correlates with the research study by Coders et al. , where it was found that pattern recognition strategies were beneficial during the practitioners’ decision making process as well as, increasing their diagnostic accuracy (Coderre et al. , 2003 p. 695). On the other hand, there is also evidence from previous studies where expert practitioners confronted with very difficult and completely unfamiliar clinical scenarios were unable to implement pattern recognition strategies alone and reverted back to the HDR model in order to resolve the problem or reach a diagnosis (Doody & McAteer, 2002 p. 267).
This can also be observed in the author’s clinical setting when radiation therapist are faced with difficult and complex planning and treatment situations. Consequently, the knowledge reasoning integration model of clinical reasoning also plays an import role in the author’s clinical context. Just, as other health allied professions, it can be said that in radiotherapy, the backbone of clinical reasoning is largely knowledge based. This knowledge may be biomedical, experiential, or a combination of both. Radiation therapists are continuously learning new technological elements of radiotherapy treatment and applying these to clinical practice.
Bolshevize et al. (1992) emphasized that during stage of early professional practice a mix of practical experience and theoretical education is needed and that clinical reasoning must be performed in the context of real patients. They also proposed that with increasing clinical experience, biomedical Knowledge becomes encapsulated in clinical knowledge. This integration of biomedical knowledge into clinical knowledge has been described as the heart of clinical reasoning expertise amongst health care workers (Bolshevize and Schmidt, 2000 p. 15).
The author describes the radiation therapist role as very flexible, in that they move between clinical areas, such as simulation[CT, MRI, Ultrasound], planning[dosimetry] and treatment units. However in today’s radiotherapy clinical environment it is difficult to keep all clinical skills sets current, thus any transition from one area to another may involve a certain amount of retraining or upgrading[extra theoretical and biomedical knowledge]. Subsequently, it can be said, the therapist is continuously incorporating theoretical scientific and experiential knowledge into their clinical practice.
Eraut 1994 & Schin 1983 also highlighted this notion, professionals continue to build their practical knowledge based on clinical experience and the understanding learned through experience (Jensen, Resnik & Haddad, 2008 p. 127). The productive integration of the relevant knowledge[biomedical and clinical] into clinical practice will in turn enable the therapist to implement and develop further clinical reasoning skills successfully. This encapsulated knowledge can also be unfolded numerous times enabling therapist diligently deal with the complexity of their clinical environment ((Boshuizen and Schmidt, 2000 p.16).
Recently, Patel et al (2005) conducted a study on medical students in problem based learning tutorials and concluded that students tended to generate a great deal more inferences, especially from biomedical knowledge. It also showed that clinical knowledge could serve as a consolidating factor for previously acquired biomedical knowledge, effectively aiding the integration of biomedical knowledge into coherent frameworks of clinical knowledge (Patel et al, 2005 p. 1202).
These findings, positively correlate with the author’s clinical context where he describes therapists, as continuously incorporating theoretical and experiential knowledge into their clinical practice and thus, enduring their clinical reasoning skills. Finally, it is also important for the author to acknowledge other studies in the literature, suggesting that health care professionals should not be locked into just a single mode clinical reasoning, but instead utilize multiple forms of reasoning, resulting in effective diagnostic accuracy, better problem solving and decision making clinical expertise (Kevin, et al 2007 p.1152) (Ark, Brooks, & Eva, 2006 p. 406).
In radiotherapy, often there is no one best way through a problem. So, the combination of more than one mode of clinical reasoning, will allow radiation therapist to develop better clinical skills and hence better able to adapt to the rapidly evolving world of the profession. This notion is also supported by the findings of Doody & McAteer (2002), where they concluded that occupational therapists went beyond diagnostic processes[such as HDR] to include reasoning processes focused on the management of the patient’s problems (Doody & McAteer, 2002 p. 260).
In the author’s clinical setting, the therapist develops a very strong relationship with his/her patients, which can often be very meaningful to the patients and can lead to a very individualized approach in managing their problems. Conclusion In conclusion, the author was able to clearly identify and associate with the HDR, pattern recognition and knowledge reasoning integration models of clinical reasoning within his clinical context. He was also able to identify clinical reasoning as the foundation of professional clinical practice and establish its important role in his discipline as well as in other health care professions.
This paper also illustrated that clinical reasoning could provide a safeguard against the risk of having the popular theory and clinical techniques of the day adopted without questions and hence thwarting alternatives theories of clinical practice. (Jones, 1995 p. 18). Therefore, it can be said that clinical reasoning in radiotherapy has also become an essential component of professional practice, enabling radiation therapists to simultaneously gather and evaluate information relevant to their patients’ planning and treatment phase.
This in turn, provides radiation therapists with competence in their decision-making process within the context of the constant changes occurring in radiotherapy planning and treatment of patients. The author also trusts that his experience in writing this paper will contribute to the limited literature in clinical reasoning amongst radiation therapists by promoting its clinical significance to clinical practice in his radiotherapy department.