No Clinical Reasoning Without Me – It’s Time to Put the Client’s Perspective in the Forefront

Generally, clinical reasoning refers to a health professional’s thinking and decision-making process. It guides practical actions, implying a process limited to the cognitive activities of health professionals. In more elaborated definitions of clinical reasoning, we may also find concepts such as collaboration and context. These imply a broader view of the reasoning process where the client and situational factors also come into play. The number of definitions of clinical reasoning are innumerable. Variations within and between different professional disciplines are equally as many. There is no established singular definition of the nature, relevant components or boundaries of a health professional’s clinical reasoning. The co-existence of multiple definitions leads to a plethora of variation in clinicians’ view(s) of clinical reasoning. These variations in turn influence their consistent and uniform application of reasoning in practice.

My name is Maria Elvén, I’m a lecturer and researcher in physiotherapy. In my PhD-work, focusing on clinical reasoning in physiotherapy, clinical reasoning was studied from a biopsychosocial and person-centred perspective. As such, clinical reasoning in relation to health and illness are dependent on biomedical, psychological and social aspects. Accordingly, to be in ‘good health’ represents different realities for different individuals. This variation emphasizes the need to grasp the persons’ individual perceptions. We must understand their own definitions of health and life situation in tandem, with their mental and bodily status from a health care perspective in the clinical reasoning process. Person-centredness, e.g., that the clinician considers the unique needs and specific health concerns of the person, and treats the individual as competent to make decisions about their own care, is a way to empower clients to take an active part in the clinical reasoning process.

Let’s pause here and reflect! Based on your view/definition of clinical reasoning, what is the goal of the clinical reasoning process? A correct diagnostic decision? A well-performed analytical thought process? A well-founded treatment decision? A satisfied clinician? A satisfied client? 

If I ask myself these questions, the ultimate goal of effective clinical reasoning is that the client achieves their own goal(s) related to their current health problem. To be able to reach this goal, the clinical reasoning process cannot be confined to the mind of the clinician, the process needs to be articulated and shared with the client. To make full use of the client as an active partner in the clinical process, shared treatment decisions are not sufficient. The client needs to be aided in supporting their role as an important  contributor to the analysis of the problem as well. This process also involves selecting and prioritizing among various treatments and management strategies that fit their actual life situation, as well as continuously evaluate their effectiveness.

We have covered a lot of ground surrounding the clinician’s inner process. The next step is to look beyond the cognitive processes of the clinician and to further elaborate on what meaningful client participation and involvement implies in the reasoning process. As suggested in my definition of clinical reasoning in physiotherapy, clinical reasoning is a process performed in partnership between the client and the clinician; ultimately stressing their shared responsibilities and equal values (Elvén, 2019). Performance of such reasoning may need training and competence development for clinicians to be able to support clients in their role as clinical reasoning partners.  

That brings us to where we are today and what I am hoping to bring into the DID-ACT project. In the DID-ACT project, the client perspective in clinical reasoning is clearly in focus. This is done by the inclusion of learning objectives related to client participation and shared decision-making. These learning objectives will influence learning activities and assessments in the forthcoming clinical reasoning curriculum development. The aim is that the client-perspective will play an increasingly important role in the learning and teaching of clinical reasoning in this project. 

I’m looking forward to contributing to a strengthened role for the client or patient in general health care, and, more specifically, clinical reasoning and I hope you’ll join me!

Elvén, M. (2019) Clinical reasoning focused on clients’ behaviour change in physiotherapy: Development and evaluation of the Reasoning 4 Change instrument. Doctoral dissertation. Mälardalen University. Västerås.

4 Replies to “No Clinical Reasoning Without Me – It’s Time to Put the Client’s Perspective in the Forefront”

  1. It is interesting that we have not progressed further when it comes to clinical reasoning, i.e. outside the clinicians head :). I look forward to hearing more about the development of knowledge in this important area of research!

  2. Thanks Maria!
    We have progressed further, I’m sure. But we still have some work to do both within and between different health professions to change the view of clinical reasoning in its foundation. It’s not a quick fix and we as educators play an important role in this work. Looking forward to discuss more with you:)

  3. I like the idea, Maria. Being in the era of chronic conditions, we need more than ever to in partnership with clients, if healthier lifestyle practices are to be achieved.

    I like famed cardiology researcher, Dean Ornish’s approach, the ‘spectrum ‘ approach. We know a great deal about what constitutes a healthy lifestyle. Ornish for example showed 30 years ago, that intensive lifestyle behavior change (diet and exercise) can ‘reverse’ occlusions of coronary arteries over a year or two. He accepts however that patients have varying levels of interest in taking the steps necessary, compared with taking drugs or having surgery, interestingly. Based on the literature, he feels it is important to lay out the spectrum of behavior change (in fact, he has a book by that name); even small steps in the right direction are proportional to benefit.

    1. Very thoughtful thoughts, Elizabeth. I think both the client and the clinician has a spectrum of choices to consider in the reasoning process and these have to be made explicit. Otherwise, it will be very difficult to make informed decisions in partnership with the client. I haven’t read the book by Ornish, but I will definitely search for it!

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How to teach synchronously in a virtual setting

  • You need a reliable camera, microphone, and virtual platform and be familiar with its features, such as whiteboard, chat, polling, breakout rooms, etc.
  • At the beginning establish communication rules, e.g. whether participants should raise their (virtual) hand, use the chat, and/or just speak. Also, we recommend asking participants to turn on their camera
  • For small group work break out rooms work very well, just be clear about the tasks the groups should work on prior to dividing them into the groups.
  • For collaboration the use of integrated virtual whiteboards or other platforms such as Padlet are very useful. Just make sure prior to the session that you have everything setup and the links at hand, e.g. to post them in the chat.
  • Allow a bit more time for starting the session and the group works as there might be participants who are not familiar with the platform or technical problems might occur.

How to motivate unprepared participants

  • Make clear that the asynchronous assignments are a core part of the course and that its content will not be repeated. Even if it is difficult, stick to that when starting the synchronous teaching session.
  • If you expect unprepared participants, you can start the session with a student-centered group exercise mixing prepared and unprepared students to increase peer-pressure and make them realize that being unprepared does not feel good.  
  • Use the introductory or closing quizzes / tests so that participants can self- assess whether they have the required knowledge and you as a facilitator can see the level of knowledge and preparation of your participants.

Further recommended reading:

How to involve participants with different levels of experience

  • To account for such different levels, we recommend making use of the asynchronous preparatory phases which also include introductory quizzes in which participants can self-assess their prior knowledge and you as a facilitator can assess the differences within your group. Participants with less prior experience can also be guided to additional preparatory resources.
  • Encourage participants to work in pairs or small groups when preparing so that they can help and learn from each other. You could even facilitate this by dividing them into groups with different levels of experience.
  • Similarly, during the synchronous phases, we recommend forming groups with participants different levels of experience and emphasize the peer support aspects of such group activities.
  • We also recommend starting with rather smaller groups and allow more time than stated in the course outlines, if you expect a heterogenous level of experience. This way you can better manage this challenge.
  • Encourage your participants to ask questions, emphasizing that nobody knows everything and that it is important for learning to ask questions.  
  • Especially in the train-the-trainer course you might have to deal with over-confident participants, who especially in an interprofessional setting can dominate the group. This is a complex cultural challenge, but you could try to establish (and follow) communication rules at the beginning of a session.  

How to address potential overlaps or redundancies

  • Identify what is already included and what is missing in your curriculum related to clinical reasoning outcomes and compare it to the DID-ACT blueprint. Prioritize learning outcomes that are not yet covered but regarded as important.
  • Identify activities, resources, or teaching sessions with similar learning outcomes that might be in need for change anyway because of low evaluation results, teachers or students struggle with it. These could be suitable for adding or replacing parts with DID-ACT activities.
  • Ask teachers and students about overlaps and gaps they see in their teaching / learning of clinical reasoning and where they struggle. This could also be done by a reflection round after related teaching activities in the curriculum
  • Although ideally a longitudinal integration is aimed at, we recommend to starting small with a pilot implementation to gain experience and develop a show case.

How to teach in an interprofessional setting

  • Allow for enough time prior to the teaching for the organization and motivation / encouragement of stakeholders and participants
  • Allow for enough time and guidance during the course so that the participants from the different professions can get to know each other and their professions and discuss their different perspectives. This might mean that you need to calculate some extra time in addition to the suggested duration of the learning unit.
  • There may be a different understanding of clinical reasoning in the different health professions, so we recommend making participants aware of this. You could for example use and adapt activities from the learning units on the health profession roles to facilitate this.
  • Courses in an interprofessional setting should not come too early in the curriculum (not before professions have formed their own professional identity - however, this also depends on the aim of the course). 
  • Make sure you have enough participants from different professions. If possible, the facilitator could divide the participants in smaller groups with an equal distribution of professions. 
  • Similarly, you need an equal distribution of facilitators / facilitators from different professions.
  • Develop customized learning materials considering the different professions. If needed you can adapt the material and activities provided in the DID-ACT curriculum.

Further recommended reading:

van Diggele, C., Roberts, C., Burgess, A. et al. Interprofessional education: tips for design and implementation. BMC Med Educ 20, 455 (2020). (Link)

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