Physio Network

[Physio Explained] Perfecting your clinical reasoning with Mark Jones

Share episode

Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.

0:00 | 19:54

In this episode with Mark Jones we cover: 

  • Common principles of clinical reasoning 
  • What Physios can do to improve their clinical reasoning skills
  • Psychosocial factors in clinical reasoning
  • Categories of clinical reasoning/hypothesis categories
  • Analysis of clinical reasoning and using this in your treatment

Mark Jones is an Adjunct Senior Lecturer at the University of South Australia with 35 years’ experience teaching undergraduate and postgraduate physiotherapy. He has over 90 publications including three editions of the text “Clinical Reasoning in the Health Professions” and two editions of the text “Clinical Reasoning in Musculoskeletal Practice”.

Want to learn more about Clinical Reasoning? Mark recently did a brilliant Masterclass with us, called, “Enhancing Clinical Reasoning: Effective Strategies for Clinicians” where he goes into further depth on this topic.

👉🏻 You can watch his class now with our 7-day free trial: physio.network/masterclass-jones

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @sarah.yule from Physio Network

👏 Become a better physiotherapist with online education from world-leading experts:

https://www.physio-network.com/

SPEAKER_02:

You think about, you form a hypothesis, and then you think about in this so-called hypothetically deductive process, you think about as I get more information through my subjective examination, questioning, through my physical assessments, and even Through my ongoing treatment reassessments, I'm testing my hypotheses. I'm constantly evaluating whether that supports my thinking so far or does it perhaps not support it and lead me down a different pathway, like a differential diagnosis to another possible explanation.

SPEAKER_01:

What are the common principles of clinical reasoning? And what can physios do to improve their clinical reasoning? Mark Jones has conducted and supervised research in the areas of clinical reasoning and musculoskeletal physiotherapy with over 90 publications, including three editions of the text, Clinical Reasoning in Health Professions, and two editions of Clinical Reasoning for Musculoskeletal Practice. Mark has done a masterclass with PhysioNetwork on clinical reasoning, where you can dive a lot deeper into this area, of which we scratched the surface in today's episode. So be sure to click the link in the show notes to watch Mark's masterclass for free with our seven-day trial. I think you're going to get a lot out of today's podcast. I'm Sarah Yule, and this is Physio Explained. Welcome to the podcast, Mark.

SPEAKER_02:

Good to be here.

SPEAKER_01:

I must say I've been looking forward to this discussion as your work has very much been a prominent feature in all of our reading lists through uni for both the undergrad courses and the postgrad courses, which very much highlights the role that clinical reasoning has as this career-long skill. But I'm curious, what does a typical week look like for you?

SPEAKER_02:

Well, I'm semi-retired, so I was a full-time academic running the master's program at University of South Australia up until a couple of years ago. And I'm continuing is what they call an adjunct where I'm still affiliated with the university and I supervise some research students and I contribute some lectures and workshops, but I'm no longer paid for my work. You know, it's my choice to keep myself affiliated, but then I'm also semi-retired, which involves the combination. I'm still doing private sort of physio lecturing and workshops and webinars and what have you, but then a lot of personal time as well, starting to get out, exploring, traveling more.

SPEAKER_01:

That sounds like a wonderful mix.

SPEAKER_02:

Yeah, it is good.

SPEAKER_01:

Well, let's dive straight into it then. The first question I have for you is, are there any common principles of clinical reasoning that can be applied to all patients?

SPEAKER_02:

I think there are. I would start by prefacing it with the point that Clinical reasoning is not an exact science. So there isn't even a universal agreement in health, in medicine, or physiotherapy, or other health professions, exactly what clinical reasoning should involve. So when I talk about common principles, I'm sort of giving a perspective, which is my perspective, but it's also based on an extensive career studying the clinical reasoning in different professions, and obviously, including physiotherapy. But I like to say upfront, there's not just one way to look at clinical reasoning. So what I want to talk about here is my own perspective. And one of the main principles that I like to emphasize is that the process that we go through. Well, it's actually a process of human judgment, clinical reasoning. So you're getting information about your patients, your client, and you're making judgments in order to manage them and to assist them with their problems. And the process is often described as being what they call hypothetical deductive. Now, that's kind of a wordy phrase, but it's quite important because the key part of that phrase is hypothesis. And I think that should be a pretty common principle that your reasoning, interpretations, judgments, inferences, analysis, all of these things should be hypotheses in the sense that a lot of our clinical judgments don't get absolutely verified. So if you think about our diagnostic judgments, so many of them can't be substantiated. with a gold standard test. There are some exceptions to that, and some of our diagnostic testing has stronger validity, but in general, it's not that great. And it's the same for other judgments, like your clinical judgments on how the problem developed, what was the cause of the problem, or we sometimes call it contributing factors, or your judgments on red flags or safety issues. So because These judgments are not black and white. What I always encouraged when I taught clinical reasoning was to think about your judgments as hypotheses. And immediately, that should encourage the thinker, the clinician, to keep their analyses open. You're not getting a bit of information and say, aha, I know what this is, and I know what to do for it, even though that sometimes is possible. So you think about, you form a hypothesis, and then you think about in this so-called hypothetically deductive process, you think about as I get more information through my subjective examination, questioning, through my physical assessments, and even through my ongoing treatment reassessments, I'm testing my hypotheses. I'm constantly evaluating whether that supports my thinking so far, Or does it perhaps not support it and lead me down a different pathway, like a differential diagnosis to another possible explanation? So I think that process in general, where you reserve your final judgments until you've got through the full examination is a good common principle.

SPEAKER_01:

So it's sort of that antidote to bias and that the challenge of when you have a hammer, all you see is nails. Rather, we hold our hypotheses lightly and then look for the evidence to confirm or refute that.

SPEAKER_02:

Yeah, and that's a really good comparison to the human bias. It's one of the common errors of human judgment and clinical reasoning. So the more thorough you are in this process that I'm describing here, the more you're going to minimize the effects of that bias. And then I think you also made a point there that's worth highlighting is that you're not just looking for things that support what you're thinking, your first impression, for example, but you're also paying attention to things that don't necessarily support it because there's no clinical pattern that the patient has every single feature. And oftentimes they have other features that aren't in the pattern. So I often talk about it in terms of looking at the positives and the negatives, but pay attention to the negatives because they're often telling you something. They're either telling you that there's a variation of this pattern that you're familiar with, or they're telling you there's other things going on. There's more than one problem, more than one pattern that you're observing.

SPEAKER_00:

Want to take your physio skills to the next level? Look no further than our Masterclass video lectures from world-leading experts. With over 100 hours of video content and a new class added every month, Masterclass is the fastest way to build your clinical skills, provide better patient care and tick off your CPD or CEUs. Click the link in the show notes to try PhysioNetwork's Masterclasses for free today.

SPEAKER_01:

So it's sounding like the first common principle is really just holding those hypotheses quite lightly. Do you have any suggestions in terms of what us physios can do to improve our clinical reasoning skills?

SPEAKER_02:

There's really a lot of things you can do. I think probably the first thing that I, when I run workshops for teachers on facilitating clinical reasoning, I make the point in every aspect of life, it's hard to improve something if you don't understand it.

SPEAKER_03:

Whether

SPEAKER_02:

you're learning to play tennis or any skill, you first have to understand the thing and to be able to critique yourself and do whatever it is better. So reasoning is no different. You need to understand reasoning generally and then you need to understand your own reasoning before you can critique it and see, are there areas in my reasoning I could improve? For example, in the masterclass that I've recorded, you could say that that masterclass is aimed at achieving that. I cover what I believe to be the contemporary theory of clinical reasoning. So it enables the person to, once you've worked through that, say, okay, I now feel I understand the whole breadth or scope of what clinical reasoning really does involve. It's not just about making a diagnosis, although that's part of it. So I think one of the first things to improving is understanding it and then understanding your own reasoning. And people probably feel they do. But if you don't understand the scope of what reasoning can be, it's hard to critique your own reasoning. So are you adequately considering the person as well as the physical problem? Are you adequately considering the environment? So all the different dimensions of the biopsychosocial model How much do they really come into your assessment and your analysis? And, you know, it varies. People will say, oh, yes, I'm biopsychosocial, but then you watch them and it's not. It's, you know, 95% physical assessment and analysis so that the psychosocial aspect is often wanting. So that would be an area, if you appreciated how important that is to health and to patients, problems that we see, Then you say, right, I need to upskill. How should I assess psychosocial? And then really importantly, because assessment is only the start, how do I make my judgments? You know, I can tell you whether a joint is stiff, a muscle is tight. I can make those kind of physical judgments. But how do I make a judgment about something like, well, the patient said they're really stressed. They've got a lot of anxiety. How do I judge whether that is contributing to their problem? Or quite commonly, it's just coexisting. They had it before the problem, and it's there after the problem. So not every aspect of psychosocial that you find is always going to be relevant to that patient. So you need to have strategies to interpret what looks like it's relevant. And it's not so different from physical. You know, we find physical impairments all over the body. And we know that you can have, I call them sort of benign impairments. Every one of us has a bit of stiffness, a bit of weakness, a bit of postural things. We all have things, but that doesn't make them relevant. They don't always cause us problems. So you, just like the physical analysis, you need to work out how do I decide when something is relevant to the problem,

SPEAKER_03:

you

SPEAKER_02:

need to do that with your psychosocial. So I guess getting back to how do you improve, one is it being aware of all that and then looking at your own reasoning and seeing how thorough you are and do I have the sort of criteria to make those judgments.

SPEAKER_01:

Sometimes one of the biggest challenges in our line of work is making sure we're aware of our blind spots. And I suppose that's something like the hypothesis categories might be really useful as a means of us being able to zoom in and then zoom out to make sure we're actually casting a wide net. Would that be accurate?

SPEAKER_02:

I think it is. And you have these different categories of judgment that are important to your role as a physio. In fact, I often will take physios back to square one and say, What do you think the purpose of physiotherapy is? And, you know, it's going to vary a bit. If you're in a sports setting out on the field or you're in a private practice or a hospital, there'll be little differences in the purpose. But you could also come up with a broad purpose, you know, all physiotherapists. And I often say something, well, very broadly, our purpose is because people come to us or are sent to us to help with their problem. Our purpose is to understand people. the person themselves to understand their context or their circumstances, and then, of course, to understand their health problems. But it's not just their health problems. It's also the person, which is the psychosocial realm, and it's their context, which is the environment realm. And then I could, you know, A patient says, wow, you ask a lot of questions. My doctor spent 10 minutes with me and you just spent 20 minutes asking questions. Why so much? I'd say, well, you're looking for help and to be able to help you, I need to fully understand your problems, but I also need to understand you and I need to understand your circumstances. And in doing that, I'll be making a number of different judgments about what's going on, about what caused it. Are there any safety issues? How much I feel I can help you? Now, those judgments, so that's what I might explain to a patient, but those judgments that I'm highlighting there, I put those down as core clinical reasoning judgments that all physios have to make. Now, I should say, like I started this talk off by saying, they're not written in stone. And the problem with ever giving a list of anything is some people never look past the list. And you say, oh, well, no, I changed that list 10 times over the last 10 years. And my so-called hypothesis categories were constantly and I'm constantly tweaking the language so that one, it reflects real practice and two, it's contemporary. So there was a time I just had a category for pathology and source. And now I've got to a stage where I feel, you know, there's so many ways we classify patients' problems. It's probably better to have an umbrella category called problem classification stroke diagnosis, meaning that whole thing. And then say, well, underneath that, we classify pain mechanisms. We sometimes classify pathology. We classify syndromes. We classify the source. So you think of here's the different systems. Some musculoskeletal physios like Simon would have their impairment system or the McKinsey system. There's classification systems. And you as a practitioner will say, I use a couple of these, don't I? Like I judge the pain mechanisms. I judge what I think is the source. I think this is the main syndrome. So you use different classifications.

SPEAKER_01:

That's fantastic. And certainly for me, looking at, for example, those hypothesis categories and looking at what information I might get from a subjective assessment with a patient, it does hold a bit of a microscope to the thoroughness of our assessment. So it is a really nice way of actually checking and seeing are we getting the richness in our subjective examination and then in our objective to give ourselves the full capacity to create a really great hypothesis that can be reviewed and refined as we continue to treat.

SPEAKER_02:

I mean, you hit on something there that's quite important in that, unfortunately, some undergraduates are still taught things like a subjective, kind of as a routine. Here's the sections. Here's the questions. So if you stop them, say, through the behavior of symptoms and say, so tell me what you have so far, they would regurgitate. Here's the aggravating factors. Here's the irritability. Here's the ease. Here's the point prior. So they could tell you what they got from the patients. But what they don't do is think on their feet. They don't give you an analysis at that point because, unfortunately, it's not always emphasized in the education. So when you're getting behavior symptoms, which judgments is it helping you with? So people think about, okay, we get aggravating factors and we get irritability. It's a great concept. That's helping me with my judgment on precautions and safety. High irritability, I'm going to do a more careful, limited examination. So I can see how the information goes across to my clinical judgment. But you can take information, for example, from the behavior, and you can also say, well, how does that help you with your problem classification? Well, you can analyze the aggravating factors in terms of what structures are loaded or stressed. the easing factors, what structures are unloaded. Now it's not a black and white, but you can say it feels better when they do this, therefore it must mean this. It isn't like that. You're putting all the information together to build a picture that it looks like that hip area is more aggravated by hip movements than it is by back

SPEAKER_03:

movements.

SPEAKER_02:

So that's tending at this early stage to support a local problem rather than a somatic referral. Now, I might change my mind later when I get additional information, but it means I'm already thinking about it. I'm analyzing what I'm hearing, but it's only because I have these categories in my head and I'm trying to analyze what the information is telling me, but not in an absolute way.

SPEAKER_01:

Absolutely. That's fantastic advice. It's probably the Black, the white and the grey in between, that makes our careers all that more interesting. Mark, those are such fantastic clinical pearls today. And I'm sure everyone listening is eager to explore this topic further and hopefully refine our clinical reasoning. So again, I think it's very much worthwhile clicking on the link in the show notes to watch your masterclass for free with the seven-day trial. And thank you so much for your time today, Mark.

SPEAKER_02:

Oh, you're very welcome. It's a pleasure. It's a topic I enjoy talking about.

SPEAKER_01:

Absolutely. Well, you're very good at it. And I think we can all certainly benefit from it. So thank you.

SPEAKER_02:

You're welcome, Sarah.