Chapter 5 Action and narrative
two dynamics of clinical reasoning
Research in clinical reasoning emerged from the medical problem-solving tradition which emphasized the hypothetical deductive method. Recently many theorists have argued that this strictly cognitive view is too narrow to encompass the myriad ways in which health professionals devise solutions for clients’ needs. We have found that the desire to conduct effective treatment, especially in the rehabilitation professions, directs the clinician to understand the client as a person who makes meaning of the illness or injury in the context of a life. By emphasizing the social dimension of clinical reasoning we are highlighting a quality of expert judgement which is by nature improvisational, flexible, and highly attuned to the specifics of the person, the condition and the context.
We discuss two streams of reasoning, active judgement and narrative. Working out narrative possibilities and making active judgements are two dynamic processes which intertwine while the clinician carries out the best treatment with and for the individual patient. We further submit that through making and reflecting on these active judgements and narrative possibilities clinicians develop their own stock of tacit knowledge and enhance their expertise. We draw upon ethnographic research projects we have conducted over the past decade, primarily (but by no means exclusively) among occupational therapists. This chapter is not a report of findings. We refer to these studies in a general way to illustrate and support a conceptualization of clinical reasoning and expertise grounded in the complexities and nuances of everyday practice in the world of rehabilitation.
Action is the essence of clinical practice. In occupational, physical and speech therapy the patient must act. Without the patient’s participation there is no therapy. One common view of action is that action takes place after one has carefully thought about the problem and its possible resolution. The assumption is that one thinks carefully about the problem, decides what the central issue is, determines the best solution, and takes action. This sequence may often be the case, but not always. Some philosophers, particularly phenomenologists, claim that thought and action occur in a rapid dynamic relation to one another, not in a fixed sequence. The word ‘judgement’ is often used to express this dynamic relationship. Buchler (1955), following on the work of John Dewey, C. S. Pierce and others, pointed out that action not only expresses the results of a judgement, it can be a judgement itself. Buchler (p. 11) commented, ‘every action is itself a judgement’. Schön (1983) submitted that reflective practitioners act first and judge the results afterward. Architecture students develop their expertise by looking at an area of land and sketching out versions of the structure they envision for that space. This action (sketching) is a way of seeing and a way of thinking. It is an act of both imagination and production, in which an image becomes visible and can be judged. The imagined building comes briefly to life in the form of a drawing. The structure is ‘built’ in imagination, action, and judgement long before the bulldozers arrive. Between the imaginative eye and the artful hand the practitioner negotiates the route between the creative image and the concrete restrictions of the size, slope and orientation of the site, using a dynamic process of active judgement.
Healthcare practitioners also use imagination and action to make professional judgements about clients’ problems and potential solutions. The patient is a ‘site’ where the best structure must be not constructed but reconstructed. Healthcare practitioners work with people in crisis, with whom action must be taken immediately. Many judgements are made before, during and after action. In professional work, action and judgement merge. The practitioner often has the advantage of having the patient – the person – as a partner, or at least informant, in the endeavour. Usually the patient trusts the clinician and is willing to respond to requests for action. The actions that the patient executes give the practitioner a great deal of information. Conversely, the clinician might take action on the patient, which provides another source of information. The clinician and patient become involved in a coordinated set of actions and interactions which many observers have characterized as a therapeutic dance.
Many professional judgements are based on observations and interpretations of patients’ actions. Clinicians want to see if and how a patient can perform an action. The practitioner judges the quality of a motion in order to make clinical judgements regarding the current level of strength or range of motion and to estimate the possible functional gains the patient may make during treatment. By judging today’s action the clinician can gauge the potential for future functional performance. The patient is asked to perform specific motions or sets of movements often and with frequent repetitions. Isolated motions, such as elbow flexion or thumb–finger prehension, are requested. Every day the therapist asks for more repetitions, more weight, more concentration, etc. Therapists remind patients that they could not do this last week or yesterday, and point out what they can do today and where they could be tomorrow or next week. The story of progress towards reconstruction is played out in increasingly better and more functional actions. Therapists want the patient’s movements to match the image in the therapist’s mind – to meet the perceived potential. Eventually the motions are combined into actions or sets of motions with a motive, such as shoulder rotation, elbow extension, wrist stabilization, finger extension and flexion to reach for an object. Later these and other motions and actions are combined so that desired functional activities, such as eating, may be performed. In a sense it is not the professional who is the therapist, but rather the patient and his or her ability to invest in meaningful action. Through this investment the patient rebuilds the body and reconstructs a sense of self as a person who can function in the world, an actor.
Practitioners take many actions while treating their patients. They also gain information from their interpretations of the sensations they receive from the patient and they learn from their own actions. The therapist tests muscle tone, adjusts the position of finger and thumb in a tenodesis grasp, or balances a child in her lap while he works with a toy. In the interest of improving patients’ potential for future action, experts evaluate patients’ actions, guide their own actions, make interpretations simultaneously, make rapid judgements, and change actions smoothly and rapidly. Action is both a concrete event and a reasoning strategy that mediates the flow of therapy from image to result. Simultaneously, clinicians learn if and how their own actions work as effective treatment strategies. In this way a wealth of personal/professional expertise is developed.
When we conducted our first study we were confident that we would discover that therapists had a great deal of professional knowledge and skill and had a great stock of tacit knowledge. We did not anticipate the degree to which they were unaware of the amount of knowledge they had. Polanyi (1966, p. 4) coined the term ‘tacit knowledge’ and described it as the stock of professional knowledge that experts possess that is not processed in a focused cognitive manner but rather lies at a not quite conscious level, where it is accessible through acting, judging or performing. This level of awareness is what Polanyi called ‘the tacit dimension’. It is a type of knowledge that is acquired through experience. Polanyi called it tacit knowledge because experts were able to act on it but could not always verbalize exactly what they were doing or why. He expressed this concisely with the words, ‘we know more than we can tell’.
In daily practice the clinician encounters a new situation, takes action, perhaps several variations of a set of actions, and reflects on them to evaluate whether the action ‘worked’. Was it effective in solving a problem with this particular patient who, in some ways, was subtly different from the last patient of the same age, gender and diagnosis? Through this action and reflection the therapist builds a stock of tacit knowledge which becomes increasingly nuanced with further experience. Tacit knowledge has some advantages and disadvantages. It contributes to efficiency. The expert can do what is required, quickly and smoothly in much less time than it takes to explain. Since tacit knowledge is developed in action, it remains accessible to immediately guide action. Clinicians often literally act before they think. This is not mindless action, it is an automaticity of expertise which does not have to be processed through the lengthier channels of formal cognition. However, the inability to explain all that one knows can cause others to question the credibility of the professional’s knowledge. Occupational therapists in our study had a particular problem with this credibility issue because they had a wealth of practical tacit knowledge and confidence in their clinical skills but did not have a rich language to explain or describe their practice, as do physicians and some other practitioners in the clinical environment. Giving language to some aspects of their practice (Mattingly et al 1997) gave the therapists a clearer perspective on their practice and a vehicle to examine and advance it.
Tacit knowledge works in the immediate situation owing to its development in the past. It can also work to help a clinician formulate an image of the potential future situation, both as an image and a guide to plan treatment. Below is an example of a clinician whose tacit knowledge was copious, and who could also articulate that knowledge given just a little prompting.
A Norwegian therapist we know read a transcript of an American therapist’s report on her work with a man with a crush injury to his hand. The report was basically a long list of abbreviations about distal and proximal interphalangeal and other joints and various soft tissue injuries. This therapist looked up from the notes and sighed. When we asked what the matter was she replied:
I can just see it all now. This man is going to get very depressed, lose his job, probably become an alcoholic, and his wife will divorce him. He will probably have bad contractures, more surgery, be committed to therapy for a while and cycle back and forth between depression and attempts to get his life and therapy back on track.
I’ve seen it all before. I have been a hand therapist for several years. As soon as I read the description of his injuries, his hand just lit up in my mind. I could just see it. Then his life just rolled along in my mind as well. I knew just how it was going to be. This is a very difficult injury and very devastating to the person.
This experienced therapist had known similar people with similar injuries in the past and was able to envision this man’s situation. The strong imagistic quality, to say nothing of the accuracy, of her comments demonstrates more than simple memory. Her capacity to suddenly see this patient in her mind’s eye is part of her expertise. The image is a vivid and powerful portrayal of the person’s future life. This therapist’s ability to create vivid images of a patient’s life, to take a minimal description of a hand injury and envision a host of life consequences, including how they might affect the emotions and motives of the patient, also reveals well developed skills in narrative reasoning.
One might assume that narrative reasoning is related strictly to telling and interpreting stories. However, it has come to be associated with a much broader human capacity. It constitutes a form of meaning making which is pervasive in human activity (Bruner 1986, 1990, 1996; Carr 1986; MacIntyre 1981; Nussbaum 1990; Ricoeur 1984). In recent years, narrative thinking has been recognized as important in clinical judgement (Frankenberg 1993; Good 1994; Hunt 1994; Hunter 1991; Mattingly 1991, 1998a,b; Mattingly & Fleming 1994). Narrative reasoning is necessary to interpret the actions of others and to respond appropriately to the social context. Bruner (1986, 1996) referred to it as a capacity to ‘read other minds,’ that is, to make accurate inferences about the motives and intentions of others based on their observable behaviour and the social situation in which they act. When we try to make sense of what another person is up to, we ask, in effect, what story is that person living out? Narrative thinking, as the anthropologist Michael Carrithers (1992, pp. 77–78) observed, ‘allows people to comprehend a complex flow of action and to act appropriately within it … narrative thinking is the very process we use to understand the social life around us’.
When occupational therapists reason narratively, clinical problems and treatment activities are organized in their minds as an unfolding drama (Mattingly 1998b). A cast of characters emerges. Motives are inferred or examined. Narrative reasoning is needed when clinicians want to understand concrete events that cannot be comprehended without relating an inner world of desire and motive to an outer world of observable actions and states of affairs. Narrative reasoning concerns the relationship among motives, actions, and consequences as they play out in some specific situation (Bruner 1986; Dray 1954; Ricoeur 1980, 1984). However, attention to the specifics of context is not sufficient to distinguish narrative reasoning from other modes of clinical thinking. As Hunter (1991, p. 28) noted: ‘The individual case is the touchstone of knowledge in medicine.’ The hallmark of narrative reasoning is that it utilizes specifics of a very special sort: it involves a search for the precise motives that led to certain key actions and how those critical actions produced some further set of consequences. Although narrative reasoning is evidently a generic human capacity, it is prone to tremendous misjudgement. As we all know, it is quite easy to misinterpret the motives and intentions of others, especially if they are strangers and come from unfamiliar social or cultural backgrounds. In some cases, and for some practices, interpretive errors are not especially important. One can make a splint, for example, without needing to have tremendous skill in interpreting the meaning of splint wearing for one’s client. But one cannot make a good decision about when to give a client a splint, or figure out how to get that client to wear it, without developing a capacity to assess the beliefs, values, and concerns of the client.
There are practical reasons why expert rehabilitation professionals in particular hone their narrative reasoning skills. The most obvious reason is that effective treatment depends upon highly motivated patients. As occupational therapists often say, in therapy, patients are not ‘done to’ but are asked to ‘do for themselves’. This ‘active healing’ process means that patients cannot passively yield their bodies to the expert to receive a cure; rather they need to become highly committed participants in the rehabilitation process. This presents a special challenge to the professional: ‘How do I foster a high level of commitment in my patients?’ This task calls upon narrative reasoning as the practitioner tries to design a treatment approach which will appeal to a particular patient. Occupational therapists refer to this as ‘individualizing treatment’. Narrative reasoning figures centrally in those health professions – such as rehabilitation therapies – where efficacious practice requires developing a strong collaboration with clients. When motives matter, narrative reasoning is inevitable, and poor narrative reasoning skills will mean that therapy is likely to fail.