Clinical reasoning and generic thinking skills

Chapter 6 Clinical reasoning and generic thinking skills



Stephen Brookfield



CHAPTER CONTENTS


The role of thinking in clinical reasoning 65

The process of appraisal: a deeper analysis 66
Critical appraisal of clinical reasoning: a context-bound and social process 68

The praxis of clinical appraisal 68

Experiential lenses of clinical appraisal 69
Lens 1: Our autobiographies as practitioners,teachers and clients 69

Lens 2: Our patients’ eyes 70

Lens 3: Our colleagues’ experiences 70

Clinical reasoning and the struggle against ’impostorship’ 70

Teaching clinical reasoning through team modelling 72

Effective team participation 73

Managing dysfunctional behaviours 73

Conclusion 74


THE ROLE OF THINKING IN CLINICAL REASONING


Clinical practice, as most clinicians know, is frequently located in a zone of ambiguity. The reality of clinical experience often stands in marked contrast to the patterns of practice laid out in introductory texts and pre-service education. Indeed, the contrast between the neatness of professional education programmes and the apparent chaos of clinical experience calls into question the usefulness of pre-service education. If the world refuses to conform to the models, concepts and research studied in professional education, what use is it to study theory and read professional literature? If the techniques acquired in school are constantly distorted or rendered irrelevant by the exigencies of practice, why should we bother learning them?


In this chapter I argue that pre-service education still plays a crucial role in professional development, but only if pre-service curricula place acquisition of the thinking skills of clinical reasoning – particularly the skill of critical appraisal – at their centre. Such skills might be regarded as the metacognition of clinical practice. They shape the way practitioners approach, analyse and respond to the multiple contexts and idiosyncrasies of practice. They do not displace the learning of specific skills or protocols, but they do frame how we determine the appropriateness of these protocols for different situations and how we modify the application of these skills in practice.


One can be technically proficient to a high level, but if one is unable to think in the way clinical reasoning demands then this proficiency is exercised haphazardly. A reliance on protocol and habitual responses works well as long as the world does not trip you up by refusing to conform to the shape you anticipate. Since the one constant of clinical practice is that nothing stays the same, it follows that the best form of pre-service clinical education develops generic skills of analysis that can increase the likelihood of clinicians taking informed clinical action.


At the heart of clinical reasoning are three interrelated skills that might be described as ‘scanning’, ‘gathering’ and ‘critical appraisal’. These skills are thinking skills – they stress analysis rather than instrumental competence.


Scanning is an act of apprehension. It describes the ways we identify the central features of a clinical situation. In scanning a situation we decide what its boundaries are, which patterns of the situation are familiar and grounded in past experience, and which are in new or unusual configurations. We also decide which of the cues that we notice should be attended to. Scanning is the initial sweep, the experiential trawl we conduct to construct the big picture.


In the gathering phase of clinical reasoning we explore the interpretive resources and analytic protocols available to help us understand the situation correctly. These include the general clinical guidelines we have learned as part of our professional preparation or through in-service development. We remember superiors’ instructions regarding what to do in such situations and also colleagues’ suggestions we have heard, or practices we have seen. Finally, we call on our own intuition. We attend to the instinctive analyses and responses that immediately suggest themselves as relevant.


In the appraisal phase we sort through the interpretations we have gathered. We decide which seem to fit most closely with the situation we are reviewing and, on the basis of these, we take informed action. Contextually appropriate reasoning is central to this phase. Scanning and gathering involve looking for patterns and broad similarities between a new situation and previous experiences. But in appraisal we judge the accuracy and validity of the assumptions and interpretations we have gathered. This occurs through a number of interconnected processes: by sifting through past experiences and judging the closeness of their fit to the current situation; by intentionally following prescribed clinical protocols and introducing experimental adaptations of these when they suggest themselves; by consulting peers prior to making clinical decisions or in the midst of action; and by attempting to analyse which of our instinctive judgements and readings we should take seriously and which we should hold in abeyance. As a result of this appraisal we take action regarding those procedures and responses that make the most sense in the current situation.


This chapter focuses on the third skill, appraisal, as the phase of clinical reasoning in which thinking is most central. Appraisal entails a detailed critical review of multiple sources, during which we decide to attend to some cues, to discard others, and to reframe interpretations that hold promise but do not entirely explain what we are confronting. In the language of formal research, this involves us in determining the accuracy and validity of assumptions and interpretations that we decide are most appropriate to a situation. In more colloquial terms, we try to judge the fit between what we think is happening and the responses that seem to make most sense.



THE PROCESS OF APPRAISAL: A DEEPER ANALYSIS


As a process, clinical appraisal involves practitioners in recognizing and researching the assumptions that lie behind their clinical practice. Assumptions are the taken-for-granted beliefs about the world and our place within it that seem so obvious to us that they do not need to be stated explicitly. Assumptions give meaning and purpose to who we are and what we do. In many ways we are our assumptions. So much of what we think, say and do is based on assumptions about how the world should work, and what we believe counts as clinically appropriate, ethical action within it. Yet frequently these assumptions are not recognized for the provisional understandings that they really are. Ideas and practices that we regard as commonsense conventional wisdom are often based on uncritically accepted assumptions. Some person, institution or authority that we either trust or fear has told us that this is the way things are and we accept their judgement unquestioningly. Clinical appraisal requires that we research these assumptions for the evidence and experiences that inform them. In particular, it involves seeing our assumptions from as many unfamiliar perspectives as we can.


Sometimes we find that assumptions about appropriate clinical responses are justified by our, or others’, experiences, in which case we feel a confidence in their accuracy and validity. When we can cite the clinical experiences supporting an assumption, we exhibit an informed commitment to it. At other times, however, we find that our assumptions are flawed, distorted or accurate within a much narrower range of clinical situations than we had originally thought. When this happens we realize that we need to abandon or reframe these assumptions so that they provide more accurate guides to and justifications for our actions.


What makes the process of assumption-hunting particularly complicated is that assumptions are not all of the same character. I find it useful to distinguish between three broad categories of assumption: the paradigmatic, the prescriptive and the causal. Paradigmatic assumptions are the hardest of all assumptions to uncover. They are the structuring assumptions we use to order the world into fundamental categories. Usually we do not recognize them as assumptions, even after they have been pointed out to us. Instead we insist that they are objectively valid renderings of reality, the facts as we know them to be true. Some paradigmatic assumptions I have held at different stages of my life as a teacher are that adults are self-directed learners, that critical thinking is an intellectual function characteristic of adult life, that good adult educational processes are inherently democratic, and that education always has a political dimension.


Paradigmatic assumptions are examined critically only after a great deal of resistance, and it takes a considerable amount of contrary evidence and disconfirming experience to change them. But when they are challenged and changed, the consequences for our lives are explosive. I think of them as the foundational building blocks that give structure to the architecture of our world-views. Paradigmatic assumptions are like load-bearing lintels in the houses of our assumptive clusters – remove them and the whole structure comes crashing down. It is because practitioners sense the potentially traumatic implications of questioning paradigmatic assumptions that they are so reluctant to do this.


Prescriptive assumptions are assumptions about what we think ought to be happening in a particular situation. They are the assumptions that come to the surface as we examine how we think teachers should behave, what good educational processes should look like, and what obligations students and teachers owe to each other. Inevitably they are grounded in, and are extensions of, our paradigmatic assumptions. For example, if you believe that adults are self-directed learners then you assume that the best teaching is that which encourages students to take control over designing, conducting and evaluating their own learning. Prescriptive assumptions are a little easier to discover. They tend to be expressed in institutional mission statements or clearly acknowledged as central to our philosophy of practice. However, although prescriptive assumptions may be espoused passionately they may play a relatively small role in determining our actions. It is not at all uncommon for practitioners to act in ways that bear little relation to their espoused assumptions regarding professional behaviour.


Causal assumptions are assumptions about how different parts of the world work and about the conditions under which these arrangements can be changed. They are usually stated in predictive terms. An example of a causal assumption would be that the use of learning contracts will increase students’ self-directedness. Another would be the assumption that if we make mistakes in front of students it creates a trustful environment for learning, in which students feel free to make errors with no fear of censure or embarrassment. Of all the assumptions we hold, causal ones are the easiest to uncover and are the ones most frequently unearthed in workshops and professional conversations. But discovering and investigating these is only the beginning of clinical reasoning. We must then try to find a way to work back to the more deeply embedded prescriptive and paradigmatic assumptions we hold.



CRITICAL APPRAISAL OF CLINICAL REASONING: A CONTEXT-BOUND AND SOCIAL PROCESS


One of the most salient features of clinical appraisal is that it is irrevocably context-bound. The same person can be highly open to re-examining one set of clinical practices, but completely closed to critically reappraising another situation or idea. Nor is a facility for clinical appraisal learned developmentally. There is plenty of evidence to show that after a breakthrough in clinical reasoning people can quite easily revert to an earlier, more naive, way of thinking and being. So clinical reasoning can only be understood, and its development gauged, within a specific context.


Clinical reasoning is also an irreducibly social process. It happens best when we enlist others – clients, patients, supervisors, peers and colleagues – to help us see our ideas and actions in new ways. Very few of us can get very far probing our assumptions on our own. No matter how much we may think we have an accurate sense of our practice, we are stymied by the fact that we are using our own interpretive filters to become aware of our own interpretive filters! This is the pedagogic equivalent of a dog trying to catch its own tail, or of trying to see the back of your head while looking in the bathroom mirror. To some extent we are all prisoners trapped within the perceptual frameworks that determine how we view our experiences. A self-confirming cycle often develops whereby our uncritically accepted assumptions shape clinical actions which then serve only to confirm the truth of those assumptions. It is very difficult to stand outside ourselves and see how some of our most deeply held values and beliefs lead us into distorted and constrained ways of thinking and practising. Our most influential assumptions are too close to us to be seen clearly by an act of self-will.


If clinical reasoning, and especially the process of appraisal, is conceived of as a social learning process then our peers (and teachers) become important critical mirrors. To become critically reflective we need to find some lenses that reflect back to us a stark and differently highlighted picture of who we are and what we do. When our peers listen to our stories and then reflect back to us what they see and hear in them we are often presented with an unexpected version of ourselves and our actions. Hearing colleagues’ perceptions helps us gain a clearer perspective on the dimensions to our thoughts and actions that need closer critical scrutiny. It also helps us to understand the commonality of our individual clinical experiences. Although no one person lives practice in exactly the same way as another, there is often much more that unites us than we realize. Talking to colleagues helps us see how much we take for granted in our own practice. Sometimes it confirms the correctness of instincts that we have felt privately but doubted because we thought they contradicted conventional wisdom or accepted clinical protocols. Peer conversation can also help break down the isolation many of us feel. Talking to other practitioners can open up unfamiliar avenues for inquiry and allow us to receive advice on how to deal with the problems we are facing.

Related posts:

  1. A history of clinical reasoning research
  2. Facilitating clinical decision making in students in intercultural fieldwork placements
  3. Clinical reasoning in physiotherapy
  4. Speech–language pathology students: learning clinical reasoning

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Apr 20, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Clinical reasoning and generic thinking skills

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