Clinical reasoning – more than problem solving…


Once upon a time, I was a baby occupational therapist, newly graduated, and I dutifully followed what I had learned as ‘the occupational therapy problem solving process’.  This process was:

  1. Identifying the problems (usually as identified by ‘the client’ who was often the person I ended up seeing, but just as easily could be the person who had referred the person I saw…) – this involved assessment
  2. Identifying the potential solutions (being creative, and based on clinical knowledge of ‘what works’ and included biomechanics, psychosocial factors, developmental stage and the end result that was being aimed for)
  3. Choosing a solution (that could be whatever was most pragmatic, least expensive, quick to implement, suited the client, or I had learned was ‘a good solution’)
  4. Implementing a solution (just getting on and ‘doing it’ – but it might involve selective grading of complexity of the activity or task or equipment or environment)
  5. Reviewing the satisfactoriness of the solution (often through ‘reassessment’, but even more often through asking ‘did it work?’)
  6. If it didn’t work, repeating the process…

What I developed through my undergraduate education was a working knowledge of anatomy, physiology, psychology (particularly developmental stages, cognition, and behaviourism), sociology (especially roles within society and responses to social environments), pathologies of various types – and the gift of learning about the value of ‘being active’ or engaged in ‘occupation’ or ‘valued activities’.  I can’t recall the exact wording, or even references now (it was HOW many years ago?!!), and I do remember graduating thinking ‘I’m not really sure what makes occupational therapy ‘different’ from other professionals, but I think it’s something to do with activity and of course, we do learn about how groups work’.

Very quickly I became quite disenchanted with occupational therapy – and quite abruptly had to face some hard facts about what I learned, and the way other professions (and this thing called ‘science’) worked.  And it was this: that problem solving process which I had hammered into me misses the point.  In fact, because of the way many occupational therapists practiced then (and I have to say, practice even now…), the profession suffered from the accusation that it couldn’t respond to – ‘jumping in with solutions before really knowing the problem’.  

Ouch!

I’ve pondered this for ages…why is it that occupational therapists, who are well-meaning, often very well educated, and have such laudable aims for their therapy, why do they ‘jump in’ with solutions so quickly?

Some of the thoughts I’ve had about this include:

– client-centred can mean that because of lack of insight by the client, contributory problems that underlie the problems the client identifies don’t get brought to light

– there is no specific step to specifically examine, through hypothesis generation, a number of competing explanations for the problem arising

– because of information processing heuristics, clinical reasoning can be shot by human characteristics common to all professions:

– the tendency to identify a pattern out of random data when it might actually be random

– the tendency to remember unusual or unique factors more readily than the familiar

– the effect of recency and primacy (information that is new or recently learned, information that comes first or is over-learned)

–  information provided/required by an ‘important’ team member is recalled quickly

– our difficulty setting aside a preliminary conclusion, along with our ability to seek confirmation that our hunches are correct (rather than waiting for more information before deciding on an option, and difficulty actively seeking disconfirmatory evidence)

– that we don’t recognise the context of the situation – why, who, what are defining ‘the problems’ – some ‘problems’ may be problematic for one party, but pretty good for another

– theory, and especially theory from other domains of information apart from ‘occupational science’ – such as neuroanatomical, cognitive, behavioural, family systems, attachment theory, biomechanics – I could go on!! need to be systematically reviewed in relation to how they might contribute to ‘the occupational performance problem’ – and this is an incredibly complex assessment model!

– the biomedical model continues to dominate and individual’s needs are ‘diagnosed’ often in terms of ‘deficits’ rather than interactions between an individual with values making daily choices of behaviours and that individuals’ environment

I’m drawing quite heavily on the abductive process in clinical reasoning now – what that means is that I have steeped myself in a number of models that appear to be relevant to pain and pain management.  One of the most prominent models is the cognitive behavioural model.  As a result, while I’m ‘assessing’ a person (translate this to ‘having a conversation with the person so I can begin to understand their situation’), I’m actively looking for patterns in their presentation.  Although they may describe their ‘problems’ at the same time I’m looking for both the good things and the not so good things about what they construe as a ‘problem’.  AND I’m looking at the various cognitive and behavioural (oh and biophysical) things that are potential explanations for the initiation and maintenance of their situation.  I’m actively seeking disconfirmatory evidence throughout the ‘assessment’ process for any hypotheses that I generate during the first contact – so, if they mention difficulty sleeping, feeling tearful, lacking energy – I’m also looking for information that might refute one of my initial assumptions that ‘they’re depressed’ – what else might explain their presentation?

Effectively, I’m broadening out the range of potential explanations that I’ll later need to systematically review.  I’m also eliminating things that I might initially think of as a ‘pattern’ but later I find to be a one-off, or unique event.

As a result of this, I look at both the client and what he or she identifies as ‘problems’, but at the same time attempting to look at strengths, possible explanations, and areas that can be explored in more detail.  This means a significantly increased emphasis on assessment (or, as I prefer to put it, learning to understand their situation).

It’s only once some explanations have been developed that possible options for changing the presentation can be identified.  Otherwise I (and the client) can risk prematurely applying a ‘solution’ that:

  1. doesn’t solve the problem, because it’s focusing on the ‘wrong’ mechanism
  2. creates other problems, because the interaction between that ‘solution’ and the rest of the system hasn’t been considered
  3. prevents uncovering deeper concerns that are maintaining (through inadvertent benefits) the situation

Well, that was a bit of a philosophical ponder!! I hope you followed it – and that you’ll think about dropping me a line to let me know what you think.

6 comments

  1. It was a great philosophical meander. Wonderful to see these things questioned!! I teach problem solving with reasonable passion – (ask my post-grad students!) so am very interested in your insights (and this is the week for problem solving!) I do believe that the basic problem solving model is applicable in all situations – well its a universal phenomenum. The difficult bit is translating when you generate the hypotheses – as you suggest, most of the time ie. there is not necessarily a one stop end point or diagnosis; however such a point is reached once you spend time with clients or try out a few ideas.
    Mattingly has suggested that narrative reasoning underpins our practice and that problem solving is mainly useful in biomedical situations – I don’t believe this and still think that the underpinning is problem solving. However, there are different types of problems – some are easy and some are decidedly complex. They are not all complex as much of the literature would have us believe.
    I do agree that we get into the business of finding solutions – is this a product of the system? ie. pressure to do just that. Do we interpret situations so that we can solve them rather than listen carefully to the client’s perspective? It can be scary not to know the answer.
    Another thought I had was I wondered if the idea of developing a ‘blue-print’ was a useful way to think about how we problem solve eg. like a landscaper – think about what people say, come up with options(blueprints), negotiate until agreement is reached.
    Anyway this is becoming as long as your entry. I have provided a link to the web site that I use with the students – please do go in and comment.

  2. Ahhh Linda, I had a bet with my student Linda that you wouldn’t be able to resist this one!!!
    I’ll certainly drop in to your website, but can’t find the link – can you re-send it?
    I’ll respond in more depth to this – coming from a scientist-practitioner model rather than a problem-solving model may well be part of the conceptual difference…
    And no, I don’t think ‘the system’ has produce this tendency for therapists to problem solve so quickly, it’s been an occupational therapy characteristic for many years, way prior to the implementation of MOH or ACC contracting…

  3. Excellent post – and I am driven here tonight (well after your publication) because I am repeatedly bouncing into poor clinical decision making in our profession and still searching for answers. More people need to study this issue.

    There is a problem in our educational process that is emphasizing an inculcation of mythology as opposed to teaching students how to approach issues with a ‘blank slate.’

    Teaching EBP is not going to be helpful if the people teaching EBP are not able to look at their own assumptions! Otherwise, we are just promoting a blind search for validation of things that only we believe which is definitely not healthy.

    I have no answers, but am encouraged that others are thinking about this. Thank you.

  4. Hi Chris
    Thanks so much for commenting – I am so fed up with poor clinical decisionmaking, it drives me nuts!
    Is it our educational process? or is it that once students leave the educational system they encounter ‘lazy’ therapists who work in a setting where therapy is routinised, the ‘problems’ already defined by either the system in which they work or the referrer.
    I laughed at your description of ‘mythology’ – that is exactly what it is! Why else would therapists continue to argue that, despite lack of empirical support for safe manual handling to prevent acute low back pain, ‘they didn’t use the techniques correctly’. I could list example after example!
    End of rant. Sorry. Breathing out slowly now!!
    Perhaps it takes people like us, on blogs like this, to generate curiousity from others in the profession – and perhaps for them to learn some scientific method?!

  5. I was doing some class prep and re-found this post – think I will link some students to it. It is just as good, three and a half years later and the second time around!!

    Hope you are well!

    Chris

    1. Thanks Chris. One day I’ll rewrite this – but I have contributed something on clinical reasoning to a book by Dr Linda Robertson, Uni Otago – so there will be something more up-to-date coming out for your students!

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