Musings on theory and clinical work


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This muse won’t be quite as lengthy as my last rant on occupational therapy and science, I promise! At the same time, it’s on a similar theme – and touches also on my post about ‘back to the basics’ where I discussed the recent review of pain contracts by ACC in New Zealand.  This review criticised the number of pain intervention services (eg injection therapies) and functional reactivation programmes that are provided without due regard to integrating the psychosocial along with the biomedical.  I suggested that perhaps providers need to be ‘risk profiled’ as well as claimants, because some of the behaviour seen in providers is likely to disregard high risk psychosocial factors and reinforce disability.

If clinicians are to be something other than ‘technicians’ applying a process to their patients, they (we) need to understand the concepts lying behind an intervention.  At the same time, we also need to be able to understand when an intervention isn’t likely to succeed, and when a variation on an intervention might suit better.  To do this requires effective clinical reasoning – aha! a theme!  I’ve hammered on a bit about clinical reasoning because it underpins the WHY we might choose to use one intervention over an other.  Clinical reasoning implies working backwards from what is evident in the patient’s presentation to hypothesise about how those features might occur.  In other words, developing a clinical theory to explain how and why the person is showing this behaviour.

Clinical reasoning can be quite straightforward in many settings.  After all, building on the knowledge of centuries, clinicians know enough about bone healing to align a broken bone, stabilise it, and wait for it to heal without doing too much thinking about it.  (Pssst! Don’t tell the orthopaedic surgeons this!)  Similarly, in an acute hospital setting, some fairly simple reasoning is needed to establish whether a person can get on and off the toilet with a raised toilet seat and then issue one if need be!  However, clinical reasoning can be (and usually is) much more complex than this.  Depending on their professional orientation, clinicians working with an acute fracture might ask why the person broke the bone, what the implications of that immobilised limb might be on occupations, might be considering the need for supports at home, might be monitoring for signs of shock – and the point is, these further interventions depend entirely on the theory-base of the clinicians working with that person.

Even in the case of someone needing a raised toilet seat in order to be discharged safely home, the clinical reasoning behind that simple intervention is not just about the biomechanics of getting on and off the toilet!  It could also be asking why the person has trouble standing up and keeping balanced, how the person might cope at night without lighting, whether the person can (or does) ask for help and so on.  Without having a good theoretical framework on which to base information collection, and a similarly effective way to organise that information, the clinician might as well simply issue a raised toilet seat and be done with it!

I’ve deliberately used simple examples to illustrate so-called simple clinical reasoning.  Now lets consider more complex examples.

Firstly, an analogy.  If I wear a set of glasses that occlude my vision on the left hand side of each visual field, I can still see. What I can see is limited, and I need to move my head around to scan the whole of my environment, but I can see.  After a while wearing these glasses, perhaps a week or so, finding my way around becomes easier, and in fact I’d have trouble after just another week of wearing the glasses, adjusting to ‘normal’ vision.  The world would look ‘normal’ to me even though part of my visual field is blocked.  New items appearing on the left side of my field of vision could suddenly ‘pop’ out of nowhere, and unless I know I’ve got those glasses on, I could be quite unaware of the amount of visual information I’m missing.

This is exactly what happens when a professional dons a single theoretical perspective.  I’m guessing we can all recall the first years of becoming a professional, and how strange adopting that new ‘persona’ felt.  After a while, though, it becomes familiar and we hardly notice it.  Then along comes new research, new theory, new models and new interventions.  The world gets a little shaken up!  We either integrate this new information, or we work hard to ignore it. ‘High risk’ clinicians are, IMHO, those who fail to recognise the contribution of information from outside their existing frame of reference. It’s my opinion that these clinicians can and should be identified, and either helped to integrate the new knowledge – or not allowed to practice in a field like pain management where the contribution of information obtained from so many fields is critical.

Bringing this back to clinical reality, if we are unaware of the theoretical models or even the professional models we use, we can be completely stumped when a new situation arises, or when a new piece of information is brought to light – a bit like that object coming into view on the left field of vision when I’m wearing those glasses!  By taking the glasses off, opening up the whole visual field, we can be much more aware of the fact that we do have constraints on what we can see, and if we look more broadly we can identify areas we want to look at in more detail.

OK, enough with the analogy.  Some clinicians scoff when I talk about my interest in science, theory, models and the process of clinical reasoning.  I think it’s vital.  Without articulating why a certain intervention is recommended, I think it’s impossible to distinguish between following a protocol as an assistant and being a versatile and adaptive clinician.  An assistant may not know how a process works, just that if (a) and (b) are following in a certain order, (c) will ensue.  If (g) or (h) are present, an assistant won’t know how to respond.  A good clinician knows that people may present with the same behaviour, but the underlying factors influencing that behaviour could be very different.  For example, someone saying that he or she can’t sleep and wakes often might be due to pain, a natural wakening during normal stages of sleep, having chronic sinus problems, low mood, anxiety – or even the effects of having a new baby in the house!  The work of clinical reasoning doesn’t start with simply ‘identifying the problem’ and then solving it: it begins with the way in which the clinician views the situation and the contributing factors.  If we’re not careful, even as experienced clinicians, we can jump to conclusions or simply ‘assume’ that the clinical problem is the one with which we’re most familiar, or the one that springs to mind the most easily.

It takes a lot of effort to avoid prematurely deciding on ‘what the problem is’ during a clinical intervention.  Being aware of our cognitive limitations, noticing our assumptions and broadening our view to include searching for as many different pieces of information as we can helps to prevent clinicians from working from a recipe – but it’s also hard work.

I’m referring back to Vertue and Haig’s paper on Abductive Theory of Method in clinical reasoning as the basis for today’s post. Read it if you’re keen on science, models, theory and clinical reasoning, and let me know what you think.

Frances M. Vertue, Brian D. Haig (2008). An abductive perspective on clinical reasoning and case formulation Journal of Clinical Psychology, 64 (9), 1046-1068 DOI: 10.1002/jclp.20504

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