Today we’re talking about a subject that really gets my nerd juices flowing!
We’re talking about clinical reasoning.
Let's get into it!
My interest in this topic runs back to the very start of my career.
Some of the first readings in my residency program were on clinical reasoning. They were dense but utterly fascinating to me. It was the first time that I can remember reading about the mind and how it works.
Of course, in school, we learn about the brain’s structure and function. But this was different. This was about the mind, and the application of the material was immediately apparent. I was hooked.
So hooked that as my residency project—which expanded to last most of the following year—I created a new electronic clinical reasoning tool for the program, which updated the old reasoning form and used branching logic to personalize the tool, based on how the resident answers the questions. The whole thing took me well over 100 hours of research, implementation, feedback, modification, etc.
Needless to say, I learned a TON from the entire process.
I want to share with you what I learned from my deep dive into the reasoning literature, as well as what I’ve learned since then through further investigation, observation, reflection, and integration.
In this article, we’ll discuss:
What clinical reasoning is
Why it’s important
How we can improve our clinical reasoning skills, discussing strategies & techniques for improving these skills along the way
*By the end, you will have two new resources for helping you improve your reasoning skills.
What is Clinical Reasoning?
Clinical reasoning is a bit of a slippery thing. Thus, there are many definitions, depending on who you read.
One author defines clinical reasoning as, “The cognitive processes, or thinking used in the evaluation and management of a patient (5).”
Another defines it as, “A process of reflective inquiry, in collaboration with a patient or family (as appropriate), which seeks to promote a deep and contextually relevant understanding of the clinical problem, in order to provide a sound basis for clinical intervention (6).”
My definition is a bit simpler: Clinical reasoning is how we think and make decisions about what to do.
To dig into some of the complexity of clinical reasoning, I want to present you with a metaphor (a simile, really): Reasoning is like juggling.
What is juggling? Juggling is simply keeping more than two objects moving through the air using only two hands.
What does juggling require?
Awareness, in the sense that the juggler must pay attention the entire time they’re juggling in order to have a constant pulse on where each object is in space. Also in the sense that the juggler must make contact with each of the objects regularly to keep them from dropping to the ground.
A balance of structure & relaxation. There is a general consistent pattern to juggling that needs to be understood and executed, but the motion of the objects is also constantly in flux and a degree of relaxation and flow is required.
Practice. The juggler must be able to notice errors when they occur and learn from them by finding strategies for overcoming future errors.
Just as the juggler must coordinate a constant flux of external and internal factors to keep the objects in the air using only two hands, so too must humans coordinate a constant flux of environmental information and personal intentions with limited cognitive capacity:
The juggler paying attention to the flying objects is analogous to us paying attention to the data that is constantly coming in during the patient encounter.
The juggler making constant contact with the objects is analogous to us holding information in our working memory, the temporary storage between short- and long-term memory that has a limited capacity.
The understanding and execution of the pattern to juggling are analogous to more analytical or deductive types of reasoning (I'll discuss it in terms of cognitive organization), whereas the relaxed flow to it all is analogous to non-analytical types of reasoning, inductive reasoning, or trusting your gut as I’ll put it.
The countless hours of practice that the juggler undergoes to be able to manage all of this is analogous to reflection.
Why Is Clinical Reasoning Important?
I have to get into the ‘why’ because if you’re anything like me, you have a bit of an obsession with the ‘why’ question (for better or worse). So why does clinical reasoning matter?
"Expertise is not an inevitable consequence of experience."
The first reason is something that was discussed in the episode & post about the test-retest model, this adage in the reasoning literature that expertise is not an inevitable consequence of experience. Instead, the authors of this paper note that, “The development of expertise requires skill in successful experiential learning, which is active in nature, and requires attention to and critique of one’s own clinical reasoning (6).”
In short, you can’t just practice and expect to get better.
Why not? Well, because just as you’ll naturally develop some areas that lead you toward the truth or improvements in your practice, you’ll also naturally develop in areas that lead you away from the truth, toward ignorance.
Why is that? Because working with people is fucking hard. And the mind wants to make it easier. So while we may objectively improve in some ways, the mind will also shield us from the pain of being wrong, leading us to develop some sneaky ways of biasing ourselves, our patients, or both, in order to make clinical practice a bit easier to deal with.
The alternative is taking an active learning approach, which requires attention and critique of one’s one reasoning.
Clinical reasoning is correlated with outcomes
Another reason that reasoning is important is that it seems to be correlated with outcomes.
One study found that ‘expert practice’ is NOT correlated to years of clinical experience (1). “The group of therapists classified as expert could not be distinguished from therapists classified as average based on their years of clinical experience, sex, or professional degree.” Rather, outcomes were correlated with other characteristics including clinical reasoning and patient-centered care (2).
The good news for you is the fact that you’re reading this shows that you’re clearly interested and intentional about improving your practice. Good on ya!
Knowledge alone isn’t enough
The last reason that reasoning is important is for the following reason (← is that enough reasons for you??):
“Most diagnostic errors are not the result of inadequate medical knowledge as much as an inability to retrieve relevant knowledge already stored in memory…the amount of knowledge appears less relevant than the organization of that knowledge (5).”
This notion is supported by a study of 190 cases of missed diagnoses in primary care physicians/general practitioners (3), which found that, “Most of the errors were judged to be due to data-gathering and synthesis problems (or cognitive errors) related to the medical history (56.3%), physical examination (47.4%).” The authors concluded, “Our findings highlight the need to focus on basic clinical skills and related cognitive processes…”
None of this is to say that we don’t need to have knowledge. After all, specialty knowledge is part of what makes someone an expert (5). But we also must understand that knowledge alone is not sufficient to help us make better decisions and elevate our practice.
How Can We Improve Our Clinical Reasoning Skills?
So now that you’re pumped on reasoning, let’s ask the big question: how can we improve our clinical reasoning skills?
There are several ways to do this. Some of the ones that I’ll discuss are commonly talked about, and some of them are less common.
1. Improve our awareness
The first & most basic requirement to improve our reasoning (or juggling skills) is to improve our awareness.
Just as the juggler cannot possibly juggle without an awareness of the position of the objects as they dance through the air, we cannot improve our thinking & decision-making skills if we’re not aware of what is happening in our minds.
Put simply: you cannot change what you’re oblivious to. This is why awareness is absolutely the foundation of reasoning skills.
What constitutes awareness?
Awareness requires both attention & intention.
Attention is the ability to focus on an object without being distracted, while an intention is a conscious goal.
The importance of intention is that it anchors our attention. Put another way: Our attention will always follow our intention.
For example, If our intention is to make our patient think we’re really smart, our attention will center around how smart we look. On the other hand, if our intention is to help the patient as best as we can, our attention will center around how well we & the patient feel that they are being helped.
One of the most common ways that our reasoning goes awry is a lack of awareness. Either we get distracted, our intentions get twisted, or both.
Improving our awareness allows us to do something truly profound—to engage in something called metacognition. You might know it as mindfulness, which is becoming quite popular these days.
Humans have the ability to do something incredible, we can observe our own minds. It’s absolutely insane that we have the capacity to do this. What exactly makes up our consciousness and where it comes from continue to be some of the biggest mysteries known to us.
Cultivating the capacity to witness the workings of our minds is a superpower. And the more you bear witness to the workings of your mind, the more awareness you gain of yourself, as well as the universe around you.
So if I haven’t stated it enough, awareness is unequivocally the most important aspect of clinical reasoning. If you do nothing but focus on building your awareness, your reasoning skills will shoot through the roof, because you’ll start to learn from everything.
Let’s talk through some strategies for improving our awareness.
There are two main strategies:
As we talked through in the episodes & posts about Law I and Law III of the Four Laws of Quality Care, intention-setting involves choosing a conscious goal, or anchor point for the session or the day.
Your intention could be something like: to be curious or compassionate, as we discussed in Law I, or it could be on something specific that you’re working on. Either way, your intention sets the anchor point for your attention.
Click here to do a fun-scroll to an infographic guiding you through 4 simple intention-setting practices.
I started meditating in 2018 and have been doing it pretty much daily ever since. I believe it to be the single most impactful thing I’ve done for my practice.
There are many methods and purposes of meditation. I’m going to guide you through some very simple practices that will help you strengthen your ability to focus without getting distracted, and to observe your mind without getting sucked in. Both of these skills are essential to improving our clinical reasoning abilities.
There are three basic practices that I recommend. Each one is successively more tricky than the last, so each is meant to be practiced for several days or weeks before moving on.
Concentration practice (the docked boat). This is simply focusing your attention on a specific object (the classic is the breath as it passes through your nose). Each time you notice the mind wander, simply bring your attention back to the breath at the nose and start over. Set a timer and repeat this process until the timer goes off (5 minutes or less is a good place to start). The goal is that our attention doesn’t move very far from its point of focus, like a boat that’s tied to a dock.
Anchored awareness (the anchored boat). This involves focusing your attention again on a specific object, but this time, when the mind wanders, instead of bringing it back to the breath, you let your attention rest on the thing that pulled your focus away for a moment. Once it dissolves, then you go back to the breath and repeat. For example, if I get distracted by a thought, once I realize that I’ve been distracted, I notice the thought, get curious about the thought, then return to the breath once it dissolves. I call this the anchored boat because you’re giving your mind a little more latitude to float, while still keeping it from drifting away entirely.
Open awareness (the free-floating boat). This final strategy involves letting your mind do whatever it will, but while observing it the whole time. What do I mean by that? I mean not getting lost in your thoughts, feeling, sensations; but rather keeping a birds-eye view. There’s an old saying: if you can see the river, you’re not in the river; if you can’t see the river, you’re in the river. Basically, if you’re aware that you’re thinking, you’re not lost in your thoughts; if you’re unaware that you’re thinking, you’re lost in your thoughts. I call this the free-floating boat because the boat is going wherever the water takes it, and you are simply witnessing it float along.
Give these a shot and let me know how it goes in the comments! Meditation tends to fall squarely in the category of things that are simple but not easy.
My intent here is to give you instructions that are sufficient for you to try this if you’re interested. But if you’re interested in exploring these practices further, I recorded guided versions of each of these practices so that you can simply sit down, close your eyes, play the tracks, and I will guide you through how to do this. They’re $5 each or $12 for all three and each one you purchase includes three files: a 5-minute, 10-minute, and 15-minute version so that you can progress in duration.
Click here to view the guided meditations.
2. Improve our cognitive organization
The second way to improve our reasoning skills is to Improve our cognitive organization.
This relates heavily to what we discussed earlier about the research that shows that many diagnostic errors are due to issues with retrieving relevant knowledge, not lack of knowledge.
To improve our odds of retrieving the relevant knowledge that we need, I recommend three strategies:
a. Use of sub-classification models
Sub-classification models are useful because they help us chunk data into categories so that we don’t have to remember as much.
There are many examples of these, but the two that I believe to be most comprehensive & complementary are:
The ICF sub-classifications, which is the lingo that’s used in the clinical practice guidelines put out by the APTA’s Academy of Orthopaedic Physical Therapy
The mechanisms-based classifications of musculoskeletal pain have been put out by several authors over the years, but most recently by Keith Smart & gang (7-9).
Sahrmann’s movement system impairment syndromes
McKenzie’s Mechanical Diagnosis and Therapy
The Treatment-Based Classification model
The real benefit of these models is that they give us a bit of a shortcut to forming clinical patterns.
The disclaimer is that while these can be very useful for helping us gain pattern recognition skills—especially in the beginning—we must learn to see beyond them and see through them so that we can appreciate the complexity and humanness of the person sitting in front of us. I find that the longer I practice, the less I think in terms of these models; but I felt that they were a godsend early in my career.
b. Engaging in hypothesis testing
Engaging in hypothesis testing means consciously forming multiple hypotheses (or a differential list) about what you think is going on after you develop an initial understanding of the problem.
Then, as you collect more data during the history & physical exam, you reorder the differential list based on data collected to reflect your current top hypotheses. In this way, you’re constantly engaging in this process of observation, hypothesis generation, and hypothesis testing in a cyclical fashion. This should repeat constantly, even once treatment begins.
c. Use of testing & treatment frameworks
The final strategy to improve cognitive organization is to use testing & treatment frameworks: predetermined models of examination and treatment so that you don’t have to think so much about what to do next.
One example would be the test-retest model, which we discussed at length in the last episode & post.
Another example is creating exam flows: written organized flows of how you do a basic exam of each body region. Once you have these memorized, you don’t have to think about what to do next, which frees up your cognitive resources for other things—very useful!
Keep in mind: these flows should be simple and flexible so that they can be adapted to the person in front of you.
3. Trust your gut
The third way to improve reasoning skills is to trust your gut.
Let’s bring it back to the juggler: The juggler isn’t tracking every single object in the air with his eyes and his mind, he has a relaxed stare that allows him to monitor all of them at once, and he lets his body guide him to flow with the rhythm of the dancing objects.
Call it inductive reasoning, call it intuition, call it instinct, call it whatever you want; we often come to conclusions without knowing exactly how we got there.
I’m here to tell you that this is OK.
Many people fear that this is a form of bias. And they’re basically right, but bias is really nothing but a form of inductive reasoning; forward logic based on incomplete data (i.e. making assumptions), which is something that our brains do all the time. Further, studies have shown that the combination of analytic and nonanalytic reasoning processes actually provides the best diagnostic results (4).
Our biggest threat when it comes to bias is ignorance: making assumptions without the awareness that we’re making assumptions; using incomplete data without the awareness that we’re using incomplete data.
If you are aware that assumptions are always happening, your intentions are clear, and you check yourself (e.g. you objectively test & retest), you have nothing to fear and you’ll actually be a better clinician because of it.
This isn’t much of a strategy as much as it is a license to be a human being and let things be unknown every once in a while. Trust your gut.
And the final way to improve our reasoning skills is to reflect, which is essentially practicing.
I found this amazing quote recently by Donald Schon, one of the early proponents of reflective practice, which states, “Reflection is the element that turns experience into learning.”
There are 3 main types of reflection, as developed by Donny Schonny:
Reflection-on-action: Learning from the past
Reflection-in-action: Learning from the present (AKA metacognition or mindfulness, as discussed above)
Reflection-for-action: Planning for the future (includes but is not limited to some of the cognitive organizational strategies we discussed above)
While reflection-in-action has been shown to be one of the biggest differentiators between novice and expert clinicians, it can be quite tricky and take time to grasp in the chaos of the clinical moment.
I said earlier that meditation was the single biggest accelerator of my practice, but in reality, reflection was that for me at an earlier stage in my career.
When I was in residency, I had a bit of a commute, so on the drive home, I would routinely run through all of my patients for the day in my head, asking myself what I did well, what I could have done differently, what I’m missing, why I did what I did, etc.
It was remarkably helpful. This was because it built the habit of reflection so that I was constantly asking myself these critical questions.
And while I started in the quietness of my car, eventually my mind started asking these questions in the busyness of the clinic, which is none other than—you guessed it—reflection-in-action!
So the strategy is to carve out some time at the end of the day to sit quietly and think about some or all of your patients, one at a time. Consider:
What happened in the session?
What did you do well?
What might you do differently if you were to repeat the session again? Why?
*It’s absolutely critical to be nice to yourself in this process. If reflection turns into a self-punching bag session, it will not serve you, especially in the long run. Always start with what went well (& save something for the end to give yourself one final pat on the back). This is not egotistical, this is not narcissistic, this is you being nice to yourself and appreciating things that you’ve actually done well after working your ass off for the last several years. More on this in a future episode & post.
See below for a printable reflection form that guides you through this process.
Clinical reasoning is how we think and make decisions about what to do
It’s like juggling
Clinical reasoning is important because it’s related to outcomes, diagnostic accuracy, and improving our practice
We can improve our clinical reasoning skills by:
Improving our awareness, through:
Attentional training practices (meditation)
Improving our cognitive organization, through:
(Delicate & hopefully temporary) use of sub-classification models
Consciously engaging in hypothesis testing
Using testing & treatment frameworks
Trusting our gut
Thanks so much for reading! If you want to learn more about ways that you can improve your practice, sign up for a free consultation for my mentorship services. We can discuss your goals & decide together what would work best for you.
Resnik, L., Hart, D. (2003). Using clinical outcomes to identify expert physical therapists. Physical Therapy, 83(11).
Resnik, L., Jensen, G. (2003). Using clinical outcomes to explore the theory of expert practice in physical therapy. Physical Therapy, 83(12).
Singh, H., Davis Giardina, T., Meyer, A., Forjuoh, S., Reis, M., Thomas, E. (2013). Types and origins of diagnostic errors in primary care settings. JAMA Intern Med, 173(6).
Eva, K. (2004). What every teacher needs to know about clinical reasoning. Medical Education, 39.
Jones, M. (1992). Clinical reasoning in manual therapy. Physical Therapy, 72(12).
Cristensen, N., Jones, M., Edwards, I. (2011). Clinical reasoning and evidence-based practice. Current concepts of orthopaedic physical therapy, APTA, 3rd ed.
Smart, K. M., Blake, C., Staines, A., Thacker, M., & Doody, C. (2012). Mechanisms-based classifications of musculoskeletal pain: part 1 of 3: symptoms and signs of central sensitisation in patients with low back (±leg) pain. Manual therapy, 17(4), 336-344.
Smart, K. M., Blake, C., Staines, A., Thacker, M., & Doody, C. (2012). Mechanisms-based classifications of musculoskeletal pain: part 2 of 3: symptoms and signs of peripheral neuropathic pain in patients with low back (±leg) pain. Manual therapy, 17(4), 345-351.
Smart, K. M., Blake, C., Staines, A., Thacker, M., & Doody, C. (2012). Mechanisms-based classifications of musculoskeletal pain: part 3 of 3: symptoms and signs of nociceptive pain in patients with low back (±leg) pain. Manual therapy, 17(4), 352-357.