That morning I received an email from a pediatric physical therapist. She told me: “Iñaki, I don’t feel safe. I did many courses but everything is mixed up in my head. I have the feeling of not knowing where to start with a child, and things get worse when the family asks me to assure them if I am going to solve the problem ”. I understood the problem perfectly, how could I not understand it if I had also gone through that? In reality, all clinicians go through this stage. I have knowledge, but how do I apply it to the reality of the patient in front of me. What is really the matter? Do I apply this procedure that I have? Are there other factors involved that I can’t see?
As the philosopher already said that “an orderly mind is better than a very full one”. Physiotherapists are one of the professions that dedicate the most time, money and weekends to postgraduate training. A lot of training, a lot of courses. But despite this, we are not always able to structure our thinking and make good decisions in our clinical practice with confidence. We know a lot, but everything is piled up in our head. Sometimes we apply the last protocol we learned last weekend of training to many patients for many weeks, hoping to see great results. But we seldom find the magic technique.
Actually, there is a way to organize our knowledge, to understand well the case that is presented to us and to make the correct decisions in treatment. This path is called clinical reasoning. Clinical reasoning is the art of making good decisions in our clinical practice. Sometimes it is thought that it has to do explicitly with the ability to make a good diagnosis. The truth is that it is much more than that. It has to do with all the decisions you make. What you choose to assess in the baby or child, what you explain or not to the family, in what conditions you refer and to whom, what frequency of sessions you are going to offer and many other questions that surround daily practice.
The degree courses in physiotherapy at the best universities in the world try to train students in clinical reasoning but it is a complex job since it is difficult to create in another, processes of reasoning, deduction or recognition of clinical patterns when there is no practice clinic. That is, if you don’t see at least 8 patients a day, how are you going to learn to manage those 8 cases. The truth is that we learn clinical reasoning over the years and postgraduate training, but everything is too slow, don’t you think? Wouldn’t it be better to learn it more quickly and reinforce it with more conscious practice?
Good clinical reasoning should include four main aspects:
A global philosophy of health and disability. It is difficult to understand what happens to the patient and what factors are involved without a global look at how we are healthy and how we get sick. This is the reason why physiotherapists trained in concepts or methods tend to excel in clinical reasoning. The concept, either Bobath, or PIMT, usually includes a thinking model, a philosophy, a paradigm that helps to build clinical reasoning. The use of scientific literature is very important, but it is not enough for clinical practice since clinical reality is multifactorial while clinical trials reduce the variables. A fantastic framework of global philosophy is the International Classification of Functioning, Health and Disability (ICF) published by the WHO. This framework supports global and multidimensional pediatric physical therapy.
Second, you need knowledge for assessment. Clinical evaluation systems or through standardized tools such as scales or screenings are key for decision-making in pediatric physiotherapy. Pediatric physiotherapy courses and training that offer proficiency in assessment are key to building good clinical reasoning. Unfortunately, these courses are sometimes less attractive than courses that will teach you “effective technique.” At the beginning, it is necessary to systematize the evaluation systems well and repeat them many times to recognize repeating clinical patterns. Clinical patterns are a quick shortcut to expertise. They help you to think faster and to choose more quickly what to assess and the important factors. The evaluation systems will allow you to reach a more precise functional diagnosis.
But clinical reasoning is not only diagnostic reasoning, but also patient management. This is the third essential point to make good clinical decisions in pediatric physiotherapy but also in any area of the health sciences in which people are accompanied and cared for. It is possible that most of the decisions to be made in clinical practice are related to the management or handling of the patient. Setting goals with the family, relating to the child, adapting to their needs and priorities, understanding their social and environmental context, or teaching new habits or exercises in a simple and didactic way are some examples of this great part of clinical reasoning.
Finally, clinical reasoning requires the development of other mental and emotional skills. In this group, the so-called metacognition clearly stands out. Metacognition can be defined as the ability to analyze and self-observe one’s own learning and practice. A good training in clinical reasoning, a true course in clinical reasoning necessarily involves reflective practice. It is not just the fact of learning to do differently, but to observe how I learn to do differently or better, what are my biases, my tendencies to error, my fears or beliefs that lead me to act wrongly in certain directions.
Here is a youtube video where you can understand much better what clinical reasoning can do to improve your clinical practice.
The online course of clinical reasoning in pediatric physiotherapy that we have developed in the PIMT concept will take you to develop these four fundamental aspects and many other details that really characterize the clinical practice of experts. Check out the program in Spanish here and ask for more info here.
Months later that colleague shared with me: “I finally got my ideas in order. Now I feel confident leading the family with a treatment plan. It’s great to feel like it really helped. “
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