According to Geisler and Lazenby,1 “More than at any time in the history of AT education, today's students must experience a different kind of education if educators intend to connect the didactic to the clinical in a manner that ensures genuine educative experiences” (p. 54). Clinical reasoning is the nuanced, complex, and context-specific cognitive mechanism that myriad health care providers employ when solving clinical problems. From physicians to physical and occupational therapists to nurses, clinical reasoning has been widely researched, instructed, and required by all branches of allied health for decades. In 2009, the notion of clinical reasoning was introduced to athletic training by providing a comprehensive overview of the theoretical and practical underpinnings and applications of this branch of medical cognition specifically for athletic training educators and practitioners.1
In the past few years, the idea that the ability to clinically reason (well) has gained more traction in the athletic trainer profession, and increasingly more attention on how to teach, measure, and evaluate clinical reasoning abilities has been observed in academic journals and at professional conferences.2,3 No matter one's profession, the ability to develop student and novice practitioners' clinical reasoning skills is paramount to advanced clinical practice and enhanced clinical outcomes. Given our current desire and need to develop and practice evidence- and patient-based medicine, the ability to clinically reason is a co-requisite to being able to find and use the latest contextually relevant, high-quality evidence.2 Whether you are supervising students or desire to become a better thinking clinician in your own right, knowing how to recognize and develop high-level reasoning skills is critical to improving your clinical competence and creating better clinical outcomes.
Brief Review of Clinical Reasoning Models
For purposes of expediency, the two primary models of clinical reasoning described by Geisler and Lazenby are “hypothetico-deductive reasoning” and “case pattern recognition.”1 Hypothetico-deductive reasoning is the first brand of reasoning that students and young, inexperienced clinicians should seek to master. It is characterized by the formation of multiple hypotheses, the collection of large amounts of information, a bit of disorganization, longer time periods to be carried out, and, pending the context, a lower degree of accuracy.
On the other end of a fluid, progressive spectrum, more experienced clinicians typically use case pattern recognition to solve clinical diagnostic problems by quickly and accurately recognizing clinical patterns early in the evaluation process, usually during the history because they are better able to recognize “key features” that they've seen or experienced before. These key features trigger autonomic connections to other pieces of the clinical puzzle in an expeditious, non-analytical manner and allow the expert to formulate a workable and plausible hypothesis (diagnosis) quickly and efficiently. This highly organized and rich network of clinical case patterns is founded upon superior organization and access to requisite biomedical knowledge, is largely dependent upon meaningful, structured experiences, and allows experts to recognize “features that don't fit” a known case pattern (signs or symptoms that don't “match” a typical case presentation), forcing him or her to investigate further for unique or outstanding cases.
Improving Clinical Reasoning Skills in Real Time Clinical Practice
If you are intending to improve the clinical reasoning skills of health care students you supervise, then the tips included herein can apply to your interactions with your students. Simply incoporate them as part of your direct inquiry and discussion with your students, as a structure for feedback and a discursive method of pedagogy.
If you endeavor to improve your own clinical reasoning skills, the key to improving your own thinking is to “think about your thinking,” or what is known as metacognition. In the context of clinical reasoning, use the cues below to reflect on and structure your assessment thinking process, or find a more experienced mentor to help you reflect upon and dissect your thinking process.
If practiced routinely and candidly, the following pearls will lead to better clinical thinking in your future decision-making endeavors and hopefully lead to an expansion of both internal and external evidence.
Formulate a Differential Diagnosis
As directed history questions are posted and keen observation of the patient's movements, reactions, postures, and apprehensions are noted, the working clinician should attempt to formulate a differential diagnosis, which is a list of the three to four most likely diagnoses given the key features of the case being presented, their meaning, and the likelihood of the diagnoses being considered. The clinician should not prematurely zero in on one particular diagnosis too early, but should allow the various diagnoses to compete with each other early on and weigh them equally from the start. The early subjective data collected should be used to form the differential diagnosis list and subsequently structure the physical examination that will then test all competing hypotheses. In his book, How Doctors Think, Jerome Groopman is just one of the medical authors who reports that 80% to 90% of all diagnoses occur in the history phase of the evaluation, so keen attention needs to be paid to the history taking and the rich data it reveals.4
Novices will tend to ask too many irrelevant questions in a quest to cover all bases, leading to distractions, disorganized thinking, a scattered back-and-forth evaluation, and confusion as more potentially irrelevant data are collected. Like a good detective, experienced clinicians use streamlined and purposeful history portions in their examinations and quickly recognize rich and meaningful “links” between data and clinical meaning—they recognize “case patterns” from known or experienced schemas, or scripts. For example, an experienced and knowledgeable clinician autonomously appreciates a chief complaint of “burning pain in the palmar aspect of the first 3 digits” to represent neurogenic symptoms of median nerve compression, but realizes that the location of the lesion could also be at the C6 nerve root level.
Weigh the Differential
Before moving forward with one particular diagnosis over the others being contemplated, the examining clinician should consider relevant probability evidence and not give too much weight to any particular diagnosis. This is where a combination of internal (from experience) and external (generated data, from the literature) evidence comes into the decision-making process—given the specific athlete being evaluated (age, sport, position, history, etc.), how likely is it that the patient actually has the diagnosis being considered?
Based on probabilities or likelihoods, the novice should force himself or herself to rank order the differential diagnoses being considered. For example, how likely would it be for a 16-year-old competitive female swimmer with a short history of insidious onset shoulder pain, without history of trauma, to actually have a rotator cuff or labral tear as a possible diagnosis? How likely would it be for her to have subacromial impingement syndrome, maybe due to scapular dyskinesis or glenohumeral instability?
Based on a combination of the data collected and any germane evidence available, what are the most likely and least likely diagnoses to keep under consideration? Novices too often think of “zebras” when they hear clomping hooves, jumping to the extreme and exotic cases because they ignore such vital and meaningful information when formulating their differential diagnosis listing. In contrast, when expert clinicians hear clomping hooves, their keen sense and respect of both internal and external evidence more often allows them to think of “horses,” or things that are more common and typical.
Defend and Define the Diagnosis
Of the key features collected or recognized in the patient case under investigation, which ones best support the primary working diagnosis? Features such as point tender to pain over the anterior talofibular ligament after a plantarflexion/inversion mechanism are defining features of a classic lateral ankle sprain, whereas increased unilateral pain in the lumbar region with extension-based activities is a defining feature of a spondylolytic reaction in young athletes. Which, if any, detract from the primary working diagnosis?
Features found that detract from a working case pattern are known as “features that don't fit,” and they force the clinician to dig deeper, repose some or all of the history questions, and maybe perform an expanded physical examination sequence. For example, pain over the tip of the medial malleolus after an inversion mechanism is a feature that doesn't fit a lateral ankle sprain diagnosis, and lumbar pain that increases with sitting and flexion is a feature that doesn't fit the diagnosis of spondylolysis. To narrow down the working differential diagnosis list, there should be a preponderance of defining features for the diagnosis being considered. In other words, the relevant and the irrelevant need to be discussed, defended, and dissected to filter out the data that were not representative or germane to the case presentation.
Does the Physical Examination Support the Working Diagnosis?
Because novice clinicians are typically entertaining multiple hypotheses as they enter into the physical examination phase, they often palpate irrelevant structures, manually muscle test physiological movements that are not needed, and perform too many special tests that collectively take far too long and give far too many false-positive and false-negative results. This scenario leads to even further testing and a revisiting of the history phase, adding more time and confusion to the process and often challenging the credibility and confidence of the evaluating novice clinician.
In contrast, experienced clinicians who have duly recognized a prior case pattern presentation and have performed a condensed and efficient history, rich in clinical meaning, will perform a much more streamlined, direct, and intentional physical examination that effectively and accurately supports and tests the number one working diagnosis and rules out any competing diagnoses. To the witnessing novice, the examination often seems too short, too abrupt, and incomplete, almost as if the expert is “skipping steps” and “cutting corners.”
After the physical examination is performed, what specific objective data have been unearthed that support the number one working diagnosis? What physical examination findings fail to support the primary diagnosis? Are there now “features that don't fit” to consider, forcing a new differential diagnosis to be formulated? Also, how much data are “left over” after the physical examination—information that didn't fundamentally contribute to the diagnosis decision?
For future diagnostic challenges, remember what steps lead to what data and what elements and findings of the physical examination turned into defining features for the eventual diagnosis. Unlike novices, experienced clinicians fully realize that the subsequent evaluation following the history and observation is actually designed to test the diagnosis being considered, rather than merely collect more data.
In his 2008 editorial, athletic training scholar, practitioner, and educator Ken Knight articulated an eloquent concern for growing “hyposkillia” and called for an increased emphasis on higher-level, more clinically relevant thinking for the athletic training profession.5 Our cousin professions have long espoused the specific importance of clinical reasoning, and their literature is ripe with examples of how the cognitive skill set can be witnessed, developed, and practiced as part of sound evidence-based practice.6–8
Clinical preceptors can use the model described herein to provide direct feedback and structure for enhancing and developing student clinical reasoning skills. Practicing clinicians can also use it to enhance their own clinical problem-solving skills by focusing on and committing to a more narrow differential diagnosis list, recognizing and storing the various defining features of known and new case pattern presentations, effectively using a combination of internal and external evidence to rank and place trust in their differential diagnoses, and streamlining and consolidating their physical examination procedures to match and test their most worthy diagnoses. Either way, thinking about one's clinical thinking and providing a mechanism or infrastructure for thinking better is certainly a sound and prudent way to improve clinical decision-making skills and counteracting hyposkillia.
- Geisler PR, Lazenby TW. Clinical reasoning in athletic training education: modeling expert thinking. Athl Train Ed J. 2009;4:52–65.
- Geisler PR, Drouin J. Integrating clinical reasoning & EBP: a pedagogical strategy for enhancing clinical decision-making (DVD). Monterey, CA: Healthy Learning; 2011.
- Heinerichs S, Vela LI, Drouin JM. A learner-centered technique and clinical reasoning, reflection, and case presentation attributes in athletic training students. J Athl Train. 2013;48:362–371. doi:10.4085/1062-6050-48.2.17 [CrossRef]
- Groopman J. How Doctors Think. Boston: Houghton Mifflin; 2007.
- Knight KL. Hyposkillia & critical thinking: What's the connection?Athl Train Ed J. 2008;3:79–81.
- Bowen JL. Educational strategies to promote clinical diagnostic reasoning. New Engl J Med. 2006;355:2217–2225. doi:10.1056/NEJMra054782 [CrossRef]
- Eva KW. What every teacher needs to know about clinical reasoning. Med Ed. 2004;39:98–106. doi:10.1111/j.1365-2929.2004.01972.x [CrossRef]
- Mandin H, Jones A, Woloschuk W, Harasym P. Helping students learn to think like experts when solving clinical problems. Acad Med. 1997;72:173–179. doi:10.1097/00001888-199703000-00009 [CrossRef]