Physiotherapists as detectives: investigating clues and plots in the clinical encounter

This article investigates the clinical reasoning process of physiotherapists working with patients with chronic muscle pain. The article demonstrates how physiotherapists work with clues and weigh up different plots as they seek to build consistent stories about their patient’s illness. The material consists of interviews with 10 Norwegian physiotherapists performed after the first clinical encounter with a patient. Using a narrative approach and Lonergan’s theory of interpretation, the study highlights how, like detectives, the therapists work with clues by asking a number of interpretive questions of their data. They interrogate what they have observed and heard during the first session, they also question how the patient’s story was told, including the contextual and relation aspects of clue production, and they ask why the patient’s story was told to them in this particular way at this particular time. The article shows how the therapists configure clues into various plots on the basis of their experience of working with similar cases and how their detective work is pushed forward by uncertainty and persistent questioning of the data.

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Examining the patterns of uncertainty across clinical reasoning tasks: effects of contextual factors on the clinical reasoning process

Diagnosis ◽

10.1515/dx-2020-0019 ◽

2020 ◽

Vol 7 (3) ◽

pp. 299-305 ◽

Cited By ~ 2

Author(s):

Divya Ramani ◽

Michael Soh ◽

Jerusalem Merkebu ◽

Steven J. Durning ◽

Alexis Battista ◽

...

Keyword(s):

Clinical Reasoning ◽

Contextual Factors ◽

Descriptive Analysis ◽

Clinical Encounter ◽

Reasoning Task ◽

Reasoning Process ◽

Linguistic Markers ◽

Clinical Encounters ◽

Reasoning Tasks ◽

To Come

AbstractObjectivesUncertainty is common in clinical reasoning given the dynamic processes required to come to a diagnosis. Though some uncertainty is expected during clinical encounters, it can have detrimental effects on clinical reasoning. Likewise, evidence has established the potentially detrimental effects of the presence of distracting contextual factors (i.e., factors other than case content needed to establish a diagnosis) in a clinical encounter on clinical reasoning. The purpose of this study was to examine how linguistic markers of uncertainty overlap with different clinical reasoning tasks and how distracting contextual factors might affect physicians’ clinical reasoning process.MethodsIn this descriptive exploratory study, physicians participated in a live or video recorded simulated clinical encounter depicting a patient with unstable angina with and without contextual factors. Transcribed think-aloud reflections were coded using Goldszmidt’s clinical reasoning task typology (26 tasks encompassing the domains of framing, diagnosis, management, and reflection) and then those coded categories were examined using linguistic markers of uncertainty (e.g., probably, possibly, etc.).ResultsThirty physicians with varying levels of experience participated. Consistent with expectations, descriptive analysis revealed that physicians expressed more uncertainty in cases with distracting contextual factors compared to those without. Across the four domains of reasoning tasks, physicians expressed the most uncertainty in diagnosis and least in reflection.ConclusionsThese results highlight how linguistic markers of uncertainty can shed light on the role contextual factors might play in uncertainty which can lead to error and why it is essential to find ways of managing it.

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