Question

1. Discuss the implications of recent research on the clinical reasoning of student physical therapists for professional education, including the need to link clinical reasoning to professional formation and the need for explicit links between the academic and clinical educational settings.

2. Describe elements of a clinical reasoning capability model and discuss this as a framework within which to develop strategies for facilitating the learning of clinical reasoning

Answer 1

1.)Discuss the implications of recent research on the clinical reasoning of student physical therapists for professional education, including the need to link clinical reasoning to professional formation and the need for explicit links between the academic and clinical educational settings

Implications :

This section focuses on the need for more larger scale studies and studies regarding the effects of other commonly implemented instructional strategies for facilitating physical therapy student clinical reasoning skills. Second, implications for my practice as an educator and researcher will be discussed. This section will detail the impact this research project has had on the educational experiences I currently provide for my students and the need for continued inquiry into clinical reasoning for continued implementation of contemporary best educational practices in the classroom. Lastly, implications for myself as an educational leader will be discussed. Specifically, how this research project has facilitated three capabilities that educational leaders need for providing learner-centered education.

Implications for future research.

Regarding future research this project only provided insight into how case-method presentation effects clinical reasoning processes in physical therapy students from a small physical therapy program located in northeast Florida. More large scale, multi-institutional studies are needed for generalizing these findings to the larger population. Additionally, this research only compared two forms of case-method presentation on the reasoning processes of students. For instance, high-fidelity computer simulations have been endorsed for promoting student learning in health professional education programs (Silberman, Litwin, Panzarella, & Fernandez-Fernandez, 2016; Wellmon, Lefebvre, & Ferry, 2017). The effects of high-fidelity simulations as well as other case presentation methods are warranted to develop a fuller understanding for how pedagogic decisions effect clinical reasoning outcomes in physical therapy students. Furthermore, this research did not inform how these problem-solving experiences carries over to clinical practice.

Future research could include group discussions and/or questionnaires that informs how these educational experiences factor in the clinical reasoning and decision making of physical therapy students during their clinical education experiences.

Implications for practice.

The purpose of this research was to explore the effects of case method presentation on the clinical reasoning hypotheses generated, strategies implemented, and errors made by physical therapy students when working through a musculoskeletal clinical problem. The study results detected moderate-to-large effect sizes for case presentation method explaining a significant amount of the variance of reasoning hypotheses, strategies, and errors between groups. Regarding clinical reasoning hypotheses, the simulated patient experience required participants to make significantly more clinical judgements regarding the clinical data they still wanted or needed to collect (i.e., minimizing reasoning errors), considerations for symptoms the client experienced (i.e., symptom characteristics), and considerations for the client’s beliefs regarding their current health condition (i.e., client perspectives).

On the other hand, participants in the written case study group exhibited significantly more instances of health condition and personal factors. Regarding clinical reasoning strategies participants in the simulated patient group exhibited significantly more instances of hypothetico-deductive reasoning and reasoning for procedure whereas the written case study group exhibited more pattern recognition strategy. These findings are interesting and mean that simulated patient experiences may be more ideal for facilitating physical examination procedural strategies and clinical judgements geared toward reducing reasoning errors.

On the other hand, written case study presentation may be a better choice if the purpose of the educational experience is to assess illness script development and facilitate sound inductive-thinking skills needed for implementing pattern recognition strategies. Additionally, the use of simulated patient experiences has been linked to facilitating non-clinical skills such as conducting subjective interviews (Rivett & Jones, 2008). Similarly, each dyad assigned to the simulated patient group initiated problem-solving sessions by conducting subjective interviews of the actor to obtain early clinical data from which to design their objective physical examination later. These results indicated that environmental differences between groups (e.g., given intentions, and extraneous load) affected the cognitive processing of physical therapy students engaged in clinical reasoning.

These results do not promote one type of case-presentation method over another but instead inform physical therapy educators regarding the pedologic decisions they make. The results of this study have already had significant implications for the physical therapy students I teach. For instance, since the initiation of this project students enrolled in orthopaedic courses in the second year of a three-year professional physical therapy program have had case-method teaching experiences presented via simulated patient. There are a few reasons I selected simulated patient as the case presentation method over written case study.

First, one of the core course objectives include these physical therapy students learn how to perform and interpret physical examination findings, especially special tests, safely and appropriately. The use of simulated patients provides students the opportunity to implement more procedural reasoning and hypothetico-deductive reasoning strategies that are more commonly implemented by novice therapists which these students are (Doody & McAteer, 2002; Gilliland, 2014). Second, these courses are offered in the immediate semesters before these physical therapy students participate in their first clinical education experiences. Clinical education experiences are a component of physical therapy professional education whereby working alongside a licensed physical therapist clinical instructor, students facilitate their learning through immersion in physical therapy practice.

As mentioned previously, simulated patient experiences have been identified to more closely mirror clinical experiences physical therapy students will encounter in the clinical environment compared to written case study does (Rivett & Jones, 2008). For example, physical therapy students will be required to conduct subjective interviews of their patients when initiating a physical therapy examination during the clinical education experiences like study participants assigned to the simulated patient condition did.

Future practice implications include continued inquiry of the effects varied educational strategies have on facilitating clinical reasoning skills in student physical therapists. Additionally, I endeavor to lead practice changes in physical therapy professional education programs through enhanced involvement in local and national professional organizations (e.g., Florida Physical Therapy Association and American Physical Therapy Association). This will ensure that larger communities of practice also benefit from my experiences as an educator and researcher.

2 ) Clinical Reasoning Domain Learning

According to the Model of Domain Learning, students may develop competence in a domain area if they acquire an adequate level of propositional knowledge, strategies to implement that knowledge, and develop an increasing interest in that domain area (Alexander, 2004). Additionally, the Model of Domain Learning separates competency into early, middle, and late levels. In this study, participants were selected from a pool of subjects who all completed their required musculoskeletal/orthopaedic component of the didactic portion of their professional education program. This education facilitated propositional and psychomotor knowledge deemed necessary for providing orthopaedic physical therapy care to clients.

Therefore, it was assumed each subject had acquired similar levels of propositional knowledge and knew appropriate strategies for providing orthopaedic physical therapy to clients. However, regarding level of interest for orthopaedic physical therapy, it was found that a larger percentage of participants assigned to the written case study group identified orthopaedics as an area of interest compared to participants in the simulated patient group. The Model of Domain Learning posits that these students are therefore more likely to develop higher levels competency (middle or late) in orthopaedic physical therapy. Pattern recognition is a form of inductive reasoning that allows clinicians to quickly identify key clinical features of a case to draw a diagnostic conclusion. Typically, considered a reasoning strategy implemented by experts (Boshuizen & Schmidt, 2018; Doody & McAteer, 2002; Edwards et al., 2004a), other research has observed pattern recognition strategy implemented by physical therapy students (Gilliland, 2017; Gilliland & Wainwright, 2017).

The findings from this research identified participants assigned to the written case study group exhibited significantly more instances of pattern recognition strategy compared to the simulated patient group. It’s possible that due to more participants assigned to the written case study group identified orthopaedics as an area of interest in physical therapy, they had already begun to develop rudimentary illness scripts for common musculoskeletal pathologies. These illness scripts may have allowed them to implement more instances of pattern recognition strategy that was identified through quantitative analysis. The Model of Domain Learning explains why learners develop the level of domain knowledge that they do. Alexander (2004) stated that acquiring certain levels of propositional knowledge, strategies for implementing that knowledge, and level of interest all promote achieving higher levels of domain learning. This study investigated participants at the same point of progression in their professional education programs. Demographic findings identified a difference in level of interest for orthopaedic physical therapy between groups. A higher percentage of participants assigned to the written case study group self-identified orthopaedics as an area of interest in physical therapy practice.

Interestingly, it was this group that exhibited a significantly higher number of instances of pattern recognition strategy. This strategy requires clinicians to identify key clinical features of a case to inductively arrive at a diagnostic conclusion. This process is only possible after the learner begins to develop illness scripts in their long-term memory for recall later. It’s possible that students who self-identified orthopaedics as an area of interest in physical therapy may had already begun to develop an illness script for osteoarthritis, the musculoskeletal condition that the clinical case portrayed.