Clinical Reasoning – Making the implicit explicit for students and CEs

Clinical Reasoning – Making the implicit, explicit for students and CEs

Clinical reasoning is one of the most critical competencies a clinician can develop. It combines cognitive strategies such as analysis and problem-solving, with in-the-moment reasoning about clients’ needs based on both current data as well as possible future factors (Delany & Golding, 2014). Due to the abstract nature of these skills, clinical reasoning remains one of the most difficult areas of practice to teach. Adding to the difficulty, is the fact that the processes involved are often “second nature” for experienced clinicians, and such integrated cognitive processes can be difficult to break down into their individual components. As a consequence, students are often unsuccessful trying to learn something that they cannot easily replicate.

Recent studies (Delany & Golding 2014; Ajjawi & Higgs, 2012) have suggested a key way for clinical educators to help to develop their students’ skills in this domain is by making explicit their own clinical reasoning in practice. Metacognitive skills – the act of thinking about thinking, play an integral role in a CE’s ability to break down these steps and focus on “thinking about thinking”.

This module aims to facilitate Clinical Educators in making their own implicit clinical reasoning more explicit for students. You will be guided through the following steps:

1. Understanding where your student is at on the Learning Cycle (Peyton, 1998) in order to identify the associated type of clinical reasoning
2. Identify strategies for students to begin developing their own clinical reasoning skills
3. Identifying strategies to make your clinical reasoning more explicit for your students

Step One: Meeting your student where they are at:

Understanding where your student is on the Learning Cycle (see Figure 1; Peyton, 1998) can help identify the type of clinical reasoning that can be expected at the novice to entry-to-practice stages. While clinicians rely on experience to recognize patterns, automatically integrating discipline-specific knowledge, clinical data and client preferences (Delany & Golding, 2014), novice and intermediate learners have considerably fewer prior experiences to draw upon (even if this is their final externship!). It is also important to remember that the step-like nature of the learning cycle will not necessarily correspond with the progression of student externships. For example, even if a student is beginning Externship 3 (and therefore have two prior clinical experiences), this may be the first time working with adults. It is worth reflecting at what level the student might be at in this scenario.

(Figure 1 Learning Cycle)

Becoming familiar with and exploring the types of reasoning associated with your student’s as well as your own competency level can help to more clearly highlight and address the gaps in knowledge, as well as the students’ areas of relative strength.

Novice and Intermediate Level Learners:
Deductive reasoning Based on knowledge, student generates hypotheses deduced from concrete results/facts (e.g. assessment results).
Entry-to-Practice Level Learners:
Inductive reasoning Based on knowledge and some prior experience, students can better (and more quickly) assess a familiar situation, leading to a generally successful outcome (e.g. recognizing a similar pattern of symptoms from a previous clinical interaction)

Step Two: Strategies for your student to employ while on their clinical externship (Cooper, Da Silva & Powell, 2017):
1. Concept Maps

The organization of knowledge is believed to be a key factor in developing clinical reasoning skills. One way to facilitate this organization of knowledge for students is through the use of concept maps. Concept maps are a concrete way of helping students articulate a logical flow in their thinking, highlighting connections between ideas. Asking students to create a concept map and talk this through with you can help students develop an internal roadmap for storing and retrieving relevant knowledge, critical to clinical reasoning.

2. One-Minute Preceptor

Cooper et al. (2017) suggest a teaching method known as the “One Minute Preceptor”. In their chapter, they suggest that the student and CE engage in 5 steps immediately after seeing a patient:

• Get the student to commit to what they think is going on (e.g. encourage student to make a hypothesis without fear of being wrong, or off-base).
• Probe for supporting evidence, why they made that decision
• Teach one or two general principles.
• Reinforce what was done well.
• Correct one or two errors in reasoning.

3. Frameworks: SLP Specific

In the Forms section of the Clinical Externship Handbook, you will see how many of the forms have been created for students to complete while on their clinical externship e.g. treatment plan and assessment plans. Similar to the idea of the concept map, the rationale behind the explicit introduction of frameworks is to facilitate students to internalize strategies and skills through explicitly writing and sharing their clinical reasoning in a logical and sequential way. Having students think and explain aloud their rationale can help identify missing information, or gaps in reasoning. Another learning framework to consider is the “Stop and think” framework, available at the following link:

4. Self-Reflections

A final critical element of developing clinical reasoning lies in a student’s ability to reflect on the clinical scenarios they encounter throughout their clinical externships. Encouraging students to actively reflect on their learning can build a store of experiences from which students can draw upon in similar situations in future practice. Self-reflection (either in written or verbal form) comes naturally to some students but can be a skill that requires greater practice for others. The Clinical Educator Handbook highlights the Gibbs Model of Reflection (reproduced below), which can be a useful starting point. More information on the Gibbs Model of Reflection, as well as other models can be found here:

Step Three: Clinical Educator Strategies: Making the implicit explicit – “Thinking about Thinking”
Three key principles underpin this approach (Delany & Golding, 2014):

1. CE’s must simplify their knowledge to reduce the cognitive work of clinical reasoning. Simplification of knowledge does not mean reducing the inherent complexity of clinical reasoning, but rather provides an entry point for students to participate in discipline-specific thinking and discourse.
2. Students can be effectively facilitated to learn by participating in the daily activities of their CEs, where peers, role models and mentors scaffold or extend learning through guidance, modelling and discussion.
3. When educators think about their own thinking, they are engaging in reflective and metacognitive thinking, and this assists them to develop a more explicit understanding of their own clinical reasoning prior to teaching others.

The following table outlines a process for achieving the principles identified above:

1. Articulation• Make explicit the thinking required
• Reverse engineer your own thinking. Explain and describe how you think through problems and issues
2. Make concrete and visible• Identify thinking behaviours – what expert thinkers ask and say when they engage in thinking
3. Refine, chunk, & sequence• Refine and group the thinking behaviours into useful tools – thinking routines
1. 4. Enculturate• Make the thinking a routine part of your teaching
• Repeat and model thinking routines
• Encourage students to frequently and regularly use these routines

At first glance, you may be asking yourself the question “where can you find the time to implement these strategies into practice?”.

While it may take some time initially to create learning templates at your site or to build the one-minute preceptor into your daily routine with students, scaffolding a student’s learning in this way can actually lead to students developing greater independence earlier in the externship, thus lessening the time required at later stages of the placement. It cannot be overstated how important it is for students to understand why they are doing what they are doing, and that starts with you, the CE. By teaching students to explicitly share their thought processes, we are facilitating the development of sound clinical reasoning, building future clinicians with strong skillsets and strong building blocks for continued learning.

Ajjawi, R., & Higgs, J. (2012). Core components of communication of clinical reasoning: a qualitative study with experienced Australian physiotherapists. Advances in health sciences education, 17(1), 107-119.

Cooper, N., Da Silva, A. L., & Powell, S. (2016). Teaching clinical reasoning. ABC of Clinical Reasoning. Wiley Blackwell, Chichester, 44-50.

Delany, C., & Golding, C. (2014). Teaching clinical reasoning by making thinking visible: an action research project with allied health clinical educators. BMC medical education, 14(1), 20.

Gibbs G (1988). Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.