Abstract

BACKGROUND AND PURPOSEClinical reasoning is a complex problemframing, problem-solving, and decisionmaking process. This process is highly dependent on context, requires interaction with the patient, caregivers, and other healthcare team members, and is influenced by models of practice.1 Additionally, this iterative process requires clinicians to make decisions and continually reassess actions taken in the face of uncertainty.1 To function as autonomous professionals, physical therapists (PTs) must develop effective clinical reasoning skills.2-3Few studies, however, have investigated the development of clinical reasoning skills in PT students. Further, there is a dearth of evidence for benchmarks or assessments of clinical reasoning development in entry-level PT education.4,5 Instruction during residency and fellowship programs has given more explicit attention to the development of clinical reasoning and metacognitive skills, but this level of attention is not the norm in entrylevel programs.4 The literature further suggests that there may be a disconnect between students' development and the thinking processes of accomplished clinicians.6 In part this minimal attention to clinical reasoning in entry-level development may be due to a lack of research regarding how best to develop these skills.5One of the first steps toward developing better-informed pedagogies and assessments for clinical reasoning skills is to examine how entry-level PT students currently approach clinical problem solving. This study examined how entry-level PT students develop physical therapy-specific diagnostic reasoning through their coursework and initial clinical affiliations. The primary research questions were: (1) What types of hypotheses and evaluations do PT students make when they evaluate a patient? (2) What reasoning errors do PT students make during the patient evaluation? and (3) How do the hypotheses PT students generate change following classroom coursework and clinical affiliations?REVIEW OF THE LITERATUREDiagnostic Reasoning as Part of Clinical ReasoningClinical reasoning in expert practitioners entails a complex interweaving of empiricodeductive and narrative reasoning.7 Diagnostic reasoning, a critical skill within clinical reasoning, is a clinical classification process that involves relating the patient's level of disability with his or her physical function and pathology.8'9 Through the diagnostic process, the clinician develops an understanding of the patient and his or her problems.10 In all health care practices, the diagnostic process directs the clinician toward the selection of appropriate interventions.11 For a PT, the diagnosis of pathology (defined as the name given to a cluster of signs and symptoms) does not always explain the underlying nature or cause of the patient's physical function or disability.11 For these reasons, the diagnostic process must be unique to the specific health care field.Physical Therapy-Specific DiagnosisSpecific to physical therapist practice, diagnostic reasoning requires clinicians to integrate their analyses of the patient's health condition and biomechanical fault with an understanding of the impact of the impairments on the patient's ability to function in daily life.10 The PT's diagnosis generally addresses the patient's condition at the level of the whole person and should categorize the condition in a way that will guide the PT's treatment plan.12 The literature on diagnosis by physical therapists identifies 3 key elements of the physical therapist diagnostic process. First, the PT must identify movement-related dysfunction.9 This process includes identifying movement impairments and their relation to the patient's physical function.13 Second, the diagnosis must direct physical therapist treatment.11 A medical diagnosis alone is not sufficient to identify the most effective physical therapist interventions.11 Through the diagnostic process, PTs must also identify factors that contribute to the patient's problem,14 as these factors often become the focal point for treatment. …

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