Reflection As discussed earlier in this course, reflection is a key component of clinical reasoning and the learning process in general. As learners engage in the reflective process, they also learn self- awareness and self-monitoring which are critical attributes of professional values and professionalism (Schön, 1983; Walmsley & Birkbeck, 2006). As Schulman (2007) highlights, one doesn’t learn from an experience or situation alone or in isolation, but rather learning occurs by thinking about the experience. Clinical narratives are written reflections of second-order experiences where the learner writes about a meaningful experience, recollecting information as the learner remembers it, re-experiencing the situation, and then re-reflecting upon the direct experience (Montgomery, 2006). The clinical narrative is a means of thinking, remembering, and processing meaningful information. It represents clinical judgment using context- dependent factors (Montgomery, 2006) While clinical narratives can be used as a teaching tool to facilitate the clinical reasoning process, they can also be used to assess a student’s reasoning process by allowing the educator to see the student’s thoughts and thinking process. Including narratives as part of practical examinations or in clinical education could be a powerful assessment tool. Narratives may also help track the development of a student’s clinical reasoning skills over time to provide evidence of areas of strength and components needing improvement. The following example illustrates how clinical narratives can be used in clinical education. When Suzanne was put on my schedule this turned out to be a challenge, and a problem. I looked up her script in our paper charts and saw her referral: knee sprain s/p fall. Sweet, I thought, this is going to be super easy. I’m sure they did an x-ray, which will show some mild inflammation and swelling, and orthopedics referred her to physical therapy for strengthening, gait training, and balance work to reduce the risk of subsequent falls. Boy…. was I wrong. Suzanne came in limping significantly and using a broken-down walker. She looked a lot older than her birth date implied and was grimacing. “What brings you to physical therapy today, Suzanne?” I said cheerily, ready to take her problem and solve it. “WELL, first off I can’t walk at all, I HAVE to get off this stinkin’ walker. I’m too young for this! Oh, my gosh, I can’t sleep, I get 30 minutes of sleep a night. This is just insane. I can’t even leave my apartment. I just lay in my bed all day… this is horrible. I don’t know what to do. I’m trying to quit smoking and I just can’t get off it. I’m trying to eat right as I have osteoporosis and I know I need to eat better. Something just has to change, I CAN’T keep living like this.” Open-ended questions were a big mistake on my part. “Okay….how about you explain to me how you fell and hurt your knee.” I proceeded cautiously throughout the evaluation; everything I asked her to do caused her so much pain she looked like someone was stabbing her. She could perform AROM no problem but providing any resistance was out of the question. Weight-bearing activities were also intolerable. I fumbled through some special tests of the knee, all turning out to be negative. The only thing I came up with was to give her a few exercises for her hip and ankle and tell her to rest and ice her knee until the pain calmed down; hopefully when she comes in next time we will be able to do more. She hobbled in to the next appointment with her walker and looked significantly worse than on evaluation. “So how have you been doing, Suzanne?” I asked. “I…. I…. I feel horrible, even worse than 3 days ago. I didn’t sleep at all last night, I kept rolling around the bed in pain. I don’t know what’s going on. There’s no way this is just a knee sprain…. there has to be something else going on!” My gut told me she was not exaggerating this time. Okay, I thought, what else COULD be going on? Perhaps it’s referred pain and the hip,
the ankle, or spine is the origin. “So you only had an x-ray and an MRI of your knee…no other joints?” I asked. “No,” she stated. I took her back to a semi-private treatment room and did every hip special test I knew. Scours and figure 4 were positive and she had half of the range of motion in internal and external rotation of her right hip compared to her left. I thought of everything I’d been presented with: inability to bear weight, reduced hip ROM, pain in the medial knee even though her knee exam was completely unremarkable, history of osteoporosis, smoker, recent trauma/fall. Hip fracture! I beamed (even though I know it is completely horrible of me to be excited about a possible fracture). What if she has a hip fracture and I figured it out! More importantly though is why didn’t the orthopedic doctor do an x-ray on this patient? Even I know that should be in the differential diagnosis list. AND hip fracture can refer pain down to the medial knee. It all makes so much sense now! Realizing this, I asked a colleague what I should do. Should I call Suzanne’s doctor and tell him what I found? Should I tell Suzanne to get an x-ray at her primary care physician or should she go to the ER since she is a female with a history of osteoporosis and a fall? I finally got her an appointment for later that day and anxiously waited for the clinic to call back with her results. After what seemed like days, the physician assistant called with the results, “…no hip fracture, we gave her a cortisone shot in her knee to take away her extreme pain. We also referred her to the pain specialty clinic because she is having major difficulty dealing with her knee sprain.” I felt so stupid. Why did I jump to conclusions like that? Did I really think this was like some sort of puzzle I could solve? Was it dumb for me to want to get the hip x-ray after all? I kept replaying the situation in my mind, only the more I thought about it the more defensive I became. If another therapist were in my situation, they would do the same thing, right? The thoughts, emotions, and reasoning process of the learner are evident in the preceding narrative. The learner is attempting to use a deductive reasoning process because she has never encountered a patient with these symptoms previously. We know this because she describes the history of the fall and the special tests of the knee and hip she performed, and she is trying to link this with a health condition or diagnosis. Initially, there are so many context-dependent variables, including significant pain, the patient’s inability to accurately report what has happened and when, and the gait dysfunction that is limiting her mobility, that the learner becomes overwhelmed. After reflecting- on-action, the learner begins to sort out the case and takes appropriate action when she thinks a hip fracture could be the cause of the patient’s pain and mobility dysfunction so she refers the patient back to the physician to rule this out. Following the negative x-ray findings, the learner questions many of her actions. In this case, the clinical instructor or mentor can provide valuable feedback about any additional tests or measures the learner could have performed to provide clarity to the situation, other questions the learner could have asked the patient, and confirm that the learner demonstrated the appropriate action in referring the patient back to the physician to rule out a fracture. This is an opportunity for meaningful learning to occur. The educator bears the responsibility of knowing what type of experiences to design based upon the learner’s needs and the type of assessment that will best match the learning experience. The information below can guide the educator based upon the level of the learner. It is important to note that these categories of learners (early to expert clinician) are generalizations and can depend on specific circumstances. For example, a learner who is close to graduation may benefit from the strategies of an early learner when faced with new or complex situations.
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Book Code: PTCA2622B
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