‘It depends’: navigating the uncertainty of reasoning in clinical practice
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We teach the theory. We demonstrate the skills. We answer questions and provide feedback. We were taught this way and the success of this pedagogical approach has been proven. Or has it?
Countless physiotherapists have graduated through a similar system and are now competent clinicians. So why are our students struggling on their clinical attachments? Did they not learn enough?
It depends.
Reasoning in clinical practice is not black and white. When students ask what they should do for a particular condition, the answer is often “it depends”. It depends on the clinical setting, the person’s goals, the person’s preferences, the chronicity of the condition, the available resources – and the list goes on. Experienced physiotherapists have the mental framework to navigate this complexity. But novices without a framework can feel lost in the uncertainty.
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Can our justifying each answer provide enough scaffolding for them to build reasoning? Well, it depends. Do we have the time? From educators, cognitive apprenticeship requires close mentorship and careful planning to avoid dependency.
Like reasoning in clinical practice, there may not be a single right answer when deciding what pedagogical approach to adopt. We developed an e-learning package for use as self-directed learning, to help our students develop clinical reasoning. It consisted of 18 case studies based on the neurological conditions covered in the modules. For each case study, students had to identify the main physiotherapy problems and the most appropriate corresponding interventions from several options.
Here’s how we did it.
1. Identify the consistent structure
“Faculty members vary” is common feedback we receive – and this is true. Our reasoning is shaped by diverse educational backgrounds, clinical experiences and individual perspectives. To provide a consistent structure that supports students in developing their reasoning skills, we came together to agree on a set of guiding principles and to define a shared set of questions that we would consistently apply across case discussions. This ensured students experienced a coherent and scaffolded approach to reasoning.
2. Make the invisible thinking processes visible
To help our students internalise the thinking process of a physiotherapist, we designed the e-learning package to present the set of guiding questions across multiple clinical case studies. This allowed students to practise structured reasoning in their own time, reinforcing the thinking process of a physiotherapist through the repeated exposure.
3. Use case studies to encourage contextual learning
The case studies were designed by members of staff who are practising physiotherapists. This reflects realistic and authentic clinical scenarios. Where possible and with permission, we included videos of actual patients to help students better visualise the case. We prioritised commonly encountered cases to increase relevance. This was also so that students could draw on these examples during their clinical placements.
4. Use different contexts to promote deeper understanding
We intentionally designed contrasting case studies to expose students to different clinical reasoning principles. This was intended to help them gradually understand why the answer is often “it depends”. By comparing and contrasting these case studies, students could deepen their understanding of how setting, priorities and presentation shape reasoning.
5. Make the learning experience enjoyable
Our e-learning package was designed with interactive decision trees so students could progress through clinical reasoning steps only when their thinking aligned with acceptable pathways. This may have created a sense of achievement at each stage. This fun structure reinforced reasoning skills and may have made the process feel rewarding for students.
Would this approach work with your students?
It depends.
Aileen Scully is assistant professor at Singapore Institute of Technology.
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