Comparing the presented model to hypothetico-deductive, pattern recognition and

Taking these elements into account and suggesting that this is a current model for ESP practice in the assessment of LBP requires this model to be compared to previous musculoskeletal models of thinking (as compared to the process comparative

description above) in physiotherapy. The hypothetico-deductive model requires the clinician to produce a hypothesis that is then tested to produce a working diagnosis (Patel et al 1997). In doing so, the clinician develops an understanding of the patient and in a deductive way works backwards from a series of possible hypotheses before settling on one of best clinical evidence. The current model provides much of this model, the prior thinking mode is one that develops thoughts generated from prior knowledge, experience and patient data before the patient is interacted with. In making use of illness scripts or pattern recognition, the clinician recognises certain features of a case almost instantly, and this recognition leads to the use of other relevant information, including “if-then” rules of prediction via the clinician's stored knowledge network or memory (Banning 2008; Doody and McAteer 2002). This form of reasoning moves from a set of specific observations toward a generalization and is known as “forward reasoning (Higgs and Titchen 2000 23-32). Forward reasoning contrasts with hypothetico-deductive reasoning where a person moves from a generalization (multiple hypotheses) toward a specific conclusion (Arocha et al

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knowledge and therefore it should be acknowledged that prior patterns are also used in a way that supports hypothetico-deductive thinking (Noll 2002). This combination of thought is expected as the ESP clinicians are experts/advanced practitioners and the literature strongly advocates pattern recognition as a marker of this practice (Curran 2006). Therefore, these two well accepted modes of reasoning are fairly embedded in the current models themes of prior thinking and formal testing. A further

acknowledged methodof reasoning discussed within the literature review is narrative

reasoning.

Narrative reasoning is defined in the literature as seeking to understand the unique

lived experience of patients that could be termed “the construction of meaning.” (Edwards et al 2004). This has been identified in a number of studies that looked at understanding the patient within their presentation from either a physical or functional perspective (Mattingly 1991; 1998). This form of reasoning is comparable to the current models’ theme of patient interaction, and allows for the patient needs,

attitudes, behaviours, fears and requirements to be assessed (Waddell et al 1984). This form of reasoning that seeks to understand the “person” therefore links to the psycho- social component of the bio-psychosocial model and is relevant when gaining an understanding of the patients presenting condition. This well accepted model above whilst linking with narrative reasoning is also explored by the ESPs and plays a key role in the development of rapport and patient interaction which was deemed vital when making judgements under the pressure of time. Therefore, ESPs may need to access this model quickly as they have reduced time with the patient but need to find strategies that will enable them to understand the patient and the links to their pain. This speed of understanding also was felt to help with ensuring that nothing was missed, and linked therefore with safety and accountability.

Safety and accountability played a role in the ESP model of reasoning. It played a part in the reasoning of these clinicians due to the extension of their role outside scope and this created anxiety and pressure due to the safety components to the job. This is comparable to the Jones et al (1995) model which encompassed the elements of precautions. Where the current model differs is that Jones et al only make reference to the precautions for the patient and not how this may affect the accountability of the clinician. This is a vital differential when taking this new model in comparative terms

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against current thinking. There is little mention in the physiotherapy musculoskeletal literature that references how accountability and the requirements of safety could bias a clinician. It could inhibit thinking, whilst stress and anxiety may, as it is argued in the literature surrounding fast-intuitive thinking, enhance a cognitive process (Critchley et al 2009), but conversely there may be elements of personal stress that prevents clear rational thought. Even reviewing a complex clinical reasoning model developed by Jones et al (1992) does not make reference to accountability and safety of the clinician, and furthermore gut-feeling.

Therefore, when trying to reach a diagnosis, it should be acknowledged that the pressure and the accountability status of the clinician may play a part in the outcome of the decision made. Gut-feeling was well recognised in the current model; however the current literature in physiotherapy does not seem to accept this as a legitimate process. Although widely discussed in the medical field (Stolper et al 2009) gut- feeling or intuitive thinking is perhaps only driven under the banner of pattern recognition, which possibly is inter-linked with hypothetico-deductive thinking. For example, driving a diagnosis deductively has to have some understanding of how clinical data fits, and so this type of illness script is the deduction, it is just a number of linked deductions that make a pattern, which has been learnt, taught or

experienced. Pattern recognition must have a process of selecting which pattern fits and so this is deductive, perhaps they are not so distinct. The important differential from this current study is the appreciation and acceptance of gut-feeling as a method that should be considered in the teaching and reflection surrounding clinical

reasoning. The main methods of reasoning in physiotherapy fail to recognise this as distinct, sub-conscious, visceral response of heightened awareness to a clinical stimulus.

This links with accountability and safety and perhaps as physiotherapists move into greater extension of their roles into medical environments, then the reasoning processes will look similar, therefore reflecting why gut-feeling in medicine and intuition in nursing have greater credibility. The final component of internal/external influences is noted by Jones et al (2008) as primarily the external influence but the elements of clinicians’ beliefs and personal values within the political and economic clinical pressures must also be accepted, certainly as a factor in possible clinical error

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needs to be acknowledged. The reduction of diagnostic error is relevant to all

clinicians and in musculoskeletal physiotherapy: researchers have attempted to reduce this by the application of clinical prediction rules. These are discussed in more detail below and are compared to the current model.