Submitted by: Jeremy Nelson MPT
It might be time to upgrade the quality of your questions that you are using in your practice. Questions are wonderful tools to produce results. Through the organization of the thought process as related to underlying observations, a structure is formed that promotes investigation and observation. Just like drawing the bow before shooting an arrow, questions build the energy necessary for action. How much energy and to what direction have to do with the question itself. Questions like tools have a structure, a form that supports its behavior and the behavior of the person using it.
When you use comparative thinking you ask certain questions that assume the answer. When using comparative thinking of “like this, like that” there is an underlying assumption. These assumptions are what Robert Fritz describes as “other than reality”, and are instead concepts about the relationship of things and as a result cause and effect. Here is an example of a question based on comparative thinking: “What muscle weakness is causing the difficult to go from sitting to standing for this patient?” Not a bad question, but it does introduce some variables into the clinical decision making process that may not be there.
Already there is an assumption that the person cannot stand because of weakness. It may also include memories of other patients that had lower extremity weakness. A quick look at the knowledge base to query “What muscles are used in standing”, returns the usual lower extremity suspects. Has is this to be included in data that indicates the lower extremities are 5/5. In this structure established by the question, the conclusion would be to assume the extremities are not strong enough. What is really driving the action here is the unexamined assumption that it is an inadequate set of legs that are the cause of the problem.
Another way to describe this is short cut thinking. Based on the diagnosis, based on the demographics of the patient, based on a number of other data points, assumptions are introduced into the clinical decision making process. Often these underlying assumptions are taken as reality and are left unexamined. How is someone to know…by observing the movement.
So, if you have read a few of our other articles you may have done this, but its worth repeating the exercise. While seated, produce a posterior pelvic tilt. Maintain the posterior pelvic tilt and T/S kyphosis as you attempt to stand up. It should be impossible, even with your arms assisting.
How did this happen? Is this some sort of voodoo, causing your legs to no longer work? No, it’s simply an inadequate COG and BOS relationship. Even with daily lower extremity strengthening over many months, you still would not have the lower extremity strength to stand up. So, if we met this patient with our assumptions left at the door why a person would not be able to stand up, and instead began assessing their current posture, strength, mobility, against the desired outcome of a COG and BOS relationship that supported sitting and standing, we would have different questions to ask. Such as “given the observation that the COG is posterior to the BOS and the patient is not able to stand up, what position must the body take to restore the COG above the BOS?” Now our decisions are rooted in reality.
When you use original thinking you ask questions that seek to investigate cause and effect. Original thinking starts with understanding what is desired, what outcome we would like to create, and then making observations about how well the performance is now. From that structure, more focused questions arise. These questions are clarifying questions often seeking more information, that lead to more observation. They maybe questions that seek to make implications explicit and gain more information about what is being concluded. Or they may be questions that seek to understand conflicting statements better.
Now, what about the role of hypothesis in clinical decision making? Of making a conclusion and then testing it against your finding? This has been the supported approach to good science. However, it is simply a more sophisticated of conceptual thinking. Newton did not conclude that the apple fell based on gravity, but instead asked the question “Why did the apple fall?” As a result of his inquiry and investigation he created Calculus as a tool to better understand what was going on, given that he did not know. This story was explained by Robert Fritz again as he described the role of structural thinking and starting without assumptions about what is causative. In much of the reading found in the physical therapy journals, much of the research is to examine the existence of conclusions already made in the professional knowledge base in different populations of patients. This is different than organizing change over time to produce a desired result.
Again the difference between original thinking and comparative thinking is found in its outcome. Original thinking the type of thinking that leads to specific unique results and often includes process invention along with process convention will support the process of producing unique specific functional outcomes that includes the patients’ medical state and functional state. Comparative thinking begins with assumptions about how the world works, and then gathers evidence to support those assumptions. In this case the database includes diagnoses, what is expected with diagnoses and the likely outcomes, treatment approaches, etc.
What we are describing is not a new diagnostic model. Instead it is a learn able skill to observe what is there so that you are better able to create a specific outcome on behalf of your patient or clients goals. This is done through visual thinking, observation, asking questions that promote further investigation until it is clear how the structured is organized to give rise to the pattern of behavior. Beginning with best questions will improve the change effort and provide the clarity of cause and effect that will assist your patient in being involved in their life as they choose.