The Impact Of Self Image On Clinical Reasoning

One patient. One clinician. One treatment room.

It should be pretty straightforward, right? Ask the right questions, get the appropriate answers, make some astute observations, add a little clinical reasoning, and get the patient moving towards a solution to their problem.

But once the patient and clinician step into that treatment room, worlds collide. It starts with what is going on in our heads before we ask or answer any questions. When two diverse self images collide in the treatment room, anything can happen, and oftentimes it does.

Clinical education programs, be they for physical therapists, chiropractors, or physicians, are traditionally focused on knowledge and skill acquisition. They rarely focus on communication or cognitive skills. Clinicians with sound clinical reasoning skills will tell you that being a good clinician isn’t all about knowledge or the “tools in the toolbox”. The process of clinical reasoning is the ability to extract useful, relevant, contextual, and meaningful data from the patient to understand the essence of their problem.

All of this is directly related to how we see the world and our interaction with that world. There is but one reality, that much we know. With that said, we choose to operate on our map of reality. For example, my map of reality isn’t any better or worse than yours – it is just different. It is defined by my experiences, my perceptual filters, and the meaning imposed by my beliefs about the world and about myself. That includes my self image, self perception, and self efficacy.

Within that framework, we select data that tends to confirm our view of ourselves. We make decisions that support this as well. All the while we are simply maintaining a comfort zone that promotes our self image.

So now take this concept into the treatment room, and multiply it by two. One patient, one clinician – two diverse self images driving the discussion.

Does the patient perceive themselves as an avoider or a confronter? A passive participant or an active one? Are their actions and behaviors consistent with these self perceptions? In the context of their injury, what meaning and role do symptoms have in their day?

Does the clinician perceive themselves as a guru or an educator? The fixer or the problem-solver? What do they believe is their role in the care of the patient? The clinician’s approach to care is driven as much by their beliefs and self perception as it is by the evidence.

This is pertinent to all areas of clinical practice and patient – clinician interaction. It could be a patient with a worker’s compensation injury who just “doesn’t want to get better”. It could be a patient who has “poor exercise compliance or adherence”. It could be a patient that when returning to their sport, always has some crisis that limits their performance at the most inopportune moment. No, these things generally aren’t bad decisions or bad luck or anyone’s fault – they may in fact all be appropriate behaviors consistent with the context of the patient’s self image and comfort zone.

It is of great benefit for the clinician to understand how the patient’s (and their own) self image(s) can play a role in the clinical reasoning process. The primary goal is not to impose our context on the patient, but to understand how they see the world, how they interpret their symptoms, the meaning they impose on their problem, and to foster an environment for growth and learning.

If we are cognizant of the existence of these potential limiters in the clinical reasoning process, then we can establish effective communication strategies to derive valuable information. The communication side of the equation is the subject of an upcoming post.

Note: For those interested in the clinical reasoning process, I will be doing a 2 hour webinar on the topic of “Cognition, Communication, And Clinical Reasoning” on Thursday 7/19 at 12:30 pm ct. You can find the course information here.

Photo credits: we are the joneses