Clinical Edge - 100. 5 practical strategies to improve your clinical reasoning & treatment results with David Toomey, Jordan Craig & Simon Olivotto Clinical Edge - 100. 5 practical strategies to improve your clinical reasoning & treatment results with David Toomey, Jordan Craig & Simon Olivotto

100. 5 practical strategies to improve your clinical reasoning & treatment results with David Toomey, Jordan Craig & Simon Olivotto

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David Pope: Hey guys, how's it going?

David Toomey: Good. Yeah, really good.

Jordan Craig: Good.

David Pope: Awesome. Welcome to the Physio Edge Podcast. It's great to get you all on and get to know you all. We're going to dive into today how we can help people improve their assessment and treatment results with clinical reasoning. And we've got heaps to explore, but really looking forward to introducing people to yourselves first as new integral members of the Clinical Edge team, and sharing tons of great info and giving people a chance to get to know you and the sort of stuff that you're going to be sharing with everyone and how you're going to be helping them clinically. It's going to be awesome. So, welcome.

David Toomey: Yeah, thanks so much. Absolutely delighted to be here and delighted to be part of such an experience and talented team. It's really cool.

David Pope: That was Dave Toomey. He's part of the team. We've got three presenters on here today. I'll give you a quick intro to the three guys. The voice you just heard, that Irish accent is a Dave Toomey. He's a physio based in New Zealand in Waiheke Island, just off of Auckland, but he hasn't picked up that New Zealand accent yet by the sounds of it and with a lot more Irish accent going on there. That's Dave.

David Toomey: Hey guys. So, I haven’t picked up the accent or any of the Kiwi-isms at this stage, yes, but I'm working on it, a work in progress.

David Pope: Nice, that's excellent. Well, we'll get a bit more from you guys all in a second, but the next guy we got on and is Jordan Craig. Jordan's a physio based up in Queensland so and we'll find out a bit more about Jordan as well. How are you going, Jordan?

Jordan Craig: Hey Dave. How are you going? Again, on the back of David's comments, I'm pumped to be a part of the team and looking forward to the content we can give and having a chat all things physio. Stoked.

David Pope: Awesome. And then, our third team member that we got going on today is Simon Olivotto. Simon's a physio based out of Sydney, not too far away. Simon I actually went to uni together and graduated in the same year at Sydney University. Hey Simon, how's it going?

Simon Olivotto: Good day Dave. Good thanks. It's like a bit of a reunion.

David Pope: It is indeed, our own mini reunion.

Simon Olivotto: As the others said, also very excited to be involved in this project.

David Pope: Awesome. Well, let's find out a little bit about you all and then we can dive into some clinical tips and helping people with their assessment and treatment and clinical reasoning. Why don't we start off in the same order. Dave, why don't you tell us a little bit about yourself and what you enjoy and what you get up to.

David Toomey: First off, my name is David Toomey. I'm originally from Limerick in Ireland. I graduated from University College Dublin, and then moved to New Zealand. Originally, I was working and being exposed to professional rugby at an undergrad level. So, very fortunate off the back of that. And then, when I finished up at uni, went back to UCD just to tutor and was doing a little bit of work with Leinster Rugby with their under 20 side and stuff like that, which was all really cool.

But I wanted to spread my experience around a little bit, and then got interviewed for a position in Auckland, which was meant to be originally an 18-month contract. And I think it's just coming up on seven-year anniversary in the land of the long white cloud. I'm absolutely loving it over here. I came over working in private practice and really enjoyed that, and moved onto some roles and a management capacity.

That, I guess, exposed me to maybe being in charge and handling the continuous professional development for a whole host and crew of people, which really excited me and management and those sorts of things which bring their own intricacies and quirks and challenges, which was awesome too.

And then, yeah, I've always been deeply passionate about learning. I went back to do a Certificate of Orthopedic Manual Techniques, which was really good to dip my toe into that, and decided I wanted to get immersed into the world of education a little bit more. So, I went back and did my postgrad in musculoskeletal physiotherapy at Auckland University of Technology. I did that full time, still was working clinically. I can never get away from that. I definitely view myself as a clinician first and foremost.

And then, recently, I have just embarked on my PhD. I'm doing that in the area of exercised induced hyperalgesia. It's a very exciting field and definitely a bit daunting embarking in on that journey, but loving the process so far and working clinically to parallel that.

And obviously doing the work now with Clinical Edge. So, a lot of plates spinning but very happy plates, if that's such a thing.

David Pope: Spinning happy plates, I like it.

David Toomey: Exactly.

David Pope: I think that's a common theme amongst everyone in the team. At the moment, you've got a nice mix. You're working clinically, at the moment, you're doing your PhD, so you've got that interest in research, and then you've also got the education stuff going on with Clinical Edge. So, you get that real nice mix of theory, also your practical stuff and teaching as well.

As I've been working with the whole team, your practical approach to education and stuff is really coming across and I think everyone's going to really benefit from having yourself and the other guys on the team that have that mixed experience and mixed interest as well. Currently, you've got the clinical stuff, you're working at a clinic, you're also doing your PhD at Auckland Uni in exercise induced hyperalgesia, and then you're working with us as well.

David Toomey: Yeah, it's great.

David Pope: And any outside interest besides physio? What sort of things do you like to get into?

David Toomey: Yeah, well, I used to play rugby and I was a hooker on the rugby fields. As a result of that, I had a couple of injuries myself. I had my own shoulder reconstructed. So now, I play touch rugby, which I'm sure you have seen some of these New Zealand rugby players, it's a much safer option to play touch rugby. So, I play touch rugby, watch a lot of movies, and with that, eat a lot of popcorn. So, it's a mutually beneficial relationship between my movie watching and my popcorn consumption. It's great. Yeah, between all that I don't have too much time for much else.

David Pope: Excellent. So, you get to come home from touch, put on a good romcom and get the popcorn out.

David Toomey: Exactly. Exactly.

David Pope: Excellent. All right, that's fantastic. And so, Jordan, let's find out about a bit about you, mate. Tell us where you're based and what you like to get up to.

Jordan Craig: Yeah, I grew up in Sydney, graduated at the University of Sydney in 2008, and from there, came up to the Sunshine Coast, the land of sun, waves, and then not so much sun and waves. From there, I've been in private practice since graduating and worked in a sports physiotherapy clinic with a large focus on acute and postoperative knee injuries. From that position, then slowly started to move into sport, and through that time, I've worked in the A-League clubs in the youth league development in a Melbourne football club.

Then from there, I worked in the NBL with the Brisbane Bullets and worked with the team there, which was great. And then, currently, I'm doing a little bit with Football Federation of Australia into some of the senior national teams in futsal. That's my sport side of things and that has coincided. Since I graduated, I've been working at university, did some tutoring for I think three or four years before going back myself to do my Masters of Sports Musculoskeletal Physio at Griffith University. That was finished in 2013 and I've been on a similar research pattern since then with research in the psychosocial influences of ACL reconstruction, and most recently, with an honor student around depression in that field.

Now, I'm probably very much like David. I've got a few balls in the air, juggling at the moment between clinical work. I'm also, current role, is lecturing at the Griffith University Medical School into their anatomy and musculoskeletal programs. Then working a bit with Clinical Edge. I think that summarises my quick journey.

David Pope: Nice. You graduated from, was it UQ?

Jordan Craig: University of Sydney.

David Pope: University of Sydney. You come from down here too. And then, you did the MMSP program, the Masters of Musc and Sports at Griffith Uni, the same one that I did, the masters up there. Because they run a cohort every two years, so you finished the cohort before me?

Jordan Craig: Yeah, yeah. One of the early ones. Before now, it's on hold for a bit, but yeah, one of the very lucky few that got to go to that program on the Gold Coast. There's worse places in Australia you could visit to go and do your masters, that's for sure. And particularly also dangerous with the nightclubs and the venues that drag you out post exams. But we'll talk about that in another podcast, I reckon.

David Pope: For sure. And not too far away from you, because you're on the Sunshine Coast, which is only just up the road a little bit from the Gold Coast.

Jordan Craig: Yeah, I would say a two hour drive, but then I'll start to sound like this is ABC talk back radio with complaining about the M1. So, let's just say it's a two hour trip up the M1, mate.

David Pope: Righto, fair enough. Good stuff. And tell me about outside of work, what sort of things you get up to?

Jordan Craig: Yeah, look, outside of work, I think I don't mind a little bit of exercise, try and do the odd, very amateur triathlon, don the onesie a couple of times per year and love to surf, love to run, play a bit of rugby union here and there depending on how my two shoulders go and if they stay in place. Basically, love a bit of music, I love a bit of chilling out. That's probably my vibe, that's for sure.

David Pope: Awesome. All right, that's great to hear. Fantastic. So, lots of stuff going on. And you said, you work teaching anatomy and in the musculoskeletal program as well. So, you've got plenty of time in the wet labs.

Jordan Craig: Yeah, definitely the wet labs. Look, I think that one of the reasons I got back into that was I distinctly remember an exercise science student asked me questions about anatomy that I just couldn't answer and I was stupidly embarrassed. And so, that one question from that student has put me back in the wet labs, which has just been such an amazing thing for my clinical work to put those questions and intuitions and what I see clinically and go and explore them from an anatomical perspective, and just see if I can get more information and have that as close to x-ray images I possibly can to think about what's under the skin that we're treating.

And it just provides a small part of what puts together which one I will get into, but has been hugely beneficial. Hopefully, we can get a few more programs to get physios back in there, but I'm very lucky. That's for sure.

David Pope: Definitely. Yeah, I love getting back into the lab too. When I was doing my masters, it was so great to get back in the labs and have a real brush up on your anatomy. I think it really helps you when you're looking at the different structures and it's surprising how much you forget even in a short time or, in my case, a longer time, between getting in there as an undergrad and then later on.

It really does make a big impact in clinical reasoning, which we're going to talk about today and as you're looking at what anatomical structures are around. That's obviously one component when you're looking at that and a pathological area, that's one factor within people's pain experience, but it's definitely one that's important to keep in mind.

Jordan Craig: Oh, spot on. We all know that as undergrads, we're just trying to keep our head above water in those anatomy labs, it's like just trying to get through the end exam, but to actually have some clinical experience to go back in there and start to build on that anatomy and not be just trying to survive and just use it for a learning experience, yeah, there's no doubt it helps. That's only one part of the small puzzle we're about to enter into. But I'll tell you what, I'm much more comfortable asking that question from that exercise science student than I was 10 or 12 years ago, that's for sure.

David Pope: Yeah. Yeah, awesome. And then Simon, you're based in Sydney and so tell us a little bit about yourself and what you're up to and your clinical interests to start off with and that sort of thing.

Simon Olivotto: Yeah, thanks, Dave. I went through uni in the year 2000 at the University of Sydney with yourself, as you mentioned.

David Pope: Yeah.

Simon Olivotto: Since then, I took on a little bit of work in some of the public hospitals and I spent about three years there just cutting my teeth in orthopedics and a bit of emergency outpatients and hands type work. Did a little bit of work in private practice and then found a pretty good job with the Department of Defense, which I've been with for the last 16 years so I really enjoy it. I was working with the army for quite a while, for about eight years. And then, about eight years ago, I've moved over. Now, I'm more at a Navy base, which I guess the army was a bit more of overuse type injuries and tendinopathies and things.

Whereas now, I see a little bit more workplace type civilian injuries with the Navy, but I still get a good mix of army as well. Like the other guys. I wanted to continue learning as well. And so, went back to uni in 2006 and completed a Masters of Manipulative Physiotherapy, it was called back then, titled musculoskeletal physiotherapist. I continued my journey working with defense, but broadened out and did a little bit of private practice work and picked up a really cool job in an emergency department doing some primary contact work on weekends as well.

I spent about the first part of six years there doing that on weekends, which I learned heaps of really cool skills there.

And then, a few years ago, I decided to take on another challenge and I entered the training program, the Australian College of Physiotherapists Specialisation Training Program, and last year, successfully got through and was awarded fellowship. So, I'm now a specialist musculoskeletal physio and tend to work more seeing more second opinions and some more of the complex patients as well. They get referred to me at work. So, that's the kind of stuff that I really enjoy seeing.

David Pope: Excellent. So, you had a broad mixer at that time by the sounds of it?

Simon Olivotto: Yeah, yeah, I'm trying to get a little bit of knowledge in lots of different areas so that I can bring it all together for when I see a complex patient and I can draw on that knowledge and help them the best way I can. Like the others said, primarily a clinician but also doing a little bit of teaching as well, bit of sessional work at Sydney Uni, and doing some presenting for the Physiotherapy Association, and obviously working with Clinical Edge now is a real cool experience to be involved with.

David Pope: Yeah, awesome. And so, you've got tons of experience and you mentioned there, you've got your musculoskeletal titling back in 2006, you really got in there well ahead of me. I waited a fair while actually.

And so, that's a really good thing to get into. And then, you did your fellowship specialisation, which is a two year process?

Simon Olivotto: Yeah, two year process. It's largely self-directed learning. So, you need to identify areas and gaps in your knowledge and develop that. In essence, had you develop your own training program and own learning needs and learning goals. The way you went about that was up to you. But it really gave excellent chance to spend time with some of the best in our profession and both watch them and gain expertise from them. But also, even more useful, was to be critiqued by them, seeing a patient and have someone really get in and ask you why you're doing things certain ways. You can really learn from that and develop as a clinician. I found that enormously beneficial.

David Pope: It's a tough thing to go through, especially when you've got people that are experts that really know their stuff. You might be, for instance, looking at low back pain, and if you've got someone that's an expert, you might've had someone like Peter O'Sullivan or someone like that looking over your shoulder and asking you questions about why you're asking that question or why you're doing that test or what information does that give you and why are you doing that treatment? Really drilling you as you go through that process. That is tough, but it's also a really worthwhile experience, isn't it?

Simon Olivotto: Yeah, massively daunting and sometimes you see these people that you've only read about in articles or seen on podcasts and things like this. And to have them there, it's a pretty cool experience. But as you said, also very tough but learned lots and lots from it, and very grateful for the experience. Recommended to anyone who's considering undertaking it.

David Pope: And I think with the combined experience of yourself going through that experience plus the rest of the team here, we've got tons of experience going through training, learning different ways of doing things, really having to test your clinical reasoning as you go through. I'm sure you've all probably felt the benefits of having to develop your clinical reasoning as you go through each of the programs and the training that you've done.

We talked about it as a team, how we'd really like to help clinicians because that's our goal. We really want to help people to become the best therapist that they can be, to achieve their potential, to really get great results and really enjoy treating people and enjoy their job. And so, as a team, we've really discussed the best ways that we can help people. And that clinical reasoning process, we all thought was a fantastic area to really help people. That's the basis of great treatment and great assessment, diagnosis and treatment.

So, I think we all came to that conclusion, that this was an excellent place where we can really help develop people and therapists that are out there and really help them with all of those areas. So, that's what we wanted to dive into today. We're going to talk about clinical reasoning because it's not always clear what is clinical reasoning. I remember I got exposed to different models of clinical reasoning and I'm sure you probably all did too at different points in time.

I got exposed to some that had merit and some that didn't, from different parts of my career. But then, when I went through my masters, there was a real focus on clinical reasoning.

I guess the first thing to discover is, before we figure out how it actually helps us and how do we use it in your clinical practice, how you can improve your results with clinical reasoning, it would be good to basically outline what clinical reasoning is. So, if one you want to dive in, give us a bit of an idea of what clinical reasoning really means to you. Jordan, how do you use clinical reasoning within your practice or when you're seeing patients?

Jordan Craig: One distinguishing feature is that reasoning or clinical reasoning is not knowledge, right? It's not that you have an abundance of increased knowledge which means that you are good at clinical reasoning. And often, sometimes the two can be polar apart. I think in what reasoning means to me is it's an accountability to me, it's a framework or a reminder of, “Can I answer the questions of why am I doing this and what is it meaning to me?” To be able to relate to the patient outcomes.

That's a non-defined term that is, that's what it means to me, is basically my values of physio and that I use all the information I can gain in an assessment or a treatment session to then pool all that to come out with a logical and structured answer. That whole thinking about your thinking, I think is a perfect, very simple way of, how often do you actually think about what you're doing? And not just thinking, because I think we could all say that in our jobs, we all think what we do. But really, have you nutted out all the different factors that may be contributing to the scenario in the patient that you're seeing? And rationalising those and putting them through your clinical sieve to create your goal or your impairment-based model would be sort of what it means to me.

And I think too on the basis of us, when you finish university, I think sort of clinical reasoning can be drummed down your throat without you really knowing sort of how to use it, right? Because you're still assimilating all your knowledge. And it sort of dies off again, you know? You don't really get pushed about your clinical reasoning until you go and either restudy. How often do you get caught into your ease and comfort of work life or in a job where you're by yourself that you just do your thing and your reasoning is, "I'm not killing anyone, so I'm going all right." It's trying to figure out, well, hang on, be a bit accountable of what you're doing, reflect and put it to a model or a process that can come out with getting more efficient targets or outcomes in your patients.

David Pope: Awesome. Tell us a little bit about yours, Simon. So, how would you think about clinical reasoning? And do you want to give us a bit of an example about how you've used clinical reasoning recently in one of your treatment sessions?

Simon Olivotto: Yeah, I think I'd echo what the other two ... What Jordy and David have just talked about as well. And I think that clinical reasoning is just a way of structuring your thoughts and gathering all your knowledge together and using that in a way that's really efficient to give you the best outcomes. One thing I've learnt is being able to get all that knowledge and your thoughts together so that you can really make some of the complex problems simple. So, I like that analogy that Jordan talked about with the sieve. It's something I think about, not being told, it's about a funnel. So, you start broad and then narrow down by selectively asking questions and doing specific tests to give you the best ... or help you get the best information you can from your clinical examination.

In terms of a clinical example, I guess I tend to really like the translational framework they use in WA, so developed by the Curtin Academics, Doctor Tim Mitchell and Darren Beales and Professor Peter O'Sullivan and Helen Slater. I think that's just a really great framework that gives you all the pieces of the puzzle that might be presenting in any one patient. And it's a nice reminder, you can go back to that and use that to ensure that you've got all the elements of the patient presentation and worked out the relevance of each and addressing them as needed. And it doesn't need to be complex. I think if you start broad, like they talk about working out first if it's a red flag, whether it's a specific diagnosis or whether it's more the non-specific diagnosis. And then you can drill down further and look at all the contributing factors.

I think the functional behavioral part of that framework is really useful. And in summary, it just looks at someone and you think how they're moving and their functional aggravating activity and trying to work out why it's painful for them. Are they moving in a way that's helpful? Or are they moving in a way that's not helpful for them? And if it's not in a way that's helpful for them, why is that so? And then you start to hunt down further and think, is it because they don't have the range of movement to achieve that adequate posture or functional activity? Or is it that they don't have the control? Is it that they don't have the strength to achieve that? Or is it just that their behavior and their beliefs are driving a certain way of movement that's not helpful for that person. So, I find that framework really useful and an easy place to kind of start and then broaden out and think of all the aspects that are involved.

David Pope: Awesome. So, do you want to give us a bit of an example there, Simon, about how you might have applied that with a recent patient? So, how you've gone through the ... You mentioned there going through the red flags and then going from broad to narrow and then figuring out their movements, if they were helpful and unhelpful, and why. So, do you want to give us a bit of a brief outline of a recent patient and how you might have gone through that?

Simon Olivotto: Sure. I guess someone today that I saw thinking that they had consistent lower back pain, I saw as a second opinion for another physio that referred to me. Basically, their main problem was that they just had trouble bending, lifting. So, it was a very flexion-based type movement. So, I considered all the red flags, we ruled that out pretty early. He had no neurology or hard neurological signs, which I quickly screened for and was able to use that to reassure him that that wasn't the case.

Next, I was left with ... And it's not a great term, and I wouldn't use it with a patient, but if you want to use the umbrella, the non-specific term, in which then I can drill down further and then figure out maybe where the source of symptoms are and what's contributing to it. So, specifically when looking at this man's problem in bending, he was painful with his flexion, particularly when returning to extension. And when I looked at changing that, I was able to reduce his pain by getting him to posteriorly tilt and relax his extensors a little bit more. So, maybe trying things say in sitting, getting him to flex in sitting where he didn't have to use his extensors as much. And he could see that he could modify his pain. So, his problem was he was holding himself too rigid, too much extension. And I could easily show him that he could modify it by relaxing a little bit more and starting his flexion from the lumbar spine.

Then I had to sort of hunt down a little bit further and try and figure out what the reason for that was. Some of the clues I got from the history and some of the questionnaires I had in the area was he was quite fear avoidant and he had beliefs that he had a bulging disc and that it was really dangerous to bend. And so, these kind of beliefs had a contribution potentially to how he's holding himself and avoiding that flexion and holding himself rigid. That was the hypothesis that I went with. And then when I got him flexing in different contexts in sitting and laying on the bed, he could see that he actually could do this. So, we used that to slightly or slowly challenge the concept, whether it was truly just a disc bulge that was driving this, or whether it was more a movement behavior. And putting that together with him being able to change by moving slightly differently got a bit of a buy in and got him flexing in a better way.

Of course, I then went through and had a look at other tests too to see what his hip extensor strength was like and see if anything there had a contribution. But it's a process of coming up with a hypothesis, figuring out what possibly is the main contributing factor and then testing that and reassessing and evaluating.

David Pope: Yeah, so sounds like you've got a fairly complex patient that's seen a couple of other therapists for a ... And undoubtedly they're good therapists that have assessed him and tried their best with him.

But what you're saying is that even with these complex patients, you can identify within that how to work it through from your broad screening questions, going through checking out if he had any of those red flags and really simplifying that process as you went through, like narrowing it down, figuring out if his movement ... With your history, coming up with a hypothesis of what's going on, testing that throughout your objective assessment, and then figuring out, is your hypothesis matching the evidence? And then going through into your treatment and seeing what's going on, if you did have helpful or unhelpful things and then performing a thorough, but efficient sort of examination.

Simon Olivotto: Yeah, having a bit of an idea and a hypothesis in your head as you're going along as to what may be the contributing factors and what may be the causes and then testing that in your clinical examination. And I think a good place to start is having a look at the main complaint, why the person's there. And this fellow, he's like, going back to Jordy talking about finding out the reason why someone's there. This fellow's problem was he had problems bending and he really wanted to be able to bend so he could lift his kayak up onto his roof and he can go kayaking.

So, the whole assessment was based around trying to get him bending better, figuring out why he can't bend and what some of the problems are. And a lot of the questioning and the testing was based around some hypotheses that I was developing throughout the clinical session that I had with this fellow.

David Pope: Beautiful. So, you've identified his beliefs and also his goals. And you've incorporated that into your assessment, also your treatment to address those and try and meet his goals and address his beliefs that he did have this bulging disc as well throughout that.

Simon Olivotto: Yeah. Yep. And he was able to see that he could flex in a different context. And if he flexed in a different way, that it didn't hurt as much. And he started to have a bit of a breakthrough where he could see that maybe protecting himself and trying to hold himself rigid and into a little bit more extension and particularly when he was rising back up from flexion wasn't helpful. And just making him aware of that, that he could do it differently. And then using reflective questioning to start asking him what he thought about that, I could start to see the cogs turn in him and get a real breakthrough and a way forward.

David Pope: Perfect. And that's really what you've described there of taking that complex patient and then identifying the factors within that that are important, coming up with a hypothesis and using that evidence informed practice to really help guide your assessment and your treatment is what you described. And that's really what we're as a team really going to try and help people to do that. So, that's our goal.

We're not looking for cookie cutter ... Everyone's not going to walk in and get that same treatment from you, are they?

Simon Olivotto: No. And I think that can get frustrating for us as physios over a while too. And I think that's what makes clinical reasoning really helpful for us because it makes our work challenging and interesting again. And I think it gives us a real motivation to help our clients and it engages clients better as well, I believe.

David Pope: We're going to give some tips on the podcast today to really help people with that process to really help improve your assessment and your clinical reasoning as you're treating patients so that you can use knowledge and the evidence to inform your practice and simplify your assessment and treatment, but really have strong evidence for what you're doing with each of your patients.

So, we're going to dive into some tips to help people with all of that. But I think there's some really nice examples of what clinical reasoning is and then how you can use it to help guide your treatment. And then it makes it enjoyable. You're not giving everyone the same, every low back pain patient the same treatment. They're individuals, you're really trying to explore what's going on, what their beliefs are, what their goals are. You've got different tests for each person based on what's going on. You're trying to prove and disprove your hypothesis as you go through. And that makes it really interesting and much more exciting as a therapist and a clinician to really have different approaches for each of your patients that really meet their needs. And it's a much more fulfilling way to work.

Simon Olivotto: Yeah. I think it's important to have patterns too and have a few common patterns that you see. And then, you can have those hypotheses in your head that you can draw on. And then you go through and test them.

For example, that fellow I saw today, his fear and the way he was holding it might not have been a behavioral thing, it could have just been that he didn't have the strength in his hip extensors. So, I need to go through and rule that kind of stuff out as a major contributor as well before you jump to it's purely a behavioral way of moving.

Jordan Craig: I think a key point there from Simon too is that complex doesn't mean complicated, right? Complex is often we put a brand to persistent pain, but it doesn't mean that it's complicated, that it's going to mean a magic trick of a guru. Simon's just showed a really nice model to be thinking from the minute the patient walked in about his problems and relating it through his subjective history to work out a working hypothesis. And that's something that I think if you sit back and be analytical of your current practice, how often do you do that in a context with a patient in front of you? How often are you working an analytical process to figure out what exactly is going on here to cause this patient's problem?

And as Simon perfectly said, you might get a nice little win in the first session, but it doesn't mean that you're celebrating out and you're popping champagne bottles. It's, "Well, I've had a win there to give me a guidance. What other things could be contributing?" And hopefully you sort of realise that there are a list of things that may be contributing here.

You've picked one and rested your hat on one that you hunted and made a change. But you've got backup plans, so that as that's your treatment plan and education, which is all back to your clinical reasoning, rather than just a, let's go an evidence-based purely approach, which is just, now I'll get them exercising and he should never see me again. It's just that nice systematic way of going about a treatment plan.

David Toomey: As the guys have alluded to, there's pros and cons of frameworks and that they can guide us. We probably don't want those to be algorithms where we're so tunnel visioned that we don't see the diamonds that are outside that, that are often what the really good clinicians pick up on. You know, a case in point might be we're given a scan or we're given a referral from a GP with a diagnosis on it. And if you're a busy clinician, you've got back to back patients, you get this referral.

There might be a certain part of you or certain clinicians out there, I know that I've definitely been guilty of this in the past where by you go, "Now the hard work has been done for me there." Do a couple of tests, and it confirms your bias or it confirms the diagnosis that you've been given. And then it's only a couple of weeks down the track that you ascertain that the person potentially did have this diagnosis or fulfills the criteria for this diagnosis. But there are other comorbidities or there are other characteristics that this patient has that mean that there's probably more pertinent things that need to be addressed. And I think that's something that is encompassed within clinical reasoning as well, you know? Asking the questions of why.

And I think Jordy has alluded to this in the past. And just always kind of bringing yourself back to the why. Why is this an important piece of information? Why am I going to do this test? Is it for ... is it a sensitive test or is it a specific test? Because if you're not asking yourself these questions, then you might just be giving a cookie cutter shoulder assessment to everybody that comes in. Whereas, if you're working yourself through that working diagnosis and then you go, "I didn't expect that. That's going to take me down this slightly different path." And that's often with clinical reasoning where the art meets science. So, completely reiterate what the two guys have said there.

David Pope: Definitely, Dave. That's great points. And I'm sure we all remember as a beginning therapist when you came out and you're like, "All right, I've got this patient in front of me. And I'm looking at this sheet of questions and reports." And you go ... I had a sheet that had all the AGGS and easing and 24-hour pattern. So, I asked all the questions and I had plenty of info about their aggravating and easing factors and 24-hour behaviors and their pain diagram and all the rest. I had tons of great info. I had absolutely zero idea how that was going to help me to come up with some more tests to do. So, I'm like, "All right, I'm pretty sure this objective's going to help clarify."

So, I've got this shoulder patient. I know that they get this pain at 90 degrees of abduction. And now what? All right, let's go into some hanging out the washing. So, we'll do some tests and we've got lots of positive and negatives. And really, I came to the end of it. I'm like, "All right. I've got no clarity at the end of that. Now what am I going to do?" And I'm sure we've all had that experience where you've just got a whole bunch of information. But it's kind of hard to know how to fit all those pieces of the puzzle together.

And it hasn't always had a great flow to know that when I get this information, for instance, if it hurts when they do a particular movement, what follow-up questions do you want to ask? And what information do each of those questions give you? And how is it going to guide your assessment and treatment?

And that's a really important component. And that's really what we want to help people to do is to be able to know, rather than just having all of these questions, a whole bunch of information. But to be able to identify how each of those parts, pieces of information really are relevant to that patient, really relevant to you as you're going through your assessment and treatment, and how that actually ... What that means and how that's going to help you as you go through your assessment and treatment.

So, rather than having a big bunch of questionable positives and negatives and things and info, a big jumble, we've got a much clearer picture of what's going on with our patient and what to do about it.

Simon Olivotto: I think that's a great summary of it, because one of the things that we know is sometimes just throwing a bucket load of tests at people, there'll be lots of false positives and some false negatives. And the more tests you throw at them, the more blurry a picture can be. So yeah, I think that's spot on. We just need to try and be specific with every question we ask. Have a purpose. And same with your tests as well.

David Pope: Absolutely. And that's what we're going to help people achieve. So, let's give them some tips that'll help them with that. Obviously we're going to give them some great stuff they can practice. But we're going to also give them ways that they can help to know what questions to ask and how to develop their clinical reasoning with the other stuff that we've got following on from this. But we've got some really good practical tips. So, why don't we dive into it? And I thought we might start with you, Jordan. And how do you think someone can improve their assessment and treatment with clinical reasoning? So, give us some ways that you think we can help people with their clinical reasoning, assessment, and treatment.

Jordan Craig: Yeah, well I think my tip's probably going to cause a lot of eye rolling, people that are listening to this going, "That's not a tip, it's just pretty straightforward." But my first one is a simple thing that sort of got drummed down my throat through my clinical reasoning pull apart was just, “Why has a patient come to see you?” At the end of the day, unless it's causing a cease of activity or stopping them participating in a certain group or social activity, sport activity, something that drives their psychosocial model as well as the biological model, they're not going to be coming to see you, right? It's obviously not having a big enough impact. So, really figuring out the functional movement that is why they've come to see you. And that just sort of there gives you your nice little point to hunt, you know?

I know we get caught up a lot about this functional position. But I just think listen to what they've come to you for, and then that starts your cortexes going absolutely nuts to figure out, well the million things that can be relating to that movement. And that then becomes your subjective questions. Everything that you ask, every question is subjective with your aggs and eases, exactly right, is that proforma is just a guide. Now, we should to really start to ... as a developing physio start to think, "What am I asking when I ask that aggravating factor and they tell me something, what do I need to know? What information will help me move towards including or excluding my hypothesis based on that movement that they've come to tell us about?"

And that then guides a nice little thing that every sort of answer you're getting to those questions and your follow up questions are a real conversation because you're trying to problem-solve, rather than just fill out an interview for 15 minutes and then you've got a nice subjective notes that you can put into your system.

That follows into your assessment in my view, in that once you've built that nice little argument in your subjective history, your assessment becomes now a tailored assessment and semi-avoids those million special tests that we can all do that then comes up with a real nonspecific injury and you bluff your way around an education to tell the patient you think you know what's going on. If you present to a patient a really nice logical model because you've broken down why and actually explained why they've come to see you in a physiotherapy term and how you can build those blocks back together, you're being an efficient clinician because you're addressing why they've come to see you. So, in my two cents, if you start with why, hunt the reason and the position, like Simon did in his clinical case he presented. It's exactly the same, you're addressing the issue they've come to see you for. And that then provides a nice little framework to starting a patient-centered approach.

David Pope: Yeah, you're really looking at the patient's goals, why they're actually there, and what they want to achieve. Like, are they there because ... Well, obviously they're there, most likely because they've got pain. But what are their goals? And what is it that they actually want to achieve? So, can you give us a bit of a patient example, a recent patient, and how their goals, their why that they came to see you, how that helped to guide your subjective and your objective?

Jordan Craig: Yeah, so I think one that sort of jumps to mind was a couple of weeks ago, an elite marathon runner. And we all know elite marathon runners run a huge amount of kilometers and straight away can become quite complex in how you ... yeah, a certain sort of injury, how you then manage the load wise. And I think prior to, I think a few years ago, I was definitely guilty of probably regressing them too much and thinking, "Okay, well if there's a tendon problem or an impingement problem, I need to be taking all that irritability out and then building that progress up." And now with all the great evidence we've got in that space, but also just going, "Well, there's no point in this patient. I really need to know exactly what changed in her programs and her life that brought this pain on," because she'd been running kilometers for decades, right? So, what happened?

I can't just say, "Well, it's because you're running a stupid amount of kilometers per week that you're injured." There's a reason. And so, all my questioning was just constantly hunting to find out what in her plan in her history, bio mechanically, psychosocially, all those models built into one to see if I could try and come up with something. And it did. As we sort of hunted around, there was some stress in her life and some anxiety related to some competition stuff going on.

And that definitely changed a pattern in her training, which was, instead of training in her normal time, she actually started to train earlier and longer to be able to accommodate some of those stresses because she just thought it was basically junk kilometers. But at the end of the day, it was actually causing fatigue states when she needed to do her quality work.

So, by just hunting those sorts of things, which are a bit external to just a pathoanatomical model meant that I could sort of get an understanding of, how do we work with those things? And a multidisciplinary approach to then from her tendon point of view that we loaded it specifically and how, and she understood the reasons that were filtering into her tendon problem, how they were to be managed to be able to keep her running because the last thing that we wanted to do was do a clam exercise and a hip abduction exercise, whatever you choose, we didn't want to do that and sideline her for three weeks and then tell her that in six weeks she could run. It was, well how are you loading this in a functional position in her running position? And what was she doing in order to be loading that tendon? It was actually weakness in the other side.

So, once I did objective measures of her non-symptomatic side was where we find that varying weakness. So, her rehab program was actually about trying to strengthen the non-injured side in order to decrease some of the internal load that was going through that tendon and that complex. So, it's just thinking outside the box, but with all of those different factors, psychosocial and her load factors. It created a case that we could present to her, that I could present to her about how we were going to fix her pain.

David Pope: Great stuff. Yeah, nice example there. That's awesome. All right then, let's have a chat about some more tips. So, Simon, what tips have you got for people that can help improve their assessment and treatment with clinical reasoning?

Simon Olivotto: I think Jordy's tip's great to start with. I want to just reiterate that, that I think getting the goals is the main thing you want to get off your patient. So, that's going to steer everything else you do. But the other two things that I would probably consider was continue to increase your clinical knowledge and have lots of different patterns that you have available in your repertoire for what you know for each different regional area. So, you know, with that shoulder, think about all the different patterns that you might see there, including neck referral or red flags. Thinking about all the types of different conditions that might present if it's a stiff and painful shoulder versus a weak and unstable shoulder versus just a painful shoulder? So, have all your different patterns and differential diagnoses for each area so you've got that on tap.

But then, just be really specific with your questioning. So, every question or test you ask, like what Jordy said, should be for a purpose. So, you can kind of ask yourself throughout your treatment, you think about why you're asking a certain question or why you're doing a certain test, not just going through the process like you were talking about where you've got a proforma and you're just ticking the boxes. Every question should have a purpose to help you figure out what the diagnosis is or how you're going to help that patient with their problem or goal.

David Pope: So, do you have an example of some follow up questions? So, for instance, as you've gone through your subjective and you're talking about being systematic and refining your questions, what's some example follow up questions? So, some information that might have come up within your subjective that then you've used to ask specific follow up questions that help to guide you or give you specific information?

For instance, I had a low back pain patient recently that had pain with sitting. And so, as they were sitting, they said their pain developed. And so, then I'm going, "All right, well what is it about sitting? Is it the position? Is it the length of time? Or is there something specific about their sitting?" For instance, is it sitting when they're driving? Or is it sitting when they've got their feet up on as footstool? Or is it sitting in the lounge chair? Or what is it about that particular position of sitting? So, for instance, in this patient, it was when they were sitting driving. So, they had their leg ... And it was right leg, they had in automatic. So, they had their right leg out.

So, we could talk about it and say, "Okay, what about when you're sitting without your leg extended? Your right leg extended. You're sitting on cruise control, you've got your leg back a bit, how is it then?" "I can sit for longer." So, we're starting to get ideas that potentially sometimes it can be the sitting position. And in this case, when they've got that right leg extended. So, then I'm starting to think maybe they've got some sort of neural sensitivity, potentially some sort of ... They didn't have any radiculopathy, so no pins and needles. But clarifying sort of within the information that they gave me that it was sitting, we could start to drill down into positions and lengths of time and say, "How long does it take?" Well, it takes 10 minutes if I sit. That's when it comes on." So, we're starting to get objective measures that we know if they come back and they've got 20 minutes, we've got an improvement.

David Pope: So, that's a recent patient example from myself. Have you got any specific ones that the information they've given you has helped then to drill down into what ... or give you follow up questions?

Simon Olivotto: Yeah, things like aggs and eases, I guess, really trying to drill down and figure out what they can't do. And then, trying to drill in a little bit deeper in not just finding out the things that are problems for them, but maybe why they can't do it. Ask them, have they tried to do that? Are they just avoiding that movement because they're scared? Like the fellow I had this morning, he doesn't bend, he didn't bend. He doesn't try lifting because he believes that it's bad for him. Whereas, other people may have tried bending and it hurts, so it makes sense not to do that. Perhaps you're thinking a bit more of a nociceptive type driver or an impairment that might be stopping them. So, you're starting to form a bit of an idea why that might be. Or perhaps someone says that they can bend for a while, but after they bend and lift repeatedly that they have trouble. So, then you might be thinking more deconditioning as a potential factor in it.

And there's so much more information even just from aggs you can get, like how much their pain is stirred up after they've done a functional movement. You can get a bit of an idea of what their pain profile might be. They may have features of temporal summation and windup and irritability, which might then steer you into less clinical examination. So, getting the aggs is really important because it helps, as Jordy mentioned, tie into what their functional problem is.

But you can also get a lot of specific information and start to formulate some ideas about what might be causing that, so that when you go and test it a little bit later, you can consider all of those possibilities and test one by one, does the person have the range of movement to be able to flex? Is it only a problem when they flex actively? Is it a problem when they flex passively?

When they posteriorly tilt, can they flex? Or is it a problem in the way that they move and their motor control? Are they initiating at their hips or are they initiating at their back? So, getting some clues from the subjective history can start steering where you might start with your objective assessment. And equally, you can rule things out and not test everything by getting some of those questions.

David Pope: Definitely. Yeah, so you might have, for instance, excluded the guy's hip pain as a source of his nociception with some of your questions about whether he had hip or groin pain or something like that.

Simon Olivotto: Yeah, you can ask questions like, are they limping? Do they have groin pain? And some of those questions are going to be a little bit more sensitive for hip joint pain, which might weigh that up a little bit more of a higher priority for you to assess. But you know, it doesn't take long to do a quick screen of your hip, really quick ways you could differentiate the hip and lumbar spine in just looking at how someone moves as well by putting their hip in a different position. So, developing these hypotheses, but also having some quick ways to test and rule it out throughout the assessment. I mentioned the hip for one, but you can equally quickly test someone's neuromechanosensitivity by getting them to flex with their chin to their chest and their foot up into dorsiflexion. And that's almost like putting them into a slump position. So, you can start to put less weight on something like that if that's not a problem for them. So, there's lots of little things that you can do to differentiate and help strengthen your thinking one way or the other.

David Pope: You're identifying those, coming up with hypothesis then as you're working through that history. You've identified there that you suspect the hip's not involved from the questions you've asked. But then if you want to just do a quick screening, you know? Well, you might use a sensitive test. So you might use your FADIR test as your sensitive test to exclude your hip joint as the source of pain, so you can quickly just rule it out. You've thought the hip joint was not involved from your subjective, that's your hypothesis. You've then tested that hypothesis with a sensitive test, which helped to rule that out. And then you've gone, "Righto, I'm happy to consider that hip joint's not involved. Let's have a look at the other things."

Simon Olivotto: Definitely. And we also remember though, it's a sensitive test. But it can be very provocative as well, and it can be positive and not be hip pain. So, you have to put that into the context of the person's clinical picture. And you can also then look at maybe say their functional aggravating activity, which is flexion and maybe put their foot up on a stool and get them to flex again. And if they're a little bit worse, you might think that their hip is a bit more implicated and it might steer you more towards that way versus if there's no difference. Then you might be thinking more lumbar spine. So, very important, as you said, to think about the sensitivity and specificity of tests. But it just highlights that if we do every single test, there'll be stuff that's positive and it can steer us down the garden path as well.

David Pope: Definitely. Really nice little tips in there for people, even if you're going through your next lumbar spine or low back pain patient, tying in some of those questions that Simon's just shared there, and also using some of those tests as well to rule in or rule out some of those things.

And we're going to give people more information about how they can use those tests with their clinical reasoning and as they develop their clinical reasoning. But they're some things you can start to practice with your low back pain patients to try and rule things in our out and coming up with hypothesis as you're working through. And then using that to guide your questions and your assessment tests. So, good thought.

David Pope: And definitely, you are going to come up with positives and negatives. And we want to help people to know how to understand that. So, more than what we can cover in the podcast today. But loads of info in that there, Simon. Thanks.

So, Dave, tell us a bit about you, mate. What tips have you got for people that are listening that they can use to help to improve their assessment treatment with clinical reasoning?

David Toomey: Yeah, look, I think we've covered heaps of really, really good points with regard to clinical reasoning as part of this podcast. But you know, a lot of us are busy treating a lot of patients back to back. The hours kind of slip away. Our list of to-dos is piling by the millisecond. So, I think a really important exercise is to actually factor in and organise little reflective exercises, you know? There's a plethora of different exercises that you can use. And sometimes it's good to go through a big haul, so something like the MCTF is a really good comprehensive model. The Uni of South Australia has another good one whereby it's going through lots of questions, asking those Why Questions that Jordy has alluded to with respect to your objective, with your subjective initially, rather. And then going in with how it's going to guide your objective. But I think that having a variety of different strategies in order to engage in those reflective exercises is the key.

So, that kind of metacognition of thinking about your thinking and potentially whether it be once a week dedicating 45 minutes to an hour those bigger type exercises, but then also having a couple of little hacks or a little couple of bite-sized strategies to be able to I guess keep clinical reasoning and critical thinking to the forefront of your mind. So, it might be something like ensuring that you apply the Peter O'Sullivan test of getting the patients to summarise the salient points of your treatment session. So, that's a mini way of potentially getting the patient or the clients to almost appraise you in terms of what has come across in your treatment session.

Another example of that might be you are giving yourself an action point of, I'm going to purposely not interrupt the patients during the first couple of minutes of my subjective exam. That's a mini little bite-sized tip that you can implement. Potentially being a little bit more concise during your explanation of maybe your diagnosis or a prognosis of, rather than rambling. As physios, we've often got the stage, so it's very tempting for us to maybe talk a little bit too long.

David Pope: You've talked about some reflection. And I want to come back to that reflection because I think that's a really good point. And then you talked about having those action points, so summarise, getting the patient to summarise the points from the treatment. And I think that works so well, getting people to tell you what you told them, you know what I mean? So you make sure they go home with those important key messages.

You had the action steps for the week, not interrupting them for the first two minutes. And that's a really important one for people listening to try that one. And two minutes seems like it goes on for ages and you think, "This person's never going to wrap it up." But the good thing is, you do get tons of good information in that first couple of minutes. And if you interrupt, there's a good chance you're never going to get that information again. And I think that was a great tip.

David Pope: Being concise with your explanations, that's a perfect one. And having goals for the day. So, you've tied in five good tips. And I want to come back to your reflection. So, you mentioned there being reflective with your practice and spending that time, 45-60 minutes a week. Tell us about how you might do it? I want an example from say the last couple of weeks of what you might have reflected on and what you've done with that reflection?

David Toomey: Yeah, look, just to very briefly go back to two of the points, I guess, or one resounding point that yourself and Simon made of the pros of going back to do your postgrad or your masters whereby you get grilled, you know? You get exposed and that can be very confronting, okay? But there's no ... Maybe this is a little bit of my imagination running wild on me, but there is nothing stopping you doing that to yourself, you know? And you can create your own Simon Cowell and your Louis Walsh and whoever else in terms of you can have your good cop and your bad cop there of drilling those questions that Jordy asked of that why, that why, that why, because a lot of us are ... If you're fortunate enough to be in a clinic whereby you've got a good team around you and you can engage in those clinical conversations and have your physio geek outs, that's awesome.

But sometimes we're super busy. Sometimes other clinicians mightn't have the same level of passion or drive as you do. But I think that the listeners of this podcast and the people who are interested enough to be here and listening and engaging with us, I think they're of the kind of caliber and quality that this is something that is important to them. So, a small little snippet that you could do and that I often do is, after I see a patient, and if I've got five minutes in between, I'll do a little clinical reasoning sandwich. So, to protect my ego, I've got maybe two positives, a positive at the start and a positive at the end, but then one work on in the middle.

So, it might be, what was something of my subjective exam that went really well? What was something of my objective exam that went really well? And in the middle of it, it might be, what was something of your objective exam that was a little bit superfluous or it wasn't relevant?

Something that is maybe an autopilot tendency that I have whereby for the last nine lower back pain patients that I've had have had some sort of, let's say, neurological component, I'm just using that as an example. It's probably not likely based on prevalence.

But you know? But maybe on the 10th, I have done some sort of neurological exam, even though nothing in the subjective has indicated that I need to engage in that.

So, it's just maybe trimming the fat on that. So, I've got my positive at the start, my positive at the end. But then a nice work on in between.

David Pope: So, you're analysing yourself or somebody else. And maybe picking out one of your patients that you've seen and then working through what you've done there and trying to identify something you've done well and then something you could improve on.

David Toomey: Yeah, and I think it's a non-confrontational way of potentially introducing it to your colleagues and your peers as well, you know? And then from that you can maybe develop a little bit more depth and start to go through maybe some more specific questions and start to almost start small and branch out in that little bit more substance.

David Pope: Yeah, talking to each of you and reflecting on my formal post grad education, one of the things that was pretty daunting for me, and it follows on from what you were discussing there, Dave, but also each of you guys have all gone through this as well. When I started off my post grad MSc and sports, and I remember the first clinical that I had, I had my patient in there. It was like the first or second day or something like that. The patient's walked in. It was a lower back pain patient. And anyway, so I said, "Yeah, good day," to the patient. And asked them ... Started to ask them about their ... I said, "What are you in here for? How can I help you?" And they started to tell me.

So, I gave them a couple of minutes. And said, "All right, great." The supervisor ducked his head inside the curtain. He was standing outside. And he says, "What do you think is going on?" I'm like, "Whoa, whoa, whoa. I just started. I don't know." And he goes, "All right then." And I'm like, "I let that one down. Geez." I'm like ... But you know, I quickly had to start developing hypotheses. And then he kept poking his head back in the curtain. He'd say, "Why did you ask that question?" Okay. He poked his head back in after I'd asked the body chart, "Okay, what's going on?" And then, "All right, what are those aggs telling you about what's going on?" And I'm like, "All right." So, he was really standing outside the curtain and really drilling me.

And I'm sure the patient knew that this was part of the whole process and they were there with us while we were going through our MSc training. So, they were cool with it.

David Pope: But it really being drilled as you're going through the patient, "Why are you asking that question? What are you getting out of that information?" Is really valuable to go, instead of just asking all these questions, I've now got to justify every question that I ask and I've got to have a reason. If I don't have a reason, he's going to drill me and say, "Well, what did you ask it for then?" Well, I'm going to look like an idiot, aren't I? So, I had to quickly come up with, "All right, I better narrow this down and start getting valuable information." And that sort of thing. So, I think that's probably something we've all been through, having someone there watching us as we're going through our assessment and treatment.

And it really does help to sharpen you, as Simon mentioned before, sharpening your clinical reasoning. It really helps you to narrow in on what's going on. And although it's really tough to have someone watching you and to be under the pump or under someone's eye, that is pretty nerve wracking at first.

But then you get used to it because it's happening every second treatment session, so you've got to get used to it. And I'm sure all the guys would agree that having someone watching you, you watching other clinicians, as you've mentioned there, Dave, is a really great way to help develop your clinical reasoning and to identify what's going on. But you also get input from other people, you get to run things past them. They're aware of what's going on. And you get to discuss it, almost like a case study and analyse what you've done well and what you haven't.

So, that's a really great way, but for people ... And this is going to be my clinical tip, and it sort of follows on from what you were saying, Dave, pretty much. But one way that can be an intro into that is by videotaping yourself with a patient, setting up an iPhone in the corner. You've got to run it past your patient. Obviously, you can't just go filming patients without them knowing what's going on. But you say to them, "Look, if you're not happy with it, that's cool. But I'd really like to film this for my own personal reflection so that I can look at what I'm doing and how I go through this. And it's for my own personal development." Patients respect that, that you're looking to improve your skills and that sort of thing.

So, that's a fairly easy way. And then you can look at that video. And I actually really hate watching videos of myself. We had to do this in our MSc, we had to watch videos of ourselves with patients. I had to record one in my clinic here, or a few of them, watch them and analyse what I'd done and write down what I did well, what I didn't, why I asked different questions.

But you know what? I picked up so many things about myself as I was doing it. I was like ... I really should have ... You know, there was a whole bunch of bad things that I picked up. Like, why am I sitting like that? Why am I asking that question? I kept saying the same thing over and over. I kept saying, "Yeah, great." Or whatever it might be. You have these little habits that you're like, you don't even realise until you watch yourself, "Why am I saying that?"

So, my clinical tip is video if you can. Watch other therapists in your clinic, get them to watch you and share tips. And question each other about it in a ... It's not an attacking kind of way, it's a really friendly working with your team mates to help to improve each other. And if you can't do that or you want an easy way in, video yourself once you've got the patient's permission and analyse it, as uncomfortable as it is to watch yourself.

Jordan Craig: Because it's hard to know, isn't it? It's hard, like yourself, if someone says, "Why do you do that?" You've probably got ... Like, I'm sure you too, Dave, and my experience in that course was, I knew why. I could answer why. But then when it sort of goes down to the deep of it, I had no idea why. I was just some sort of quick run off that, of course this is why I do it because I always do it. That was sort of what you end up getting caught into, right? But I still remember him asking me sort of why I was doing a mobilisation. I said, "Well, you can see. I'm doing a quarter mobilisation of the ankle. Like, this is pretty standard, stock standard manual therapy."

And I couldn't understand why he said why, but when I was doing it, was I maniping C1 at the same time because I was pulling so hard?

So, it then makes you think a bit about what you're doing that, what am I trying to achieve here, rather than just pulling away at this ankle thinking I was being Mr. Musculoskeletal man and probably dissociating his hip joint. And he's probably in for a TKR at the moment. But at that stage, I thought I had the answer to why no problems. So, I was just ... I think, summing us is just, it's really hard. It's a train wreck watching yourself. I used to fall into an abyss thinking, "What am I doing?" But it gives you a really nice ... As a feedback to sort of go, "Why did I do that? And did that question or did that assessment ... Was it really ... Did that give me everything that I needed?" And those questions that other people can ask you do the same thing.

David Pope: Yeah, I think that's great. I think it is, it's definitely uncomfortable.

David Toomey: Yeah, definitely it's like that ... What do they call it? The Hawthorn effect…we behave different when we know we're being observed. And that's definitely the case of the first couple of peer reviews that I would have done on my colleagues and that they would have done on me. But I think that once you get over that initial awkwardness, the pros are just so exponentially more fruitful than the cons. So, just kind of push through that little bit of awkwardness. And more often than not, as fumbly as you feel that you're going, the person who's observing you, even if that is your iPhone or your Android, they're going to be picking up lots of clinical pearls in terms of the things that you're doing really well. And often if you do share that with somebody, you think that they're only going to be picking up on the things that you missed. But they're going to be learning so much on the things that you do really well as well. So, I think being a bit compassionate and a bit of self-love with the old clinical reasoning is really important too.

Jordan Craig: And do those videos increase or decrease the popcorn consumption, Dave?

David Toomey: Well, they make me sick to my stomach watching them. So, it decreases temporarily. But it levels out after, don't you worry.

David Pope: You need some salt on the popcorn to help to mitigate the nausea.

David Toomey: Exactly. I'm not a sweet popcorn guy. Always salty.

David Pope: Good. Excellent. And I think this is a fantastic place to wrap up the podcast. But you know, there's obviously a lot that's involved in clinical reasoning. And we have ... The great thing is, within the team here, within the four of us, we've got lots of great experience around clinical reasoning, exposed to different models and different ways of learning. And that's really what we're going to help people to understand, how they can apply the different models, and how they can improve their clinical reasoning and those benefits.

So, that's kind of what we've got coming up for people as well. We're releasing a whole module on clinical reasoning on how people can improve their clinical reasoning and use that to improve their treatment, assessment, treatment, make themselves more efficient and really have great clinical reasoning and good assessment and treatment outcomes.

So, tell us a little bit about some of the presentations that you guys are ... because we're going to have ... At the moment, we've got nine or 10 presentations within that clinical reasoning module and we've got other ideas as well to include and we've got lots of great content. So, tell us a little bit about what you've got planned. And I know, Simon, you're kicking off the module, so why don't you tell us about what you've got in mind for some of your presentations?

Simon Olivotto: Yeah, I'm going to talk a little bit about, much like Jordy was talking about is centering yourself with the person's goals and the reason why they're here for your appointment. And then drilling down a little bit further and looking into some of the frameworks and all the different pieces of the frameworks and how to put that together. And I guess the theme of the opening presentation will be just how we can start broad with a clinical question or a clinical problem as someone presents, and then narrow it down. And just using specific questions and specific tests and having a structured process to come to a defined point. So, starting broad and narrowing down. And I guess, to sum it up, making the complex simple.

David Pope: And you're going to be talking about ... As well as all that, you're going to be talking about some of those outcome measures that people can use to help with their interventions and their planning of their treatments as well.

Simon Olivotto: Yeah, one of the later presentations I'm starting to develop as well is just collating all the different outcome measures that we may use and discussing how to apply them and minimally clinically relevant changes that we should be looking for and some of the other outcome measures that we're going to be looking for that helps us gain information for our treatment and assessment.

And also, putting that into a presentation about prognosis, which will be really interesting as well, what things we can look out for and what information we can get, how to give someone an information and an idea of how long we think this condition is going to take to get better, or how long it's going to take for them to solve the problem that they've come to us for.

David Pope: Yeah, and that's the question every patient wants to know, how long is it going to take to get better? And that's really what you're going to be helping within that presentation, how are you going to know how long it is until the patient can return to activities? And that critical thinking. So, really looking forward to that one as well. So, that's fantastic. So yeah, looking forward to those, Simon.

Simon Olivotto: Yeah, they're going to be good hopefully. Looking forward to developing them.

David Pope: Yeah, yeah. So, tell us now, Jordan, what have you got coming up within the clinical reasoning module?

Jordan Craig: Well, I realised my first one's just talking about myself, which is not that academic. But the reason I've done that was to ... I've just put myself under the microscope, under the clinical reasoning microscope to just give an example of, I think, hopefully just some other punters around are going through their post university graduation to then in the big wide field of physiotherapy and finding your feet to then going through a natural process of learning and rollercoaster.

So, there will be some applying some academic frameworks to that, so that I can get away with it being an academic presentation. But it will have all bits and pieces around my journey that I've put definitely under the microscope and pulled to pieces, as my early stage presentation.

David Pope: That's really good because really, we all have a clinical journey. Our clinical reasoning develops different ways. And so, what we're really trying to give people is an example of how your clinical reasoning develops and different stages that your clinical reasoning will go through and how that applies to you, to people watching it. How will their clinical reasoning develop? And how can they use it as their career progresses and their skills progress? What can they look forward to?

Jordan Craig: Yeah, definitely. And I think just too, people are going to be so different around the physiotherapy continuum, right? So, it could be anywhere through the continuum that people are in their careers. But just having a quick snapshot of, okay, well if you were to do that and you put yourself through the journey, where do you think you are? And have a look back and you're quite early in that journey, so therefore you take some tips on, all right, what things did I pick up that I'm maybe doing or that I could be critical of? Or potentially if you're at the end of career, how have you looked back on that? And what things can you learn from looking back at those? Is definitely the scope that we looked at in giving a bit of a clinical context and just a real life example of what we mean by clinical reasoning, instead of us falling asleep to some long-winded clinical reasoning lectures. It was, let's think about it as a real practical part to take to your clinic on Monday.

David Pope: And then, tell us about your follow-up presentation after that?

Jordan Craig: Yeah, so then after that, it was just around ... And I allude to in my presentation a bit about how to avoid recipes. So, using objective assessments, how are you using those? You know, we've all learnt them at various different institutions. But what information are you getting from those? How are you unraveling those? Hopefully not just printing it in the next Women's Weekly recipe for May.

So, trying to put it into an actual little package to give your patient an answer that you have a plan, more importantly of what you're going to do with the patient than, like you explained earlier in the podcast, Dave, around doing 1,000 different objective tests and having absolutely no idea what to do with all that information.

David Pope: Yeah, give people clarity on how they can use their objective measures or objective assessment to guide their treatment.

Jordan Craig: Yeah, definitely. Just, it's hopefully a quick sort of practical, as best you can over the interwebs, but a practical approach to how you summarise all that stuff and use that information, not just a ... It's not going to be an hour lecture on all the special tests that we know.

David Pope: And then, your other presentation you're looking at?

Jordan Craig: Yeah, the last one will then just be then the clinical patterns. So, how do we pick up in both subjective, objective history some of the patterns that we'll see and align those to the different models or different biopsychosocial versus pathoanatomical versus your impairment base, and things like that just helping with the reasoning perspective, what we can draw out of those things in a patient presentation to help us get there without ... not taking shortcuts, but using those ... What are we looking for in each of those items that may lead us to put it in our funnel or our sieve to come out with something to present at the end.

David Pope: Yeah. And Simon mentioned that earlier on about having patterns that you're recognising as well. And that's part of that heuristic learning of identifying different patterns. And you're going to sort of look at those patterns, whatever that might be, whether identifying tendinopathy, your bone stress, different ... Your psychosocial factors or any of those sort of patterns that you're likely to pick up within the clinical picture and clues that'll help as you're going through your subjective and your objective that help you identify those patterns and understand what's going on, so you're really clear about that as you are going through that. So, I'm really looking forward to that, it's going to be awesome.

Jordan Craig: Cool, yeah. I'm really looking forward to it. It's been fun to produce, so hopefully we get going and everyone enjoys it because from a physio perspective, I can't wait to get involved and listen to it all because I wish this was around when I was going through, it's something that is not talked about a lot in the education space. And I think it'd be great.

David Pope: Yeah, definitely. And I think that's one of the things if we all sort of sat down and thought about, what is it that we wished we had as we were going through our education or as we were going through our clinical career that really would have helped us? And this is the sort of stuff that we want to share with people, the stuff that we wish we had have had. I wish I had have known about clinical reasoning when I started my masters or much earlier, and had this sort of information so that I knew which tests and which ... About patterns and about how to identify the psychosocial factors and the prognosis and all those sort of factors as well, sort of going through to really help to accelerate that whole learning process and get those results that you want quicker.

Jordan Craig: Yeah, spot on.

David Pope: Yeah. So all right, and Dave, you've got some presentations too, so tell us a little bit about your presos in the clinical reasoning module that we're going to be releasing for Clinical Edge members.

David Toomey: Yeah, so I'm going to be doing a presentation on clinical reasoning errors that you may be making without even knowing it, and how to avoid those errors. So, as part of that, I'm going to be taking everyone through why potentially clinical reasoning can break down or some of the mistakes or shortcomings that occur with respect to clinical reasoning. And also, how to spark these in yourself and colleagues. I think that the term biases is kind of thrown around a lot. But some of the experts out there have started to refer to it more as a cognitive disposition to respond. So, these biases that we talk about, they're not always a negative thing.

Sometimes they're what provide us with really sharp tools that can kind of trim the fat and be shortcuts to success. But sometimes when we're thinking on our feet and we're thinking potentially at a subconscious level, we do cut corners and we can have some errors there, whether it be not leading you to ask the right questions or potentially it might affect your diagnosis or your management.

So, I think being aware of these for conciseness, we'll call them biases. But for that conciseness, I think that being aware of these shortcomings is really important. And I think what that will do is it'll help us to gain a deeper understanding of why these things occur because we're all prone to them, there's nobody that is exempt from bias, so it's about kind of owning it and then potentially giving the listeners and members a toolbox to be able to strategise to prevent them occurring mainly in the future. So, really exciting kind of bringing the subconscious to the conscious. So, it's a very, very exciting presentation.

Then also, as I kind of touched on there with you guys, I'll be looking to give you some tools, some of the bigger and smaller tools to engage in those exercises in clinical reasoning. So, bridging the gap between the theoretical and the practical, which is really appealing and excites me as a clinician to be able to have some tactile and tangible tools that you can implement with your patients and clients on a daily basis. And then, later on, looking at doing a presentation on the role of evidence informed practice and where that filters in to the clinical reasoning process. So, it is obviously a big component of it. In that presentation we'll be delving into that and taking a deep dive into where it fits in with your reasoning and the pros and cons of that.

David Pope: Sounds fantastic. So, you've got a ton of great stuff there that's going to help people to identify their biases. We've all got them, so how they're going to pick up theirs and how it's actually affecting their treatment and their assessment and their clinical reasoning. It's going to be good to identify those and give them those tools. And then how to work through their tricky patients. And then that evidence informed practice. That's the one that everyone wants as well, wants to know about. How do I tie in the evidence into what I'm doing with my clinic with my patients? So yeah, we've got an awesome module. And that's all going to be out for members.

And really, our goal is to help you develop your clinical reasoning. So, that's our goal, and we've put these presentations all together into a structure to really, as part of our approach that we're going to take to giving you great resources and train you through different aspects here. And clinical reasoning is a great way to kick it off.

We've got tons more coming up after that. We're going to be looking at communication, red flags, and lots of great stuff. And diving into specific areas as well, each of the regional areas and really taking you through comprehensively how to assess and treat all those. So, that's all basically going to be available for Clinical Edge members to really develop their skills comprehensively. That's our goal.

So, I'm really looking forward to working with you guys. I'm really excited about the stuff that we've got coming up. And you know, being able to share your knowledge and experience with everyone and on the podcast, for Clinical Edge members as well.

So, we've got lots of great stuff. And I'm hoping to get you guys on every month and have a chat about all the different aspects as we're going through it and share more tips and ways to help people improve their assessment and treatment and results.

So, thanks everybody for coming on the podcast. It's really been great to have you on and share those tips with all the listeners.

Simon Olivotto: Thanks, Dave.

David Toomey: It's been awesome. Thanks so much for having us on.

Jordan Craig: Yeah, thanks for your time. And look forward to the next chapter.

David Pope: Yeah. Awesome. Now, tell everybody where can people find out more about you on social media? Are you on Twitter or anywhere like that?

Jordan Craig: Impending the Twittersphere, mate. So, follow. I'll get onto people soon. But Instagram, just @jordycraigphysio).

David Pope: Beautiful. Simon?

Simon Olivotto: Yeah, I'm on Twitter as well, Simon Olivotto (@SimonOlivotto).

David Pope: Perfect, O-L-I-V-O-T-T-O.

Simon Olivotto: Yes.

David Pope: Yeah, and Simon's the regular Simon way. Yep. Cool, excellent, yeah. Get on Twitter, follow Simon. And what about you, Dave?

David Toomey: Yeah, I'm on Twitter, new to the Twitter verse or Twitter sphere, whatever way you want to put it. I'm @physio2me. So, play on words, thought it was cool at the time. But is a bit of a nightmare when you're telling people on podcasts.

David Pope: Is that the number two, is it to? Two?

David Toomey: Yeah.

David Pope: Yeah, yeah.

David Toomey: Number two. Yeah.

David Pope: Yeah, perfect. Excellent. All right, well thanks everybody and we'll look forward to having you on another podcast. And thanks for sharing all those clinical tips with people about how to improve their assessment, treatment, and clinical reasoning. So, you guys have a great evening.

David Toomey: Cheers, Dave.

Jordan Craig: Cheers, Dave. Thank you.

Simon Olivotto: Yeah, thanks Dave, you too.

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