Red Flags II A guide to solving serious pathology of the

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 Acknowledgements

We would like to thank all of the staff from the

musculoskeletal service in Bolton Primary Care Trust
who contributed to these case studies along with Celia
Gardner for the inspiration which has led to this book.

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 Chapter 1

Clinical Reasoning

According to Waddell (2004) up to 40% of back pain

patients fear they have some serious disease. This
creates an environment in which it could be very easy
to be misled. Although this is an important issue,
the clinical findings and the clinical reasoning of the
clinician must influence the direction of travel. The
following extract from a patient’s story published in
the BMJ (Greenway 1994) illustrates this concern over
serious pathology very well, especially considering that
the patient in question was himself a general practitioner
(GP). The patient presented with low back and leg pain.
Following a number of consultations with a variety of
professionals including a physiotherapist, he sought the
help of a neurosurgeon. The surgeon indicated that the
signs were not clear-cut, and this caused the patient
some alarm!
‘What did he think it was? Probably a disc but we need
to think about ankylosing spondylitis, he said. Unsaid,
he must have been thinking of spinal tumours, lym-
phoma, tuberculosis because I certainly was. For the

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 Clinical Reasoning

next week I woke in the early hours thinking I would be

brave and dignified as I approached death. I feared the
ankylosing spondylitis most. I began to grieve the loss
of my love of mountain walking and dinghy sailing. I
tried unsuccessfully to keep my worries from my
partner. She was supportive. We planned for a life of
disability.’
Clearly this patient’s medical background served to
considerably heighten anxiety levels in the face of
clinical uncertainty. As stated in the introduction, as
practitioners we are obliged to accept some degree of
uncertainty during the clinical reasoning process, but
we should remember that this uncertainty could have a
profound effect on the patient if it is visible to them.
Figure 1.1 illustrates varying degrees of certainty
with respect to the theft of a handbag. The index of sus-
picion is different in response to the different presenta-
tions of the scene of the crime. This logical reasoning
process is synonymous with the clinical reasoning that
takes place in practice.

HISTORICAL PERSPECTIVE
The Hippocratic Oath was written in about 400bc.
Hippocrates was the most prominent physician of
antiquity, and Hippocratic medicine represents the most
significant historical landmark for the evolution of
Western medicine. Before Hippocrates, medicine was
practised as an empirical art that was overtly religious
and superstitious in nature. A modern version of the

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 Clinical Reasoning

1. 2.

3. 4.

Fig. 1.1 1. Room with handbag, door closed. 2. Room with no

handbag, door closed. 3. Room with no handbag, door open.
4. Room with no handbag, door open and room dishevelled.
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 Clinical Reasoning

Hippocratic Oath (Box 1.1, italics added for emphasis)

was written in 1964 by Louis Lasagna, Academic Dean
of the School of Medicine at Tufts University, USA. This
modern version is used in many medical schools
around the world today. We have emphasized (text in
italics) two of the sections that are particularly relevant
to the holistic nature of clinical practice associated with
serious spinal pathology.
The Hippocratic approach to medicine assimilated
the accumulated knowledge of the past and formed a
logical and rational diagnostic system. This was based
on a careful, systematic and holistic clinical observation
of the individual patient; quintessentially that is exactly
what clinicians today should be doing. Hippocrates
believed in the healing power of nature and diseases
were attributed to natural rather than supernatural
causes. It is also interesting to note that Hippocrates
treated patients holistically as ‘psychosomatic entities’
in relation to their natural environment (Marketos &
Skiadas 1999) and that he began to document a patient’s
pallor, pulse, excretion, etc., which are the seeds of a
medical subjective history that we would gather in
clinical practice today.
Aristotle in the third century bc also made major
contributions to medicine, but it is his contribution to
clinical reasoning that we wish to focus on here.
Aristotlean philosophy used a system of ‘practical rea-
soning’ which is still relevant today when considering
the possible tension that exists between individual,
holistic patient-centred care and the application of
evidence-based practice (Gillies & Sheehan 2002). The

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 Clinical Reasoning

Box 1.1 Hippocratic Oath – the modern version

(Lasagna 1964)
‘I swear to fulfill, to the best of my ability and judgment, this
covenant. I will respect the hard-won scientific gains of
those physicians in whose steps I walk, and gladly share such
knowledge as is mine with those who are to follow. I will
apply, for the benefit of the sick, all measures [that] are
required, avoiding those twin traps of overtreatment and
therapeutic nihilism. I will remember that there is art to
medicine as well as science, and that warmth, sympathy, and
understanding may outweigh the surgeon's knife or the
chemist's drug. I will not be ashamed to say “I know not,” nor
will I fail to call in my colleagues when the skills of another
are needed for a patient's recovery. I will respect the privacy
of my patients, for their problems are not disclosed to me
that the world may know. Most especially must I tread with
care in matters of life and death. If it is given me to save a
life, all thanks. But it may also be within my power to take a
life; this awesome responsibility must be faced with great
humbleness and awareness of my own frailty. Above all, I
must not play at God. I will remember that I do not treat a
fever chart, a cancerous growth, but a sick human being,
whose illness may affect the person's family and economic
stability. My responsibility includes these related problems,
if I am to care adequately for the sick. I will prevent disease
whenever I can, for prevention is preferable to cure. I will
remember that I remain a member of society, with special
obligations to all my fellow human beings, those sound of
mind and body as well as the infirm. If I do not violate this
oath, may I enjoy life and art, respected while I live and
remembered with affection thereafter. May I always act so
as to preserve the finest traditions of my calling and may I
long experience the joy of healing those who seek my help.’

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 Clinical Reasoning

potential problem is that evidence-based practice is

developed from populations rather than from individ-
ual patients. Clinicians, however, usually see only
individual patients at any one time; this leads to the
problem that is posed by the question ‘What should we
do when the individual patient varies from the descrip-
tion of the population on which the best evidence is
based?’ In addition, the problem of applying robust
clinical reasoning in this field of practice is further com-
pounded by the fact that much of the evidence within
the Red Flag literature is of a low level.
Gillies & Sheehan’s 2002 paper offers a comprehen-
sive and very useful insight into applying Aristotlean
philosophy to patient care in the twenty-first century.
They focus on Aristotle’s ‘practical reasoning’ approach
which is a form of clinical decision making that allows
for flexibility depending on ‘what suits the occasion’.
However, they stress that this is not an excuse for care-
less or sloppy thinking, rather it is an acknowledgement
that guidelines can only be based on what has occurred
previously. New clinical situations contain many inde-
terminate elements, some of which may be subtle and ill
defined, and unique to that particular situation. Each
patient is different and deserves individual considera-
tion, and not an unthinking, automated and crude
application of evidence-based practice. Making good
clinical decisions is therefore based on making the indi-
viduality of the situation central to the process. It is
important to stress that this does not imply that evi-
dence-based practice and guidelines have no place in

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 Clinical Reasoning

clinical practice; their place is vital to aid accurate

decision making when the patient presents with fea-
tures that suggest their application is appropriate. In
summary, Gillies & Sheehan (2002) argue that clinical
decision making is the result of a perception by the
practitioner of the individual situation that takes into
account all of the particulars and not only those that are
easily measurable.
Dawes et al (2005) argue that knowledge is either
tacit or explicit. Tacit knowledge is non-research knowl-
edge, for example the ability of the healthcare pro­
fessional to recognize when a patient is ill by their
appearance, behaviour and overt symptoms, i.e. ‘the
wisdom of experience’. Explicit knowledge is based on
research evidence. John, who had malignant myeloma,
provides a good illustration of this (Greenhalgh &
Selfe 2003):
‘He moved to a chair in reception and sat down
and soon began to half lie on to the next chair. Within
two minutes he stood up and leaned against a
cupboard.’
The department receptionist was tacitly able to
recognize the very high level of John’s discomfort. Her
description to the clinician was then supplemented by
explicit knowledge based on specific signs identified
during the course of the subjective and objective
examination.
To successfully achieve the effective integration of
tacit and explicit knowledge in a practical reasoning

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 Clinical Reasoning

approach requires well-developed perceptual capacity

for ‘situational appreciation’ and confidence to deal
with indeterminacy; these qualities develop through
training and experience, and require regular, thoughtful
reflection on clinical practice.
It is comforting to remember that as clinicians we do
not necessarily need to understand complex theories of
decision making, however, for those interested in this
subject, the next section of this chapter goes on to
discuss some of these theories. Finally, before leaving
Aristotle it is worth considering his Categories – these
are individual words and include the following (The
Internet Encyclopaedia of Philosophy 2008):
l Quantity
l Quality
l Relation
l Place
l Time
l Situation
l Condition
l Action
Aristotle used these words in this order to ‘gain
knowledge of an object’. It is interesting to note that
if we were asking a patient questions related to the
World Health Organization (WHO 2001) International
Classification of Function (ICF) components of change
in body structures/functions or activities/participation,
we could more or less use the same set of words in the
same order, and that would give us a large quantity of
clinically useful information.

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 Clinical Reasoning

CLINICAL DECISION MAKING

Much of the literature on clinical decision making
explores the differences between experts and novices in
their approach to problems. Novices tend to rely on
abstract principles and piecemeal understanding in
contrast with experts, who rely on past experience and
holistic understanding (Benner et al 1999). Experts
are therefore better able to see the bigger picture
of a patient’s problem and assess the importance of
the combined interaction between many signs and
symptoms rather than focusing too narrowly on specific
individual items. During this chapter we focus on the
idea of the ‘big picture’ and concentrate on a holistic
approach.
A review of the diagnostic accuracy of the subjective
history, the objective examination and the erythrocyte
sedimentation rate (ESR) in low back pain (van den
Hoogen et al 1995) reported that few studies presented
data on the diagnostic accuracy of combined positive
findings. The authors highlighted this as a problem, as
traditionally diagnosis is based on a combination of
findings. We have previously discussed the complexity
of clinical reasoning processes in serious spinal path­
ology (Greenhalgh & Selfe 2006). Broadly speaking,
models of clinical reasoning are split into two groups:

l Analytic/reductionist
l Holistic/constructionist

Analytic models of clinical decision making as listed

by Rashotte & Carnevale (2004) are:

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 Clinical Reasoning

l Bayesian probability (Fischoff & Beyth-Marom

1988)
l Clinical continuum (Hamm 1988)
l Decision analysis (Doubilet & Mcneil 1988)
l Brunswick lens (Wigton et al 1988)
l Information processing (Elstein & Bordage 1988)
l Reflection in action (Schon 1988)

In contrast to these analytic models is a construction-

ist model in which intuition plays a central role.
Intuition has not gained legitimacy as an approach to
clinical practice (Rashotte & Carnevale 2004) and it is
viewed as a basis for irrational acts of guessing (Benner
et al 1999). However, intuition and Aristotlean practical
reasoning are both of importance to physiotherapy
practice and should not be discounted as valid
approaches to practice. There is a sound body of evi-
dence supporting the legitimacy of intuition in clinical
decision making (Benner et al 1999; Schon 1983; Schon
1988).
Physiotherapy as a profession has problems with
both knowledge and evidence. As the physiotherapy
paradigm is still emerging from the medical empiricist
domination of the past century, physiotherapy knowl-
edge tends to be undervalued. In addition, many
routine clinical procedures are not well supported by a
strong evidence base (Straszecka 2006). In this chapter,
it is the constructionist (holistic) model of clinical rea-
soning that incorporates intuition and practical reason-
ing on which we will focus with respect to serious
spinal pathology.

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 Clinical Reasoning

Rashotte & Carnevale (2004) identify the following

elements of a successful constructionist approach:
l Recognition that each case is unique
l Identification of elements that are familiar and
unfamiliar
l Conduct ‘on-the-spot’ experimentation for competing
hypotheses
l Maintain openness to revising opinions
In our previous model of three-dimensional (3D)
thinking, we proposed that during patient consulta-
tions, a physiotherapist draws on their previous
experience and knowledge, and that, simultaneously,
each patient consultation adds to the physiotherapist's
knowledge and experience. Developing this model
further (Fig. 1.2), it is important to note that during
a patient consultation each new piece of information
gained by the therapist is assessed for diagnostic
alternatives – each of which is simultaneously assigned
with levels of certainty and plausibility by the
therapist.
Plausibility will be derived mainly from the thera-
pist’s previous experience; certainty will be derived
mainly from the therapist’s existing knowledge base.
On completion of the initial assessment, a hierarchy of
diagnostic hypotheses is compiled by the therapist and
a diagnostic conclusion reached, which is referred to as
‘the conclusion of the greatest belief’ (Straszecka 2006)
(Fig. 1.3). The conclusion of the greatest belief then
informs the decision making of the therapist in terms of
informing the next stage of the patient’s journey. For

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 Clinical Reasoning

Emotions

Experience Knowledge
Plausibility Certainty

Input Clinical Output

reasoning
Unique patient Unique therapist
scenario response

Verbal and Verbal and

non-verbal non-verbal
communication communication

Fig. 1.2 Adapted model of 3D thinking.

example, in some complex situations it may be extremely

difficult to interpret non-classic signs and symptoms,
therefore the clinician’s conclusion of greatest belief will
suggest that further diagnostic testing or onward refer-
ral to a specialist is indicated. Using this kind of termi-
nology is very useful as it helps to remind us that we

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 Clinical Reasoning

Question 1 Plausibility
Is the patient’s 95% (high)
current problem
simple mechanical
low back pain?
Certainty
(low)
Single body The
of conclusion
evidence of the
(indeter- greatest
Question 2 minacy) belief
Plausibility
Is the patient’s (low)
attribution of their
low back pain to
‘moving that
bloody wardrobe’ Certainty
six months ago (high)
appropriate?

Fig. 1.3 Flow chart illustrating how to arrive at the conclusion

of the greatest belief.

work with uncertainty and imprecision in our clinical

decision making on a day-to-day basis, and that what
we are actually doing is generating hypotheses.
One of the reasons for uncertainty in any clinical
encounter is that the cause and subsequent course of
any specific disease or condition is idiosyncratic, i.e.
heterogeneous disease presentation. Put more simply,
the same disease or condition will manifest itself differ-
ently in different people at different times. This is a key
challenge for therapists and one which we attempt to

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