Mid-way through the main development phase we arranged a feedback evening with a sample of the target group, represented by 6 final year students from the European School of Physiotherapy who had a varied level of clinical reasoning skills. The students worked their way around the first draft of getPTsmart.com and did one of the case studies (and ate a good pile of our home-made pizza – you got to be well-fed to work well).

Here is a summary of the main feedback themes we identified from the student feedback. The feedback we received from our teachers mainly covered the same topics and was very similar. In the last half of the production phase we went through the cycle of discussing, redefining and specifying our ideas for possible solutions with our professors over and over and over again. The process was invaluable.

Main feedback themes

I’m used to a certain electronic patient documentation system (e.g. Abakus) – why should I bother with a new system and HOAC II?

Our response & actions:

• We clarified the purpose of getPTsmart.com on the homepage. For this we developed a catchy slogan for the homepage that immediately emphasises that getPTsmart.com is for learning to structure your mind for clinical reasoning.
• We developed the six points under ‘Why getPTsmart.com?’ in which we give short and precise foundations for our choice of tools and content.

I feel lost going through the case steps. If I don’t figure out a website after 15 min, I’m gone for good.

Our response & actions:

• We moved the actions to take to the top of each clinical reasoning section to emphasize purposeful, hypotheses-driven clinical reasoning. We changed the display of the actions to take in a way that clearly distinguishes each step and emphasises working through the sections in a step-by-step manner. This was the very first idea anyway!
• We removed the actions to take from the Toolbox as the students spent too much time trying to learn each step before actually starting to work with the case study. Initially we had placed the actions to take in the Toolbox for the user to get an overview.
• We refined and refined the text in the actions to take. We met with HOAC II specialists whose input led us to especially clarify the first section of the actions to take and to emphasise the inclusion of anticipated problems in the first two sections. We also further defined and specified the terminology and dictionary items.

Attractive e-learning environment

Background

Clinical teaching in clinical setting is at the centre of medical education. However, as the clinic is the site of practice as well as of learning, conflicts of interest often emerge (Spencer in Grant 2008). Time and competing pressures on the clinician in his role as a teacher and a practitioner often make deliberate teaching of clinical reasoning in a clinical setting sparse and difficult to manage (Grant 2008, Rencic 2011).

Integrated solution & benefits

• Online clinical reasoning is potentially a highly effective and powerful support for learning & teaching clinical reasoning (Ryan et al. 2004, Grant 2008).
• The general benefits of distance learning methods, i.e. accessibility in time & space, quality- assured material, ease of use and cost-effectiveness, fit well into the concept of distributed system of practice applied in education of health sciences.
• Learners require longer time in processing data than experienced clinicians (Rencic 2011) and the time-independent environment allows learners to take the time they need to for each clinical reasoning step.
• A web application makes it possible to deliver learning material via different media (online, print-out, video). Multi-modal learning has been proven to be more effective than uni-modal learning (Fadel et al. 2008) and students appear to wish to retain printed text that offers active learning, problem solving and feedback (Grant 2008).
• An e-learning platform offers a stimulating learning environment with a fresh and inspiring look & feel.
• A web application is easy to update and extend ensuring that the content continuously matches the latest concepts and available evidence in physical therapy.

Clinical reasoning

• Echternach JL, Rothstein JM: Hypothesis-oriented algorithms. Phys Ther. 1989;69:559-64.
• Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen G. Clinical reasoning strategies in physical therapy. Phys Ther. 2004;84:312-35.
• Engelbert R, Wittink H. Klinisch redeneren volgens de HOAC II (eng. Clinical reasoning with the HOAC II). Houten: Bohn Stafleu van Loghum; 2010.
• Escorpizo R, Stucki G, Cieza A, Davis K, Stumbo T, Riddle DL. Creating an interface between the International Classification of Functioning, Disability and Health and physical therapist practice. Phys Ther. 2010;90:1053-63.
• Higgs J, Jones M. Clinical decision making and multiple problem spaces. In: Higgs J, Jones MA, Loftus S, Christensen N. Clinical reaoning in health professions. Amsterdam: Elsevier;2008. p. 4-19.
• Interactive Guide to Physical Therapist Practice. Alexandria: American Physical Therapy Association; 2003.
• Kesselring J, Coenen M, Cieza A, Thompson A, Kostanjsek N, Stucki G. Developing the ICF Core Sets for multiple sclerosis to specify functioning. Mult Scler. 2008;14:252-4.
• Norman G. Research in clinical reasoning: past history and current trends. Med Educ. 2005;39:418-27.
• Rauch A, Cieza A, Stucki G. How to apply the International Classification of Functioning, Disability and Health (ICF) for rehabilitation management in clinical practice. Eur J Phys Rehabil. 2008;44(3):329-42.
• Rauch A, Escorpizo R, Riddle D, Eriks-Hoogland I, Stucki G, Cieza A. Using a case report of a patient with spinal cord injury to illustrate the application of the International Classification of Functioning, Disability and Health during multidisciplinary patient management. Phys Ther. 2010;90(7):1039-52.
• Riddle DL, Rothstein JM, Echternach JL. Application of the HOAC II: an episode of care for a patient with low back pain. Phys Ther. 2003;83:471-85.
• Rothstein JM, Echternach JL. Hypothesis-Oriented Algorithm for Clinicians: a method for evaluation and treatment planning.1986;66(9):1388-94.
• Rothstein JM, Echternach JL, Riddle DL. The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management. Phys Ther. 2003;83(5):455-70.
• Schenkman M, Deutsch JE, Gill-Body KM. An integrated framework for decision making in neurologic physical therapist practice. Phys Ther. 2006;86:1681-702.
• Shumway-Cook A, Woollacott MH. Motor control: translating research into clinical practice. 4th ed. Baltimore: Lippincott Williams & Wilkins; 2012.
• Steiner WA, Ryser L, Huber E, Uebelhart D, Aeschlimann A, Stucki G. Use of the ICF model as a clinical problem-solving tool in physical therapy and rehabilitation medicine. Phys Ther. 2002;82:1098-107.
• Thoomes EJ, Schmitt MS. Practical use of the HOAC II for clinical decision making and subsequent therapeutic interventions in an elite athlete with low back pain. J Orthop Sports Phys Ther. 2011;41(2):108-17.

Expert practice

• Black LL, Jensen GM, Mostrom E, Perkins J, Ritzline PD et al. The first year of practice: an investigation of the professional learning and development of promising novice physical therapists. Phys Ther. 2010;90(12):1758-73.
• Jensen GM, Gwyer J, Shepard KF, Hack LM. Expert practice in physical therapy. Phys Ther. 2000;80:28-43.
• Resnik L, Jensen GM. Using clinical outcomes to explore the theory of expert practice in physical therapy. Phys Ther. 2003;83:1090-106.

Teaching clinical reasoning

• Atkinson HL, Nixon-Cave K. A tool for clinical reasoning and reflection using the International Classification of Functioning, Disability and Health (ICF) framework and patient management model. Phys Ther. 2011;91:416-30.
• Kassirer JP. Teaching clinical reasoning: case-based and coached. Acad Med. 2010;85(7):1118-24.
• Rencic J. Twelve tips for teaching expertise in clinical reasoning. Med Teach. 2011:1-6.

E-learning

• Clarke A, Lewis D, Cole I, Ringrose L. A strategic approach to developing e-learning capability for healthcare. Health Info Libr J. 2005;22(Suppl 2):33-41.
• Fadel C, Lemke C. Multimodal learning through media: what the research says [online]. San Jose: Cisco Systems Inc; c 2008 [last update March 2011; cited 2011 Nov. 1]. URL: http://www.cisco.com/web/strategy/docs/education/Multimodal-Learning-Through-Media.pdf.
• Grant J. Using open and distance learning to develop clinical reasoning skills. In: Higgs J, Jones MA, Loftus S, Christensen N. Clinical reasoning in health professions. Amsterdam: Elsevier; 2008. p. 441-9.
• Irby M, Wilkerson L. Educational innovations in academic medicine and environmental trends. J Gen Intern Med. 2003;18:370-6.
• Ryan G, Dolling T, Barnet S. Supporting the problem-based learning process in the clinical years: evaluation of an online Clinical Reasoning Guide. Med Educ. 2004;38(6):638-45.
• Woltering V, Herrler A, Spitzer K, Spreckelsen C. Blended learning positively affects students’ satisfaction and the role of the tutor in the problem-based learning process: results of a mixed-method evaluation. Adv Health Sci Educ Theory Pract. 2009;14(5):725-38.

Communication & documentation

• Harman K, Bassett R, Fenety A, Hoens A. ‘I think it, but don’t often write it’: the barriers to charting in private practice. Physiother Can. 2009;61:252-8.
• Jette AM. Toward a common language for function, disability, and health. Phys Ther. 2006:86:726-34.
• Jette AM. Toward a common language of disablement. J Gerontol A Biol Sci Med Sci. 2009;64(11):1165-8.

The three trial cases

We created three cases (Anna, Paul and Maya) to feed the case study database of getPTsmart.com. All three cases are based on patients we worked with in our internships. The content of ‘Anna’ works with common problems met in neurological rehabilitation providing case content that most users are familiar with. ‘Paul’ offers more challenging case content that encourages users to work with varied aspects of the HOAC II clinical reasoning process. ‘Maya’ is a case with more complicated problems that work with the more complex aspects of the HOAC II and stimulate the users think about the possibilities and responsibilities of working in a multidisciplinary team.

Different levels of difficulty

We do our very best to accommodate users with different levels of knowledge, experience and clinical reasoning skills. Therefore, we have worked out case studies at three levels of difficulty. The level is of course a little bit arbitrary, but the levels go along these lines:

• Easy: content is very much simplified; case includes 1-2 problems.
• Medium: content is simplified, yet more complex than an easy case; 3+ problems; anticipated problems.
• Hard: all the more complex (multipathology) cases with a variety of different problems.

Neurological PT

All case studies at this stage are about neurological physical therapy. We have two reasons for this. First, the complexity of neurological cases allows us to demonstrate different dimensions of the HOAC II. Second, we like neurological PT and wanted to have a chance to develop our own knowledge during this project. Plus, importantly, we had case studies from our internships and could therefore work with a sample set of real-life cases.

Structure

Each case study is built up with an introduction, seven clinical reasoning steps and conclusion. All clinical reasoning steps proceed in the same step-by-step manner: actions to take, case details, solution, rationale & evidence. We have extensively discussed the structure with clinical reasoning and HOAC II experts at the Hogeschool van Amsterdam (Engelbert 2011, de Bakker 2011, Voigt 2011, van Egmond 2011, van Hartingvelt 2012, Simons 2012).

The ‘actions to take’ follow the original HOAC II algorithm by Rothstein et al. (2003) and constitute the centrepiece for learning the HOAC II way of clinical reasoning. The final format has been reviewed and approved by the HOAC II specialists at the Hogeschool van Amsterdam.

The ‘case details’ are given in flow text and at the beginning of each section, we have included a Canvas filled with case details up to that section. This way the user can go through the entire case in a step-by-step manner or choose to focus on a specific part of the clinical reasoning process and still be able to easily catch up with the case content.

In the ‘solution’ we offer one expert-validated solution. The idea is that the user compares his solution to the provided solution. This way the user gets immediate feedback on his work and automatically reflects on his clinical reasoning process. When we give the solution in the Canvas, all case details related to that section are highlighted for easy overview. At the end of each section give the ‘rationale’ for the provided solution and list the ‘evidence’ we have used. The rationale is kept short, yet precise to avoid overload of information.

Integration of different elements of clinical reasoning skills

Our aim is that the case studies help users develop their knowledge but also cognitive and metacognitive skills. Cognitive skills are developed with constant analysis of data and synthesis of the collected information. Metacognitive skills are improved with reflection of own progress. All three factors are key elements in the development of clinical reasoning strategies and professional growth (Atkinson et al. 2011). The little yellow sticky notes are meant to motivate the users. They are also a means for us to give case specific tips when necessary.

We hope the case studies are clear and easy to follow and help you develop your clinical reasoning skills. We would love to hear your comments and ideas about them so please feel free to leave us your feedback through the ‘feedback’ button on the left side of each page!

HOAC II in clinical practice

• The HOAC II is a conceptual framework. As a conceptual framework it provides a logical structure and a guideline that helps PTs develop comprehensive and coherent plans for patient management (Schenkman et al. 2006, Shumway-Cook et al. 2012).
• The HOAC II provides a way to engage in the conscious, process-like, systematic and effective practice as advocated for instance by the Royal Dutch Society for Physical Therapy – KNGF (Pistorius et al. 2006).
• The HOAC II represents contemporary, evidence-based physical therapy practice that incorporates the concept of prevention, a topic receiving much attention in physical therapy (Pistorius et al. 2006).
• The HOAC II aids problem-solving in clinical practice (Engelbert 2011).

HOAC II in the PT world

• The HOAC II, in part or whole, is a component of several clinical reasoning frameworks developed for specific areas of physical therapy. These include for instance the task-orientated approach advocated by Shumway-Cook et al. (2012), the integrated framework for neurological physical therapy by Schenkman et al. (2006) and the clinical reasoning framework developed for neonatal physical therapy (Sweeney et al. 2009).
• The most recent KNGF Evidence Statement for children with writing problems (Nijhuis-van der Sanden et al. 2011) converted its conclusions into recommendations for clinical reasoning using the HOAC II as the clinical reasoning framework.

HOAC II in education

• In the Netherlands the HOAC II is the cutting edge clinical reasoning framework. Currently six physical therapy programmes are in the process of further implementing the HOAC II in their curriculum (Engelbert 2011).
• The Dutch National Diploma for Physical Therapy (2008) establishes the HOAC II as one of the two profession-specific models of clinical reasoning covered in the Dutch PT progreammes. The other one is the Rehabilitation Problem Solving-model (RPS).

No consensus on the best clinical reasoning framework across all forms of PT practice has been established (Shumway-Cook et al. 2012). Based on literature and the communication we have had with HOAC II experts and those making decisions in physical therapy education, we believe the HOAC II offers an efficient way to structure your mind for clinical reasoning and clinical problem solving. The well-structured thoughts then allow for efficient communication between clinicians and give depth and quality to documentation.

The American Physical Therapy Association (APTA) developed Vision 2020 as their official vision statement for the future of physical therapy (APTA 2000). The vision calls for autonomous physical therapy practice that is characterised by independent, self-determined professional judgement and action. It is well-noted that clinical reasoning skills are at the heart of professional accountability and autonomy (Rothstein et al. 2003, Edwards et al. 2004, Higgs et al. 2011). Importantly for students and novice physical therapists, research has concluded that expertise in physical therapy is not necessarily based on the years of experience but rather on the development of advanced clinical decision making skills (Resnik et al. 2003, Atkinson et al. 2011).

To accommodate for the development of clinical reasoning skills, regulatory bodies and educational institutions seek solutions to implement sound clinical reasoning frameworks into their practice guidelines, curricula and continuing education programmes (de Bakker 2011, Engelbert 2011). However, the complexity and abstract nature of the subject have made such an implementation a major challenge.

Consequently, finding ways to practice case-based clinical reasoning outside the clinical settings remains a challenge for students and clinicians alike. It seems that internationally recognised clinical reasoning frameworks appear too complex and big in theory for them to deliberately employed in studies and practice routines.

This is where getPTsmart.com fits in.

For students & clinicians

With the help of getPTsmart.com students and physical therapists can engage in develping their clinical reasoning skills in a contemporary, time-independent environment that serves as a link between the classroom and clinical practice. getPTsmart.com is primarily targeted for physical therapy students in the last year of their entry level education as well as for novice physical therapists. During the development of the site, the target group is mainly represented by third year students of the European School of Physiotherapy (ESP), Amsterdam, the Netherlands.

For teachers & professors

Teachers and professors are encouraged to use getPTsmart.com in their clinical reasoning modules. The case studies or parts of them serve as self-explanatory preparatory homework material. The differences in the students’ solutions and the provided solutions will then serve as discussion points in the following class.