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He strongly exhales three times in a row without inhaling cheap isoniazid 300mg with visa professional english medicine, which helps to push the excess air out of the lungs isoniazid 300 mg with amex medicine 6 year program. Patients should do the above exercises and take five drops of the remedy every five minutes order isoniazid line medications for bipolar. Within half an hour buy isoniazid with amex symptoms zinc deficiency adults, even some of the worst asthma attacks can be brought under control. It is also known that asthma occurs more frequently in emotionally sensitive children. We believe in behavioral medicine and cognitive psychology, and that behavior and emotional states are the reasons a sensitive child sometimes can develop asthma, which limits his interaction with his peers and environment. Asthma prevents a child from taking part physically in something that he may not feel confident in doing. We also see that emotional sensitivity can produce a type of anxiety which has long been related to breathing. With this in mind we must realize that many children with asthma must also get some intervention in the emotional sensitivity during an asthmatic spasm. This does not have to be immediate, but should be done within twenty- four hours after any type of spasm, as this can help relieve some deep, emotional causes. This intervention need not be extreme for most children, as simply talking about some of their deep, hidden feelings regarding stresses, trials and turmoil in their lives may be enough for them to handle their emotional sensitivity, which then can also improve the asthmatic condition. This is a piece of paper about eight inches in length and three inches wide that the patient holds at one end, with his arm fully extended straight out from his chest. When there is asthmatic spasm, and inappropriate air in and out of the lungs, the patient is unable to blow over the piece of paper. In the office this type of "spirometer" allows us to demonstrate to the patient just how effective the program can be. When a bronchial spasm occurs in the office, we give the patient ten drops of the Asthma formula, teach him the relaxation exercises and meditation on the bronchial tree, and show him how to do the exhaling exercises (three times vigorously). By doing the exhaling three times every five minutes, and having the patient relax and meditate, we always see a dramatic increase in the breath within fifteen minutes. We caution the patient that when he gets home, sometimes in the presence of an allergin (such as dust or dog hair) it might be more difficult to control asthma. Sometimes the home is also an emotionally-sensitive area that can induce more disturbances. We do find, however, that patients who are taking inhalant steroids will very quickly build up large requirements for those drugs, and may have difficulty stopping those drugs. We find that drugs dealing with symptomatology alone can create extremely disturbing side effects and extreme dependencies in the patient. If these cannot be removed, then proper allersode desensitization of inhalant allergies is extremely important. Results and Discussion: In using the above therapies we have easily treated over one hundred cases of asthma. Complex homeopathy and behavioral therapy make it very easy to develop safe, simple-to-learn and -use programs for the doctor to prescribe. The quantum quality control techniques used by New Vistas assure a good blend of product that can be utilized for significant results. This is very powerful in behavioral therapy, as we are trying to increasingly empower our patients against their own diseases, and show them that they can control their own healing processes. If you learn and recognize the reason behind the various discussions in this paper, you will see how powerful they can be in dealing with a wide variety of asthmatic conditions. Proceedings of the Natural Medicine Conference at the Royal Society of Medicine in London England 5. Using the Auscaultcardiogram / Fetaphone in Pregnant or non Pregnant Patients, 32. Daniel’s Story the story of my son Daniel born autistic who was cured by energetic medicine 13. Proof of the Efect of the Mind (How and why science has improperly rejected and illegally covered up the non- 14. Nelson’s Essential Homotoxicology local universe premise proving the efects of the mind) 35. Nelson’s Impairment Manual plotted to cover up the fact that synthetic drugs are not compatible with the human and how natu- 16. The Angel Story in Pictures the story of Bill to Desire in a beautiful large cofee table 46. Woman’s Health A Treatise for Evolution in Law / the next step Equal Economic Education 70. Basic Biofeedback Physiology For All International Medical University Staf and Therapists 52. Symptom Operationalization (Repertory) For Homeopaths, Nurses and Scio Biofeedback Therapists 58. Desire has developed a new and exciting style of mov- ie making that has Hollywood shaking in fear. Her Intellectual Angel Movies are a fantastic unprecedented and inventive style of movie aimed at the sophisticated intelligent audience. De- sire has the courage and fortitude to make over 35 movies that challenge the system and the powers of big money. As Einstein once said “great spirits get incredible resistance from mediocre minds”. Judging from the petty trivial critiques and biased twisted criticisms it can be said that Desire must be one great spirit. Desire was awarded the frst prize in a contest of Car- diologists in Florida in 1989. She has become the world’s most famous expert on Natural and Energetic medi- cine. The story goes on and on this is just a brief set of the ever growing legend and saga of Desire D. The petty mind can come at you from any angle and the only de- fense is steadfast dedication to the truth. When you read or watch her scientifc journals, clinical studies, advanced scien- tifc papers, medical discussions, philosophical essays, social themes, and intellectual movies you can see a world class ge- nius. Petty minds will say that it is too good to be true, well Desire is so true to be good. The courage to stand up and prove that all synthetic drugs are incompatible with the human body. The intrepid pluck resolution to let the big head choose her sex not the little head’s presence. It is a constant bat- tle against the small and petty minds to fght for freedom and awareness. A modern day warrior fghting for rationality in an ever increasingly stupid and judgmental world, Desire fghts on against all who live in false belief. With over 5 patents, 10 trademarks, thousands of copy- rights, and a host of other leading edge changes to help natural medicine, Desire is now a Professor Emeritus of Medicine at the International Medical University.
Loftus 2006) isoniazid 300 mg online symptoms 6dpiui, with insights of narratives to make sense of the multiple factors that would simply not have been possible with and interests pertaining to the current reasoning research from a strictly Cartesian point of view cheap 300 mg isoniazid with visa medications without a script. A place for new research directions 219 Interdisciplinary research also includes investiga- occurring within practice models and clinical tion of emerging and potential trends in clinical reasoning models (see e purchase generic isoniazid canada sewage treatment. This proposition calls for informed groups (with their diverse backgrounds) and practice purchase 300 mg isoniazid amex symptoms and diagnosis, that is, practice informed by these include patients as members of multidisciplinary understandings. The linguistic turn is the simple but pro- adoption of the critical social sciences as the basis found recognition that our use of language is fun- for emancipatory practice (Trede et al 2003). We are now beginning to appreciate the assumptions of much past research, the acceptance extent to which linguistic and discursive forms of new academic disciplines with different such as metaphor and narrative form a part of the assumptions holds promise of providing exciting phenomenon of clinical reasoning (Loftus 2006). We hope that they come to a deeper understanding of their patients’ would be both pleased and surprised at the extent problems, and equip them with the cognitive tools to which their call has been answered. We stand to accompany those same patients on their on the verge of a vital expansion in the scope of journeys through illness and its treatment (see also research in clinical reasoning that can go in many Chapter 32). It clinical reasoning by pursuing promising new reflects cutting edge research which calls for clin- directions in research and by sharing across disci- ical reasoning research and practice to be plines the findings of such research. Unpublished Charon R 2006 Narrative medicine: honoring the stories of PhD thesis, University of Western Sydney, Sydney illness. Oxford University Press, Oxford Aristotle S (trans H C Lawson-Tancred) 1991 the art of Crepeau E B 1991 Achieving intersubjective understanding: rhetoric. Penguin Books, London examples from an occupational therapy treatment Benner P 1984 From novice to expert: excellence and power in session. Social Science and Medicine 33:947–957 Elstein A S, Schwartz A 2000 Clinical reasoning in medicine. Charles C, Gafni A, Whelan T et al 2005 Treatment decision In: Higgs J, Jones M (eds) Clinical reasoning in the health aids: conceptual issues and future directions. Physical Therapy Malt U F, Olafson O M 1995 Psychological appraisal and 75:267–280 emotional response to physical injury: a clinical, Fleming M H 1991 Clinical reasoning in medicine compared phenomenological study of 109 adults. American Medicine 10:117–134 Journal of Occupational Therapy 45:988–996 Nietzsche F (trans W Kaufman, R J Hollingdale) 1968 the will Gadamer H-G 1989 Truth and method, 2nd revised edn. Vintage Books, New York [Opening chapter Continuum, New York quotation based on Book 3, quotation no 481, p. Seminar presentation at the Schon D A 1987 Educating the reflective practitioner: toward? Faculty of Health Sciences, University of Sydney, a new design for teaching and learning in the professions. Australia, May 5 Jossey-Bass, San Francisco Higgs J, Titchen A 2001 Professional practice in health, Shotter J 2000 Seeing historically: Goethe and Vygotsky’s education and the creative arts. Culture and Psychology Jensen G M, Shepard K F, Hack L M 1992 Attribute 6(2):233–252 dimensions that distinguish master and novice physical Trede F 2006 A critical practice model for physiotherapy. Physical Unpublished PhD thesis, University of Sydney, Australia Therapy 72:711–722 Trede F, Higgs J 2003 Re-framing the clinician’s role in Jensen G M, Gwyer J, Hack L M et al 2007 Expertise in collaborative clinical decision making: re-thinking physical therapy practice: applications in practice, practice knowledge and the notion of clinician–patient education and research, 2nd edn. Learning in Health and Social Care 2(2): Kuhn T 1996 the structure of scientific revolutions, 3rd edn. Professional Education: A Multidisciplinary Journal PhD thesis, University of Sydney, Australia. Sage, London Wittgenstein L (trans G E M Anscombe) 1958 Philosophical McCormack B 1998 An exploration of the theoretical investigations, 3rd edn. Treatment decision making in the medical encounter: the case of shared decision making 299 28. Clinical reasoning to facilitate cognitive– experiential change 319 This page intentionally left blank 223 Chapter 20 C lin ical reason in g in edicin e Alan Schwartz and Arthur S. In this chapter we sketch our Problem solving: diagnosis as hypothesis current understanding of answers to these ques- selection 224 tions by reviewing the cognitive processes and the hypothetico-deductive method 224 mental structures employed in diagnostic rea- Diagnosis as categorization or pattern soning in clinical medicine and offering a selected recognition 225 history of research in the area. We will not consider Multiple reasoning strategies 226 the parallel issues of selecting a treatment or devel- Errors in hypothesis-generation and oping a management plan. For theoretical back- restructuring 226 ground, we draw upon two approaches that have Decision making: diagnosis as opinion been particularly influential in research in this revision 227 field. The first is problem solving, exemplified in Bayes’ theorem 227 the work of Newell & Simon (1972), Elstein et al Errors in probability estimation 227 (1978), Bordage and his colleagues (Bordage & Errors in probability revision 228 Lemieux 1991, Bordage & Zacks 1984, Friedman the two-system view 229 et al 1998, Lemieux & Bordage 1992) and Norman (2005). The second is decision making, includ- Educational implications 229 ing both classical and two-system approaches, Problem solving: educational illustrated in the work of Kahneman et al (1982), implications 229 Baron (2000), and the research reviewed by Mellers Decision making: educational et al (1998), Shafir & LeBoeuf (2002) and Kahneman implications 230 (2003). Conclusion 231 Problem-solving research has usually focused on how an ill-structured problem situation is defined and structured (as by generating a set of diagnostic hypotheses). Psychological decision research has typically looked at factors affecting diagnosis or treatment choice in well defined, tightly controlled situations. Behavioural decision research, on the of working memory, hypothesis generation is a other hand, contrasts human performance with a psychological necessity. Novices and experienced normative statistical model of reasoning under physicians alike attempt to generate hypotheses uncertainty. It illuminates cognitive processes by to explain clusters of findings, although the content examining errors in reasoning to which even of the experienced group’s productions is of higher experts are not immune, and thus raises the case quality. Other clinical researchers have concurred with this view (Kassirer & Gorry 1978, Kuipers & Kas- sirer 1984, Nendaz et al 2005, Pople 1982). We will examine these conflicting inter- to recognize a malfunction and then to set about pretations later. The diagnosis is thus an explanation of disordered function, where Data collection and interpretation possible a causal explanation. In most cases, not all of the information needed Next, the data obtained must be interpreted in to identify and explain the situation is available in the light of the hypotheses being considered. Physi- what extent do the data strengthen or weaken cians must decide what information to collect, belief in the correctness of a particular diagnostic what aspects of the situation need attention, and hypothesis? Thus data collection A clinician could collect data quite thoroughly is both sequential and selective. Experienced phy- but could nevertheless ignore, misunderstand or sicians often go about this task almost automati- misinterpret a significant fraction. In contrast, a cli- cally, sometimes very rapidly; novices struggle to nician might be overly economical in data collection develop a plan. This was an important finding for two reasons: Early hypothesis generation and selective 1. This approach, are solved by a process of generating a limited exemplified in patient management problems number of hypotheses or problem formulations (Feightner 1985), facilitated investigation of the early in the workup and using them to guide amount and sequence of data collection but offered subsequent data collection and integration. Each less insight into data interpretation and problem hypothesis can be used to predict what additional formulation. To deepen understanding occurs rapidly and automatically, even if clinicians of reasoning processes, investigators in the prob- are explicitly instructed not to generate hypoth- lem-solving tradition have asked subjects to think eses. Given the complexity of the clinical situa- aloud while problem solving and have then ana- tion, the enormous amount of data that could lysed their verbalizations as well as their data Clinical reasoning in medicine 225 collection (Barrows et al 1982, Elstein et al 1978, the number and content of clinical simulations in Friedman et al 1998, Joseph & Patel 1990, Nendaz an examination than they were prior to this discov- et al 2005, Neufeld et al 1981, Patel & Groen 1986). Page et al 1990, van der Vleuten & Swan- Considerable variability in acquiring and inter- son 1990). Felto- the finding of case specificity also challenged vich et al 1984, Kuipers et al 1988). This shift led the hypothetico-deductive model as an adequate naturally to the second major change in research account of the process of clinical reasoning. Study of clinical judgement separated from data employed a hypothesis-testing strategy, and diag- collection.
Flexion and extension take place in a plane at right angles to the plane of the scapula buy isoniazid american express medicine venlafaxine. Continuation of extension beyond the vertical position of the arm is called hyperextension discount 300 mg isoniazid with amex medications 122. Abduction and adduction take place partly at the shoulder joint buy isoniazid without a prescription symptoms tracker, and partly by rotation of the scapula buy cheap isoniazid line symptoms your dog is sick. A rotation of the humerus that carries the fexed forearm medially is medial rotation. The opposite movement in which the forearm is carried laterally is lateral rotation. It follows that any mus- cle passing from the trunk (or scapula) to the front of the humerus will be a medial rotator. The shallowness of the glenoid cavity and the laxity of the capsule give the shoulder joint great freedom of movement, but this is at the expense of stability. Of all joints of the body the shoulder joint is most liable to dislocation (See below). The tendon (of origin) of the long head of the biceps brachii lies within the capsule of the shoulder joint. In os- teoarthritis of this joint abnormal irregular projections develop from the bones concerned and friction against them can lead to damage to the tendon ending in rupture. The subacromial bursa lies deep to the coracoacromial arch and the adjoining part of the deltoid muscle. During over-head abduction the greater tuberosity slips below the bursa and comes to lie deep to the acromion. When the bursa is infamed (subacromial bursitus) pressure over the deltoid, just below the acromion elicits pain, but pain cannot be elicited after abduction (as the bursa is now under the acromion). Subacromial bursitis is usually associated with infammation of the supraspinatus tendon. Typically the head of the humerus is displaced forwards and comes to lie in the infraclavicular fossa just be- low the coracoid process. It will be recalled that the capsule of the shoulder joint is least supported inferiorly. Hence the head of the humerus frst passes downwards and then moves anteriorly or posteriorly. Dislocations at the shoulder carry the risk of injury to the axillary nerve, to the brachial plexus (especially the posterior cord), or to the axillary artery. These dislocations may sometimes be accompanied by fracture of the greater tuberosity of the humerus. Sometimes dislocation of the shoulder joint may occur repeatedly (recurrent dislocation), and may occur even with trivial force. Rupture of the tendinous cuff (rotator cuff) involves injury mainly to the tendon of the supraspinatus muscle. The patient is unable to initiate abduction at the shoulder joint, but can maintain it once the arm is partially abducted. Strain of the supraspinatus is common in persons who have to work for long periods with the arms in slight abduction (e. Sprengel’s Shoulder A condition in which the scapula (and therefore the shoulder joint) is placed higher than normal is called Spren- gel’s shoulder. These are the lower end of the humerus and the upper ends of the radius and ulna (7. The capitulum of the humerus articulates with the concave upper surface of the head of the radius (humero- radial joint); and the trochlear of the humerus articulates with the trochlear notch at the upper end of the ulna (humero-ulnar joint). The cavity of the joint is continuous with that of the superior radio-ulnar joint, the two sharing a common synovial membrane. All the three joints mentioned above are collectively referred to as the cubital articulation. Its medial fange is larger than the lateral and projects downwards to a lower level (7. As a result the lower edge of the trochlea is not horizontal, but passes downwards and medially. The trochlear notch on the ulna consists of an upper part present on the anterior surface of the olecranon and a lower part present on the upper surface of the coronoid process. The upper and lower parts of the trochlear notch may be separated by a non-articular area. The articular surface of the trochlear notch is divided into medial and lateral parts by a ridge that projects forwards. The attachment of the articular capsule to the lower end of the humerus is shown in 7. It will be seen that considerable non-articular areas of the humerus are included within the joint cavity. These include the coronoid and radial fossae in front, the olecranon fossa behind, and the fat medial surface of the trochlea (7. Inferiorly, the capsule is attached to the coronoid and olecranon processes of the ulna around the margins of the articular surface. On the lateral side it is not attached directly to the radius, but to the annular ligament of the superior radi- oulnar joint, which encircles the head of the bone. The capsular ligament is thin anteriorly and posteriorly, but is thickened on the medial and lateral sides to form the ulnar and radial collateral ligaments. Its apex is attached to the medial epicondyle of the humerus, and its base to the ulna. The ligament has thick anterior and posterior parts, and a thinner intervening part. The anterior band is attached below to the medial margin of the coronoid process; and the posterior band to the medial side of the olecranon. These two parts are connected by an oblique band to which the thin intermediate part of the ligament is at- tached. A space exists between the oblique band and the bone, and synovial membrane may bulge out through this gap in the attachment of the capsule. The synovial membrane of the joint is extensive and covers all non-articular areas of bone enclosed within the capsule. Over these fossae, and in some other regions, the synovial membrane is separated from the capsular liga- ment by pads of fat. These pads ft into empty spaces in the joint at different phases in its movements. The elbow joint receives its blood supply from the arterial anastomoses around it. It receives its nerve supply from nerves that cross it: mainly the musculocutaneous and the radial, but also from the ulnar, the median and the anterior interosseous nerves. Bending the elbow so that the front of the forearm tends to touch the front of the arm is fexion. These movements are complicated by the fact that the line of the joint is not at right angles to the long axes of the arm and forearm, but (as seen above) it runs downwards and medially.
In a test of diagnostic reasoning order isoniazid 300mg online treatment 3rd metatarsal stress fracture, both success- (novice cheap isoniazid 300 mg overnight delivery symptoms rheumatic fever, advanced beginner cheap isoniazid online mastercard 4 medications at target, competent quality 300 mg isoniazid symptoms you have cancer, proficient ful and unsuccessful diagnosticians used a hypoth- and expert) (Table 11. Research the Dreyfus & Dreyfus conception of expertise on the clinical reasoning of expert physicians is much more focused on the context of actual prac- demonstrated that in familiar situations experts tice. Several critical elements emerged from their did not display hypothesis testing but instead used model (Dreyfus & Dreyfus 1980, 1996): (1) exper- rapid, automatic and often nonverbal strategies. This explains why non-reflective (but when a situation is novel, experts tend to ask fewer, more relevant questions experts engage in deliberation before action); and perform examinations more quickly and accu- (5) intuition of experts or the knowing how to rately than novices. Skill is identified as an overall approach stems from the physician’s prior relationship with to professional action that includes both percep- the patient. The traditional methodology of tion and decision making, not just what we would providing clinical cases that are decontextualized think of as technical skill or technique (Benner and ‘clean’ may not be particularly valid means 1984; Benner et al 1996, 1999). The knowledge nec- of assessing the full range of processes and behaviors essary to perform the skill is practical knowledge (i. The Dreyfus model captured the complexity of Although there has been prolonged debate and con- nursing expertise that is acquired from deep, troversy in expertise research on the acquisition of intuitive and holistic understanding of a situa- expert characteristics, there continues to be strong tion. Benner argued that skilled know-how or agreement on the characteristics of experts. In fact, practical knowledge is a form of knowledge, not that consistency is seen here in the characteristics just application of it. Furthermore, knowledge is of experts identified by Glaser & Chi (1988): not possessed by an individual in isolation, but Experts mainly excel in their domain of rather is based upon the ‘shared life of a work expertise. A case or scenario is presented to who have a more superficial representation of subjects. Expertise and clinical reasoning 127 Experts spend more time trying to understand (Edwards et al 2004; Gwyer et al 2004; Jensen et al the problem and experts have strong self-mon- 1999, 2000, 2007; Resnik & Hart 2003; Shepard et al itoring skills. These are all professions where human inter- actions and care are central aspects of the work. In Another way to look at the key elements of exper- these studies we find that the clinical reasoning tise is to cluster them into categories. Sternberg & process is not as analytical, deductive or rational Horvath (1995) described three such clusters of because the focus of care is a much larger process categories for thinking about expertise in real- that extends beyond the identification of a diagno- world settings: sis. Knowing a patient, understanding his or to bear more effectively on problems within her story, fitting the patient’s story with clinical their domain. Experts can problem-solve are the kinds of integral components solve problems within their domain more effi- of clinical reasoning that emerge from these stud- ciently through self-regulation and use of ies. Experts are more likely to arrive at cre- in clinical reasoning and expertise in occupational ative solutions to problems. Each of fine the problem to reach an insightful these investigations represents important and pro- solution that would not occur to others. Experts continue to build their practical in occupational therapy, Mattingly & Fleming knowledge base through a repertoire of examples, (1994) originally proposed three types of reasoning images, illness scripts, and understanding learned in their ‘theory of the three-track’ mind. This type of reasoning is inquiry or metacognitive strategies to think about similar to hypothetical-propositional reasoning what they are doing, what worked and what did in medicine, but in the case of occupational not work. Although much of the expertise research therapy the focus is on identifying the patient’s has been done contrasting the performance of functional problem and selecting procedures to novices and experts, it is investigations of actual reduce the effects of the problem. This is the reasoning that more fully the knowledge, experience and complex takes place during face-to-face interactions human decision making embedded in expertise between therapist and patient. Qualitative research methods have been central tools in investigative work and theoretical writing A fourth form of reasoning, narrative reasoning done in several applied professions such as (Fleming & Mattingly 2000, Mattingly & Fleming nursing (Benner 1984; Benner et al 1996, 1999), 1994), is used to describe the story-telling aspect teaching (Berliner 1986, Sternberg 1998, Tsui 2003), of patient cases. This making sense of the illness experi- ence is shifting the thinking and dialogue from a physiological event to a personally meaningful one for the patient. Reflecting on ethnographic research work done in occupational therapy since Clinical Virtue their original work, Mattingly & Fleming (1994) reasoning highlighted two key concepts in clinical reasoning: active judgement and narrative. Working together, these two streams of reasoning are core processes for occupational therapists. Knowledge Movement In physical therapy, Jensen and colleagues devel- oped a grounded theory of expert practice in physi- cal therapy (Jensen et al 1999, 2000; Shepard et al Student 1999). It is proposed in this model that expertise in physical therapy is some combination of multidi- mensional knowledge, clinical reasoning skills, skilled movement and virtue ure 11. All four Clinical Virtue of these dimensions (knowledge, reasoning, move- reasoning ment and virtue) contribute to the therapist’s phi- losophy of practice. For novices, each of these core dimensions of expertise may exist but they do not Knowledge Movement appear to be as well integrated ure 11. As novices continue to develop, each of the dimensions may become stronger, yet they Novice may not be well integrated for proficient practice. When the expert therapist has fully integrated these dimensions of expertise, that in turn leads to an explicit philosophy of practice ure 11. In this model of expertise it is difficult to Virtue reasoning highlight only one dimension such as clinical reasoning, as all dimensions could be seen as con- tributing to thinking and actions of expert pra- Knowledge Movement ctitioners. Therapists Although experts in that study possessed a draw from several sources such as specialty knowl- broad, multidimensional knowledge base, Resnik edge, clinical knowledge gained through reflection & Jensen (2003) discovered that years of clinical on practice and listening carefully to their patients. Dreyfus model, that experience is a critical factor the clinical reasoning dimension of the model in development of expertise. In Resnik & Jensen’s has two core components: (1) it is a collaborative study this was not observed, and in fact, some process between therapist and patient in which therapists classified as experts were relatively the patient is seen as an important source of knowl- new physical therapists. In these instances, they edge; and (2) therapists demonstrate evidence of theorized, knowledge acquisition was facilitated strong self-monitoring reflection skills in this col- by work and life experience prior to attending laborative process. Function, as defined by the physical therapy school, by being in a work envi- patient, forms the core of a framework used in ronment that offered access to pooled collegial establishing patient care goals. Skilful facilitation knowledge, and by practitioners’ values and vir- of movement focused on function, done through tues of inquisitiveness and humility which drove data gathering, hands-on skills, assessment palpa- their use of reflection. Furthermore, expert therapists used practice, seen in behaviours such as care and com- the rich knowledge base of colleagues and sought passion for patients, non-judgemental approaches out knowledgeable mentors to assist them in chal- to patients, admitting mistakes and taking deliber- lenging cases. Thus, in their theoretical model, ate actions such as reporting unethical behaviour expert therapists’ knowledge base comprised of colleagues or advocating for patients. At the foundation of the patient-centred In-depth ethnographicwork by Edwards and col- approach they identified an ethic of caring and a leagues (2004) on expert physical therapists’ clinical respect for individuality, a passion for clinical care reasoning strategies further revealed an interplay of and a desire to continually learn and improve. The different reasoning strategies ineverytask of clinical primary goals of empowering patients, increasing practice (for example interactive reasoning, diag- self-efficacy beliefs and involving patients in the nostic reasoning, narrative reasoning, ethical care process are facilitated by patient–therapist col- reasoning, reasoning about teaching). Rather than laborative problem solving and enhanced through contrasting the cognitively-based rational models attentive listening, trust building and observation. Resnik & Jensen reported that these required to understand and engage patients and efforts not only promoted patient empowerment caregivers. Critical reflection is required with either and self-efficacy, but also resulted in greater conti- process. Emo- practice’ in order to improve understanding of tions play a key role in the perception of the expert practice. Benner (1984) suggested that they tive accounts of actual clinical examples as primary may even act as a moral compass in learning tools for understanding the everyday clinical and a practice. The interpersonal skill of engaging caring knowledge and practical reasoning that with the clinical and human situation is called were used in nursing practice.