It's the final countdown...

(Those of you who know that song, you're showing your age!!)

Well it's getting close. Deadlines next Tuesday and I'm still working through my final assignment for clinical reasoning. It's getting better I think but I'm still unsure about the balance of literature/reflection/"I did this and thought that". After talking to A I thought I better send in my draft too, even if grossly incomplete. I know I will struggle with word count too! (I always do).

No time to waste, onwards and upwards! It's the final countdown.....

My new model

Just got the okay for my model for the assignment. I was concerned because while I initially didn't think my thinking had changed that much (see previous post), once I sat down and put all the elements together, suddenly I realised that it had changed A LOT. So much so that I wasn't even sure it qualified as a clinical reasoning model anymore. The reason for that is that in my mind clinical reasoning is quite allied to problem-solving. And problem-solving is quite narrow, as in what is the problem, and how do we fix it. And my approach to therapy in general now has broadened SO MUCH! That is why I was concerned my model wouldn't be accepted.

Well now my task is to put down in words the thinking behind the picture. I even managed to come up with a visual representation of my thinking - me the reader/writer. Haven't I stretched myself this semester! :p

I'm not quite sure yet what I will write. Because it's a bit of a journey into my own mind, and it'll take a bit more reflection to uncover why I think that I think the way I think I do, it's also going to be a bit of a surprise, I think. Hmm.

Beginning of the end

We have received our assignment marks and God has been very generous to me again! I am really looking forward to reading the comments though because I think it will be helpful and useful for my final assignment. Well, I haven't really gotten into the final assignment yet but I'm gonna! I got out my original model from week 1 today and had a look. Nope, still looks the same. Has my reasoning changed? Yes I think so. But how, aha, that is the million dollar question... I'm going to have to trawl through all the past weeks' readings again, consolidate, review and all that and figure out my current model of reasoning. I suspect it'll be fleshing out the original one more than devising a completely new one. I can't have changed THAT dramatically in less than a semester can I?

At the moment feeling both excited and still not quite ready. Just been wokring hard on another course so my mind is sort of still stuck on other matters. But it'll be good now to turn my hand to something different, and hopefully I'll get my assignment and be inspired by the comments on that! And hopefully I'll get it from the post before the rain gets it!

Mid term and ethics

Hmm a bit of a lull here, not that I haven't been reflecting but reflects that I have been busy getting my assignments in (not only for this course but two others as well, and submission to PG forum!)

Actually I really enjoyed getting back to course work and being done (for now) with assignment deadlines. Was quite relaxing and enjoyable reading some interesting articles and answering some questions! I particularly enjoyed Mary's session on Monday because ethics is always so interesting to think and talk about, because there is no "right answer". It's very enriching to be in a diverse class, especially with a mix of practice experience, study experiences, life experiences, ages, because everyone's opinion is a bit different (sometimes a lot different) and really gets the thinking going. It's easy to fall into established patterns of thinking within ourselves or within a close community of like-minded people so I find it really good to stimulate a bit of debate especially when things seem so "obvious", to go hang on, take a step back and think about "who says its obvious" and "why do I think it's obvious"?

Very stimulating conversations on Monday, it was great to be surrounded by people in practice who each contribute a slightly different take based on their practice settings. I think there is real value in this because as students our examples (or I should only speak for myself, so my examples) are theoretical or taken from very meagre placement memories or generalised. Usually quite generalised, maybe deducted/derived from theory. Or my own stereotyped thinking/accepted and unchallenged beliefs and prejudices.

And it really made sense to me to talk about ethics and ethical reasoning as part of this course (I must admit I did not see this coming! Duh!) because it's all about how we reason and why. We've touched on ethics before, in other courses in undergrad level but I think the literature shows people don't really consciously apply models of reasoning and a lot of action stems from intuition (which people then reflect upon afterwards). So it'd be useful to think about situations and principles that may guide us, before we are faced with ethical conundrums. I love being challenged by "what would you do" scenarios because it really makes me stop and go, "That's right, what WOULD I do?" Often, it's not that "obvious".

Anyway one assignment down and one to go. And 2 more other courses' assignments. This semester has gone/is going so fast!

the assignment

Reflecting on my assignment, or reflecting on what to put in my assignment, has been a confusing and illuminating process. It's not been clear cut, although starting out I kind of thought/hoped it would be. But clinical reasoning is not clear cut, so how can an assignment be clear cut? It's about reading and understanding, and re-reading when I realise I have not properly understood, and about breaking down and putting back together. Lots of people have said almost the same thing, but not entirely the same, which is why I find it tricky. Cos when you go to put it down on the paper I suddenly feel less confident about who said what and why that is different to the other.

So finding out 3 track mind isn't the be-all and end-all of clinical reasoning was quite a shock... They seem to be the gurus and their study was so earth shattering I guess I never thought to question it. We are still impressed by numbers I guess. A 2 year long ethnography is pretty impressive, although when I went back to look at the study, I found 1) yes there were mental health OTs 2) all hospital based 3) no men!

No men! I bet that skewed the results a lot. Wonder if anyone's thought of that.

Tacit knowledge, expertise and all that unfamiliar stuff...

I found it interesting that people on this course who are experienced practitioners all seemed to have really "hit a spot" when they read about tacit knowledge and expertise, "things we know but can't say" etc... I suppose it makes sense, because reading something that describes one's experience accurately which one never could quite put into words is very cathartic, and I have experienced that myself on other occasions. But not in this area, maybe because I lack that tacit knowledge, I don't have any knowledge that is "hidden" that I don't know of, maybe because I am a novice.

I feel a bit of a pang because I am clearly missing something, some eureka moment, but by the time I get to expert level (when is THAT going to be!) I would not experience the lightbulb going off because I am already armed with this knowledge, this theoretical knowledge so that when I gain that professional craft knowledge and tacit expert understanding, I can't quite be surprised by it. Unless I forget all that I have learned and read about in this course by the time I get there, which is a real possibility of course, seeing as it will be years away and I'm probably going to have other things forefront in my mind when I am in practice trying to "learn the craft" other than my tacit knowledge, or lack of. Hmm. One of those things we can only wait and see I guess. I wonder, like in those time travel stories, now that I know this, when I get there to the future, will this knowledge affect the way my tacit knowledge base is built over the next however many years?

Is any of this making sense? Is this rambling just a product of a sleepy afternoon? Am I having an existential moment or just caffeine/sleep deficiency??

Reflecting on work so far..

I'm glad we have to do this midway assignment because it's really making me think, go back to, re-digest, re-read and understand the material we've covered so far. I suppose that's the point of assignments. I thought I understood the readings and concepts we were going along week by week but it's only when I start to pull the ideas and concepts together for my assignment that I realise I need to dig deeper, and start to do so. I think it's coming together though. Well not quite yet, but I think it should do.

There are so many ideas out there, mostly not really competing with each other, but sort of similar-but-expressed-in-different ways. Almost like no one talked to each other before coming up with this stuff, or, everyone wants to be the one who came up with it! Or, we're all really similar and people are doomed to always repeat what others have said and few can be truly original or novel.

I don't mind. Sometimes reading about something written in slightly different ways helps to increase the depth of understanding and that surely is a good thing.

OT as parents??

Monday was a very interesting session. We talked about the different roles that OTs can have in the client-therapist relationship, such as collaborator, ally, mentor, parent, friend, advocate etc. Two that were somewhat more debatable or maybe controversial were parent and friend. People I think were generally cautious about using the term "friend" and my opinion was that it's good to be friendly, but not to actually become friends. That's not what we're there for, it can create conflict of interest, dependency on the client's part (I'm thinking of people who are particularly vulnerable to this - people who are socially excluded/isolated in some way) and maybe loss of professionalism. Not to mention illegal - not in our scope of practice! I think some elements of friendship are desirable in the therapeutic relationship, like being honest, warm, collaborative, listening, friendly and personable... But the role of "friend" I think we should avoid. Certainly in my study of/work with complex populations with complex needs, they can be quite vulnerable to exploitation (not that OTs would deliberately but it's sort of a subtle unconscious process) in that someone interested in them and in helping them comes along and they start thinking "Oh yay I finally have a friend who cares" but then the therapeutic relationship comes to an end one day, as it must, and then they are disappointed and "rejected" and all that. It's just not sustainable and being your client's friend is not the answer. We must help our clients to find/make friends in the context of activities and groups out in the community, help them find their solutions, not to BE the solution. How many clients can we realistically befriend anyway?

The other thing was parent. I recognised many aspects of the parental role and I agree some people almost need parenting, or re-parenting, to be un PC. Some people have never had a real parent, or one who fulfilled the role well. Nurturing, caring, providing rules, boundaries and structure, encouraging, those are all good things to certain clients in certain situations. I think even parenting can be "client-centred" in a way, because you are working for the ultimate good of the client. But I guess the adage that "Mother knows best" must be examined in terms of the OT role, especially vis a vis client centred practice. Does the OT know best? Does the client know best? Is there an absolute answer, a truth, a "right way" or "best way"? All very interesting thoughts.

ps I was really amazed at how differently others defined or regarded "parent". To me, parent is all about control and punishment, but to some others, it's about nurturing and tenderness! It's not cultural, because I'm sure some of my childhood friends think the opposite of me, and some kiwis must agree with me. Just goes to show how everything is relative. That is why we mustn't jump to conclusions or assume anything.

Artistry

We've just been talking about "Artistry", what it is, who has it, how do you get it? I think it's a bit like, maybe a wee bit lower than "genius", which is a hard-to-define but easy-to-spot extra something. Not many people have posted their comments yet on the forum, but so far two of us agree it's something that comes with time and experience, you're not born with it. But then, in some other realms, maybe you can be. I thought of a video we were shown last year in class. I think this guy has artistry, and one could argue although he put a lot of time and work into it, he was also born with a special something that the next guy didn't get. Talent, perseverance, passion, commitment etc. He's only young, but I don't think that takes away from his artistry. If not all experts automatically gain artistry (not the automatic linear process from novice to expert), then maybe artistry lies on a totally different plane/scale/spectrum to the other "stages". Anyway, I'm putting up this video with an interview cut into the celebrity stunt one. Enjoy!

Better late than never!

Got myself a slot to interview an OT for last week's course work on Novice/Expert - hope this isn't too late but I thought it would be good to do the exercise and get some practice examples since I don't have access to OTs around me quite that readily. Thanks heaps!! :)

Thinking about assignment

Just started thinking about the assignment recently so dug out the old FW journals to have a look in. It's hard when I'm not in practice, to have to come up with "practice examples" or examples of this or that sort of reasoning. I'm sure there are there somewhere, only that I haven't got that big a store of practice experience to draw from, plus I might not even recognise them as examples of whichever type of reasoning they really are! I sure hope something pops out at me because otherwise I'll be stuck for my assignment.

Other thing is that I managed to locate a copy of Rogers & Holm from first year!!! I knew I had it somewhere but it took a bit of sleuthing to find it. Problem with paper articles is that the ones I think are useful to keep, I may not look at but the one article I eventually need to refer back to probably wasn't deemed (in my undergrad mind) interesting enough to file separately from all the other papers of the semester in my special "articles folder"! Well that just proves you can never predict what you'll want to go back and have another look at.  I'm sure clinical reasoning was not too high on my list of interests in first year, probably didn't really know what it was :p

Narrative (reasoning)

Wow narrative vs narrative reasoning is a rather confusing concept. Ok I get narrative, as in my own narrative and my client's narrative. That's a bit like the "illness stories" I have been reading about in Arthur Frank's work. Narrative as a story, okay. But narrative reasoning? The group session this week made me think about whether narrative reasoning is part of, subsumed under the 3 track, or is it an alternative model to explain reasoning? Or...

I get the New York Subway example, and I also thought of an example of my own from placement - when I was doing paeds, and I was working with a boy with autism, who was a bit sensory defensive (is that the term?), anyway he hated getting shaving foam on his fingers and one day when I came up with an idea to use his love of animals to try and help him engage and challenge his defensiveness and try to overcome it. When we got to the part where we were supposed to do the shaving foam (because we used to do a series of short activities, all represented in a visual schedule, which he liked), I sprayed it in a thick line instead of just everywhere, and told him that was a river, then I produced a huge bucket of tiny plastic animals and said well here are the animals and they want to cross the river so shall we help them? The boy started off gingerly but he warmed up and seemed to really enjoy lining them up in the "river" and almost seemed to forget the shaving foam was all over his hands. The animals didn't end up "crossing" the "river" but instead he helped them to "swim" all along up and down the river and ended up having a grand old time!

I think that's what meant by narrative reasoning?

Practical examples from practice

After participating in some online tutorials and of course the ongoing work on moodle, a lot of which involves contributing to a forum, I started to think that maybe it would be easier to analyse my own clinical reasoning if I were in practice, even if only so that I had more examples to draw on to analyse. When it comes to thinking of examples from practice, I only have my placements to think about and I find it quite hard to come up with some off the top of my head. It must be partly due to the fact that I have simply forgotten some of my fieldwork experiences (and here, my old fieldwork journals are going to be useful to jog the memory) but it could also be due to the fact that I don't realise I have had the experiences, as in, true to the novice model, I haven't registered salient bits of encounters with clients. Hmmm. There must be a wealth of only subconsciously registered information which I may only be able to access under hypnosis! Or maybe not.

I'm glad they mix up students and therapists. I really enjoy reading real life examples, not only do they help to explain concepts (I'm a true kinesthetic) but they are interesting from the point of view of "what happens out there" as well.

Reflections on Schon chapter

Borrowed the book "The reflective practitioner" by DA Schon because it was too long to photocopy and I'm glad I did. It was a really interesting and thought provoking chapter on the evolution of the epistemology (? correct usage here?) of the professions. The chapter itself is called "From technical rationality to Reflection-in-action" and I found it useful to read about the history of the "professions" and how the scientific method was valued above all use, about how basic and general science was "higher" than applied, and the divide between theory (guided by non-contextual research) and practice.

He described a dilemma between "rigor" and "relevance" between which practitioners have to choose when inevitably they encounter situations which are not well-formed and mere repetitions of textbook cases. I reflected that as occupational therapists, because we work with human beings, there is little doubt in my mind that it would be rather useless to "stay on the higher ground" and dismiss everything that doesn't fit into theory and "science" as anomalies. I mean, what's "normal" right?

The author conveyed a reasonable mistrust (or maybe rejection) of the Technical Rationality paradigm and I felt that there is still *some* place for research, although we must be ready to realise that not everything will fit nicely into categories (or maybe few things do!)

I felt this reading contrasted a lot with Rogers' (2004) Occupational Diagnosis, which called for better labelling and categories in order to further the knowledge and the profession! She even said that if we had good categories for labelling impairments and aetiology, we could share knowledge better. I must admit I wasn't terribly excited about the idea that differentiating between patient with 1A (can't shower due to visual impairment) and 1B (can't shower due to muscle weakness) was going to revolutionise our practice. My immediate thought was, well what if the patient can't shower, and he has both muscle weakness and visual impairment, but probably could manage if his wife didn't have issues of anxiety and control?

Rogers, J. C. (2004). Occupational diagnosis. In M. Molineux (Ed.), Occupation for Occupational Therapists (pp. 17-31). Oxford: Blackwell Publishing.


Schon, D. A. (1983). The reflective practitioner: How professionals think in action. USA: Basic Books.

Week 2-3

This is the start of week 3 and I've been keeping busy trying to stay on top of our coursework and prepare for the second honours school next week. (!!!!)

Just did an interesting exercise where we had to identify the different types of clinical reasoning in some case studies. When I first read the article by Fleming (1991) last week I thought I understood the different types of reasoning fairly well, but perhaps initial beliefs are not always true because when I finally managed to get into the wiki today (after hitting a brainwave and trying it out on Firefox instead of my usual Safari) and read other people's comments I thought hmmm maybe I don't understand it that well after all. Not that other people's comments did not make sense, but that they had interpreted the scenarios slightly different to mine. I suppose the point of the Fleming's article was that the three tracks or strands of reasoning are woven together and are not always easy to distinguish; I especially found the more I re-read the interactive and conditional reasoning descriptions the more I found it difficult to differentiate them. Both are about the person's experiences and about their lives and the meaning they find in their condition apart from the symptoms, both are about understanding the person as a person and not just a set of impairments, both have to do with broader therapy than just making up for dysfunction. The main thing I could find to help myself separate them (if they are indeed discrete) would be the temporal factor in conditional reasoning whereby the person is placed and understood in a broad context of time, past, present and future an a visualisation of what "could be" if therapy was "successful".

I need to read more about this perhaps written by others to see if that helps and maybe over time I'll get a better grasp of these concepts. Hopefully!

Hello and welcome!

Working through the learning tasks for this week for the Clinical Reasoning paper, I have decided to start this blog as my reflective journal. Usually I'm an avid journaller and I cover the page with heaps of tiny scribbles (although somewhere along the way I began to type my journal into Word as a private document - simply because I type faster than I write and develop less of a cramp!).

This time, seeing as it's the new year (yes it's already mid Feb, I know) and it's the season for new beginnings and self-improvement challenges and all that, I decided to blog online. It's not the technology part that will be the new challenge (thanks to last semester I took that on with my DiverseOT conference presentation) but it's the blogging publicly. For one thing, I can't just say what I like because my thoughts and conclusions may be questioned and challenged. Of course I'm still going to say what I like :p because it's my journal, but I'm going to stretch myself and think more broadly/deeply/fully about whatever logical fallacy/error of thinking/unqualified statement people care to point out to me. See, I was also reading the PG student handbook earlier, and it mentioned "collegial relationship", which appealed to (the geek/undiscovered intellectual in) me. Esteemed colleagues, we are on a journey!