Matthew described putting the pieces together after examining Ana when he wrote, “upon completion of the examination, I hypothesized that the disk pathology was the source of Ana’s symptoms.” Kelsey’s narrative states that she “tried multiple different seating systems with pressure-relieving cushions with the patient, utilizing a range of transfer techniques.” This reveals reasoning occurring before seeing Mr.
Gleeson, as advanced planning would have been required. These types of statements are peppered throughout all participants’ narratives. They tend to show up as
statements of fact, without further elaboration or other signals that they represent any particular challenge. In this way, they didn’t strike me as revealing the essence of participants’ reflective processes, at least not their critical (Mezirow, 1991) or deeper levels (Boud, 1985) of reflection. In other words, they didn’t seem to represent problematic or unresolved situations of the type theorists seem to agree frequently trigger reflection (Mezirow, 1991; Schửn, 1983; Dewey, 1933).
Several participants, however, described situations that required them to change course in the moment. Geoff and Joel provided examples of this theme in the
descriptions of their initial encounters with Judge Callahan and Mrs. Cheung,
respectively. Each described being surprised by the fact that the patient he greeted in the waiting room didn’t fit what he’d anticipated based on the referring diagnosis. Each took it in stride, processing the new information in the moment and using it to form an alternative plan for evaluating his patient. Were they also using reflection-in-action to quickly challenge an underlying assumption in order to shift gears (Schửn, 1983;
Mezirow, 1991)?
While describing it as challenging, Joel’s portrayal of his initial encounter with Mrs. Cheung reveals both the need for a change in plan and his ability to think on his feet in order to meet that need. Mrs. Cheung was referred for treatment of low back pain, and while Joel had noticed in the medical record that she’d been recently
diagnosed with Parkinson’s Disease, he’d focused primarily on the referring doagnosis of back pain as he anticipated her first visit. Joel’s practice at the Berwick Health
Center involved treating primarily patients with orthopedic conditions, many with back pain. When he met Mrs. Cheung, however, he discovered that she had significant movement problems of the type caused by Parkinson’s Disease. He wrote the following:
The evaluation was a challenge for me in that I had to adapt my plan in the moment when it was clear that impairment-based tests and measures, as I would normally perform on a low back patient, were not indicated due to the degree of her functional deficits…
I was immediately able to recognize the patient’s movement pattern from a prior clinical experience I had… I was able to draw on this experience to recognize that this patient evaluation was going to be very different than my typical lumbar spine evaluation and was going to have to be functionally based.
(Joel’s narrative, Appendix C)
In the end, Joel began by evaluating Mrs. Cheung’s functional movement, as he would with any patient presenting with neurologic dysfunction. He did not do the tests he would have performed if she were the typical patient with low back pain. The fact is, those tests would have required Mrs. Cheung to assume positions and perform movements that, given the severity of her Parkinson’s, she couldn’t do. Thus, Joel began in the only place he could and proceeded from there, thinking on his feet the whole way.
In Geoff’s narrative this theme shows up, also at the beginning of the story and triggered by similar circumstances.
He [Judge Callahan] was referred to an orthopedist, was diagnosed with patellar tendonitis and referred to physical therapy. When I questioned him about needing a wheel chair and crutches, he replied that they help him get around due to recent onset of right leg pain, but that he was referred to PT for his left knee. Despite Judge C’s focus on the left knee, I was also concerned about his limited function and use of assistive devices, and knew I would have to [re-]prioritize my examination to better understand how to meet his
functional needs. (Geoff’s narrative, Appendix C)
In the context of the larger story, as we saw in the previous section, Geoff’s challenge was less about determining how he should alter his examination clinically, than about getting Judge Callahan’s buy-in, which wasn’t easily accomplished. Thus, the situational complexity confronting Geoff required him to integrate, in the moment, his clinical impressions and the messages Judge Callahan was sending about his view of why he was there and what was going on with him.
In the above examples, participants’ planned examinations didn’t fit the realities of the situations that presented themselves, forcing a change of course. As I analyzed the narratives of all six participants, I noted that they devoted more text to their
descriptions of these types of situations than they did to the before or after processing I discussed earlier. Their texts revealed complexities that made the situations inherently challenging, and to varying degrees, as we saw with Joel and Geoff, they discussed how they reasoned through those complexities to arrive as a course of action.