What I Expect from Physical Therapy Case Conferences: Perspectives for Mutual Learning in Clinical Practice
Case conferences in clinical settings are not merely 'presentation opportunities.' They are chances to deepen our understanding of the stories of the patients we encounter daily, establish appropriate hypotheses, verify them, and discuss the effectiveness of interventions, thereby continuously refining our clinical reasoning. However, in practice, issues often arise such as 'focusing solely on mechanical explanations,' 'presenting information in a fragmented manner,' or 'failing to tell the narrative sufficiently.'
Therefore, in this article, I have organized the approach to case studies that I expect from my fellow staff members.
1. The Basic Clinical Stance of Hypothesis-Verification
First, I want to emphasize that the core of a case study is the hypothesis-verification process.
A hypothesis is a tentative answer to the question, 'What is the factor hindering the patient's needs?' In deriving this, it is necessary to clarify the comprehensiveness and logic of the information, as well as the academic framework upon which it is based (Jones et al. 2000).
Verification asks, 'Is an appropriate method being used to confirm that hypothesis?' It is essential to consider whether biases and the influence of variables have been accounted for, whether necessary negative findings have been identified, and whether interventional evaluation—that is, confirming changes by applying some form of stimulus or trial—has been performed (Testa et al. 2016).
Clinical reasoning is not established through thought experiments alone; it requires the practice of 'moving and verifying' through evaluation and intervention (Christensen et al. 2017). We must not forget this stance in case studies.
2. How to Capture the Patient's Story
The next important point is patient narrative. A case study does not end with an 'anatomical analysis of symptoms.' It requires the presenter to describe in their own words what kind of life the person has led and why they ended up receiving rehabilitation.
Are the needs (what is truly necessary for the patient) rooted in the narrative?
Have the needs become a means to an end? (e.g., Is 'being able to walk' not the goal itself, but connected to the quality of life and role fulfillment that lies beyond it?)
Have you exhausted the questioning by repeatedly asking 'why' regarding the needs until you can no longer dig any deeper?
Narrative-based medicine is considered key to improving medical education and clinical quality (Greenhalgh & Hurwitz 1999), and in the field of physical therapy, it is argued that 'clinical practice is the reconstruction of a story' (Mattingly 1998). Case studies based on these principles are what lead directly to practice.
3. Basic Structure of Presentation Materials
Presentation materials in a case study should not be just a summary of medical records or a list of information, but a logically constructed presentation. The basic flow is as follows.
Background: Awareness of the problem and the location of the issue. Especially important is the 'title' (i.e., the heading).
Question: Clearly state the concerns you have regarding this case.
Information Gathering: Narrative, medical record information, medical history, and current illness history.
Declaration of Needs: Verbalize the patient's core goals.
Hypothesis: A tentative answer as to 'why those needs are being hindered.'
Method: Evaluation and interventional evaluation (including stimuli that indicate improvement or deterioration).
Results: Treatment effects and responses
Conclusion: Answers to the "questions"
Generalization: How the learning can be applied to other cases
The structure of academic case reports also follows this flow (McEwen 2001), and in educational research, the presentation of a "logical process connecting questions to conclusions" is recommended (Higgs & Jones 2008).
What is important here is that each element is connected by arrows.
Hypothesis → Method (Evaluation/Verification)
Method → Results
Results → Re-examination of hypothesis
Question → Conclusion
The quality of a case study changes significantly depending on whether this series of relationships can be explained logically.
4. Academic and clear description of movement
When describing movement observation, beginners tend to lean toward "mechanical explanations." While mechanics is certainly the most understandable language, it is necessary to be aware of the following beyond that.
Use relative expressions for posture evaluation (e.g., "the head is positioned anteriorly relative to the trunk")
Subdivide and simplify evaluation tasks, and devise ways to reduce variables
Specifically state "what action changes the movement" (interventional evaluation)
Present with videos or photos whenever possible
Cook (2001) indicates the necessity of supplementing movement evaluation not only with mechanics but also from neurological and psychological perspectives. Such multifaceted viewpoints enrich clinical reasoning.
5. To improve the quality of discussion
The value of a case conference is reflected in the final discussion. In a good presentation, many of the opinions and questions that arise are directly linked to the theme the presenter was grappling with. Conversely, if information is lacking, elementary questions such as "What kind of patient is this person in the first place?" will fly around, and it will not be possible to proceed to a deep discussion.
Therefore,
Always include information that the audience would consider 'essential for discussion'.
If you choose to omit information, be clear about your intent and prepare supplementary materials if necessary.
Such considerations are indispensable.
Case conferences are an educational activity that promotes the 'externalization of thought' (Eva 2005) and are positioned at the center of the cycle for developing clinical judgment in learners (Levett-Jones 2010).
6. To make case conferences a 'place for growth'
Finally, I would like to emphasize repositioning case conferences from something done out of a sense of obligation to an activity necessary for growth.
Telling the patient's story in your own words
Deepening the understanding of needs and forming hypotheses about the factors hindering them
Performing assessments and interventions to test hypotheses and confirming changes
Logically explaining that entire sequence of thought
By carefully following this flow, case conferences become more than just presentation practice; they become a training ground for continuously honing clinical reasoning.
Our clinical practice can only grow through the accumulation of cycles: 'observing movement,' 'listening to stories,' 'forming hypotheses,' 'performing some form of intervention,' and 'verifying changes.'I ask my fellow staff to treat case conferences as a microcosm of this process and to apply it back to their daily clinical work.
References
Jones, M. A., Jensen, G. M., & Edwards, I. (2000). Clinical reasoning in physiotherapy. Physical Therapy.
Christensen, N., Black, L., Furze, J., & Jenson, G. M. (2017). Clinical reasoning: Survey of teaching methods in physical therapist education programs in the United States. Journal of Physical Therapy Education.
Greenhalgh, T., & Hurwitz, B. (1999). Narrative based medicine: Why study narrative? BMJ.
Mattingly, C. (1998). Healing dramas and clinical plots: The narrative structure of experience. Cambridge University Press.
McEwen, I. R. (2001). Writing case reports: A how-to manual for clinicians. American Physical Therapy Association.
Higgs, J., & Jones, M. A. (2008). Clinical reasoning in the health professions. Elsevier.
Cook, C. (2001). The role of functional movement assessment in clinical practice. Journal of Manual & Manipulative Therapy.
Testa, M., Rossettini, G., et al. (2016). Interventional assessment in manual therapy: How and why. Manual Therapy.
Eva, K. W. (2005). What every teacher needs to know about clinical reasoning. Medical Education.
Levett-Jones, T. (2010). Clinical reasoning: Learning to think like a nurse. Pearson Education.