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INTRODUCTION

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If we always do what we've always done, we will get what we've always got.

—Adam Urbanski

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*Mr. Ketterman's Case

It seems as though other people must have had patients with all of Mr. Ketterman's problems, even though I don't very often see anyone like this. Maybe I can find some recommendations in the literature about how to treat him. (See Appendix for Mr. Ketterman's health history.)

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Early physicians learned the art of medicine by tutorial, observing their mentors and discussing the decisions they made.1 In this manner the rich wisdom of practice was passed from one generation to the next. Of course, errors in thinking were also passed on. Our current health care system has formalized this process of passing on knowledge through organized education that includes both formal academic preparation and well-defined clinical education requirements. During this formal education students are often asked to explain their clinical decision making, but experienced teachers and mentors seldom explicate their own. In addition, explicit processes to explain or improve clinical decision making are considerably diminished once the practitioner has met entry-level requirements. Licensed practitioners, be they physicians or physical therapists, usually make their clinical decisions in isolation, often with only the patient as a fellow participant in the process. This means that there are few opportunities to articulate, examine, and validate the clinical decision making process. We continue to support behaviors that often are just as likely to lead to the continuation of poor decision making as to better decision making. Some would even say that our current health care system forces us to work against the process of making clinical decisions explicit for practitioners, thus forcing isolated and isolating practice environments on young practitioners.

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Many systems have been developed in response to this problem. They are primarily divided into two approaches. The first is a process approach that provides templates that encourage good decision making—helping us with the way we think. The second is a content approach that provides guidelines about what the decisions should be—suggesting to us what to think. When used together these two approaches can be very successful in helping us reflect on and improve our decisions.

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PROCESS APPROACHES TO THE WAY WE THINK

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The linguist B. L. Whorf has said, "Language shapes the way we think, and determines what we can think about."2 In Chapter 1 we discussed the language of physical therapy practice, focusing on enablement/disablement models and on the patient care management model as sources of the language we use to communicate. We can also view these models as guides to our thinking processes, leading us to organize our clinical decisions in certain ways, to adopt new ways to think.

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Enablement/Disablement Models

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The use of a disablement model as a basis for our thinking leads us first to recognize that ...

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