Cause at the core of clinical reasoning

For various reasons I have been once again thinking about the pervasiveness of cause at the core of clinical reasoning, clinical knowledge and clinical practice. Of course from the distributive law this can become: clinical (reasoning, knowledge and practice).

Circulating around for physical therapists (and PT educators and students) there are many: 1. models of clinical reasoning; 2. philosophies of practice; 3. proposals for generating and interpreting evidence; and 4. proposals for translating evidence to knowledge. Interestingly the concepts of causal inference, assumptions and reasoning are not highlighted as much as one would expect in these models. Perhaps it is so pervasive as to be ignored much of the time (such as oxygen in air). But, like oxygen in air, when it is missing it has an impact.

Early in the history of this blog I started with a post on the Case for Cause. I make this claim: “I do not imagine there is much debate about the importance of causal reasoning in clinical practice, or that causal reasoning presupposes cause, causation, causality. So this post does not provide a justification for cause, it presupposes cause as important and attempts to explain how cause will be used in development to avoid extremes, and to avoid skepticism.”

I believe that might have been a mistake. Of course it is from that platform (possible mistake) that the blog proceeded with months of posts on “causal models” as an approach to provide a reasonable understanding of an underlying “causal structure” and methods to do so with “graphical causal models”, “directed acyclic graphs (DAGs)” and “Bayesian networks”.

I am not saying that putting “cause” at the core of clinical reasoning and clinical epistemology is a mistake. But perhaps starting a blog that “presupposes cause as important” might have been a mistake. Perhaps I needed to justify cause at the core of clinical reasoning and clinical epistemiology first. Due to the time space continuum that is now impossible (to do the justification first), but it is not irrevocable. Therefore over the next “n” posts (number to be determined), the blog will put forth a justification of cause as the core to clinical reasoning and clinical epistemology. Going back to the foundations of this blog: Cause, models and inference in Physical Therapy: Developing a knowledge based practice; cause is what is real, it exists, we make models to attempt to understand it, to know about it, inferences are the logical-rational approaches we use to take that knowledge to proceed from one set knowledge of a possible world, to another set of knowledge of a possible world (i.e. a world that has X and Y combined with knowledge that X and Y cause Z leads to knowledge of a world with Z by deduction). (Not going to get into the connection  between knowledge and belief here right now, but it will most likely come up in the justification of cause - basically, anything we propose to know, we do so with a certain belief and belief is where we can start to consider the probability of truth of the knowledge).

While there have been numerous posts about cause (how can there not be, it is the core); these upcoming posts will attempt to justify cause as the core for clinical reasoning and clinical epistemology. I will also attempt to justify why cause as the core that needs to be explicitly considered, and how doing so is beneficial and binding to several ongoing projects about practice in the profession related to: clinical reasoning, evidence, knowledge translation. If cause is at the core of these projects then it provides a natural connection point between them for consideration. For example, evidence of a causal relationship results in knowledge of a causal structure which produces an improved causal model which is reasoned about inferentially to make practice decisions. This also allows us to consider how ethical and moral categories impact causal structure and resultant decisions.

Cause being at the core does not dismantle or alter any of the existing systems out there right now (any of the 1. models of clinical reasoning; 2. philosophies of practice; 3. proposals for generating and interpreting evidence; and 4. proposals for translating evidence to knowledge). Cause being at the core simply highlights a pervasive feature of them all, and possibly results in an expansion of the methods used to articulate, teach, disseminate and use the models. And, as many of you know, I believe putting cause at the core means putting causal models and causal structures as elements of knowledge from which to base practice, and provides a way to compare and contrast existing models of reasoning, practice, evidence and translation.

As a start - if anyone can think of an example of a clinical scenario where causal reasoning is NOT involved (even a very isolated and fabricated scenario) - please share it with me

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