The Evolution of My Clinical Reasoning in Fellowship: Beyond Applying Concepts

Written by: Mina Pitello, MOTR/L

Virtual Hand Therapy Fellow

When I began my fellowship, I approached treatment with the belief that good clinical

reasoning was built on knowing the “right” diagnosis and applying the right “treatment intervention.” I

centered sessions around a mindset based in anatomy, biomechanics, and order of intervention. While these concepts still remain present in my treatment post-fellowship, it is through this fellowship that I have been challenged to reframe my approach and assess something far more complex than the ailment in front of me: the person as a whole.

Over the course of this fellowship, my clinical reasoning evolved from simply identifying impairments to appreciating the intricacy of factors that influence recovery. I have learned that successful rehabilitation is rarely isolated to diagnosis and intervention as they relate to structures alone; instead, a more successful outcomes-based approach requires balancing tissue healing, movement quality, patient understanding and personal goals for outcome, psychosocial considerations, communication, and flexibility in treatment sessions.

To Protocols, and Beyond

In my earlier career, I relied heavily on established rehabilitation protocols. This provided structure and confidence, particularly when managing postoperative patients. In contrast, this fellowship has taught me that no protocol fits every patient perfectly.

While in the fellowship, two individuals on my caseload with a similar surgical repair and the same

postoperative protocol presented with vastly different pain levels, movement patterns, fears,

motivations, and recovery trajectories. With the confidence I gained through the fellowship, I began to

use protocols as guidelines rather than rigid rules. The clinical reasoning I have gained prompted me to ask, “What will this patient tolerate today?” “What are the true barriers to progress?” “Are these symptoms related to tissue healing, guarding, or pain?” “Does this patient need progression, downgrading, or reassurance?”

This shift has allowed me to become more observant as a practitioner. I notice more confidence in my treatment interventions, communication with my patients and physicians, and less reactivity when patients don’t quite fit the mold with their progression. Instead of using a protocol, I started treating the patient.

Communication, the Forgotten Treatment Modality

Perhaps one of the most valuable lessons I have learned is that communication in itself can be

therapeutic.

The way we communicate can influence patient expectations, confidence in care, and adherence to the individual’s plan of care. The deeper understanding I have gained in fellowship has allowed me to better simplify complex concepts without oversimplifying the patient experience.

Patients have reported better outcomes with a better understanding of their condition and empowerment in their recovery.

Not only has my ability to confidently understand and communicate concepts with patients improved, but the Fellowship has also allowed me to more effectively and confidently communicate with surgeons, therapists, trainers, and other healthcare professionals to improve continuity of care and patient outcomes.

Learning Comfort in Uncertainty

One of the most humbling aspects of fellowship was appreciating that clinical reasoning, and its

development, is not a static concept. There were patients who progressed exactly as expected and

others who challenged every presumption I had. Some cases improved with classic interventions, while others required creativity, patience, and continued reassessment.

Over time, I have become more comfortable admitting uncertainty and adapting my plan as new

information or results become available. Rather than viewing uncertainty as weakness, I now see it as

part of being a thoughtful and ever-evolving clinician.

This experience has not simply been about accumulating knowledge, but refining judgment.

Moving Forward

As I reflect on this fellowship experience, I realize the greatest change in me as an occupational

therapist was not only in the techniques I use to guide my interventions, but in the way I think about

each patient and their care. My clinical reasoning has evolved to be less of a rigid impairment-based

framework and more of an individualized, whole-person, adaptable process.

I now approach my practice with greater curiosity, humility, and appreciation for the complexity of

human recovery. Fellowship has strengthened my technical skills without a doubt, and more importantly, it has shaped how I listen, analyze, communicate, and problem solve.

The lessons learned throughout this fellowship will continue to influence my practice long after this

program has ended. I am grateful to the mentors, classmates, and patients who contributed to my

growth.