Thanks for sharing your thoughts on this important issue in physiotherapy education and practice. I enjoyed reviewing the article and learned a lot, especially from the section on Balint groups, which I’d never come across before, and which sounds like a wonderful activity to conduct in the classroom or clinical context.
Below are some suggestions that I think might help to improve the article. Please feel free to let me know if there are any items that you’d like to discuss further.
> Diagnostic uncertainty in musculoskeletal pain
The title and next sentence (i.e. “clinical decision making”) suggests that this is more broad than “musculoskeletal pain”. Consider enlarging the perspective throughout so that the piece is relevant to a larger audience.
> This paper outlines considerations for diagnostic uncertainty in physiotherapy practice
The title suggests a different audience i.e. physiotherapy educators. This seems to suggest that this relevant for those who are already in practice. Consider rephrasing.
> our key strategies to help student and novice physiotherapists
Again, a disconnect with the title and previous sentence i.e. “educators” in the title, “practitioners” in the previous sentence, and “students and novices” here.
The conclusion is quite long relative to the rest of the abstract. Consider including more information about the strategies, and reducing the length of this conclusion.
> face the significant challenge of assessing and managing pain of increasing prevalence and complexity
If the emphasis of the piece is on “diagnostic uncertainty” more generally, then consider removing references to pain. However, if there is a point to be made about “diagnostic uncertainty in the assessment and management of patients with musculoskeletal pain”, then this focus should be consistent throughout the piece. My suggestion is that “diagnostic uncertainty” is general enough that a broader emphasis is warranted.
> provide an accurate explanation of the patient’s health problem
This is the point I was referring to earlier i.e. that this could have a more broad focus.
> This dilemma
Is “a subjective perception of an inability to provide an accurate explanation of the patient’s health problem” a dilemma in the true sense of the word? As in, a difficult choice that needs to be made. What is the difficult choice you’re referring to?
> The implications of this dilemma
Again, it’s not clear what the dilemma is. The “inability to provide an accurate explanation” doesn’t seem to fit the definition of a dilemma.
Why is this in scare quotes?
> including physiotherapists when managing individuals presenting with pain
Does it only impact physiotherapists managing individuals presenting with pain, or is the sentence no less accurate if you end it at, “…including physiotherapists”? This is in line with my question about whether or not the emphasis could be more broad than “pain”.
> four key considerations for addressing diagnostic uncertainty in the context of physiotherapy education are presented
The reader would benefit from knowing where these four strategies came from, and how they were selected, presumably from among others. Including some support for this selection would be helpful. If no direct evidence is available (i.e. you simply chose them), then a short reflection on the thinking process and decision-making would also be useful.
Applying a critical lens to diagnostic uncertainty
> Tversky and Kahneman noted, “the brain appears to be programmed to provide as much certainty as it can. It is designed to make the best possible case for a given interpretation rather than to represent all the uncertainty about a given situation” (Tversky & Kahneman, 1974). Put simply, we are hardwired to seek certainty and thus we actively avoid unpleasant emotions that arise from uncertainty (Berker et al. 2016).
I think that this section could be moved later in the section. The sentence “When we look critically at physiotherapy education…” seems – at least to me – to be a stronger opening.
> than exploring the individual’s pain experience. The pattern recognition
The previously highlighted section (“Tversky and Kahneman noted…” could be inserted in between these two sentences.
> Clinical reasoning in pain presentations cannot be separated from diagnostic decision making
The sentence would read just as well if “in pain presentations” were removed. Again, aiming to broaden the concept for a more general audience.
Recognising and normalising uncertainty
> that it is not only “safe” but also helpful
Why is “safe” included in scare quotes?
> Beck and colleagues (2020) have recommended that educators communicate messages such as “making a diagnosis is sometimes challenging, and often times there are several possibilities that we may need to consider”
When direct quotes are used, the page number of the source should be included in the citation.
> with non-specific or complex pain presentations being managed effectively
Again, removing the word “pain” leaves the sentence more broadly applicable, while losing none of the value.
> The issue with uncertainty is not about learning how to eliminate it but how to manage it
Is this really about “managing” uncertainty, or is it more about acknowledging and embracing it; more of an acceptance with being in its presence. “Managing” has a connotation of controlling it, which isn’t the message I got from reading the piece.[jetpack-related-posts]