Causal Knowledge

Bridging Research and Practice

One of the most persistent challenges in clinical practice is the "clinician’s dilemma"—making decisions and taking action based on less-than-perfect knowledge. In my Linda Crane Lecture (and this paper), I proposed a framework for addressing this challenge: knowledge-based practice (KBP). KBP recognizes that practice relies on causal knowledge, which can be encoded through causal models. These models are not static; they are dynamic tools for integrating evidence, reasoning, and iterative refinement.

Why Causal Models Matter

Causal models are central to clinical reasoning because they connect empirical observations to the real-world complexities of practice. Unlike traditional evidence-based practice (EBP), which often translates evidence into generalized protocols that are difficult to apply to a particular patient, KBP emphasizes the development of causal models that reflect the realities clinicians face every day. For instance:

• They help navigate the complexity of competing hypotheses in differential diagnosis.

• They provide a structured framework to integrate multiple pieces of evidence.

• They shift the focus from rigid protocols to adaptable, knowledge-informed decisions.

Possible causal model relating electrical stimulation to possible outcomes. (a-v)O2, arteriovenous oxygen difference; 6MWD, 6-minute walk distance; HRQOL, health-related quality of life. Notice that claims that Estim, which changes muscle physiology will impact HRQOL must deal with possible modifying effects of EVERY SINGLE VARIABLE that the causal path must traverse between ES and HRQOL (minimally, since there are many more mechanistic variables being ignored in this model (all models are wrong, some models are useful).

Critical Realism as a Foundation

The epistemological foundation of KBP is critical realism, which acknowledges that while our knowledge may never perfectly reflect reality, it can still guide effective action. In this sense, causal models are not merely theoretical constructs but practical tools that synthesize evidence and reasoning to support clinical decisions.

Connecting to the Clinical Inquiry Fellowship

The Clinical Inquiry Fellowship (CIF) is designed to nurture physical therapists who are ready to move beyond traditional EBP. Fellows are trained to:

• Develop and refine causal models as part of their clinical reasoning toolkit.

• Engage critically with evidence, recognizing its limitations and contextual relevance.

• Contribute to the scholarly evolution of clinical reasoning through research and publication.

This approach aligns with CIF’s mission to redefine clinical inquiry as a dynamic, evidence-informed process that transcends the limitations of logical positivism.

Why It Matters for Physical Therapy

For too long, the gap between research and practice has stifled innovation and limited clinicians’ ability to act confidently in complex situations. KBP, supported by tools like causal models, offers a way to bridge that gap. It empowers therapists to practice with both humility and decisiveness, acknowledging the imperfection of knowledge while striving to refine it continuously.

The CIF, as a community of scholars, will play a vital role in advancing this paradigm. Through mentorship, research, and collaboration, our fellows will not only challenge the status quo but actively shape the future of physical therapy practice.

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Call to Action If this resonates with you, consider joining us at the Clinical Inquiry Fellowship. Together, we can build a foundation for clinical reasoning that is as dynamic and adaptable as the realities of practice demand.