Chapter 9 Dimensions of clinical reasoning capability
In the context of our complex healthcare environment, most clinical situations are characterized by varying levels of certainty and agreement as to the appropriate or ‘right’ decision to be made and course of action to be undertaken. This uncertain and at times unpredictable practice environment presents many clinical reasoning challenges, even for experienced clinicians. When we consider the array and magnitude of potential challenges this same practice context poses for less experienced or new clinicians, the need is clear for a focus on the development of capability in clinical reasoning during professional entry educational programmes.
This chapter draws from findings of a doctoral research project undertaken by Christensen, in collaboration with Jones, Edwards and Higgs, which explored how the development of capability in clinical reasoning can be facilitated in the context of professional entry physical therapist education (Christensen 2007). This research employed a hermeneutic approach to the interpretation of texts constructed from previously published literature and transcribed records of interaction with research participants. The research involved focus group and individual interviews with student physical therapists who were nearing the completion of their respective professional education programmes at four different physical therapy schools in California. Here, we introduce and discuss the concept of clinical reasoning capability, one of the main outcomes of this research. Ways in which students can be guided towards development of that capability during the professional entry education process are discussed in Chapter 36.
In our explorations we adopted the term capability from the higher education literature. Capability was defined by John Stephenson (1992, 1998) as the justified confidence and ability to interact effectively with other people and tasks in unknown contexts of the future as well as known contexts of today. Stephenson (1998, p. 2) explained that ‘to be “justified”, such confidence needs to be based on real experience’. Specifically, capability is observed in confident, effective decision making and associated actions in practice; confidence in the development of a rationale for decisions made; confidence in working effectively with others; and confidence in the ability to navigate unfamiliar circumstances and learn from the experience (Stephenson 1998).
In their phenomenological study of professional doctoral students in a work-based learning programme, Doncaster & Lester (2002) sought to understand what is involved in being and becoming capable. They concluded that capability may best be conceptualized as ‘an “envelope” or complex bundle of abilities and attributes which is personal to individual practitioners, and which is exercised in equally personal ways in relevant contexts’ (p. 98). Participants’ descriptions of ‘being capable’ included both ‘outer’ and ‘inner’ dimensions. The outer dimension of capability was linked with action; capable action involved initiating or managing change, especially in difficult or complex contexts. Closely related to this was the ability to work effectively with others to effect change through collaboration and consensus. The inner dimensions of capability varied considerably among participants, but Doncaster & Lester identified several commonly recognized qualities and skills that contributed to effectiveness. Specific examples were the ability to get things done, leadership ability and ability to inspire others into action in support of ideas and goals. All of these abilities required skills in communication, listening, facilitation, tact, persuasion and the ability to work with others. Other key elements of capability included intellectual or thinking abilities, such as critical thinking, reflection, synthesis, creativity, evaluation and intuition. Closely related to these were breadth and depth of understanding in action, involving the ability to see the big picture, understand the wider context and wider implications (of policies or actions) and engage in systems thinking.
Capability, then, cannot be precisely defined and therefore cannot be tied to a list of profession-specific technical skills and abilities, characteristic of ‘capable practice’. Rather, high-level capability results when practitioners have opportunities and resources for professional growth, encounter events or circumstances that spur them to action in this regard and are motivated to succeed or change in their practice (Doncaster & Lester 2002). In other words, capable individuals are skilled experiential learners. Capable individuals are motivated to develop their knowledge intentionally, through application and processing of their knowledge via reflective learning from practice.
Clinical reasoning is a process that links and integrates all elements of practice (such as philosophy of practice, generation and use of practice knowledge, profession-specific technical skills, communication and collaboration, ethics and identity). Within clinical reasoning, these integrated elements are brought to life and developed. Capability in clinical reasoning involves integration and effective application of thinking and learning skills to make sense of, learn collaboratively from and generate knowledge within familiar and unfamiliar clinical experiences.
Our recent research has identified that key elements of capability are directly applicable and recognizable in the clinical reasoning of skilled and experienced physiotherapists, and that capability in clinical practice is best observed through the clinical reasoning of skilled clinicians (Christensen 2007). Descriptions of characteristics of the clinical reasoning and practice of expert physiotherapists (Edwards et al 2004, Jensen et al 1999) show deep similarities to descriptions of performance of capable individuals: for example confidence and effectiveness in decision making, in providing contextual justification for actions and decisions, in motivating self and others, in communicating and collaborating with others to effect change and in critical, reflective thinking.
There are also similarities between capability and the Aristotelian notions of practical knowledge and reasoning, and obvious links to descriptions of the application and generation of practice knowledge in the clinical reasoning of skilled practitioners (Higgs et al 2004). Practical reasoning involves the application of both theoretical knowledge and, most significantly, experiential knowledge. A key feature of practical reasoning is that this experiential knowledge is both applied to and arises from practical activity, and is open to revision or expansion by processing new experiences in light of past experiences (Gadamer 1989). Practical reasoning is highly contextualized in that it is applied to concrete situations and results in particular actions relevant to the specific situation(s).
Another key feature of practical reasoning is that it is inherently ethical in nature. This is because it requires subsequent decisions for action, decisions that are determined by close consideration of the broader moral and ethical issues at play in the context of a particular situation (Dunne 1993). This action is oriented towards ‘doing the right thing’ based on taking all situational variables and constraints into account (Gadamer 1989, Schwandt 2001). Recently authors have described the practice of expert physiotherapists as profoundly influenced by their context, ethics, values and virtues (Edwards et al 2005, Jensen & Paschal 2000). Likewise, capability is observed when we see people ‘taking effective and appropriate action within unfamiliar and changing circumstances’, which ‘involves ethics, judgements, the self-confidence to take risks and a commitment to learn from the experience’ (Stephenson 1998, p. 3).
The clinical reasoning process is the ‘navigation system’ upon which skilled clinicians can confidently rely for direction in decision making and action, in both familiar and unfamiliar clinical situations. ‘Justified confidence’ in thinking, learning and associated actions is the hallmark of capability and is developed through successful experience in living out, or putting into action, what one knows (Stephenson 1998). Capability is characterized by the confidence to take risks, to try new things in practice and to make mistakes. Clinical reasoning provides a firm foundation for practice, not only for making decisions in uncertain situations and trialling new procedures but also for prompting reflection and learning from practice experiences both familiar and innovative.
Clinical reasoning is the vehicle for experiential learning from practice; it is well accepted that the process of thinking about one’s own thinking and the factors that limit it facilitates learning from clinical practice experience (Eraut 1994, Higgs & Jones 2000, Schön 1987). Thus, clinical reasoning serves to develop as well as to demonstrate practice capability.
Experiential learning is a goal of capable action and results from translating knowledge and reason into action in the context of living and working with others (Stephenson 1998). A key element in any individual embodiment of capability is the motivation and skill to learn through experiences in any (known or unknown) situation. Christensen (2007) found that capability in clinical reasoning was observed in clinicians who were confident in their skills and motivated to continually learn from collaborative work with patients in practice. We propose that clinical reasoning capability develops from, and contributes to, skill in collaborative clinical reasoning and experiential learning from reasoning experiences. Capable practitioners have been described in the literature as skilled and motivated experiential learners (Doncaster & Lester 2002, Stephenson 1998). Capable clinical reasoners, then, are skilled and motivated to learn from experience through intentional reflective processing of their reasoning in practice (Christensen 2007).
The research reported in this chapter (Christensen 2007) showed that capable clinical reasoners demonstrated sound thinking and learning skills. Dimensions of clinical reasoning capability, as discussed below, can be interpreted as being congruent with the descriptions of clinical reasoning of expert physiotherapists in recent research-based literature (Edwards et al 2004, Jensen et al 1999). These dimensions were often underdeveloped, disconnected, or absent in the conceptions of and reflections on clinical reasoning of the student physical therapist research participants studied by Christensen. The limited connection between these thinking and learning skills in the understandings of, and reflections on, clinical reasoning of most of the student physical therapists participating in the study served to highlight the lack of adequate attention to the learning of clinical reasoning in their professional educational journeys and clearly indicated the importance of developing the clinical reasoning skills of capable practitioners.
Given that capability has been described as a complex and multifaceted construct, not amenable to descriptions of specific technical skills or qualities, we suggest that the dimensions of clinical reasoning capability discussed here are not a comprehensive set of dimensions. Nor can they completely comprise the capable individual clinical reasoner’s ‘envelope’ or bundle of abilities and qualities. They have been chosen for their pivotal role in the reasoning of skilled practitioners and for the type of thinking in clinical reasoning that facilitates experiential learning. Learning from clinical practice requires thinking and learning skills to be integrated and applied to both the doing of the clinical reasoning (for example dialectical thinking, complexity thinking) and the processing of the experience of clinical reasoning (for example reflective thinking, critical thinking, complexity thinking). The four dimensions of clinical reasoning capability described here are reflective thinking, critical thinking, dialectical thinking, and complexity thinking.
The process of reflection relates to clinical reasoning of a practitioner, both when engaged with a patient over a period of time, considering and evaluating performance in past experience, and also in an immediate sense, reflecting in the moment while working with a patient. Schön (1987) described two types of reflection in practice that illustrate this distinction as reflection-on-action and reflection-in-action.
Reflection-on-action refers to thinking back on experiences ‘to discover how our knowing-in-action may have contributed to an unexpected outcome’ (Schön 1987, p. 26). In this sense, reflection becomes a way of cognitively organizing experience through construction of a sense of coherence, and facilitating planning for future action (Forneris 2004).
Reflection-in-action, as described by Schön (1987, p. 26), is reflection that occurs in the midst of action, without interruption of the action upon which the practitioner is reflecting. He described this type of reflection as thinking that modifies what is being done while it is being done, and which can thus impact on the situation at hand while it is still being experienced. Some scholars, however, have expressed concern about identifying as reflection this phenomenon that is characterized by the rapidity and relative superficiality with which someone can truly reflect on a situation while engaged in action (Eraut 1994, Van Manen 1995). Eraut (p. 149) suggested that this sort of reflection is more accurately viewed as a metacognitive activity than a reflective one. On the one hand this disagreement is about terminology; on the other it relates to the nature of reflection and metacognition as phenomena. In this chapter we propose that a heightened level of awareness involving critique of one’s thinking and other actions (which we have previously called ‘metacognition’; see Higgs & Jones 2000) is an essential element of sound clinical reasoning. This behaviour broadens the ‘bigger picture’ focus of experiential learning engendered by (after the event) reflection-on-action to also include the potential to learn from the smaller decisions and critiques within practice. Such reflective self-awareness (metacognition) facilitates concurrent learning within the details and patterns of response to individual decisions, actions and procedures in practice.
It is important to differentiate the process of reflection, as discussed above, from the process of critical reflection. The following section details critical thinking and describes the role of reflection in critical thinking in practice.
Critical thinking in professional practice is intimately linked to the process of reflection. However, ‘reflection is not, by definition, critical’ (Brookfield 2000, p. 126). Scriven & Paul (2004, p. 1) defined critical thinking as ‘the intellectually disciplined process of actively and skilfully conceptualising, applying, analysing, synthesising and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning or communication, as a guide to belief and action’. It is a skill that can be applied when developing an understanding of a particular situation or context, and also can be applied to the examination of thinking (one’s own or that of others) in the context of particular situations.
Forneris (2004. p. 1) argued that, ‘the outcome of thinking critically in practice is the achievement of a coherence of understanding. This can be defined as an awareness of assumptions, and how these assumptions connect to the reasoning used within the context of a situation to create new knowledge and generate an appropriate new action’. With grounding in an extensive comparative analysis of the work of the educational theorists Freire, Schön, Argyris, Mezirow, Brookfield and Tennyson, Forneris (2004) identified four core attributes of critical thinking: reflection, context, dialogue and time. When applied to clinical reasoning, these four attributes of critical thinking are a useful framework within which to conceptualize all the different elements of practice and the factors influencing collaborative clinical reasoning that are linked to critical thinking.
Reflection attaches meaning to information, and ‘illuminates the why and the reason for what we do and how we critically discriminate what is relevant’ (Forneris 2004, p. 4). As Mezirow (2000) explained, reflection allows for interpretation of experience; as part of reflection the thinker comes to know the ‘why’ of a situation by subjectively and objectively reframing the context to bring to light the underlying assumptions used to justify beliefs. New knowledge may then be produced if a new perspective on experience is achieved. ‘Reflection, as an attribute, is a means of engaging critical thinking processes in practice’ (Forneris 2004, p. 5).
Context refers to the ‘nature of the world in a given moment’ (Forneris 2004, p. 8). Through experience of living amongst the realities of a situation, understanding of that situation is achieved. Critical thinking in practice implies achievement of understanding in the context of that moment in practice. ‘Context encompasses culture, values, facts, ideals, and assumptions. All of these shape how we construct knowledge in practice’ (p. 9).
Dialogue is an ‘interactive process of evaluating perspectives and assumptions within context, in order to develop an understanding’ (Forneris 2004, p. 10). Brookfield (2000) contended that a critical dialogue requires an ongoing, evolving exploration of how the context of a situation influences the way that situation is understood. This interaction in critical conversation ‘involves participation in constructive discourse to use the experience of others to assess reasons justifying these assumptions, and making an action decision based on the resulting insight’ (Mezirow 2000, pp. 7–8). Critical conversation can occur with oneself, with patients/clients, peers, and mentors; any of these potential partners in constructive discourse related to any of the many facets of clinical reasoning in practice can serve to provide the clinician with an opportunity to self-examine more clearly from another perspective, and can facilitate experiential learning.
Time as an attribute of critical thinking connotes that past learning may be recalled in the present context and may also inform future action. Time also influences understanding, in that time taken to reflect on experience is necessary to the development and understanding of patterns and meaning (Forneris 2004). This is a key element that must be considered when working toward the facilitation of experiential learning through clinical reasoning.
Extending the idea and role of critical thinking to focus on thinking about thinking, Paul & Elder (2006, p. 4) defined critical thinking as ‘the art of analyzing and evaluating thinking with a view to improving it’. In effect, critical thinking about thinking promotes learning from and about thinking. Skilled critical thinkers, when applying their critical thinking to any situation, have been characterized as employing self-direction, self-monitoring and self-correction in the development of their thinking (Scriven & Paul 2004). In action, critical thinking is characterized by a consistent commitment to raise well-formulated and clear questions; to gather and assess relevant information; to think open-mindedly within alternative systems of thought; to recognize and assess assumptions, implications and the associated practical consequences; to communicate effectively with others in engaging with and finding solutions to complex problems (Paul & Elder 2006).
There are clear links between the above description of critical thinking as applied to one’s own thinking and the process of metacognition. Metacognition has been described as the integrative link between knowledge and cognition in the clinical reasoning process (Higgs et al 2004), and as the self-monitoring employed by the therapist in order to detect links or inconsistencies between the current situation and expectations based on learning from past clinical experience (Higgs & Jones 2000). Metacognition may involve reflecting on and critiquing data collection processes and results, considering different strategies of reasoning and reviewing personal biases or limitations in knowledge depth, breadth or organization.
Examining the writings of certain theorists about critical thinking, Forneris (2004) perceived that the meaning implied by their use of the word critical was overtly political (Argyris 1992, Brookfield 2000, Freire 1970). For example, Brookfield (2000, p. 126) explained that the word involves ‘some sort of power analysis of the situation or context in which the learning is happening’. Critical thinkers and learners must ‘try to identify assumptions they hold dear that are actually destroying their sense of well-being and serving the interests of others: that is, hegemonic assumptions’ (p. 126). This focus then promotes social action towards change when ‘people learn to recognize how uncritically accepted and unjust dominant ideologies are embedded in everyday situations and practices’ (p. 128). This interpretation of critical thinking relates directly to the role of critical thinking in recent discussions of the emancipatory nature of collaborative clinical reasoning (Trede et al 2003) and is relevant to improving one’s thinking and to fostering recognition of habits of thought and unfounded beliefs in the thinking of others.
The clinical reasoning of expert physiotherapists has been described as dialectical reasoning (Edwards & Jones 2007). In the context of their model, dialectic refers to movement between two fundamentally different (and potentially opposing) ways of thinking. Through this dialectic process of engagement in various reasoning strategies (some aligned with empirico-analytical thinking and others aligned with interpretive thinking, for example), physiotherapists collaborate with their patients to achieve a holistic understanding of both the biomedical aspects and the lived experience aspects of the patients’ worlds (Edwards & Jones 2007, Edwards et al 2004). A number of scholars (e.g. Basseches 1984, Kramer & Melchior 1990, Riegel 1973) have discussed the development of dialectical thinking in adults as an advanced skill level, or stage of cognitive development, which allows adults to cope with the inherent contradictions and complexity of life (Merriam & Caffarella 1999).
Basseches (1984) situated dialectical thinking as a middle course between what he described as universalistic formal thinking and relativistic thinking. Universalistic formal thinking assumes that there are fixed universal truths and a universal order to things (a perspective that can be aligned with an empirico-analytical research paradigm). Relativistic thinking assumes there is no one universal order to things, and that ‘order in the universe is entirely relative to the people doing the ordering’ (p. 10) (a perspective that can be broadly aligned with the interpretive research paradigm). Dialectical thinking moves along a continuum between the poles of universalistic formal thinking and relativistic thinking, drawing upon each as needed to promote appropriate interpretation of the many different facets of a particular phenomenon or situation, and to facilitate development of understanding in complex circumstances.
There are strong arguments for this sort of thinking, considering the perspective that a clinician is a complex human being, working with other complex human beings within a complex environment – the ‘swampy lowland’, where ‘messy, confusing problems defy technical solution’ (Schön 1987, p. 3). Dialectical thinking ‘considers both the deductive and inductive aspects of a situation in terms of an open system subject to feedback and change’ (Pesut 2004, p. 157). Dialectical thinking has also been discussed as an integral component of thinking within a complexity perspective.
Current literature and models of clinical reasoning (e.g. Higgs & Jones 2000, Pesut 2004) have characterized the thinking involved in the clinical reasoning process as non-linear, and not truly represented by the stepwise single-dimensional process found in early models of diagnostic reasoning in medicine. Current conceptions of clinical reasoning portray a type of thinking in practice where practitioners are ‘required to weave multiple threads together into a fabric of care’ (Pesut 2004, p. 152).
Increasingly, authors have advocated the adoption of the metaphors contained within complexity science as a way to understand and cope with the escalating complexity in health care (e.g. Plsek 2001, Sweeney & Griffiths 2002, Zimmerman et al 2001). It is argued that ‘we must abandon linear models, accept unpredictability, respect (and utilize) autonomy and creativity, and respond flexibly to emerging patterns and opportunities’ (Plsek & Greenhalgh 2001, p. 323). Suggestions (explicit or implicit) for the application of the concepts of complexity theory to ways of thinking in practice have also begun to appear in recent nursing and allied health literature (Forneris 2004; Pesut 2004; Stephenson 2002, 2004). These metaphors, derived from complexity science, include the foundational concept of complex adaptive systems. ‘A complex adaptive system is a collection of individual agents with freedom to act in ways that are not always totally predictable, and whose actions change the context for other agents’ (Plsek & Greenhalgh 2001, p. 625). Examples of complex adaptive systems encountered in the practice of health care include the human behaviour of patients, the whole of the healthcare system, the immune system, the patient and his or her family, the musculoskeletal system and healthcare teams within healthcare centres.
Description of the systems involved in health care (social, political, professional, human) as complex adaptive systems is contrasted with the more historical, traditional medical view of systems as mechanical in nature (for example the body as a machine metaphor, derived from Newtonian scientific principles) (Plsek 2001, Sweeny & Kernick 2002, Zimmerman et al 2001). Mechanical systems are characterized by linearity and predictability, and as such it is possible to know and predict in great detail what each of the parts will do in response to a given stimulus in a variety of circumstances, as they rarely if ever demonstrate surprising or emergent behaviour (Plsek 2001).
Proponents of the adoption of a complexity view of health care argue that, in today’s world, there are growing numbers of situations in which the traditional medical paradigm, and even early interpretations of the biopsychosocial model, are insufficient to frame and explain situations and provide guidance for action (Borrell-Carrió et al 2004, Holt 2002, Plsek 2001, Zimmerman et al 2001). In his discussion of the limitations to our understanding that arise as a result of the continued dominance of an inadequate traditional scientific model, Holt described linear thinking as ‘a sort of “mischief” which creeps into much of the way we conceptualize the world’ (p. 36).
We contend that current models of expert physiotherapist practice and of the clinical reasoning of expert physiotherapists (Edwards & Jones 2007, Edwards et al 2004, Jensen et al 1999), when viewed within a complexity perspective, also demonstrate characteristics of complex adaptive systems. Arguments for the inclusion of ‘systems thinking’ as a key skill in clinical reasoning have been presented by several authors (Pesut 2004, Stephenson 2004). Contemporary systems thinking, as described by these authors, reflects the complexity perspective and implies recognition of the dynamic relationships between the many elements and players in a given situation. This thinking incorporates induction (forward reasoning, reasoning from specific cues toward a general judgement), deduction (reasoning from a general premise toward a specific conclusion), and dialectical thinking (Pesut 2004, Stephenson 2004).
Richard Stephenson (2004) also discussed the thinking required for individualized consideration of the weighting of all relevant factors acting within the person acting as a system as essential to the reasoning process. In discussing clinical reasoning in the context of a complexity view of human behaviour, Stephenson (2004) described the need for consideration of each agent or component within the system (for example motor skills, thoughts and beliefs, communication, emotional arousal responses) as variable in degree of influence on and from the behaviour of the system as a whole. The degree to which a particular agent influences or ‘drives’ the behaviour of a system depends on both the internal (within the person) and external (the context within which the person is functioning) conditions acting in the system at the time (Stephenson 2002). Stephenson (2004) referred to this degree of influence of a particular component or agent within a system as its ‘weight’, explaining that due to the ability of complex adaptive systems to self-organize through feedback, this weighting of agents results from past history of activity which either positively or negatively impacts upon the system, and thus increases or decreases the amount of influence an individual agent holds over the system at present.
Stephenson (2004, p. 171) portrayed clinical reasoning (including the dialectical thinking processes involved) as a ‘tool through which the potential weight of each influence can be explored, requiring knowledge of all potential influences’. He stressed that as a whole system, no one component or agent acting in the human system has assumed priority or dominant influence on emerging behaviour. In addition, when considering which influences are driving the system in particularly adaptive or non-adaptive ways, different health professions cannot consider specific components in isolation from the whole of the system of influences (for example physical health as distinct from environmental and psychosocial influences on disability). Thus it can be argued that complexity thinking is required for the sort of holistic clinical reasoning required to make wise decisions in such complex situations involving complex human beings.
The argument has been put forth in recent medical literature that education of new practitioners for capability, as opposed to competence, is essential when preparing new professionals to practise in today’s complex healthcare environment (Fraser & Greenhalgh 2001, Rees & Richards 2004). Capability extends beyond the notion of competence to include the capacity of individuals to realize their potential in unknown future circumstances; this is related to the ability to adapt to change, generate new knowledge, manage one’s own continual professional development and contribute to shaping the future (Fraser & Greenhalgh 2001, Stephenson 1998).
For allied health professions this focus on capability meets the call for education that focuses on preparation for practice in the complex healthcare environment of today and tomorrow. In particular, professional education curricula need to focus on the development of generic thinking and learning skills (in addition to technical, profession-specific content). Development of thinking, learning, and clinical reasoning skills are critical when considering that new healthcare practitioners must not only be qualified to practise as individuals, but also need to be able to work in teams and be ready to contribute to the development of the profession (Higgs et al 1999, Jensen & Paschal 2000).
We suggest that development of students’ thinking and learning skills that contribute to capability in clinical reasoning should be a priority, not just for academic and clinical educators but for all practitioners. There is widespread agreement that expertise evolves over time as clinical practice experience is accumulated. However, it is also well recognized that any number of years of experience will not automatically result in expert clinical performance. It can be argued, then, that experts are clinicians who are more successful than non-experts in learning from their practice (Cervero 1992, Higgs et al 2004). We have proposed that skilled practitioners must be capable clinical reasoners. Facilitating the development of capability in clinical reasoning in professional education programmes is one step towards facilitating movement of all clinicians towards more expert practice, and thereby facilitating the generation of high quality practice knowledge for development of the profession itself.
Stephenson (1998) argued that the outcome of any higher education process should be judged by the extent to which it: (a) graduates students who are confident and able to take responsibility for their continued personal and professional development; (b) prepares students to interact effectively within their life and work contexts; and (c) promotes and motivates students to continue to pursue excellence in the generation and use of knowledge and skills in practice. Capability implies both fitness for purpose (working and adapting to change within an existing system) and fitness of purpose (envisioning and working for change to the system itself) (Doncaster & Lester 2002). Similarly, capability in clinical reasoning implies a motivation to learn from and improve personal practice – effective work within a system – but also a motivation to learn about and work to change for better professional practice itself – effective work on a system.
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