Author Response.

We want to thank our colleagues, Dr Bartlett, Dr Mitchell, and Dr Swaine for their thoughtful, provocative responses to our article. Each commentator addressed different areas for their comments and critique that will be the focus of our discussion here. In addition, all 3 commentators saw our detailed methodology as a major strength of the research that will be helpful for other qualitative researchers. We thank them for their compliments. We also want to acknowledge that the original manuscript reviewers for Physical Therapy raised numerous questions for the qualitative methods used. It is our hope that as manuscript reviewers, as well as readers, become increasingly familiar with the rigor inherent in good qualitative research, the explanation of qualitative methods will be allowed to parallel the current expectations for presentation of quantitative methods.

Dr Bartlett and Dr Mitchell raise the question of generalizability of results. In our report, we used the term "transferability" and drew a parallel to the concept of external validity. Although this term is similar to external validity, the underlying assumptions for transferability arise from the philosophical foundation of qualitative methods. We are not talking about the issue of generalizability based on statistical logic but rather the issue of generalizability based on theoretical inference. In qualitative research, there is a small sample, not a random sample, that has been selected purposefully because of the contributions each of them will make to the emerging theory.[1] The term "transferability" refers to application or the extent to which the findings of a particular study may be applied in a similar context.[2-4] A well-known anthropologist, Dr Fred Erickson,[5] argues that the "general lies in the particular." That is, by studying specific cases in great detail and comparing them with other cases, we can transfer or generalize to other similar situations. Is the reader convinced that this thick description applies to his or her situation? We have a good example of that discussed in Dr Swaine's commentary where from her perspective she believes that these same dimensions of expertise would be identified regardless of specialty area.

A second concern is the knowledge base dimension and experts' reported use of scientific evidence. Dr Bartlett expresses concern at what appears to be an overreliance on knowledge obtained through methods other than the scientific method. There may be several explanations for this. Our subjects did express a value for scientific evidence and incorporated it into their practices, and this is discussed in more detail as part of our individual cases in our book.[6] Our experts could distinguish the practices in their areas that are supported by evidence and those that are consensus driven. They have contributed to the literature and participated in professional activities that create consensus on practice elements. The data we are able to share in this article are limited by space. Although we did not ask our subjects to rank the importance of the various sources of knowledge, we would speculate that patient-based knowledge would emerge at the top. This is not surprising, given our study of expertise in the practice setting where knowledge and clinical reasoning are interdependent phenomena. Research in medicine demonstrates that with increasing clinical experience, biomedical knowledge becomes integrated with the clinical knowledge.[7-11] We also see that in the creation of new scientific knowledge, experts will use their knowledge of the patient as a driving force for new investigative questions.

There is an important distinction about knowledge and types of knowledge used in practice. This is the distinction made between declarative knowledge (useful in guiding the action) and procedural knowledge (clinical knowledge), the knowledge of knowing how to do things. One of the most fundamental differences between experts and novices is that experts bring more knowledge in terms of amount and type to bear in solving the problem.[9-11] The use of declarative knowledge, the knowing of facts and information, often is of limited value in solving professional problems in practice unless the practitioner can couple the declarative knowledge/scientific knowledge with other types of knowledge such as knowledge of the patient as well as their tacit or implicit knowledge.[10-12] The knowledge base of an expert has been transformed and shaped by his or her experience so that he or she is able to bring multiple forms of knowledge to the practice setting.[9-11] This apparent underemphasis on knowledge obtained through the scientific method may also be due in part to our focus on collecting data in the midst of clinical practice.

Dr Bartlett also expresses concern that this cohort of experts did not appear to integrate evidence-based practice into their daily decision making. We agree that evidence-based practice is important, but our experts tell us that the evidence underlying their practice comes from many different sources. From our own perspective, as well as those of others,[3,13-15] not all evidence for clinical interventions and, in our case, physical therapy interventions will come from randomized, controlled clinical trials because much of physical therapy practice is not amenable to study this type of research design.

Dr Bartlett also stated that reference to critical appraisal was missing. We disagree and would argue that critical appraisal is evident through experts' ongoing reflective process. Our experts demonstrated consistent evidence of higher-order thinking processes (metacognition) through their ongoing self-assessment and ability to think and change their actions while engaged in practice. Dr Bartlett's comments center on the well-recognized distinction of research and practice. We believe our experts demonstrated significant links between these worlds. They displayed mastery of current scientific evidence, but they are often found solving clinical problems for which there is precious little evidence or consensus to guide practice. As stated by Sackett et al, "The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise, we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice."[16(p2)]

Dr Swaine raises questions about sampling and random assignment of treatment sessions. These questions can be answered by returning to the fundamental assumptions for the methodology. Again, sampling is a frequent concern raised to qualitative researchers because we use small samples and do not use probabilistic sampling strategies. We use theoretical sampling; that is, we select individuals who can well represent the phenomenon of interest and, yes, it is biased, because we want to find the subjects who will provide us with the richest data possible to further understand expert practice in physical therapy.[17]

In terms of whether we biased the reactions of the therapists, one of the standards of verification is prolonged engagement in the field. We were comfortable with our therapists, and they were comfortable with us. We collected data long enough and over enough cases so that we were hearing and seeing the same things. The perspective of the qualitative researcher is not on eliminating the impact of the researchers on the research but on acknowledging what our presence brings to the process. There is no way to escape the social world. We address this through self-monitoring, use of consultants, and methods of triangulation.[2-4]

Dr Swaine also raises an extremely important question about instilling professional virtues: Can it be done with students? This is a question we have discussed many times. We believe, as many do in health care, that health education programs often pay insufficient attention to the development of students' moral reasoning skills and ethical judgment.[18] We can identify for students as well as facilitate their development of these virtues through course content, designing explicit learning experiences and emphasizing role modeling of these virtues by academic and clinical educators. We believe that opportunities to grow in these personal virtues should be provided at all points on the professional development continuum. In professional education, performance feedback must be explicit to ensure minimum competency in professional behaviors,[19] but examples of virtuous practice must be examined and discussed to motivate young professionals to increasingly intense levels of self reflection. Our experts clearly demonstrated that the path to virtuous practice leads through the development of significant self-knowledge.

Dr Swaine pointed out with some frustration that the mean number of years of experience of our subjects was 22 years. We believe this is an artifact of the nomination process; that is, being well known and highly regarded by your peers is often associated with visibility over a number of years in practice. The literature on expertise suggests that the average number of years to gain expertise in a profession is about 10 years.[20] The more important dimension here is motivation and inner drive. Inner drive, high motivation, and a passion for learning were shared characteristics among our experts. These personal attributes also address Dr Swaine's question about whether every expert is a workaholic. We do not think so. We did not highlight the personal lives and activities of our experts. We did, however, hear consistent stories about their love of their work as well as maintaining a balance of work and personal time. Work is an exciting challenge to them--if they were not continually challenged, they would not continue do it. In their early development phases, they made sacrifices and took time and pursued additional education, even without financial support.[6]

Dr Swaine also asks why we did not include communication as one of our dimensions of the framework. Communication skills are a fundamental aspect of patient-therapist collaborative endeavors and patient-centered care. In essence, communication is integral to all 4 dimensions of expertise rather than being considered a separate component.

Dr Mitchell has raised an excellent point regarding whether one could expect a generalist to exhibit the same dimensions of expertise as those held by clinical specialists. Our answer is "yes." We have no reason not to expect that the same dimensions would hold for generalists. We selected subjects for this study who had chosen to specialize their practice because this facilitated the identification of practitioners who would be considered experts through a peer nomination process. Therefore, we provided a description of expertise in physical therapy practice as we observed it among 12 specialists. We, too, are interested in the consistency of the elements of expertise should this be studied in a group of generalists who are recognized for their expertise in practice. We welcome further research regarding generalists whose practice often crosses boundaries of many of the specialty areas. One logical comparison would be between practitioners who have similar years of experience but differently judged expertise. Neither of these comparisons have been conducted in physical therapy at this date, and we do not suggest the generalization of our data describing specialists to either generalists or experienced practitioners.

We also believe that entry-level curricula should be designed to foster the development of generalists. Our suggestions for teaching strategies reflect this belief. For example, teaching students to value patients as a source of knowledge and learning to carefully listen to patients and develop manual skills as well as cognitive skills are the basic tools of the generalist long before one develops a clinical specialty area.

Dr Mitchell questions whether time is a necessary element for the development of the expert. Time alone, of course, does not appear to be enough. We have all witnessed mediocre therapy practiced by clinicians who have many years of experience. A primary difference between these therapists and those who have acquired expertise may be in how they use time. Our respondents demonstrated a sustained and thoughtful process of reflection in and on action.[6] This use of reflection has been identified by other researchers studying expertise[21] and is clearly instrumental in the development of the expert's knowledge and clinical reasoning skills.

We certainly concur with Dr Mitchell that the relevance of patient care outcomes to the level of therapist expertise needs to be identified and researched. The comparison of outcomes of physical therapist intervention between novice and expert clinicians is a fascinating challenge, and one we encourage our colleagues to pursue. We have learned from the study of both novices and experts that the dimensions of outcomes must be broadly defined to accurately capture both the nuances and the objective differences when describing the complex process of recovery of function under the care of a physical therapist. This is not a challenge for the faint of heart, but Dr Mitchell reinforces the importance of asking the question: "What differences between novice and expert clinicians matter?"

However, we disagree with Dr Mitchell that it is premature to consider changes in the practice environments and professional education based on our findings. Let us begin now to develop in our students and young colleagues those behaviors, virtues, and ways of thinking that are consistent with the development of clinical expertise. It will do no harm and may have tremendous benefits in the quality of patient care and in the joy of being a physical therapist.

References

[1] Morse JM. Qualitative generalizability [editorial]. Qualitative Health Research. 1999;9(1):5-6.

[2] Lincoln Y, Guba E. Naturalistic Inquiry. Newbury Park, Calif: Sage Publications Inc; 1985:289-331.

[3] Murphy E, Dingwall R, Greatbatch D, et al. Qualitative research methods in health technology assessment: a review of the literature. Health Technology Assessment. 1998;2(16). Available at: http://www. soton.ac.uk/~hta).

[4] Creswell J. Qualitative Inquiry and Research Design. Newbury Park, Calif: Sage Publications Inc; 1997:193-218.

[5] Erickson F. Qualitative methods in research on teaching. In: Whittock M, ed. Handbook of Research on Teaching. 3rd ed. New York, NY: Macmillan Publishing Co; 1986:119-161.

[6] Jensen GM, Gwyer J, Hack LM, Shepard KF. Expertise in Physical Therapy Practice. Newton, Mass: Butterworth-Heinemann; 1999.

[7] Boshuizen H, Schmidt HG. The development of clinical reasoning expertise. In: Higgs J, Jones M, eds. Clinical Reasoning in the Health Professions. Newton, Mass: Butterworth-Heinemann; 1995:24-48.

[8] Patel VL, Kaufman D, Magder S. The acquisition of expertise in complex dynamic medical environments. In: Ericsson KA, ed. The Road to Excellence. Hillsdale, NJ: Lawrence Erlbaum Associates Inc; 1996:127-165.

[9] Higgs J, Jones M, eds. Clinical Reasoning in the Health Professions. Newton, Mass: Butterworth-Heinemann; 1995.

[10] Sternberg RJ. Abilities are forms of developing expertise. Educational Researcher. 1998;28:11-20.

[11] Schon D. The Reflective Practitioner: How Professionals Think in Action. New York, NY: Basic Books; 1983.

[12] Reber AS. Implicit Learning and Tacit Knowledge: An Essay on the Cognitive Unconscious. NewYork, NY: Oxford University Press; 1993:64-72.

[13] Popay J, Williams G. Qualitative research and evidence-based healthcare. J R Soc Med. 1998;35:32-37.

[14] Greenhalgh T. Papers that go beyond numbers. In: How to Read a Paper: The Basics of Evidenced-Based Medicine. London, England: BMJ Publishing Group; 1997:151-162.

[15] Di Fabio RP. Myth of evidence-based practice [editorial]. J Orthop Sports Phys Ther. 1999;29:632-633.

[16] Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. New York, NY: Churchill Livingstone Inc; 1997.

[17] Morse J. What's wrong with random selection [editorial]? Qualitative Health Research. 1998;8:733-735.

[18] Smith SR, Balint JA, Kause KC, et al. Performance-based assessment of moral reasoning and ethical judgment among medical students. Acad Med. 1994;69:381-386.

[19] May WW, Morgan BJ, Lemke JC, et al. Model for ability-based assessment in physical therapy education. Journal of Physical Therapy Education. 1995;9(1):3-6.

[20] Ericsson KA, ed. The Road to Excellence. Hillsdale, NJ: Lawrence Erlbaum Associates Inc; 1996.

[21] Martin C, Siosteen A, Shepard KF. The professional development of expert physical therapists in four areas of clinical practice. Nordic Physiotherapy. 1995;1:4-11.

Gail M Jensen, PT, PhD Jan Gwyer, PT, PhD Katherine F Shepard, PT, PhD, FAPTA Laurita M Hack, PT, PhD, MBA, FAPTA