Competence and Complacency.

To the Editor:

The title of the article by Jensen et al in the January issue, "Expert Practice in Physical Therapy," immediately attracted my attention. Perhaps somewhat naively, I hoped for ideas or information that might help me improve as a therapist. I was disappointed. However, I was inspired/provoked to write my first Letter to the Editor.

With all due respect, it is not especially insightful or practically helpful to conclude that multidimensional knowledge, clinical reasoning ability, focus on movement, and caring and commitment constitute key dimensions of expert practice in physical therapy. I do not disagree with the authors' conclusions, and I commend them for a thorough, methodical, reasonable approach to achieve their stated purpose. I do have 3 comments related to issues brought up in the article and commentaries.

First, I consider that peer designation is an incomplete, and possibly misleading, way to identify experts. For clinicians, experts may be individuals who likely have a kind of personal charisma, a reputation, and popular appeal--but no significantly different levels of knowledge, reasoning ability, focus on movement, or caring and commitment from other less popular or less charismatic individuals. I wonder about the selection process being a popularity contest of a sort. For me, the critical test of an expert--results and effectiveness--was dismissed, presumably as too difficult to determine reliably. For patients, the expert very likely may be the therapist who is associated with their successful recovery, most of which, I believe, is patient-generated and due to spontaneous recovery. The so-called expert's intervention, very likely unsophisticated and routine, may have been incidental and may have had minimal impact on the patient's recovery. From the patient's perspective, however, that therapist performed as an expert. For physicians or academicians, the expert is probably associated with credentials, degrees, publications, or presentations, regardless of clinical effectiveness. My point is that the concept of expert is "in the eye of the beholder."

Second, the authors twice refer to mediocrity in a way that implies that it is easily identified. I wonder if it is any more or less readily recognized than expertise. I would contend that the mediocre therapist may be simply and correctly characterized by varying degrees of the same 4 dimensions associated with experts. Is the distinction between expert and mediocre merely one of degree?

Third, I propose that the concepts of competence and complacency replace expert and mediocre. A physical therapist is, by definition, an expert in movement--its analysis, components, and recovery. The competent therapist retains and maintains this expert status by demonstrated commitment to ongoing learning, driven and motivated by caring, that is, wanting to help patients with movement problems. The complacent therapist relies on the results of a licensing exam and minimal continuing education requirements, if necessary. The complacent therapist makes excuses for ineffectiveness and probably relies on a combination of personal appeal and spontaneous recovery to disguise deficiencies. Students should continue to be trained for entry-level competence as movement experts, that is, as physical therapists. It is not possible to predict where entry-level competence will lead. In my view, the degree of caring about patients and commitment to physical therapy are the key determinants of either continued competence or comfortable complacency. Unfortunately, the virtues of caring and commitment are not universal and are not readily teachable.

David J Smyntek, PT
4797 Cadwallader Sonk Rd
Vienna, OH 44473

Author Response:

We thank Mr Smyntek for his comments on our recent article on expert practice in physical therapy.

Mr Smyntek's first comment has to do with "peer designation" as an incomplete and possibly misleading way of identifying experts. The criteria by which a group of"experts" is identified or selected continue to be discussed by researchers across disciplines.[1-3] Just who is an expert? Is it, as Mr Smyntek suggests, someone with a kind of personal charisma, reputation, or popular appeal who is identified by peers? One of the most important criteria for identification of experts among peers is to ask: To whom would the nominator refer a patient with complications or a family member for care?[1-4] This type of question provides a personalized dimension to the recommendation. When making a decision about a family member, you would want him or her to go to the "expert" in the community. We also agree that expertise is partly in the eye of the beholder, so how can we best find experts except by asking those who might make the best judgment about this?

Mr Smyntek next comments that mediocrity may be characterized by varying degrees of the same key dimensions of practice--multidimensional knowledge, clinical reasoning ability, focus on movement, and caring and commitment (virtue)--that we posed for the experts. He asks, "Is the distinction between expert and mediocre merely one of degree?" Not necessarily. We view expertise as a multidimensional concept, and we believe that practitioners can be at various places along a continuum. That is not to say that expert behavior is about being perfect all the time; rather, there is evidence of competence and performance across dimensions.

Mr Smyntek's final comments are that the concepts of competence and complacency should replace the concepts of expert and mediocre and that the virtues of caring and commitment are not universal and cannot be taught. We disagree. Instilling professional virtues is about development of students' moral reasoning skills and ethical judgment. As Dr Ruth Purtilo wrote in the foreword of our book, Expertise in Physical Therapy Practice: "In today's social environment, expert clinicians tell us that the notions of healing, cure, and comfort must be expanded and contextualized to reflect individual and social values and priorities without losing the life-generating aspects of more traditional meanings."[4(p xv)] This is the role of professional virtues.

Gail M Jensen, PT, PhD
Associate Professor
Department of Physical Therapy
School of Pharmacy and Allied Health
Faculty Associate
Center for Health Policy and Ethics
Creighton University
Omaha, NE 68178
([e-mail])

Jan Gwyer, PT, PhD
Associate Clinical Professor, Director of
Doctoral Studies, and Doctor of
Physical Therapy
Duke University
Durham, NC

Katherine F Shepard, PT, PhD, FAPTA
Professor and Director
Doctor of Philosophy Program in
Physical Therapy
Department of Physical Therapy
College of Allied Health Professions
Temple University
Philadelphia, Pa

Laurita M Hack, PT, PhD, MBA, FAPTA
Associate Professor and Director
Department of Physical Therapy
College of Allied Health Professions
Temple University

References

[1] Elstein AS, Shulman LS, Sprafka SA. Medical problem solving: a ten-year retrospective. Eval Health Prof. 1990;13:5-36.

[2] Chi MT, Glaser R, Farr MJ, eds. The Nature of Expertise. Hillsdale, NJ: Lawrence Erlbaum Associates Inc; 1988.

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

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