Invited Commentaries.

Following are 3 invited commentaries on "Expert Practice in Physical Therapy."

As members of a young and growing profession, many physical therapists aspire to develop expert knowledge, skill, and judgment through clinical and continuing education experiences. Jensen and colleagues have elaborated on these traditional markers of expertise[1] by conducting a qualitative research project using the grounded theory approach to discover the core dimensions of expert practice in physical therapy in the 1990s. They identified 4 aspects of expert physical therapy practice: knowledge, clinical reasoning, movement, and caring attitudes. I will highlight what I perceive to be the major strengths of the research conducted by Jensen and colleagues and then discuss aspects that I found to be missing from the theoretical model. I believe that these aspects need to be incorporated in a subsequent revision if the intent of this line of investigation is to help us develop clinical expertise and advance as a profession.

Jensen and colleagues engaged 12 acknowledged experts in geriatrics, neurology, orthopedics, and pediatrics in a study to identify dimensions of clinical expertise in physical therapy practice. This group of investigators has extensive collaborative experience in fieldwork methods. They make the case that the use of qualitative research methods is appropriate for the study of human behavior (such as expertise), given the nature of the phenomenon and the interest in understanding what expertise is in the context of everyday practice. This is reasonable. Despite having only a superficial understanding of qualitative research methods, I believe that a major strength and contribution of this article is the detail with which the process of investigation was described. The authors defined grounded theory, the multiple case study design, and the processes of comprehending, synthesizing, theorizing, and recontextualizing to arrive at a working conceptual framework. Expert consultants provided guidance at the beginning of the project and after initial data collection. Qualitative methodological issues similar to reliability and internal validity were addressed.

One question arising out of qualitative investigations is the generalizability of the results. Although the issue of transferability (similar to external validity) was identified, evidence of generalizability was not provided. Would a similar theoretical framework have evolved if a different set of peer-identified experts had been selected, or does the use of the multiple case study design alleviate this concern? The remaining methodological issues in this qualitative investigation are well-referenced and will be of interest to those who want to learn more about this method of inquiry. Overall, in the context of my superficial knowledge of qualitative approaches, I perceive a major strength of this investigation to be the adherence to rigorous standards of scientific inquiry as it relates to the grounded theory approach.

The result of this rigorous process is a theoretical model with 4 core dimensions of expert physical therapy practice. The important role of clinical reasoning is supported by the quotes from individual participants. This investigation highlights the importance of 2 previously unrecognized aspects of expert physical therapy practice: movement and caring attitudes. Three issues that concern me relate to the knowledge base dimension. My concerns might simply reflect a lack of explicit description in the article; alternatively, they might reflect a lack of value of scientific evidence supporting physical therapy practice by physical therapists who were designated by their peers to be clinical experts. First, there is an apparent reliance by the acknowledged experts on sources of knowledge obtained through methods other than the scientific method. Second, there is no indication that the clinical experts engaged in critical appraisal of information obtained through various sources. Third, the tentative nature of "truth" was not explicitly recognized in any of the quotes. I believe that objective knowledge (in addition to subjective knowledge), independent critical appraisal, and appreciation of our growing knowledge base are critical determinants of both clinical expertise and professional advancement. Ideally, these aspects of knowledge ought to be valued and acknowledged by those recognized as clinical physical therapy experts.

In the literature review, the investigators referenced the 3 types of knowledge described by Higgs and Titchen[2]: knowledge derived from research, practice, and self. My understanding is that the participants had the opportunity to describe their type and source of knowledge through the procedures used to collect data for preparation of the initial case reports. Although the model seems to capture the knowledge derived from practice and the knowledge derived from self, the knowledge derived from research is not apparent in the results. For example, we do not know whether the literature obtained from the library reflects authoritative or scientific sources.[3] This is troubling, particularly in the context of the well-recognized uncertainties associated with clinical decisions. We do not "know" with certainty about many aspects important to practice; knowledge from the scientific method provides us with the greatest (albeit never absolute) certainty.[4] It is readily acknowledged that the results of group studies might not apply to individuals.[5] Nonetheless, physical therapists need to recognize that the application of known probabilities of outcome (for example) derived from data can be useful and beneficial in individual decision making and that this method is better than relying on traditional, authoritative, or logical sources of knowledge alone.

Reference to critical appraisal was missing from the description of results relating to the knowledge base. As stated in the Guide to Physical Therapist Practice,[6] "critical inquiry is the process of applying the principles of scientific methods to read and interpret professional literature" and it includes "analyzing and applying research findings to physical therapy practice." We will not advance as a profession without individual critical appraisal. The expert clinicians in the sample were reported to have a range of 10 to 31 years of experience. Given that we do not know the year in which the data were collected, these clinicians entered physical therapy practice earlier than 1989. Although great emphasis is currently placed on evidence-based practice in entry-level curricula, this might not have been the case at the time they received their academic preparation. Although the clinical experts might have been exposed subsequently to this new emphasis through graduate work and professional reading,[8-10] the results do not reflect an embodiment of a value for evidence-based practice into their daily decision making.

Although the knowledge base of each physical therapy expert was identified to be dynamic and multidimensional, the tentative nature of the "truth" that defines our knowledge base at any time was not explicitly recognized. Philosophers of science believe that the continued growth of knowledge will be with us for a very long time due to the "infinity of our ignorance."[4] Given that effective and efficient physical therapy services require that physical therapists integrate examination, evaluation, diagnosis (or screening), prognosis (or risk factors), and intervention (or prevention),[6] physical therapists also need to know how to access and critically appraise the newly published health care literature to differentiate adequate or excellent measurement tools and protocols from inadequate ones as new knowledge develops.[11] The skills required to do this were not apparent in the results of this investigation.

These clinical experts were reported to be highly motivated to continue learning. Some of the methods of learning described were going to the library, reading articles, reviewing the literature, taking a long-term course, and learning from mentors. If any of these sources included new scientific research articles (ie, peer-reviewed, primary source research reports) that were independently critically appraised and evaluated, this did not come through in the description of the investigation. Although the authors state, "Our work suggests that there is a need for education to be rooted in practice, taught around patient care by people who understand both patient care and the relevance of scientific knowledge for the advancement of patient card' (italics mine), this is the first time that scientific knowledge is mentioned in the context of the results.

This group of experienced investigators has clearly made 2 significant contributions: (1) they have prepared an excellent example of a qualitative investigation using the grounded theory approach, and (2) they have added to our understanding of expert practice in physical therapy as it currently exists. By knowing more about how experts think and perform in practice, educators will have information to plan learning experiences for entry-level and continuing educational programs to facilitate the development of expertise. The investigation of expertise has progressed from studies of problem-solving skills, to research into the structure of knowledge, and now (through a grounded theory approach) to an understanding of the behavior of acknowledged experts in daily practice. I believe that the next step is to revise aspects of the knowledge base dimension to explicitly incorporate sources of knowledge obtained from the scientific method (in addition to practice experience with patients and clients) and explicitly acknowledge the importance of independent critical appraisal in advancing the knowledge base of the profession of physical therapy as it grows over time. If we want to promote an evidence-based practice, future expert clinical physical therapists will embody these aspects of expertise. Jensen and colleagues are to be commended for their detailed investigation of expert practice and also for their aspirations in facilitating excellence among physical therapy practitioners, thus advancing our profession.

Doreen Bartlett, PT, PhD Assistant Professor School of Physical Therapy 1588 Elborn College Faculty of Health Sciences The University of Western Ontario London, Ontario, Canada N6G IH1 ([e-mail])

References

[1] Thompson D, ed. The Concise Oxford Dictionary of Current English. 9th ed. Oxford, England: Clarendon Press; 1995.

[2] Higgs J, Titchen A. The nature, generation and verification of knowledge. Physiotherapy. 1995;81:521-530.

[3] Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice. East Norwalk: Conn: Appleton & Lange; 1993.

[4] Popper KR. Conjectures and Refutations: The Growth of Scientific Knowledge. London, England: Routledge & Kegan Paul Ltd; 1989.

[5] Fletcher RH, Fletcher SW, Wagner EH. Clinical Epidemiology: The Essentials. 3rd ed. Baltimore, Md: Williams & Wilkins; 1996.

[6] Guide to Physical Therapist Practice. Phys Ther. 1997;77:1163-1650.

[7] Harris SR. How should treatments be critiqued for scientific merit? Phys Ther. 1996;76:175-181.

[8] McQuarrie A. The bridge to survival: from clinical opinion to evidence. Physiotherapy Canada. 1997;49:11-12.

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

[10] Rothstein JM. Editor's note: Disciples, demigods, and data. Phys Ther. 1998;78:1044-1045.

[11] Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical Epidemiology: A Basic Science for Clinical Medicine. 2nd ed. Boston, Mass: Little, Brown and Company Inc; 1991.

A caveat must be stated at the outset: this commentary is directed at the research report as it stands on its own merits, that is to say, without reference to the investigators' prior work related to clinical practice competence.

The aim of this qualitative study incorporating a grounded theory approach was to begin to answer the question of what constitutes the core dimensions of clinical expertise in 4 physical therapy specialty areas. At first glance, the inclination is to critique the methodology by debating: (1) whether qualitative research is really research, (2) qualitative versus quantitative research, and (3) the development of theory by the inductive, as opposed to the deductive, process. After some reflection, the inclination was dismissed in favor of discussing selected substantive issues.

The rationale for this decision is based on my convictions stemming from experience and doctoral preparation in medical sociology. Qualitative research definitely is research and has a rich history in the social and behavioral sciences, tapping aspects of human behavior elusive to quantitative assessment. Grounded theory provides insights and directions for further study of behavior that may be missed by a reliance only on existing theory or deductive reasoning. Given the nascent state of research in physical therapy, which is primarily in the realm of the basic and clinical sciences, qualitative research and grounded theory fill a critical void.

The key question that remains to be clarified is: Who is the expert in physical therapy? The expert is described as a clinician who exhibits some combination of knowledge, reasoning, movement skills, virtuous behavior, and a conception of physical therapy practice. Is this expert a recognized specialist or an experienced generalist, or both? One would expect the expert to be the specialist, because the intent and the focus of the study are on selected specialists. The terms "expert" and "clinical expertise," however, have various referents, perhaps by design. If that is so, then the issue of expert practice is clouded. Should entry-level (professional) curricula be designed to foster the development of specialists or generalists? The specific teaching strategies suggested for student learning, for example, lead one to think that entry-level students should be taught to be experts or at least embarked on the expert road. Are students expected to become experts with specialized skills or knowledge derived from training, or experts with specialized skills or knowledge representing mastery of a particular specialty area?[1] According to the Commission on Accreditation in Physical Therapy Education's evaluative criteria,[2] entry-level students should become generalists, not specialists. What appears to be advocated is for all therapists to be experts, not just those who practice in a specialty area. An acknowledged unknown confounding the matter is the clinical expertise possessed by physical therapists, who are not considered to be specialists. What about the therapist who has worked in a particular practice setting (eg, a rehabilitation facility) throughout an extended professional career? Is that person a specialist? What we do not know is whether his or her expertise has the same dimensions as those of the specialist or whether there is a difference in kind or degree. In the same vein, if practice settings allotted time and opportunities so that therapists could become "better and wiser clinicians," would experts be the result? The implication is that experts would evolve.

Anecdotally and experientially, we know there are differences among physical therapists; some therapists are more knowledgeable and skilled than other therapists. The phenomenon may be one of determining what came first, the chicken or the egg. To generalize the dimensions of the expert generated by the study to all practicing physical therapists is not only questionable and inappropriate, but also misleading.

A recurrent theme in the accounts of specialists is knowledge gleaned from experience. Knowledge from experience, as well as other sources, is purported to be a fundamental distinction between the expert and the novice. Experience connotes knowledge, skill, or practice arising from participation in clinical activity and may

refer to a singular event or an accumulation of events over time.[1] One could say, then, that time is a component of experience and, by extension, to knowledge. In a sense, the expert has time on his or her side, whereas the novice does not. Time alone does not lead to knowledge, but it may be a related factor. Time may be a necessary element for the development of the expert, just as time is necessary for a child to mature. Intuitively, time is variable depending, for example, on aptitude, initiative, opportunities, and resources. The expert may be the product of a maturation process that is interwoven with time. The novice, however, could be an expert in the process of becoming--given time.

The specialists studied learned from their patients, were challenged by them, cared for them, were committed to them, and felt good about themselves. Whether they are more competent therapists and whether they have better patient outcomes than other therapists are persistent, nagging questions that have not been resolved. The answers lie out of the scope of this study. Yet, they go to the heart of the matter. Should the profession have experts, and foster the development of experts, just so we can say we are experts? Conventional wisdom dictates otherwise. Experts can help to improve the quality, efficacy, and efficiency of patient care. Is it important to identify the core dimensions of the expert? Yes! Is it sufficient to do so? No! Studies designed to evaluate experts' treatment outcomes must be done, but first we must know what an expert is--in a specialty area and in physical therapy in general. Because this study is a beginning attempt to define an expert, it is premature to suggest changes in practice environments and professional education programs based on the study findings.

In summary, the authors have addressed a question that has relevance across the whole spectrum of physical therapy: clinical practice, education, administration, and research. They carried out their study very systematically and with appropriate checks and balances. Understandably, they have raised more questions than they have answered. They are to be commended for tackling what to many people would be an onerous and too time-consuming task, and doing it well.

Ruth U Mitchell, PT, PhD Professor Emerita Division of Physical Therapy The University of North Carolina at Chapel Hill Medical School Wing E, CB# 7135 Chapel Hill, NC 27599-7135

References

[1] Mish FC, ed. Merriam Webster's Collegiate Dictionary. 10th ed. Springfield, Mass: Merriam-Webster Inc; 1993.

[2] Commission on Accreditation in Physical Therapy Education. Evaluative Criteria for Accreditation of Education Programs for the Preparation of Physical Therapists. Alexandria, Va: American Physical Therapy Association; 1996.

Jensen and colleagues are to be commended on their work in the field of expertise in physical therapy practice. They have conducted a timely and important study that has important implications regarding the future of our profession as we embark on the new millennium. In this qualitative study, the authors used a grounded theory approach to develop a theoretical model of expert practice in physical therapy. Their model included the following 4 dimensions of expert practice: knowledge, clinical reasoning, movement, and virtues. By identifying the critical dimensions of expertise, the authors have provided educators in academic and clinical settings with information essential to guide them in curriculum development and the structuring of the clinical practice milieu to facilitate the process of expertise development.

The authors have well summarized the literature, including their work, in the field of clinical expertise to situate the reader who may not be familiar with the research on this important topic. They also provided detailed descriptions of the methods used and have well schematized the steps in the development of their model. Coming from a training background in quantitative research methods, I was impressed by the rigor with which this qualitative research study was conducted. Jensen and colleagues meticulously applied standardized methods to collect and analyze an enormous quantity of data. One can appreciate the time and effort that went into conducting this interesting study.

I do, however, have the following questions regarding the methods used. First, did all the experts identified using the selection criteria agree to participate in the study? If not, how did the individuals who refused to participate differ from the study participants? Second, did the therapists select the therapist-patient sessions, or were they chosen randomly? Perhaps the experts acted differently from the way they normally do because they were aware that the treatment session was being videotaped. Moreover, if the participants were aware of the study objectives, they may have altered their behavior to suit the investigators and biased the results. This information would have provided some insight into the representativeness of the therapists and the treatment sessions.

I found the article very thought provoking, and I was left with mixed feelings about the results of this research. On one hand, I was encouraged, knowing that we now have a better idea about how experts practice physical therapy--essential information for the future of our profession. Clearly, the dimensions of expertise identified here deserve closer scrutiny by all those involved in the training of physical therapists. As educators, it is our responsibility to ensure that these dimensions are incorporated into the education of physical therapists. If our education programs do not strive toward developing expert clinicians, we will not advance our profession.

On the other hand, I found myself slightly discouraged by the results. I also question whether "clinical practice and education can be designed in a manner to address these multiple dimensions of professional competence." Current physical therapy education programs probably incorporate 3 of the dimensions into their curriculum. Educators can provide the necessary theory to form a solid knowledge base for students. We avoid providing "recipes" of how to maximize a patient's motor function and thus promote the development of clinical reasoning. We also are probably very good at teaching the technical skills related to movement assessment. I fear, however, that not enough emphasis is being placed on instilling professional virtues among our students, particularly in the classroom setting. For all we know, this may be the most important dimension of clinical expertise. Can students be taught these virtues, or do they constitute innate characteristics of individuals who strive to be expert clinicians (eg, nurture versus nature)? Should we develop and use methods to accurately screen for these characteristics among those seeking admission to physical therapy programs?

It was disappointing to see that the experts had, on average, 22 years of clinical experience. Can therapists only attain a level of expertise with many years of experience or toward the end of their career? If this is the case, there is little hope for our profession. It appears that graduate studies might be an important criterion in determining whether a therapist becomes an expert (eg, 2 clinicians held only a Bachelor of Science degree). One might question whether experts seek advanced training, or does advanced training make a person an expert? The data further revealed that the experts were hard workers who loved their work. The words of one expert ("Basically I worked 7 days a week.") lend support to the idea that experts continue to work outside regular working hours. How many hours a week did they actually work? How often were weekends and evenings devoted to their work? If experts do, in fact, devote so much extra time to their work, is it reasonable to ask this of every clinician? Quantitative data addressing these issues need to be collected to complete the professional profile of the experts.

I also suggest that a closer examination of the practice milieu of the expert clinicians involved in this study could shed some light on the impact of the work environment on facilitating the process of expertise development. As alluded to by the authors, one needs to determine the mechanisms or strategies that may have facilitated this process. It would be interesting to learn whether the experts obtained any special recognition (monetary or otherwise) from their employers with respect to their advanced education. How much money is reserved annually for the clinician to participate in continued education activities?

In presenting their results, Jensen and colleagues frequently refer to the communication skills of the experts. Their previous work[1,2] revealed that master clinicians demonstrate strong verbal and nonverbal communication skills. In this study, experts were shown to demonstrate consistent active listening skills. They also expressed the belief that good patient education is an essential component of patient care. Due to the emphasis on the importance of communication, I wondered why communication did not appear as one of the core dimensions in Figure 3. I think we underestimate the impact of these skills in promoting compliance adherence (and ultimately better outcomes) among our patients (see Haynes et al[3]). I am also worried that our students may not be equipped with these skills unless they have an opportunity to observe and learn them from expert clinicians who supervise them during their clinical placements.

I do not fully agree with the authors that future work should validate their model across experts in other speciality areas. Experts in the 4 major speciality areas of physical therapy were studied. I purport that these same dimensions will be identified regardless of the speciality. I say this because, while reading this article, I was struck by the similarities between the dimensions of the expert clinician and those identified in the literature on client satisfaction.[4,5] For example, in a content analysis of "satisfaction" questionnaires used by medical professionals across multiple specialities, Ware and co-workers[6] found that interpersonal manner, technical quality, accessibility and convenience, and financial aspects were the most commonly measured dimensions of care. Instead, I suggest that future research should include the use of quantitative methods to obtain data to supplement the results of this qualitative study.

In conclusion, I think it is most appropriate that this important, thought-provoking article is included in the January 9000 issue of Physical Therapy. It is time that we closely scrutinize the manner in which we are training physical therapists. This article should be required reading for all people involved in the education of physical therapists. We must ask ourselves whether we are providing our students with the appropriate tools necessary to the process of expertise development. Should we not try harder to motivate our students to become expert clinicians and give them a thirst for knowledge that in the long-term will serve to develop a better quality of care for our patients? I applaud the work of the authors. Their research has provided the basis and the catalyst for us to critically examine our education programs and practice milieus for physical therapists. Let us not miss the opportunity to do so.

Bonnie R Swaine, PhD Professeure Adjointe Ecole de Readaptation Faculte de Medecine

Universite de Montreal CP 6128 Succursale Centerville Montreal, Quebec, Canada H3C 3J7 ([e-mail])

References

[1] Jensen GM, Shepard KF, Gwyer J, Hack LM. Attribute dimensions that distinguish master and novice physical therapy clinicians in orthopedic settings. Phys Ther. 1992;72:711-722.

[2] Jensen GM, Shepard KF, Hack LM. The novice versus the experienced clinician: insights into the work of the physical therapist. Phys Ther. 1990;70:314-323.

[3] Haynes RB, Taylor DW, Sackett DL eds. Compliance in Health Care. Baltimore, Md: The John Hopkins University Press; 1979.

[4] Keith RA. Patient satisfaction and rehabilitation services. Arch Phys Med Rehabil. 1998;79:1122-1128.

[5] Heinnemann AW, Bode R, Cichowski KC, Kan E. Measuring patient satisfaction with medical rehabilitation. Journal of Rehabilitation Outcomes Measures. 1997;1:52-65.

[6] Ware JE Jr, Davies-Avery A, Stewart AL. The Measurement and Meaning of Patient Satisfaction: A Review of the Literature. Santa Monica, Calif: Rand; 1977.