The difference between knowing and applying.

As the complexity of physical therapy interventions grows and the options for examination and evaluation increase, the knowledge that practitioners must obtain and carry with them threatens to reach unmanageable levels. Therefore, like other members of the health care team, we are highly dependent on our literature and our ability to quickly and in a clinically practical manner extract salient information for the management of our patients. But this challenge--the retrieval of evidence for everyday practice--is only one part of the daunting task we face.

In dialogues about evidence based practice, we often forget that most proponents of this approach believe in something more than the application of data in a vacuum. As Sackett et al (1) state,

   Evidence-based medicine (EBM) is the integration of best research
   evidence with clinical expertise and patient values.

Clinical expertise and patient values are critical to the way we care for our patients and how we relate to them as partners in care.

"Clinical expertise" is a difficult term to operationally define. Too often, clinical expertise is viewed as something that gurus and masters of the continuing education lecture circuit have, but in reality they have not yet demonstrated that they can be any more effective than anyone else. Clinical expertise is a property that is held by all physical therapists who practice effectively; though they might not be able to define "clinical expertise," they can demonstrate it. Among the characteristics of the clinical expert is, I believe, the ability to identify relevant patient attributes, taking into account not only the examination findings but the values and culture of the patient, attributes that can be used to guide patient management and the application of evidence. In many ways, it is the behavior of the physical therapists that takes them beyond the level of automaton and allows for the integration of evidence and science into the humanistic practice that has been the hallmark of physical therapy since the profession began.

This integration is made all the more difficult because of the way in which journals (including this one) present research data. We have yet to find and implement a user-friendly context in which clinical studies are reported in a manner that allows readers to identify all critical variables and patient attributes. We do not make clinical application to specific patients easy, and, as a result, we make it harder for physical therapists to exhibit clinical expertise. Making authors report more details on their subjects, particularly the characteristics of patients who respond to intervention and those who do not, requires a rethinking of research designs and a major change in the way articles are written. We can take solace in knowing that our profession is not alone in seeking better ways for journals to present data and for authors to look at and report their results.

The process of decision making often seems so obvious to clinicians that, when teaching, they fail to inform their students about it. They take it for granted, as though it were a natural process that evolved rather a deliberate, ]earned process. In many of the case reports submitted to the Journal, authors fail to adequately explain how and why they chose examination procedures and how the results of the evaluative process led to choices regarding interventions. Clinical expertise is something we may value, but it is something we rarely explore and detail. In an evidence-based world, we need to know more about how clinicians think.

How to help physical therapists apply new knowledge and the best research evidence in the context of patient values has been a topic of considerable discussion but little scientific investigation. Often the difficulty lies in the paucity of knowledge about outcomes and how outcomes are achieved (our literature is filled with papers examining poorly detailed interventions) and about how to predict which patients can expect to receive beneficial outcomes. We are, for example, only beginning to see research that looks at cultural differences among patients (the Journal looks forward to publishing papers on this critical attribute during the next several months). A clinical expert knows when to apply an intervention, but the task of the expert is made easier when the literature informs these choices. For instance, do men and women respond equally well to an intervention? Do people of different cultures respond in the same way to interventions? Do members of one ethnic group handle a child's disability any differently than members of other ethnic groups do?

The ability to consider all salient facts in determining and implementing patient care is called "clinical reasoning" by Edwards and colleagues in this month's Journal (pp 312-335). Using a qualitative research design, they examine the clinical reasoning of physical therapists identified as experts. Although we do not know whether the therapists they studied actually obtain better outcomes than other therapists do, the authors note that these therapists are viewed by their peers as experts. Based on a study of these therapists, the authors developed a model of clinical reasoning that, as they state, offers "clinical reasoning strategies."

The model proposed by these researchers is examined by Laurie Hack, PT, PhD, FAPTA, and Julie Fritz, PT, PhD, in the invited commentaries that follow the article. Clearly, the concepts proposed by Edwards et al are not universally accepted. The dialogue is rich and insightful and illustrates how little we actually know about clinical reasoning (or clinical problem solving). We all may have opinions on the topic, but the information to support any set of views is minimal. Because we all have the same data set available to us--the same literature and the same evidence--the reason why some physical therapists succeed and others rail remains an enigma, and, as long as it remains an enigma, I foresee continued variations in patient care. The mystery should not persist, because this is a topic that lends itself to research, and, most important, to inquiry using a variety of methods from myriad points of view.

Edwards and colleagues are to be congratulated for their efforts and for the development of a model of clinical reasoning. The commentators also play a key role by applying a critical eye and beginning a dialogue. What we need now is more dialogue and more research, so that as the evidence related to patient care increases, the evidence can be used effectively, taking into account the patient's values and identity, including culture and family roles. Among the questions we need to answer is whether effective practice in this era of evidence and accountability requires a new type of clinical thinking and problem solving altogether. For example, when there was little research-based data on patient care, the outstanding clinicians may indeed have been those who could base their decisions on personal experiences--physical therapists who almost intuitively generated an internal database. Now, we can do better. We should be able to use research data and not rely totally on personal recall and anecdotal experience.

As of press time, APTA's Hooked on Evidence project (see page 306) has about 1,200 extractions from 250 journals. The research of Edwards et al challenges us to consider not only that growing evidence, but also how we can use it.

References

(1) Sackett DL, Straus S, Richardson S, et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. London: Churchill Livingstone; 2000:1.