The novice versus the experienced clinician: insights into the work of the physical therapist.

Key Words: model, theoretical; Physical therapy profession, professional =; Professional practice; Professional-patient relations.

Who is the master physical therapy clinician? What distinguishes a master clinician from a novice? Why do some physical therapists seem more successful than others? How do successful master clinicians learn and accumulate knowledge? How can we most efficiently help the novice develop into a master clinician? These questions formed the basis for our exploration into the work of physical therapists.

The notion of looking at the wisdom of the practitioner as a source for understanding the complexities of skilled performance is not new.[1] We know that professionals learn and develop knowledge through practice and that experience is a requisite for expertise but is not the only factor that contributes to expert practice.[2,3] Benner states

  Expertise develops when the clinician
   tests and refines propositions, hypothe
-   ses, and principle-based expectations
   in actual practice situations.... Not all
   knowledge embedded in expertise can
   be captured in theoretical propositions,
   or with analytic strategies that depend
   on identifying all the elements that go
   into the decision. However, the interac
-   tions, expectations, meanings and out
-   comes of expert practice can be
   described, and aspects of clinical
   know-how can be captured by inter
-   pretive descriptions of actual
   practice.[4(pp3,4)]

Several investigators have examined the basis of professional competence. Benner conducted a study of nurses working in actual patient care situations and developed a model of expertise in clinical practice.[4] She discovered that formal rules had limits in actual clinical situations; that is, rules about technique or procedure that are applied rigidly without some understanding of the situation may be harmful. She investigated what Schon [2] would call the "indeterminate zones of practice," that is, those areas of practice that are characterized by uniqueness or uncertainty or that involve a conflict of values. Elbaz [5] and others [1,6] have been investigating the practical knowledge embedded in the practice of teaching. They emphasize that teachers' practical knowledge, gained through experience, is at the heart of professional practice. Researchers studying the individual characteristics of experts and novices in a variety of fields have demonstrated that differences between expert knowledge and novice knowledge are related to the individual's ability to combine knowledge with experience, to be able to know what is important, and to recognize and appreciate the significance of critical cues.[7-9] Payton, [10] in a descriptive study analyzing the clinical reasoning process of 10 expert physical therapy clinicians, found that these therapists used a process similar to the clinical reasoning process described for physicians.[9] That is, these expert therapists began formulating preliminary hypotheses early in the patient interview process as they gathered data. At present, we have little understanding of why some physical therapists with extensive technical knowledge and experience go on to become master practitioners while others remain mediocre. What cognitive and behavioral processes do therapists use? Could knowing these processes help guide us in our selection of potential students, or could we design learning experiences that would help develop similar processes in novices?

We still have much to learn about professional practice, particularly investigations conducted within the natural practice environment. The wealth of knowledge embedded in the clinical actions of physical therapy practitioners is currently poorly understood. In order to learn more about who the master clinician is and how he or she develops, we began to systematically observe and record what clinicians do. The purposes of this investigation were 1) to develop and test an observational instrument that could be used to systematically observe physical therapist-patient interactions and 2) to develop an initial conceptual framework that could be used to guide further studies of the work of physical therapy clinicians.

Method-Research Design Conceptual Framework

A preliminary conceptual framework for the study of physical therapy practice was developed from a review of the literature and analysis of data collected during pilot observations. The Figure provides a graphic representation of the conceptual framework. The first level of the framework represents the components of the physical therapy practice environment, including characteristics of the therapist, patient, and organizational settings that we anticipate may have a potential effect on patient outcome. Physical therapist professional characteristics include age, gender, sociocultural background, level of experience, educational preparation, professional orientation such as skill or interest in clinical specialty areas, personal traits including values and the ability to care, expectations for therapy, and expectations for the course of the patient's disease. Client characteristics include age, gender, sociocultural background, education, expectations for physical therapy, and expectations regarding the course of illness or disability. Organizational factors include type of setting, payment system, geographic location, other personnel involved in the patient's care including physician specialists and support personnel, and time constraints. At the second level of the conceptual framework are the tools used by the physical therapist including communication techniques, manual techniques, and modalities. At Level ill is the dynamic therapeutic intervention, or "black box" or filter, that all of the identified Level I and Level 11 factors are filtered through. At the end of this filtration process is the patient outcome. We call the therapeutic intervention the black box because we know so little about what happens between therapist and patient. The focus of our observations and instrument development was to begin to look at this black box and explore what actually happens during the time the patient is in the physical therapy clinical setting. We were particularly interested in determining whether experienced clinicians and less experienced clinicians used different therapeutic interventions.

Participants and Selling

A purposive sample was used. In order to limit numerous variables in this study, we elected to study therapists and patients in outpatient settings and observe only patients with musculoskeletal problems. We first selected therapists on the basis of experience as a practicing physical therapist. Years of experience is one criterion that may distinguish a master clinician from a novice. However, in this study, we did not attempt to fully define a master clinician. At this initial level of investigation, our observations were of highly experienced and less experienced clinicians working with similar patient populations. These therapists were selected so that a variety of orthopedic outpatient settings were represented. Although we wanted to generally control for type of patient sample and setting, we did not want to constrict either the patient diagnosis or setting so exclusively that problems of external validity would confound the usefulness of our findings. Thus, we sought an identified, but broadly representative, sample of orthopedic outpatient settings. Our therapist sample contained 8 physical therapists-2 with less than 2 years of experience, 3 with 3 to 7 years of experience, and 3 with more than 13 years of experience. The four outpatient settings were an outpatient department of a large hospital, two physical therapist-owned private practices, and a sports medicine center. One of the therapists with less than 2 years of experience worked in a sports medicine facility; the other therapist was employed in a hospital outpatient department. One of the therapists with 3 to 7 years of experience was employed in a private practice setting; the other 2 therapists were employed in a hospital outpatient setting. All therapists in the most experienced group worked in private practice settings.

Data Collection

For this stage of our research, the therapeutic intervention, or the black box, was our primary focus. We defined the therapeutic intervention as a single treatment session, thereby eliminating evaluation sessions as well as any longitudinal analysis. All patients and therapists observed signed informed consent forms for human subjects as approved by Temple University's Institutional Review Board.

We collected data through nonparticipant observation, recording of field notes, and audiotaping of each treatment session. Two researchers simultaneously collected data on each patient at each site. The field notes included the following demographic data for each therapist: age, gender, sociocultural background, level of experience, and educational degrees. We recorded each patient's age, gender, sociocultural background, diagnosis, and number of previous physical therapy treatments. The field notes also included a rough sketch of the physical environment and a record of nonverbal activities including eye and hand contact between the therapist and the patient.

Initially, all three researchers observed two pilot treatment sessions to practice data-collection skills and to generate preliminary coding categories. The preliminary coding categories for the therapists were 1) Seeks Information, 2) Rewards/Encourages, 3) Educates, 4) Instructs, 5) Social Interchange, and 6) Miscellaneous. The preliminary coding categories we generated for the patients were the following: 1) Reports Status or Responds to Physical Therapist, 2) Seeks information, 3) Rewards Physical Therapist, 4) Social Interchange, and 5) Miscellaneous. These coding categories were then used in coding the pilot observations. After detailed analysis of the pilot data by the three researchers, the coding categories were revised and continued undergoing some revision into the initial phases of data collection and analysis. The coding categories for the patients remained the same. The revised coding categories for the therapists, however, underwent these changes: 1) A category was created that represented the simple commands given by the therapist or comments related to the mechanics of the treatment procedures; 2) the category Instructs was clarified by changing it to Instruction to Patient on How to Do an Activity; and 3) the category Educates was redefined as Explanation to include therapist statements that inform or explain why to a patient, relieving the coder of the responsibility of making a judgment about whether a statement pertained to education or to another coding category. The finalized coding categories and examples of how the coding categories are applied to therapist-patient verbal interchanges are shown in Tables 1 and 2. Each time either the therapist or patient spoke was considered one response block. Each response block therefore contained one or more sentences. The coding categories were applied to the response block, not to the individual sentences. Table 3 gives some examples of coding categories applied to response blocks. We then observed, in pairs, 19 treatment sessions involving eight physical therapists in four different settings.

Data Analysis

Each audiotape was transcribed by one of the researchers who had performed the data collection. The transcription included both the verbatim data from the audiotape and the nonverbal and environmental data recorded in the researcher's field notes. This integrated transcription was then coded by all three researchers, the two researchers who had done the observation, and the third researcher not present at the observation. We applied a coding system as advocated by Strauss.[11] The first step of analysis is open coding, where field notes are carefully scrutinized and the data are analyzed minutely. In this study, all transcribed data were exhaustively coded using an open coding procedure and the coding categories shown in Tables 1 and 2. The mean percentage of agreement for coding among the three researchers was established at 89%. A Kappa (K) coefficient for overall agreement statistics was also calculated to correct for chance agreement.[12] The Kappa value across all ratings for the three researchers was .75. An external coder, who is an expert in therapistpatient communications, assessed the reliability of the coding scheme. We found 85% agreement between samples coded by the external coder, who was not involved in the research, and the researchers. The Kappa value for overall agreement when using the outside coder was .69.

Next, five categories, or themes, were generated from analysis of our coded data and field note observations. The five themes were 1) therapist allocation of treatment time, 2) the types and uses of information gathered from the patient, 3) impact of the therapeutic environment on the therapeutic intervention, 4) degree of responsive therapeutic interaction, and 5) therapist integration of nontherapeutic interaction with therapeutic interaction. These themes appeared to be different dimensions within the organizational setting and were the therapeutic intervention that distinguished between the type of work performed by the less experienced therapist and that performed by the more experienced therapist.

Results and Discussion

Field data, researcher interpretations, and support from the literature are integrated here in a discussion of the study's two purposes: 1) development of an instrument for systematic observation of physical therapist-patient interactions and 2) development of an initial conceptual framework to describe the work of the physical therapist. As, previously stated, we were particularly interested in determining how the work of the experienced clinician differs from the work of the less experienced clinician. As the data from therapists with 3 to 7 years of experience did not contrast sharply with the data of either the novice or the experienced clinician, we focused our analysis on the decided differences between the most experienced and least experienced therapists.

Observational instrument

We developed seven coding categories for physical therapist statements and five coding categories for patient statements. These coding categories emerged from our data collection and analysis. Our categories are similar to categories identified in a recent review article on patient-physician communication by Roter et al. [13] These authors found that a number of investigations had examined physician-patient communication with little agreement on the basic definition for the coding categories or communication variables. They used a metaanalysis to review 80 manuscripts published from 1962 to 1986 and through a process of consensual validation identified six broad categories of communication process variables. These categories are information giving, information seeking, social conversation, positive talk, negative talk, and partnership building. All categories except partnership building refer to both physician and patient. For the patient, information giving pertains to volunteering information (eg, symptoms), responding to the physician's comments, or answering the physician's questions. For the physician, information giving includes giving information, instructions, or suggestions or answering questions. Information seeking refers to the patient's questions about the medical intervention and to the physician's requests for patient information. Social conversation for both patient and physician includes all casual conversation (eg, greetings, social remarks). Positive talk refers to behavior that reflects agreement, approval, support, reassurance, or attention. Negative talk is defined as behavior that demonstrates disagreement, tension, or antagonism. Partnership building is defined as the physician asking for the patient's suggestions, opinions, or ideas; making interpretations for the patient; and reflecting or acknowledging the patient's statements. Table 4 demonstrates the similarity between our coding categories and those generated by Roter et al.[13] One noticeable difference between their categories and our therapist categories is the distinct categories we use that pertain to instructing and teaching the patient (Tabs. 1, 2).

We also found that the researchers who had actually collected the data had higher reliability (89% agreement; K = .75) in applying the coding categories than the external coder (85% agreement; K = 69). We attribute this discrepancy, in part, to researcher knowledge of the actual treatment milieu and to the use of voice inflections, which influences the use of the coding categories. Different tones of voice can convey different meanings. For example, a therapist might say, "That's it," in a calm, information-giving tone of voice to tell the patient that he or she had correctly performed a procedure. This observation would be coded MP (Simple Commands or Comments Related to Mechanics of Treatment Procedures). Alternatively, the therapist might say excitedly, "That's it!" to reward a patient for a difficult maneuver. This observation would be coded R (Rewards/Encourages). It would be difficult for any external coder to interpret the intent of such a phrase from the printed material alone.

We also believe that to obtain a more complete understanding of nonverbal communications such as touch, posture, and eye contact, which are an integral part of the therapeutic intervention, we may need to obtain videotape recordings. Perry looked at nonverbal communication between therapist and patient in a practice setting.[14] Although she found that nonverbal communication was used to establish and maintain an emotionally supportive treatment setting or to clarify or explain treatment instruction, therapists and patients were aware of such nonverbal behavior only 50% of the time. Videotaping would allow the patterns of visual, verbal, and manual communication to be analyzed more thoroughly, providing that such data can be collected in an unobtrusive manner.

Conceptual Framework

We selected our sample of therapists to represent a diverse group in terms of years of experience in the field. Our intent was to collect data in an actual practice setting in order to provide us with a better understanding of the characteristics of different therapists who represent a wide range of experience. Because our data analysis demonstrated that 12 years or more of experience did indeed differentiate highly skilled from less skilled (less than two years' experience) therapists, we will use the terms "novice" and "experienced clinician" throughout this section.

Five themes emerged from our analysis of the data. These themes are tentative and represent a small part of the conceptual framework we proposed (Figure). For example, two themes-allocation of treatment time and impact of the therapeutic environment-are part of the organizational factors that influence the therapeutic intervention. The other three theme's-types and uses of information gathered from the patient, degree of responsive therapeutic interaction, and therapist integration of nontherapeutic interaction with therapeutic interaction-pertain to patient-physical therapist interactions that occur during the therapeutic intervention. All five themes will continue to be refined as research in this area continues and our understanding of the work of the physical therapist evolves. This discussion will focus on the examples from our data that support these five themes and represent what we consider possible dimensions of the practice environment and therapeutic intervention that may differentiate experienced clinicians from novices.

Allocatior of treatment time. We observed At therapists vary in how they allocate treatment time, that is, in how much time is spent in direct contact with the patient and in how this contact time is used. For example, we noticed that our more experienced therapists spent an "intense dose of time" with each patient in hands-on care, seeking information and evaluating and educating the patient. These therapists appeared to manage their time so that less time was spent going from one patient to another. When we look across our sample of eight therapists and compare total treatment time to time spent in direct patient contact, we see that our highly experienced group used more of the total treatment time in direct patient contact (Tab. 5). A second observation was that the therapists differed in bow they used direct patient time. The following excerpts from the transcripts provide an example of how a less experienced therapist (novice)-patient dialogue differed from a more experienced therapist-patient dialogue. During each dialogue, the same activity-application of ultrasound-was occurring.

Novice:
  Physical therapist  PT): "Is it getting
    warm yet?"
  Patient  X): "Not yet."
  (long period of silence.)
       PT; "Have you been walking?"
       X: "i did yesterday."
       PT:  Were you sore?"
       X: "Not too bad."
       (Long period of silence.)
       PT: "Does it hurt in your shoulder?"
       X: "That is the spot right there. I can
       feel it every time you move over it."
        Long period of silence.)
       PT: "How much time have you been
       leaving the collar off?"
       (Site 1, PT-A, X-40, p 1.)
Experienced therapist:
       PT: "Now I'm going to get started here
       (with the ultrasound), and then grad
-       ually I'm going to have you bring
       that right knee up to your chest, but
       gradually. Now I'm going to do this
       with a little stretch. Did you do a lot
       of walking this morning?"
       X:  Yes. I usually walk in the morning,
       about three blocks."
       PT: "How did you feel?"
       X: "OK when I first put my leg out.
       Initially, getting up in the morning;
       that is when it pulls. When I walk to
       the bus, it eases."
       PT:  "How is it during the course of the
       my?"
       X; "It is better during the day but
       worse at night."
       (Site 111, PT-A, X-35, p 1.)

Impact of therapeutic environment. A second theme, also part of organizational factors in the conceptual framework, is the impact of the therapeutic environment on the treatment session. Again, the more experienced therapists were observed to handle interruptions and tasks outside of direct treatment efficiently without disrupting the treatment session. These excerpts from the transcripts were typical of the differences we observed.

Novice:
       (Middle of a treatment session; the
       patient is lying prone on the table;
       the therapist is applying electrical
       stimulation.)
       PT: "Do you feel anything?"
       X: "Yes, but with the other machine, I
       felt more."
       PT:  Yes, that other one seems to work
       better. Are you comfortable? I'm
       going to get your appointments for
       next week."
       X: "You can give it to me early in the
       morning."
    PT: "How early?"
    X: "I have to go to school at 11:30.
       Probably 9 AM."
    PT: "I can give you an 8:30. Too early?"
    X: "Why don't you wait until I get off
       the table, then I can look at the
       schedule."
    PT: "If you wait, by that time, other
       people will have taken them."
    (Site 1, PT-A, X-26, p 1.)
Experienced therapist:
    (Patient requests progress note from
       physical therapist at beginning of
       session.)
    PT:  "When you go out, give that to the
       secretary. You don't want me to
       send it? You want to pick it up?"
    X: "Yes. That way, I will get it."
    PT:  All right, so you want a progress
       note. Now, first of all, tell me what
       has been going on. it looks much
       better."
    (At end of treatment.)
    PT:  All right. I want you to take that
       letter and give it to the secretary and
       have her remind me what I am sup
-       posed to do with it. All right? We
    will   get those papers organized."
    (Site 11, PT-A, X-46, p 2.)

Inexperienced therapists, like inexperienced teachers, appear to have concerns about "survival issues."15 For example, developing teachers are concerned about class control and following the rules. The novices we observed reacted quickly to most environmental stimuli such as intercom interruptions and patient scheduling tasks, often losing focus on direct patient care activities. They, too, may be more concerned than more experienced therapists about survival issues and feel they are unable to exert control over their environment.

Types and use of information gathered. Additional differences were noted between the experienced therapists and the less experienced therapists in the kind of information they gathered from the patient. We found that the frequency data from the therapists' coding categories did vary across therapists, with the less experienced therapists seeking more information from the patient and the more experienced therapists demonstrating more social interchange and giving the patient more information or explanation as to why something was happening. What is not evident in these frequency data is how therapists used the information gathered from the patient. Reviewing our field notes and transcripts, we found that experienced therapists consistently built their questions on the patient's responses, as demonstrated in these examples:

Experienced therapist:
   PT: "What has happened with the
      knee?"
   X: "Well, I started out pretty well."
   PT:  What is  pretty well?'
   X: "i did the whole routine every day
      for about four or five days."
   (Site III, PT-B, X-48, p 1.)
Experienced therapist:
   PT: "Do you live on the first floor or
      second floor?"
   X: "The first floor. I'm very careful of
      going up stairs."
   PT: "Is there a railing on the steps? Do
      you use it?"
   X:  Yes. I put both hands on the railing
      to come down."
   (Site II, PT-A, X-86, p 2.)
This type of information gathering is
in contrast to that of the less experi
-enced therapists, who tended to ask
questions in a perfunctory manner
or focused more on mechanical
procedures.
Novice:
   PT: "How are you feeling today? Any
      changes in your symptoms?"
   X: "It has been acting up."
   PT: "Feeling any better with traction?"
   X:  i had traction before."
   PT:  You made the full 15 minutes,
      right? Any problems with that?"
   (Site 11, PT-B, X-48, p 1.)
Novice:
   PT: "You were the same after Friday?"
   X:  Yes. "
   (Therapist brings in hot pack.)
   PT: "Has anything changed since you
      first came into therapy?"
   X: "i don't think so. The pain is not
      stable, and the pain on the right leg
      has been all the way down."
   PT:  All right. if that gets too hot, let
      me know." (Places hot pack on
      patient's back.)
   (Site 1, PT-C, X-48, p 1.)

Degree of responsive therapeutic interaction. The theme of responsive therapeutic interaction between the therapist and the patient emerged from a careful examination of the verbal and nonverbal transcript data. We found in our transcripts of the highly experienced therapists multiple examples of these therapists integrating verbal encouragement and tactile cues (eg, guiding the patient through a motion or exercise while providing verbal encouragement). Two of our three experienced therapists never took their hands off the patient from the beginning to the end of the treatment session. Their hands appeared to be a constant source of communication to the patient as well as used for therapeutic intervention. The less experienced therapists had a much more mechanical approach to patients. The following excerpts are an example of the two approaches:

Experienced therapist:
   (Therapist is performing a hold-relax
      technique with the patient.)
   PT: "Now push and relax ... trust me
       .. and relax (externally rotating the
      shoulder) and push and relax and
      push back toward me... (in soft
      voice) back toward me. Now up and
      out and relax...."
   (Now working with patient on extrem
-      ity testing and rehabilitation system.)
   PT: "Ready, and now 1 up, 2 up, 3 up,
      4 up, and 5 up. Come on, push and
      rest. How does that feel? ... OK,
      ready? I up ... 6 up, come on bring
      it on home, now good!"
   (Site 11, PT-A, X-48, p 3.)
Novice:
   (Therapist is standing away from
      patient while instructing patient in
      exercise technique.)
   PT: "Now just go straight up and down
      and then go right in a circle and
      then left.... flow much weight do
      you have on that? Four pounds?"
   X: "That's not too much?"
   PT: "No. Now side to side ... then try
      circles. "
   X: "It is harder to go that way."
   PT: (Ignoring patient's last comment.)
      Let's have you go 10 times in one
      direction and 10 in the other. Then
      10 up and down. Then I'll be back
      to increase the weight." (Therapist
      leaves treatment area.)
   (Site 1, PT-C, X-57, p 2.)

Integration of therapeutic and social interaction. As we discussed previously, the experienced therapists were more likely than the less experienced therapists to engage in social interaction, yet, at the same time, these therapists were fully involved in carrying out their treatment. Our transcripts are full of representations of the effortless integration of therapeutic and social interaction that occurred during the treatment session. These experienced therapists appeared to "enter the lives" of their patients, eliciting and giving information about the present disability within the context of each patient's life style. The example in Table 6 provides a comparison of experienced and less experienced therapists' coded field notes relative to this theme.

Throughout our discussion of the five themes, we have differentiated between experienced therapists and less experienced therapists (or novices). We are not implying that mere experience correlates with expertise. However, in our sample, the behaviors and interactions of the experienced therapists were distinctly different from those of the rest of the group. The confounding nature of experience and expertise will continue to be a problem in studying the work of the physical therapist, as it currently is in studying the work of teachers.[6] To understand the interaction between these two variables, we must study how experience changes therapists without turning them into experts.

What we did find in our experienced group of therapists appears to be consistent with mastery characteristics in other fields. Benner found that inexperienced nurses were rule-bound in their approach to practice, whereas master clinicians intuitively grasp important cues and respond competently. [4] Elstein et al found that expert physicians were good at clarifying their data and understanding exactly what the patient was saying.[9] Tammivaara and Yarbrough, in summarizing the results of interviews with experienced physical therapy clinicians, describe competent physical therapists as those who listen well, detect confusion, seek clarification, and know when one is being understood.[16] Similarly, we observed that the inexperienced therapists in our study were much more procedural and mechanical in their interactions with patients, whereas the experienced therapists were more responsive, listened intently, and built on what the patient said.

Directions for Future Research

There is much to be learned about physical therapy practice and the evolution from novice to master clinician. Our study focused on the development of an initial conceptual framework and one tool necessary to begin to look at physical therapist-patient interactions. We investigated one dimension, that is, observable interactions in one type of patient care setting. In the future, we will need to learn much more about the characteristics and actions of experienced clinicians in a variety of patient care settings. We will need to get "inside the heads" of experts, as Payton [10] did, to fully understand their wisdom and how that wisdom is applied to real practice settings. Other professions are looking at models of expertise.[4,6] What are the stages of development for physical therapy expertise? We will need longitudinal studies to help uncover the process of change from novice to master clinician or the reasons for the lack of change. Data from patients will be necessary in exploring patient satisfaction and outcome. Like many other professional fields,[17] we also know very little about the role of entry-level education in the acquisition of knowledge that would lead to clinical expertise in physical therapy. We anticipate that our original conceptual model will be altered many times as we gain in our knowledge of the work of the physical therapist.

Conclusion

The purpose of this study was to develop a framework and themes that could be used in investigating the practice of physical therapy. Our observational instrument for coding therapist-patient interactions and our conceptual framework can now be used in future research. The analysis of data, coupled with findings from other studies, suggest that experienced clinicians possess attributes that are different from those of novices. We currently lack understanding of the development of physical therapy expertise. Continued research in this area is crucial to the improvement of physical therapy practice and professional education.

Acknowledgments

We are indebted to the physical therapists and patients who allowed us to observe them during physical therapy sessions. We also thank Elsa Ramsden, PhD, PT, for her thoughtful and insightful comments in the development and testing of our observational instrument and Jan Gwyer, PhD, PT, for her assistance.

References

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2 Schon D: The Reflective Practitioner: How Professionals Think in Action. New York, NY, Basic Books Inc, Publishers, 1983

3 Cervero R: Effective Continuing Education for Professionals. San Francisco, CA, Jossey-Bass Inc, Publishers, 1988, pp 38-56

4 Benner P: From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA, Addison-Wesley Publishing Co Inc, 1984

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8 Larkin J, McDermott J, Simon DP, et al: Expert and novice performance in solving physics problems. Science 208:1135-1142, 1980

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10 Payton OD: Clinical reasoning process in physical therapy. Phys Ther 65:924-928, 1985

11 Strauss A: Qualitative Data Analysis for Social Scientists. New York, NY, Cambridge University Press, 1987

12 Walter SD, Cook RJ: A PC Program for Analysis of Observer Variation. Department of Clinical Epidemiology and Biostatistics, McMaster University Medical Center, Hamilton, Ontario, Canada, 1988

13 Roter D, Hall J, Katz N: Patient-physician communication: A descriptive summary of the literature. Patient Education and Counseling 12:99-119, 1988

14 Perry JF: Nonverbal communication during physical therapy. Phys Ther 55:593-600, 1975

15 Fuller F, Brown 0: Becoming a teacher. In Ryan K (ed): Teacher Education: SeventyFourth Yearbook of the National Society for the Study of Education. Chicago, IL, University of Chicago Press, 1975, pp 25-52

16 Tammivaara J, Yarbrough P: In transition: Perspectives on physical therapy and competent physical therapists. In: Physical Therapy Education and Societal Needs: Guidelines for Physical Therapy Education. Alexandria, VA, American Physical Therapy Association, Department of Education, 1974, pp 19-27

17 Kennedy M: Inexact sciences: Professional education and the development of expertise. In Rothkopf E (ed): Review of Research in Education. Washington, DC, American Educational Research Association, 1987, vol 14, pp 133-168

G Jensen, Phd, PT, is Assistant Professor, Division of Physical Therapy, School of Health Related Professions, The University of Alabama at Birmingham, UAB Station, Birmingham, AL 35294 (USA).

K Shepard, Phd, PT, FAPTA, is Associate Professor and Assistant Dean of Graduate Studies, College of Allied Health Professions, Department of Physical Therapy, Temple University, Philadelphia, PA 19140.

L Hack, Phd, MBA, PT, is Principal and Co-owner, Philadelphia institute for Physical Therapy, Philadelphia, PA 19104.

This research was presented at the American Physical Therapy Association/Canadian Physiotherapy Association joint Congress, Las Vegas, NV, june 12-16, 1988.

This study was partially supported by the Dean's Research Incentive Award, College of Allied Health Professions, Temple University.

This article was submitted June 12, 1989; was with the authors for revision for nine weeks, and was accepted January 19, 1990.

(Tables and other figures omitted)