Sunday, December 28, 2008

Are you an expert clinician?

ResearchBlogging.orgIf you've been reading my posts for a little while now, you might have noticed I place a high value on education. I've been teaching as an adjunct instructor for over eleven years at a local university and regularly take students on clinical rotation. After a recent four-week (entirely too short) rotation with two year-one PT students, I found myself looking back on to their experiences at the clinic and wondering what I could have done better. They both had a great experience, but I couldn't help but wonder why I wasn't quite settled with the approach I took with them.

I began looking into clinical education models across several disciplines and found there is actually quite a bit of literature out there on the subject. One article in particular caught my mind regarding the differences between what's considered to be "novice" and "expert" clinicians. I was curious for a couple of reasons. Firstly, I wanted to know if my expectations of the students were matched appropriately to their skill level. For example, how can I bring a year-one along compared to the more advanced students without either frustrating or overwhelming them? Secondly, I was pretty curious to see if, despite my experience and board-certification, I could consider myself as an expert!

Today's article comes from the PT Journal back in 1992. The articles author, Mark Jones, provides a very straightforward discussion of clinical reasoning and the nature of expertise. Since the authors/editors of these articles do a much better job of outlining their ideas than I do of encapsulating them into my blog, I have provided a link to the full text article here.

Defining Expertise

Traditional notions of expertise have related to experience. Students were often considered novices while advanced practitioners were considered experts. While this may often be the case, a more precise delineation of what constitutes expertise may be useful. The author contends that expertise be considered along duel continuum of both generic and specialized knowledge. A sub expert is someone who possesses adequate generic knowledge, but insufficient specialized knowledge of a given domain. Predictably an expert possesses both generic and specialized knowledge of the domain.
An expert is distinguished through utilization of superior organization of generic and specific knowledge, hypothetico-deductive reasoning, and pattern recognition.

Expert Practice

Clinical reasoning will be influenced by a combination of the therapist's knowledge base along with their cognitive and meta cognitive skill set. Cognitive literature suggests that these components can be improved with effort, but can suffer through neglect. This indicates that the most expert clinical reasoning comes from not only knowledge, but the ability to step back and examine our cognitive biases when dealing with a case. Additionally, the reasoning process can only be as good as the collected information. It is critical that the clinical environment be designed in such a way to optimize the collection of accurate and reliable information from the patient. Our busy clinics can impose obvious limitations on the information gathering process such as group norms, time limitations, unrealistic productivity standards, and overextended case loads.

Teaching Students to Become Experts

Obviously, getting a student to become an expert is a tall order and not entirely realistic. However, we can teach the students to exercise their clinical reasoning muscles (i.e. the brain) by challenging them to go beyond the books in determining the best course of action. As Jones puts it:

Facilitating students' clinical reasoning requires making them aware of their own reasoning process and designing learning experiences that promote all aspects of the clinical reasoning process while exposing the errors in reasoning that occur. This requires access to students' thoughts and feedback on thinking processes. That is, students should be taught to think and to think about their thinking. This can be achieved by promoting students' use of reflection to encourage awareness and promote integration of existing versus new knowledge. When combined with a better awareness of one's own cognitive processes (ie, metacognition Metacognition refers to thinking about cognition (memory, perception, calculation, association, etc.) itself or to think/reason about one's own thinking. Types of knowledge ), the students' processing of information is enhanced and clinical reasoning is facilitated. Learning experiences to facilitate clinical reasoning using both reflection and metacognition are described elsewhere.

The process of reasoning should not, in my view, be addressed to the neglect of knowledge. Rather, facilitating the clinical reasoning process will assist the students' acquisition of knowledge. In turn, good organization of knowledge leads to better clinical reasoning. The importance of one's organization of knowledge is closely linked to the accessibility of one's knowledge. Knowledge that is acquired in the context for which it will be used becomes more accessible. Although clinical knowledge is typically presented in the context of patient problems, this is less commonly the case with the basic sciences (eg, pathophysiology). Approaches to physical therapy education in which the acquisition of knowledge is facilitated by teaching centered on patient problems provide, in my opinion, the ideal environment for building an accessible organization of knowledge and fostering clinical reasoning skills.

Next Step...

Last year I implemented a clinical rotation syllabus that emphasized reading peer-reviewed literature on topics such as LBP, shoulder examination, and pain science. This year I will begin incorporating clinical reasoning activity to supplement this knowledge-based curriculum. I'm sure the students will go home with some pretty good brain cramps, but will be better clinicians for it. I know I'll feel better knowing that they got the most out of their rotation at our clinic! I hope you will find this information and the article helpful in guiding your students to become better providers.

An interesting note: I found a more recently published article on clinical reasoning in the PT Journal from 2006 and plan to review it on this blog at a future date. Great stuff!

Jones M (1992). Clinical reasoning in manual therapy Physical Therapy, 72 (12), 875-884


  1. Great post yet again Rod. Heck of a weekend for you! Love the topic here, I have had many of the same thoughts regarding my students. I too have a binder of peer-reviewed research that I have accumulated over the years. I have categorized it over time and it really becomes a resource after a while. I only include articles that I consider to be "classics," the best of the best. I will pick a topic-of-the-day for the students, maybe based on an eval for that afternoon, and require pre- and post-reading. This has helped supplement my teachings as I can not do it all myself!

    To me, an expert has both intelligence and experience. That is why a new grad or student can not be an expert. Our thought process is shaped by our past patients and experiences, both positive and negative. For example, my examination for a patient with a suspected rotator cuff tear is very deliberate and systematic. I will not waste time and perform every special test I know, I will continuously narrow down my exam cluster based on the feedback and results of each test.

    Students on the other hand, are in the mold of performing every test they can think of on a patient and then trying to put it all together at the end. Experts, take the result of a specific test and allow it to dictate the next test in your sequence. Only experience can effectively do this.

    Keep up the good work Rod.

  2. Thanks for all the great posts! I have been reading a e-mailing your last 4 or 5 posts to all my PT friends. So timely, all your topics.

    This post on students really interests me. I often struggle with how much guidance and what type to offer my students. I give 1 article weekly for discussion and wish we had time for more.

    There have been many discussions of how much time our clinicians should be allowed to block off patient care time for additional meetings or instruction. I have my students come in early or meet during I being too tough?

  3. Thank you both for your kind comments. Mike your blog is looking great as always. Hopefully we can get even more of our colleagues on the blogosphere.

    Amy. I really do struggle with how much to throw onto my students. The last two year-ones understandibly needed more hand holding. Earlier this year I had two year-threes (Just hired BOTH of them!) and they took every challenge and ran it into the endzone. I guess its just as much of a feeling out process for the CI as much as the students. It may also be volume dependent. It's hard to spend time teaching when you have a 15-20 patients on your schedule! Frankly, I feel more motivated to teach when I have all my ducks in a row at the clinic (paperwork caught up, giving patients individualized time, etc...). In short it's a never ending pursuit for me as well. Best of luck to you and my sincerest thanks for passing on my posts!

  4. I discovered your blog when I was googling information to help me study for my NAIOMT Level III oral/practical (North American Institute of Orthopedic Manual Therapy). Now that I am done and passed, I really want to congratulate you on a really neat blog. I passed the entry on the "Pain in the Brain" video around to my co-workers because I thought that explained a complex topic in more simple terms, making it easier to communicate with patients.
    I think this blog entry is timely since I have my next 15 week, year three DPT student starting next week. I too have a binder I have put together for students, with articles, typed in-services I have prepared that I expect them to read before hand, eval forms and explanations, etc. The more skills I attain though, as a manual therapist over the years, the harder it is to get them to the point to just hand patients to them without finding the time to in-service them quite a bit first, and practice a few things. Like you say, when you have a full patient load, up to 18 a day, it makes it harder still.
    You know after nearly 30 years, over 60 continuing ed courses, taking students for 28 years, I still have a hard time saying I am an "expert" since there is always so much more to learn!
    Barb Carusillo PT, OCS, CMPT

  5. I discovered your blog when I was looking for information to help me study for my Leve III NAIOMT (North American Institute of Orthopedic Manual Therapy) oral practical exams, and now that I have passed, I wanted to take the time to tell you how really cool your blog is. I shared your entry on the "Pain in the brain" video with my co-workers.
    I think this entry is very timely for me since I have a 15 week year 3 DPT student starting next week. I too have a binder, with eval forms and sample sequences and explanations, articles, and the didactic part of in-services I try to get in while they are on clinicals. So many have the basic info, but really have not learned a lot of techniques, so it is hard to have them treat patients until they get these skills. That is the challenge sometimes when our case load is full.
    And even after nearly 30 years of practice, and over 60 continuing ed course over the years,
    I still have trouble calling myself an "expert" because there is always so much more to learn!
    Barb Carusillo PT, OCS, CMPT

  6. Barb thank you very much for the kind words on my blog. It sounds like you are doing great things for your students, while not loosing sight of the fact that we're all somewhere on that learning curve. Your comittment to learning in the presence of all your experience is truly inspiring. Best of luck to you!