Experts…at least on paper.
I was very impressed with the Jensen article. I appreciate the historical analysis of experts. To believe that an expert simply knew more and was able to solve problems better than anyone else is disheartening. I work with others that are certified in MDT and though we go about treatment strategies in similar fashions, we compete against each other with paper patients. One strategy that we use to refine our skills in a group setting is a version of 20 questions. One therapist will create a case study and each therapist is attempting to ask the fewest questions in the history section in order to create a hypothesis to solve the patient’s puzzle. Though there are varying degrees of experience in this group, the therapists that consistently attend the study group are typically able to solve the case puzzle within 3-5 questions, whereas others may take 10-20 to create a hypothesis. I agree with the statement that experts are able to recall meaningful, selective knowledge. I can appreciate the next generation, which describes recall of patterns. This is extremely important for orthopedics. Patterns take much time to learn, but once a pattern is consistently witnessed, the therapist can be confident in the treatment approach.
I find the “necessity of self-monitoring through self assessment” to be extremely important in my practice. The saying “if all you have is a hammer, then everything looks like a nail” comes to mind. There are many therapists that force extension because it is the most common pattern, although the patient may not be an extension responder. I have had to step back many times to reassess my rationale for a treatment approach in order to ensure that I am not just following a preconceived bias.
The fact that the therapists were videotaped is interesting. There is one point in the paper when the therapist changed demeanor from clinical to personal while doing soft tissue mobilization prior to traction. I wonder if the therapist was taught this somewhere along the educational spectrum or if this is inherent. This skill has to do with “reading” reading the patient. I am reading a book called Telling Lies by Paul Ekman in order to better understand body language. This therapist either learned or inherently knew to change the approach at that time. To me, this is interesting.
I subscribe to the paragraph on page 34, “The expert therapists in this study shared…”. This is a central component to MDt. At no point do we utilize the word compliance, but instead emphasize therapeutic alliance. In other words, a team approach to fix the patient, with the patient’s preferences, judgments, and decisions having as much importance as the clinician’s knowledge of the problem.
Bill Curtis, PT, cert. MDT lectured to our class about MDT and at the time I had a hard time believing that spine symptoms could be fixed in days. I called, pardon the language, bullsh_t. I spoke to Bill after the lecture and because he did not have any research to back his claims, I had a hard time believing him. That was the greatest thing to have happened to me as a therapist, because he challenged me to do a clinical with him. I learned more in the 8 weeks as to how to fix people than I ever did in school. At that time I knew that I had to work with him in order to continue learning the secrets to solving the puzzles. I see some of my colleagues struggling with spines, and think that I would’ve been in the same boat if I didn’t seek out a mentor with more experience and abilities than I had at the time.
I like the statement that the OC made “you made a lot of mistakes”. I actually feel bad for some of the early patients that I treated. It’s one of those situations that if I knew then what I know now. Some of those patient’s wouldn’t have needed 15-16 visits in order to be back to 100%.
I thought that it was common sense that listening to patients is vital for proper classification and treatment. Apparently I was wrong. This is a skill that has to be learned and practiced in order to master. When working with PT students, I ask them to follow along and just write down on the form the information and we compare forms after the evaluation. Initially, the students miss so much relevant information, but by the end of the clinical are able to catch all relevant information and information that may not be as relevant to the case as much as relevant to the patient.
It is interesting that therapists are classifying patients, although they do not classify formally. Anthony Delitto stated in one of his papers that a clinician will attempt to classify all the patients. The NC stated that he/she “form opinions pretty quickly about certain patterns” and the OC stated “I constantly try to make sense to see how certain clinical pictures behave”. At this point, they are initiating a rudimentary classification process. Also a strong theme in this paper is therapeutic alliance. It comes up many times in the article.
I like that the experts used little equipment and gave few exercises. I tell patients that I can give them a book of exercises to do at home or I can give them one or two that will fix their complaints, which I also learned from Bill.
All therapists “set high standards and were driven to stay current in their specialty area”. As much as I agree with this statement, this statement also disheartens me. As professionals, I would expect this mentality from all of my colleagues, not just “experts”.
I love this article and am not speaking to all of the points of the article, just those that I find interesting or of differing viewpoints than those taught in school.
The comment on page 41, “If expertise in physical therapy is some combination of knowledge…can clinical practice and education be designed in a manner to address these multiple dimensions of professional competence?” I think that the first question to be asked is does everyone desire to be an expert. The desire to be an example and set an example for other PT’s to follow has to come before attempting to teach the skill set of an expert, in my opinion.
Another great question posed was “Why do some therapists continue to develop into expert clinicians, while others lapse into mediocrity?” Can this be detected during the interview process for PT schools? This question is very thought provoking in that it may be possible to create a profession of experts if we choose the right students.
Again, I loved the article and found certain elements as basic, such as caring and compassion being cornerstones of experts, while I believe that the other concepts, indirectly described in the article, are intriguing.
Excerpts and opinions based on the following article:
Jensen GM, Gwyer J, Shepard KF. Expert practice in physical therapy. Phys Ther. 2000;80(1):28-43.