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Title : Good Health and Are you an expert clinician?. Elvonda
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Good Health and Are you an expert clinician?. Elvonda

If 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

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