The focus of research into the development of expertise in physiotherapy has been on establishing the characteristics of clinical experts in an attempt to guide novice practitioners to better utilise their time and available resources (Jensen et al., 2000, Lindquist et al., 2006, Christensen et al., 2008, Petty, 2015). Accumulating evidence (Eraut 1994, Fish and Coles, 1998, Jensen et al., 2000, Titchen, 2001, Haynes et al., 2002, Rushton and Lindsay, 2010, Petty, 2015) suggests that clinical expertise is developed through:
1) Clinical experience of high quality to build up knowledge and skills;
2) Postgraduate education that promotes the critical exploration of practice knowledge;
Box 3.2: Assessment criteria for global clinical reasoning competencies. Adapted from Yeung et al. (2015a, p. 309).
o Use different forms of knowledge to support hypotheses and management plan.
o Explain the significance and interaction of the subjective and physical examination data collected.
o Generate plausible and reasonable hypotheses.
o Critically evaluate sources of information and the claims they make.
3) Observing and being observed by a clinical mentor, with timely and specific feedback about development needs.
While this body of evidence does not detail the journey through which practitioners advance their expertise, Benner’s (1982) seminal model of developing clinical expertise in nursing is, according to Google Scholar analytics, a highly cited model in which different levels of expertise in healthcare literature are examined. Benner (1982) proposed that the practitioner progresses through five stages of practice, namely novice, advanced beginner, competent, proficient and expert levels (Figure 3.1). Similarly, Richardson (1999) used the term ‘patient mileage’ to conceptualise the number of patients that a physiotherapy practitioner needs to see to gain expertise. Such a notion of advancing expertise through experience is not supported in the literature (Titchen, 2001).
These models overlook the role of postgraduate education and critical reflection on experience as important factors in developing expertise. Petty and Morley (2009) argue that developing expertise can be difficult unless practitioners change their frame of reference e.g. routinely-performed patient assessments and management. The development of cognitive skills, as an important dimension of clinical reasoning, is not possible if practitioners do not become critical and evaluative of their routinely- performed patient assessments and management (Lake and McInnes, 2012). According to Petty (2015), this does not happen unless practitioners socialise in their workplace and expose their practice to their colleagues, which therefore ensures a high quality clinical experience.
Figure 3.1. Characteristics of skills development in nursing. Adapted from Benner (1982)
In the context of understanding the development of expertise in clinical reasoning skills, early research in the medical field indicates that expert practitioners tend to ask a few properly-timed questions and make diagnostic decisions in less time than less experienced practitioners and students (Rimoldi, 1988). However, this research was conducted using quantitative data collection methods which limited comprehensive understanding of the context of clinical reasoning. This research was also located within behavioural psychology literature; thus, it did not offer an account of the cognitive processes that drive clinical reasoning, such as hypotheses generation and testing.
On the other hand, cognitive-grounded clinical reasoning empirical studies examined how practitioners organised knowledge (Schmidt et al., 1990), processed information and clinical cues (Tanner et al., 1987), and solved clinical problems (Elstein et al., 1990). Utilising this cognitive approach, multiple researchers examined the differences between
novice and expert practitioners (Patel and Groen, 1986, Ericsson and Simon, 1998, Norman and Schmidt, 2000). While this research immensely facilitated understanding the cognitive dimension of clinical reasoning, the use of research tools such as ‘think-aloud’ to understand cognitive activities might not reflect an authentic form of clinical practice. The differences between novices’ and experts’ clinical reasoning were examined with the emergence of qualitative, exploratory and ethnographic research (Laufer and Glick, 1996). The characteristics of clinical expertise in clinical reasoning were identified as: high level of cues identification, prioritising assessment, advanced level of knowledge, flexibility in thinking, knowledge synthesis and integration, and specific identification of patients’ problems (Bordage et al., 1990, Boshuizen et al., 1995, Norman, 2005). Similar empirical evidence was identified within musculoskeletal physiotherapy practice (Doody and McAteer, 2002, Black et al., 2010, Ajjawi and Higgs, 2012, Petty et al., 2011a, Constantine and Carpenter, 2012).
These studies viewed expertise as an individual cognitive attribute with little regards to the context in which clinical reasoning occurs. In particular, how the interaction with others changes processes of clinical reasoning. Evidence from occupational therapy literature suggests that the development of expertise requires positive attitudes towards the collective processes of clinical reasoning more than having specialist knowledge (Whitcombe, 2013). Similarly, Gabbay and LeMay (2011) used the concept of ‘clinical mindlines’ to suggest that expert practitioners rarely access or use research-based evidence directly. Instead, they identified that practitioners rely on collectively reinforced, internalised and tacit guidelines they named ‘mindlines’. These mindlines are socially constructed knowledge from a blend of several sources, including education, peers and tacit experience, among many others. Therefore, an advanced expert level of practice is dependent on knowledge that is contextually bounded in practice. This is in
accord with Norman et al. (2007), who note that the ability to identify clinical reasoning errors was impacted by practitioners’ biographies and personally constructed illness scripts more than their de-contextualised knowledge. Thus, clinical-based pedagogy that engages practitioners in collaborative activities has the potential to facilitate mastery in clinical reasoning skills.