M-1: Expert Problems
The label of "expert" has value. It signals "someone who knows a lot about something". It comes with suggestions of "I know what I'm talking about" and "the buck stops here". It's especially useful for marketing, the education (swaying?) of public's perspective, and focusing a given fields' potential energy into kinetic energy for meaningful impact.
What is expertise? How important is it to be an "expert"? What does it take to become an expert?
These questions and more will be explored in this series titled "The M-Series". Now, in Part 1 we will try to address some of the questions above.
The Physical Therapy Education System in the US tends to promote Physical Therapists as Experts in Conservative Musculoskeletal Care. And, in at least two studies show physical therapists are more knowledgeable than general physicians when it comes to musculoskeletal care. (one, two). Does simply knowing more make you an expert? Does experience play a role?
Time under the belt means little to nothing when it comes to developing clinical expertise. Just a few years of "evaluated experience" tends to put young clinicians years ahead of their more experienced peers in terms of clinical reasoning skills and efficiency in filtering out ineffective clinical interventions. Many times a mentorship or apprenticeship model does a wonderful job of bridging this gap. This doesn't require an official residency, but it does require consistent feedback, constructive reviews, enduring curiosity, and a decent breadth of didactic & experiential knowledge. The sharper the feedback loops, the steeper the learning curve. This stage must involve learning new things and developing an understanding of their application.
According to Diane Lee, clinical expertise comes down to doing the right thing at the right time. Other clinicians will likely have similar perspectives with a couple of their own unique additions.
Here's what Dr. Sackett, et al had to say on the topic of clinical expertise in a 1992 paper:
” Clinical experience and the development of clinical instincts (particularly with respect to diagnosis) are a crucial and necessary part of becoming a competent physician. Many aspects of clinical practice cannot, or will not, ever be adequately tested. Clinical experience and its lessons are particularly important in these situations. At the same time, systematic attempts to record observations in a reproducible and unbiased fashion markedly increase the confidence one can have in knowledge about patient prognosis, the value of diagnostic tests, and the efficacy of treatment.
In the absence of systematic observation one must be cautious in the interpretation of information derived from clinical experience and intuition, for it may at times be misleading.”
A few years later (1996) Dr. Sackett, et al described clinical expertise as:
“By individual clinical expertise, we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care.”
Clinicians and academics (including the arm-chair variety) make unforced errors when "clinical expertise" is viewed as sharply distinct from "Patients' Values & Preferences", and "Best Research Evidence". Clinical expertise is not simply a chronological period of time. It is more than "knowing the research" - whatever that means. It is also more than a strong recognition of patients' values and preferences.
Clinical Expertise is the delivery of clinical care (blending of clinical experience with published research) within the context of patients' values & preferences. "Clinical Expertise" also suggests repeatable and predictable outcomes. After all, would you label someone an expert if s/he can't repeatedly execute within their field of expertise?
THE EXPERT PHYSIO
There's more to physiotherapy expertise than the ability to contextualize evidence, or having the skills to perform manipulations, or displaying the knowledge to develop a prescriptive exercise plan. There's more to it than dry needling, or the strength of your "modern pain science" game.
Maybe Diane Lee is right. Maybe "Clinical Expertise" is simply the ability to do the right thing at the right time.
Filtering through the research to figure out what "doesn't work" or what's contra-indicated is undoubtedly useful. However, this doesn't necessarily tell you what will work for all the clients on your schedule in the clinic. Nuance exists. It exists within published research, within the building and growth of therapeutic alliance, and within the internal catalogue of experiences all curious clinicians accumulate. The process of interpreting and organizing the data points of information (research, experience, contextual factors, etc.) into an the "right-here-right-now" to help someone make meaningful strides in their journey toward recovery is what a clinical expert does... repeatedly.
Clinicians operate on the front lines of healthcare. It's where all the potential energy of a basket-case of factors (medicine, society, economics, political systems, etc.) transforms into the kinetic energy of healthcare. So, while Skills Proficiency and Clinical Reasoning are necessary, they are not sufficient for physiotherapy expertise. Here is an open-ended list of useful concepts to help you develop physiotherapy expertise:
- The Ability to Execute via an Adaptive Organizational Framework
- A Recognition of One's Circle of Competence
- An Effective Dose of Social and Emotional Intelligence
- A Sense of Purpose
- An Autodidactic Bend
- A Synthesis of the Rational and the Intuitive
- The Freedom and Willingness to Change One's Mind
The Reversal. Two blindspots of "expert advice".
Let's take a step back, and define the word "expert".
According to Mirriam-Webster, an expert is someone "having, involving, or displaying special skill or knowledge derived from training or experience". The word "expert" first appeared in the 14th century, originally meant "experienced", and drew "from Latin expertus 'tested, shown to be true,' from past participle of experīrī 'to put to the test, attempt, have experience of, undergo.'"
This definition strongly hints towards some potential pitfalls of following "expert" advice. let's (very briefly) touch on two of them: 1) the unintended quarantining of one's self in the past, and 2) the problem of conflation.
1) The Gravity of the Past. To become an expert in a given subject requires deep studies into the specific field , conferring with others involved in the field, and focusing sharply to gain the greatest amount of knowledge in this field. S/he gradually views the world through the lens of their "expertise". The field's common vocabulary becomes the language you use in daily life. This adopted language and perspective further molds biases, preferences, and risk tolerances. Eventually this deep focus can morph into a tunnel vision of his/her world. S/he is so well-versed in what was important that s/he can't incorporate novel ideas into a creative future. The future starts to look like different versions of the past. It becomes difficult to imagine something entirely novel. We become blinded to possible futures.
Manoj Bhargava, the creator of 5-Hour Energy drinks, doesn't mince his words when it comes to his opinions on experts and their biases to the past.
"Most inventions were made by people who didn't have a background in what they were inventing. If you look at throughout history, the great stuff was made by people who didn't follow the rules of the experts. Experts are great for telling you what you shouldn't do, and for that they're useful; but what you should do, they don't have a clue." - Manoj Bhargava, Creator of 5-Hour Energy
The American Physical Therapy Association provides another example of this problem of clinging to the past: The OCS. The Orthopedic Certified Specialist (OCS, which I now dub "Outdated Clinical Specialist") simply creates more experts of the past; it does not foster a foundational clinical framework on which the clinician can organize new knowledge or skills. It simply reinforces the findings of studies that (for large part) have not been replicated. One thing an OCS - maybe - does do, however, is signal "expertise" to the public.
2) The Conflation Problem. Mirriam-Webster defines conflate as "to combine (things, such as two readings of a text) into a composite whole." Contemporary use of the word generally denotes the false merging of two or more ideas into a misleading whole. Here's an example: asking a medical doctor for nutritional advice. Many people confuse the idea of a medical doctor and an expert on all-things-nutrition. The fact is that these are two different things. Majority of medical doctors are simply not trained on diet & nutrition. Even though most medical doctors will say that diet & exercise are major factors in healthy longevity, they aren't well-trained in either. Here's a direct quote from the article:
"In a 2015 survey of 121 four-year medical schools, Kohlmeier and colleagues found that 71 percent did not require at least 25 hours of nutrition education and that fewer than 20 percent required a nutrition course — fewer even than 15 years before."
It's true; experts are human and commit unforced errors all the time. Sometimes these errors are unfortunately immense. I'm sure you can come up with a number of examples on your own.
In summary, yes experts are useful, but they come with intrinsic pitfalls. Multiple threads of knowledge and experience (among other things) combine to form "an expert"... sort of like a sweater. And, like a sweater, it might not be appropriate for all seasons...
We have attempted to address some of the preliminary questions about clinical expertise.
Next we will explore how to identify & survive experts' errors. You will be able to easily apply these concepts to reduce the chances of committing these errors yourself.