Expert Decision Making in Physical Therapy−−A                                Survey of Practitioners                      ...
Research ReportExpert Decision Making in Physical Therapy-A Survey of PractitionersFour hundred American and 384 Australia...
similar reasoning processes.12-7 Cur-        and constraints early, performing an                  therapy practitioners i...
styles described by McKenney and             We performed a reliability analysis for          birth educators and consulta...
United States                                                 Australia                             80                    ...
01 llrnlted value                                                                                                         ...
Of limited value                 Geriatrics                Australia                                       United States  ...
United States                                                                Australia              6           4         ...
-Table 3 Analysis-of-Variance Summay for Relationship Between Cognitive Style         .Categoy, Sex, and County           ...
more efficiently. Educationally, there                                                                                    ...
-Appendix. 1. sex:                   Clinical Decision-Making QuestionnaireSectlon I--DemographicsPlease circle the approp...
-Appendix.Sectlon Il-Sources                   (Continued)                      of lnformatlonThere are many ways a physic...
-Appendix.          (Continued)42. 1 plan my assessments in a systematic manner so as not to forget anything.43. During th...
References                                          ers to clinical decision making.J Med Educ.       Statistical Analysis...
Expert Decision Making in Physical Therapy−−A                               Survey of Practitioners                       ...
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Phys ther 1991-may-190-202

  1. 1. Expert Decision Making in Physical Therapy−−A Survey of Practitioners Bella J May and Jancis K Dennis PHYS THER. 1991; 71:190-202.The online version of this article, along with updated information and services, can befound online at: This article, along with others on similar topics, appears in the following collection(s): Clinical Decision Making Professional Issuese-Letters To submit an e-Letter on this article, click here or click on "Submit a response" in the right-hand menu under "Responses" in the online version of this article.E-mail alerts Sign up here to receive free e-mail alerts Downloaded from by guest on March 23, 2012
  2. 2. Research ReportExpert Decision Making in Physical Therapy-A Survey of PractitionersFour hundred American and 384 Australian pkysical therapists, nominated by Bella J Maytheir peers as expert clinicians, were studied to evaluate whether a particular cog- Jancls K Dennisnitive style was prevalent among expert clinicians, to identzb preferred sources ofinformation for clinical decision making, and to determine the similarities anddflerences between American and Australian therapists. Results were based onusable surucy responsesfrom 348 American and 290 Australian therapists Eighty-eight percent of the American therapists and 82%of the Australian therapists iden-tifed themelves as working primarily in general practice, orthopedics, or neurol-ogy. The physical therap?.assessment and intemiews with the patient were thepreferred sources of information in both countries. The physicians referral andcommunications with other health care personnel were reported to be of limitedvalue as sources of information by most respondents. Overall, both groups re-sponded most positively to the receptive style of data gathering and the systemticstyle of information processing Therapists working primarily with neurologicallyimpaired patients responded most positively to the preceptive style of data gather-ing and the intuitive style of information processing. Therapists working primarilywith patients with orthopedic disorders responded most positively to the systemticstyle of information processing. /May BJ, Dennis JK Expert decision making inphysical therapy4 survq of practitioners. Phys Ther 1991;71:190-206.1Key Words: Data collection; Decision making; Physical therapy profession, inter-national; Questionnaires.Physical therapists are assuming in- ing the experts themselves what they nursing, and physical therapy, and thecreasing independence in making do or believe they do. findings generalize across areas of cpatient care decisions. Understanding study. Decision making is influencedthe dimensions of expert decision There has been considerable research by knowledge, the way experiencemaking will help current practitioners into clinical decision making, has structured that knowledge, theimprove their skills and educators information-processing strategies, and type or format of the decision task,prepare students more effectively. It differences between expert and nov- the limitations in human informationseemed appropriate to begin an in- ice behaviors in the past two decades. processing, and the social and contex-vestigation of expert behavior by ask- Research has been done in many tual elements of the decision.-l4 fields, including medicine, education, Decision making has generally been found to include (1) the use of criticalB May, EdD, PT,is Professor, Department of Physical Therapy, School of Allied Health Sciences, cues or forceful features for promot-Medical College of Georgia, Augusta, GA 30912-0800 (USA). Address all correspondence to Dr May. ing the recognition of specific clinicalJ Dennis, MAppSci, PT,is Assistant Professor, Department of Physical Therapy, School of Allied patterns and (2) the early generationHealth Sciences, Medical College of Georgia. of hypotheses for organizing the ac- quisition and interpretation of infor-This article is adapted from a paper presented at the Tenth International Congress of the WorldConfederation for Physical Therapy, Sydney, Australia, May 17-22, 1987. mati0n.~.*,5Preliminary evidence sug- gests that physical therapists useThis article was submitted Februaly 15, 1983, and was accepted September 24, 1990.22/190 Physical Therapy /Volume 71, Number 3 /March 1991 Downloaded from by guest on March 23, 2012
  3. 3. similar reasoning processes.12-7 Cur- and constraints early, performing an therapy practitioners in eachrent research does not support the ordered search for information, and country?popular belief that clinicians collect a completing one step before progress-complete, routine database before ing to the next, and (2) intuitive, char- 3. Is cognitive style preference influ-deciding about the patients problems. acterized by keeping the total prob- enced by country of practice, sex,Experts, when compared with novices lem in mind and considering or major practice area?in the same field, exhibit a superior alternatives simultaneously. The intui-structuring of knowledge into clini- tive person may move from one thing Methodcally relevant patterns that are un- to another, relying on cues andlocked by key cues in the decision hunches. The results of Borksl2 study Subjectsenvironment. Patterns stored in mem- of physical therapy students suggestedory enable the expert to recognize that cognitive style influenced clinical Subjects were selected through ameaningful relationships and generate evaluation performance. The ability to nomination process. Elected national,likely hypothe~es.7~9.~~,~~.17 Recently operate in the intuitive mode was state, section, o r special interest grouppublished models1*20 attempt to help associated with a better performance officers holding comparable positionspractitioners organize key pathologi- in history taking and physical assess- in both countries were asked to nom-cal concepts as a guide to decision ment, whereas students who operated inate individuals whom they consid-making. Isychological research indi- primarily in the preceptive mode ered to be expert clinicians and whocates that human information process- were less likely to accurately deter- were involved in direct patient careing is subject to bias introduced by mine a simulated patients problems. activities at least 25% of the time.the presentation of the task and by In nursing, Hayes-Roth and Hayes- Over 800 nominations, which in-strategies used for selective attention Roth25 suggested that systematic deci- cluded 700 individual names, wereand interpretation of the environ- sion making might be effective in received from US officers. All individ-ment.3 If the patient referral, for ex- solving simple problems but that op- uals named more than once and aample, contains a specific diagnosis, portunistic decision making, that is, random sample of the remainingthe diagnosis has been shown to be a responding to the stimuli as they oc- nominees were used to obtain a sam-biasing factor in both medicine in curred, might be more effective in ple of 404 individuals. In Australia,England2:l and physical therapy in complex situations. Few studies have over 500 nominations, which includedA~stralia.;!Z~~3 specifically examined the relationship 384 individual names, were received of cognitive style preference to deci- and became the group selected toCognitive style, which can be defined sion making. receive the an individuals preferred way ofthinking and organizing information, A study of expert clinicians in the Procedureshas also been studied for its effect on United States and Australia was under-decision making. McKenney and taken as the first stage in the process Survey instrument development.Keenzqdeveloped a paradigm of cog- of describing expert behaviors. The We developed an instrument tonitive style that was used by Bork12 in study was designed as a preliminary gather data on expert physical thera-a study of cognitive style influences investigation into the nature of data- pists preferred sources of informa-on decision making by physical ther- gathering and information-processing tion and to measure the experts self-apy students. McKenney and Keensz4 phases of expert clinical decision perception of their decision-makingparadigm reflected four styles of cog- making. A second purpose was to behaviors, focusing on cognitive stylenition, two related to the data- compare the reported decision- preference. The instrument evolvedgathering phase and two to the making processes of therapists in a from a multistep process that in-information-processing phase of deci- country with direct client access to cluded interviews, categorization ofsion making. The data-gathering styles physical therapy (Australia) with the the interview statements and scoringwere defined as (1) receptive, a style reported decision-making processes procedure, pilot testing, and final con-generally characterized by suspending of therapists in a country with limited struction of the instrument.judgment until all possible data have opportunity for direct client accessbeen collected, paying attention to (United States). Specific questions Interviews. We tape-recorded inter-detail, anti attending to the implica- addressed by the study were: views with eight physical therapiststions of each piece of data individu- working in Georgia in different prac-ally, and (2) preceptive, a style charac- 1. What are important information tice settings. Interviews were con-terized by moving from one section sources for expert physical thera- ducted by both researchers, with oneto another, seeking and responding to pists in the United States and doing the questioning and the othercues and patterns as a guide to data Australia? making notes and monitoring the tapegathering. The information-processing recorder. The purpose of the inter-styles were defined as (1) systematic, 2. Is there a particular cognitive style views was to develop a set of "real-characterized by a consciously me- preference among expert physical world statements reflecting the char-thodical approach, defining problems acteristics of the different cognitivePhysical Therapy /Volume 71, Number Downloaded from by guest on March 23, 2012
  4. 4. styles described by McKenney and We performed a reliability analysis for birth educators and consultants toKeen2*Respondents were first asked each category, followed by a factor industry).to describe their clinical decision- analysis. We eliminated some state-making processes and then asked to ments and moved others to different Sources of information. Frequen-recall specific situations that illus- categories if the factor analysis indi- cies were computed for each sourcetrated simple decision making and cated a better fit and if the statement of information by country, and fre-difficult decision making. An unstruc- had face validity in the new category. quency tables, cross-tabulated withtured format was used to provide re- We retained 48 items, which were place of employment and major prac-spondents with the opportunity to randomized for inclusion in the final tice area, were then generated. Chi-describe their decision-making pro- survey instrument. At the end of this square analysis was not performedcesses in their own words. phase, the alpha value for each cate- because the numbers in some prac- gory was above .6, with one category tice groups were extremely small andCategorization.We then screened (systematic) above .7. we preferred to retain qualitative dif-the interview statements, identifying ferences at this level.some that matched the cognitive style We decided to proceed with thedescriptions and others that did not study, but to perform more reliability Cognitive style preference. Wefit. The latter appeared to be state- and factor analyses before analyzing reevaluated category reliability for thements of affect or belief (eg, state- the final data. Comments on clarity combined sample and for each coun-ments 63 and 67 of the Appendix) or were used to revise all three sections. try separately. Each category wasstatements about specific knowledge The final survey instrument was simi- scored by calculating the mean scorerequirements for decision making lar in structure to the pilot question- of the items in the category. The(eg, statement 55 of the Appendix). naire and is depicted in the Appendix. scores of subjects who responded toTo offset the limitations of the small fewer than 75% of the items in a cate-and geographically discrete interview Data Anaiysis gory were dropped from the calcula-sample, we added statements gath- tions of that category. The scores ofered from our collective experience. Responses to the survey instrument subjects who responded to 75% orThe first draft of the survey contained were coded as indicated on the ques- more, but less than loo%, of thesix logically derived components: one tionnaire. Data analysis included the items were calculated as the mean offor each of the four cognitive styles, following. the items answered. We then per-one defined as affect, and another formed a principal components analy-defined as knowledge. Demographics. Frequencies were sis using the parallel-analysis method calculated to provide a description of to determine whether the instrumentScoring. We developed individual the two samples. The years since was actually measuring different fac-scores by averaging the responses to graduation were collapsed into three t o r ~Parallel analysis is reported to .~~items within each category (affect, major categories for general descrip- be the most consistently accurateknowledge, receptive, preceptive, sys- tive purposes (ie, 0-10, 11-20, 20+), method for determining the numbertematic, and intuitive). but five categories (ie, 0-5, 6-10, 11- of major components to retain2 15, 16-20, and 20+), were retainedPilot test. A sample of 21 practicing for analyses of variance (ANOVAs) Analysis of variance. Before per-physical therapists in the United States related to cognitive style. Places of forming the ANOVAs, open responsesand 20 physical therapists in Australia employment included private practice, ("other") were reviewed individuallyfrom different practice settings was hospitals, rehabilitation centers, and and either assigned to another re-used to evaluate the pilot survey in- other areas, as listed in Section I of sponse or dropped from the analysisstrument, which contained three sec- the questionnaire (Appendix). We for that variable. The two nationaltions. The first section requested de- identified six major practice-area samples were analyzed separately us-mographic information, such as sex groups for the purpose of analysis. ing a one-way ANOVA to identifyand years since graduation. The sec- General orthopedics, manual therapy, within-nation differences in cognitiveond section asked respondents to in- and sports physical therapy were style attributable to sex, years sincedicate the value of sources of infor- combined to form an orthopedics graduation, place of employment, ormation, using a four-point numerical group; adult and pediatric neurology major practice area. The Tukeys Hon-scale ranging from "very valuable" to were combined to form a neurology estly Significant Difference (HSD) Test"of no value," with a fifth point if the group. General practice, geriatrics, procedure was used to identlfy differ-information was not available. The and cardiopulmonary physical therapy ences between groups at the signifi-third section required responses to 55 remained as initially established. The cance level of .05. For each categorystatements on a four-point scale rang- sixth group, education, comprised of cognitive style, two-way ANOVAsing from "strongly agree" to "strongly physical therapy educators and practi- were used to compare the means ofdisagree." Respondents were also tioners whose professional role was the Australian and American therapistsasked to comment on the clarity of primarily patient education (ie, child- by sex, years since graduation, placethe items. Physical Therapy /Volume 71, Number 3 /March 1991 Downloaded from by guest on March 23, 2012
  5. 5. United States Australia 80 80 U) C C $ 60 60 k U) C E "- 40 40 0 b n 5 z 20 20 Percentage of 0 0 time spent in 0-1 0 11-20 20 + 0-1 0 11-20 20 + patient care 0 -5 %2 % Years Since Graduation 26Oh-75% 76%100%Figure 1. Experience characteristics of American and Australian physical therapists showing years since graduation and the per-centage c$ time spent in patient care.of employment, and major practice samples are comparable in composi- lian therapists, 52%). Hospitals em-area. tion (except for the education group, ployed 29% of the US therapists, com- - in which childbirth educators and pared with 18% of the AustralianResults consultants to industry were mainly therapists, and rehabilitation centers represented in the Australian therapist employed 11% of the US therapists,We examined the data for a response sample). Approximately half of both compared with 2 1% of the Australianset effect within the two countries. samples were employed in private therapists. Of the remaining places ofThere was greater variance in the Aus- practice (US therapists, 49%; Austra- employment, 5% of the US therapiststralian therapists responses, indicating worked in a school system, 4% ingreater heterogeneity in the sample, community care, and 2% in physicalas compared with the American thera- therapy education; 7% of the Austra-pists responses. Table 1. Major Practice Areas lian therapists worked in community/ day care centers and as consultants toDemographics industry and 2% in physical therapy Practice Area Unlted States Australia education. Different practice charac-Usable responses were received from teristics and health care structures348 (86%) of the American nominees General practice 75 (22%) 52 (18%) made the samples less comparable inand from 290 (76%) of the Australian Orthopedicsa 153 (44%) 110 (38%) terms of this variable.nominees. Fifty-six percent of the Neurologyb 77 (22%) 75 (26%)American respondents and 76% of the Sources of Information Cardiopulmonary 18 (5%) 17 (6%)Australian respondents were female. Geriatrics 15 (4%) 17 (6%)Figure 1 outlines the experience char- There was a great deal of similarity inacteristics of each sample, showing EducationC 10 (3%) 19 (6%) the value placed on various sourcesyears since graduation and percentage Total 348 290 of information between the two coun-of time currently spent in direct pa- tries. Not surprisingly, therapists intient care. Table l depicts the distri- aGeneral orthopedics, manual therapy, sports both countries and in all types ofbution of the respondents across ma- physical therapy. practices valued their own assessmentjor practice areas for each country h d u l t and pediatric neurology. more than any other source of infor-and indicates that the two national "Academic, obstetrics-gynecology, preventive care.Physical Therapy /Volume 71, Number 3 /March 1991 193/25 Downloaded from by guest on March 23, 2012
  6. 6. 01 llrnlted value Valuable Geriatrics Australia Unlted States Neurology Australia co Unlted States : 8 Cardiopulmonary Australia 5 Unlted States ,m P Orthopedics ~usttal~a Unlted States General ~ustraas Unlted States 0 10 20 30 40 50 60 70 80 90 100 Percentage of RespondentsFigure 2. value of physicians orders (;ompared for American and Australian physical therapists by major practice areamation (US therapists, 88%; Australian The reported value of direct commu- Principal Components Analysistherapists, 89%). nication with the physician is illus- trated in Figure 3. Most Australian Seven factors were identified. WePhysicians orders were generally con- therapists found direct communica- compared the items in each factor forsidered of limited value by therapists tions with the physician of value congruence with the logical categori-in both countries (US therapists, 58%; (56%430%); the responses from zation that we had previously im-Australian therapists, 53%). A greater American therapists were similar posed. Although the reliability of thepercentage of Australian therapists (58%-68%), except for therapists cognitive style categories had beencompared with American therapists working in geriatrics. In geriatrics, the satisfactory in the pretest, regroupingreported that physicians orders were majority of American therapists found some items and eliminating others innot available (12% versus 4%, respec- direct communications with the physi- accordance with the principal compo-tively) (Fig. 2), because referral is not cian of limited value (53%). nents analysis strengthened the statis-required for treatment in Australia. tical basis for the survey instrument bThe value of physicians orders varied The reported value of other sources without altering the logical premiseswith area of practice; more Australian of information was somewhat on which it was based. We retainedtherapists (60%) involved in cardio- practice- and employment-specific. the four categories of cognitive stylepulmonary care, for example, valued Most respondents valued the patients (receptive, preceptive, systematic, andphysicians orders than did American past medical history (75% overall); intuitive) and identified two othertherapists (46%). The percentage of however, 20% of the therapists in pri- categories (physician dependency andAustralian therapists working in ortho- vate practice and 14% in home health holism), which will not be reportedpedics and neurology who valued care did not have it available. Overall, in this study. The seventh factor iden-physicians orders (28% and 25%, 26% of American therapists and 57% tified minor components, includingrespectively) was considerably lower of Australian therapists found radio- some universal value statements, andthan was that of American therapists graphs a valuable source of informa- was not retained. Our final categories, (46% and 45%, respectively), and tion. Sixty-seven percent of American their alpha values, and the relatedmore Australian therapists than Ameri- cardiopulmonary therapists, but only instrument items for both nationalcan therapists reported the nonavail- 34% of the orthopedic therapists, samples are shown in Table 2.ability of physicians orders. found radiographs they read them- selves quite valuable.26/194 Physical Therapy /Volume 71, Number 3 / March 1991 Downloaded from by guest on March 23, 2012
  7. 7. Of limited value Geriatrics Australia United States Neurology Australia 4 United States 8 Cardiopulmonary Australia E 0 United States Orthopedics Australia United States General Australia United States 0 10 20 30 40 50 60 70 80 90 100 Percentage of RespondentsFlgure 3 Value of direct communication with the physician compared for American and Australian physical therapists by major .practice area.Analyses of Variance with the preceptive style than those group is not reported in detail be- employed in hospitals. The private- cause its composition was not compa-The one-way ANOVA indicated that practitioner group also responded rable between countries. The Tukeyscognitive style preferences were not significantly more positively to the HSD Test procedure identified theinfluenced by years since graduation, systematic style and less positively to following groups to be significantlyexcept for Australian therapists gradu- the intuitive style than those em- different at the .05 level. Some of theated for 5 years or less, who re- ployed in rehabilitation centers. Other differences were shared betweensponded significantly less positively to comparisons were not significant. countries, whereas others werethe receptive category (F=3.51, df=4, country-specific.In the United States,P< .Ol). fie one-way ANOVA also re- Effects of major practice areas the cardiopulmonary physical therapyvealed differences related to place of within countries. Differences in group responded more positively toemployment. Private practitioners in means of the five major practice the preceptive style than the orthope-both the United States and Australia groups in both countries are illus- dics and geriatrics groups, the ortho-identified significantly less positively trated in Figure 4. The education pedics group responded more posi-Table 2. Cognitive Style Categories Unlted States Australla - -Category Survey Instrument Item X SD Q X SD QPreceptive 30, 46, 53, 60, 64, 70, 76 2.07 0.20 .60 2.22 0.28 .56Receptive 34, 36, 39, 40, 56, 58, 73 1.47 0.02 .60 1.53 0.06 .65Systematic 42, 45, 59, 66, 69, 72 2.28 0.48 .74 2.36 0.43 .69Intuitive 31, 33, 51, 52 2.47 0.09 .57 2.79 0.22 .62Physical Therapy/Volume 71, Number 3/March 1991 195/ 27 Downloaded from by guest on March 23, 2012
  8. 8. United States Australia 6 4 General - 0 0 i ; - 0 Orthopedics a : Cardiopulmonary Q, : .- i. > .- : C . Neurology C 3 - Geriatrics 0 9) 0 : s i 3 A P u .......-------..----------.-----.---......--..--.-------.------------------,----...A.. .- + 0 0 C 0 i : (I .-c .I 0 6 . C 9 g ;2- . : fi 4 0 rn 8 5 - . 9 i; . " Q, I 8 #J i 9) 1 I I I I I I I z I Receptive Preceptive Systematic Intuitive Receptive Preceptive Systematic Intuitive Cognitive Style CategoryFlgure 4. Cognitive styles of American and Australian physical therapists by major prac :tice area.tively to the systematic style than the were no significant differences for categories. The Australian orthopedicsgeneral practice and cardiopulmonary country o r sex for receptive data gath- group responded least positively tophysical therapy groups, and the gen- ering o r between countries for sys- the preceptive category, but the inter-eral practice group responded more tematic information processing. Fe- active effect was not significant. Thepositively to the systematic style than male physical therapists in both neurology groups in both countriesthe neurology group. In Australia, the countries reported significantly did not respond positively to the sys-general practice group responded greater identification with the precep- tematic approach, nor did the geriat-more positively to the preceptive style tive mode of data gathering than male rics group in Australia. Major practicethan the orthopedics group; the neu- physical therapists, and the US sample area was significant for the receptiverology group responded more posi- overall responded significantly more category, with the orthopedics andtively to the intuitive style than the positively to this category than the Aus- cardiopulmonary physical therapyorthopedics group, although the tralian sample. Male physical therapists groups in both countries respondingmean response was not in the posi- in both countries responded signifi- more positively to this style than thetive range; and the orthopedics group cantly more positively to the systematic geriatrics and education groups.responded more positively to the sys- mode of information processing than Country effects remained the strong-tematic style than the geriatrics group. did female physical therapists. Ameri- est predictor of identification with theIn the combined sample, the orthope- can female physical therapists re- intuitive style. The Australian neurol-dics group responded more positively sponded positively to the intuitive cate- ogy group had the most positive iden-to the systematic style than the neu- gory, but the two-way interaction was tification with the intuitive style; anrology and general practice groups, not significant. American physical ther- interactive effect was also noted forand the neurology group responded apists overall had a greater affinity for this group.more positively to the preceptive style the intuitive category than the Austra-than the orthopedics group. lian physical therapists.Results of the two-way ANOVAs are Analysis by major practice areareported in Tables 3 and 4. There showed significant d8erences in all28/196 Physical Therapy /Volume 71, Number 3 /March 1991 Downloaded from by guest on March 23, 2012
  9. 9. -Table 3 Analysis-of-Variance Summay for Relationship Between Cognitive Style .Categoy, Sex, and County rect involvement with acute respira- tory care. Dennisz2reported that, despite direct access, the majority of patients (67.2%) came to physical therapists in private practice in Victo- ria (Australia) via physician referral and that clinicians reported variedPreceptive strategies to maintain and strengthen direct communications. The clinicians Source also wanted to educate physicians Sex about the skills and values of the Country physical therapist. Sex x country Residual Other sources of information. TheReceptive much higher values reported by the Source cardiopulmonary physical therapy Sex groups in both countries may reflect the use of radiographs for treatment Country decisions, whereas the orthopedics Sex x country groups may use radiographs to rule Residual out diagnostic alternatives. TherapistsSysternat~c in both countries showed consider- Source able flexibility in using sources of Sex information based on availability. Count?/ Cognitive Style Preferences Sex x country Residual Overall. The total samples identilica-Intuitive tion with receptive data gathering and Source systematic information processing Sex suggests a response set based on valu- Country ing the scientific approach and believ- Sex x country ing it is appropriate in physical ther- Residual apy evaluation, but it may also reflect actual practice. Positive response was strongest for the receptive category. Statistically, the most strongly positiveDiscussion treating patients with vertebral prob- items in the subscale were collecting lems o r similar nonspecific diagnoses. information to confirm findings,Sources of Information Our results are congruent with stud- checking out ideas, and gradually ies in Australiazzand Canada29 that building a picture of the patientsPhysicians orders. More than half have demonstrated dissatisfaction with problems. Researchers suggest thatof the therapists in both countries the information received from medi- expert decision makers are subject toconsidered the physicians orders of cal practitioners about the patients logical errors, including a redundancylimited value, which may reflect the medication and overall health status. phenomenon, in which clinicians con-therapists levels of independence o r tinue gathering data to substantiatethe con1:ent of the referral letters. We Value of direct communication. findings after there is sufficient evi-expected that a group of expert clini- The value placed on direct communi- dence for a conclusion.3~22 Efforts atcians capable of specifying patients cation with the physician was not sur- cost containment may not be compati-problems (diagnoses) and making prising. Considering that Australian ble with the receptive approach (forindependent treatment decisions physical therapists have direct access, example, cost of procedures, duplica-would find physicians orders of lim- however, it is worthy to note that di- tion of tests), and clinicians may needited value; however, it would be inter- rect communication with physicians is to review their own cognitive styleesting to determine what therapists equally, if not more, important to preferences in relation to the de-expect from the referral. In Australia, them as compared with American mands of the health care system. Re-Twome!Ps suggested that the patients physical therapists. The higher value dundancy in evaluation may requireradiographs, the results of special placed on direct communications by further investigation. The statisticaltests, and a request for physical ther- the Australian therapists in cardiopul- differences between countries areapy were all therapists required when monary care may reflect a more di- interesting, but we believe they arePhysical Therapy /Volume 71, Number 3 /March 1991 Downloaded from by guest on March 23, 2012
  10. 10. more efficiently. Educationally, there are important implications for theTable 4. Analysis-of-VarianceSummary for Relationship Between Cognitive Style relationship between cognitive styleCategory, Major Practice Area, and Country and clinical decision making. With an understanding o a students cognitive f style preference, faculty can guide the student to select more effective learn- ing strategies. Faculty can also struc-Preceptive ture case studies and learning experi- Source ences to elicit desired approaches to MPAa decision making. Country MPA x country Future Studies ResidualReceptive Considerably more study is needed & Source on the effects of cognitive style prefer- ence and the physical therapy task on MPA decision making. Hammond et abo Country suggest that performance is most ac- MPA x country curate when task attributes are Residual matched with cognitive attributes. WeSystematic hesitate to suggest that therapists Source choose their respective practice areas MPA because they are attuned to different Country cognitive styles; rather, we believe that most clinicians, faced with a dif- MPA x country ferently structured problem type, uti- Residual lize a different cognitive strategy. ThisIntuitive hypothesis could be the subject of Source further investigation. We also plan to MPA use the scale with new graduates to Country compare their cognitive style prefer- MPA x country ences with those o expert groups. f Residual Conclusions"Major practice area. A study of expert decision-making behaviors in the United States anddue to the greater heterogeneity of raises the question of whether patientthe Australian sample. care tasks in different areas of physical Australia revealed an overall prefer- therapy differ in these dimensions. ence for ones own assessment as aDifferences by major practice source of information, for the recep- Our profession espouses the scientificarea. All subscales showed effects for method and analytical thinking but tive style of data gathering, and forpractice area. These findings are con- the systematic style of information may also need to consider the influ-gruent with literature suggesting that ence of task structure on cognitive processing. Significant differencesproblem structure evokes cognitive strategies. were found for major practice areasbehavior.*,30.31Hammond et a3 de- 1O in both countries, which suggests dif-scribed task characteristics likely to Understanding the relationship be- ferent cognitive approaches for dif-induce intuitive or analytical process- tween cognitive style preference and ferent task structures. Country effectsing, which may explain our findings, were also found between American clinical practice may help cliniciansIf the task offers a large number of gain an improved perspective on their and Australian therapists.cues simultaneously, it is hard to de- own performance. As we bring as- Acknowledgmentcompose into discrete parts, and, if pects of our activities into consciousmeasurement is perceptual, it favors awareness, we are better able to de- would like to thank Harry Davisintuitive processing. Tasks with fewer termine our own strengths and weak- of the Medical College ofand sequential cues, which can be nesses and lhus reduce the potential D~~~~~~~~ of ~ ~statistics, ~ ~ ~decomposed into discrete parts and for error As our understanding o the f and Cornputen for his invaluable as-measured objectively, favor an analyti- decision-making process increases, so sistance in research design and datacal (systematic) approach. This finding will our ability to make decisions analyses.30 / 198 Physical Therapy/Volume 71, Number 3 /March 1331 Downloaded from by guest on March 23, 2012
  11. 11. -Appendix. 1. sex: Clinical Decision-Making QuestionnaireSectlon I--DemographicsPlease circle the appropriate number to indicate your response. 2. Years since graduation from entry-level physical therapy 1. F 1. CL5 y 2. M 2. 6 10 y 3. 11-1 5 y 4. 16-20 y 5. 20+ y program: 3. Degree awarded: 1. BSIBA 2. Certificate 3. MAJMS 4. If you have completed a post-entry-levelmasters 1. Physical therapy 5. Administrationlmanagement degree, please indicate the field by circling the number. 2, Education 6. Public health 3. Anatomy 7. Behaviorallsocial science 4. Physiology 8. Other: 5. If you have a doctorate, please indicate the degree. 1. PhD 2. EdD 3. DSc 4. Other: 6. If you have a doctorate, please indicate the field. 1. Education 4. Behaviorallsocial science 2. Anatomy 5. Administrationlmanagement 3. Physiology 6. Other: 7. If you are currently involved in a post-entry-level degree 1. MAJMS 2. PhD 3. EdD 4. Other: program, please indicate the degree by circling the appropriate number. 8. Please indicate the field. 1. Physical therapy 5. Administrationlmanagement 2. Education 6. Public health 3. Anatomy 7. Behaviorallsocial science 4. Physiology 8. Other: 9. Employment: Please indicate the one setting in which 1. General hospital 6. School system you treat the majority of patients. 2. Rehabilitation center 7. University teaching hospital 3. Home health care 8. Mental retardation center 4. Private practice 9. Physical therapistlphysical therapist assistant education program 5. Nursing homelextended 10. Other: care facility10. What percentage of each work week do you spend in 1. 0%-10% 2. 11%-25% 3. 26%-50% 4. 51%-75% 5. 75%+ direct patient services?11. Which of the following best describes your major practice 1. General practice-varied diagnoses and age groups area? Please circle only one. 2. Primarily general orthopedics 3. Primarily specialized orthopedics (eg, mobilization) 4. Sports physical therapy 5. Cardiopulmonary 6. Adult neurology 7. Pediatric neurology 8. Pr~marily geriatrics 9. Other:12. Please indicate the percentage of time each week you 1. 0%-49% 2. 50%-64% 3. 65%-79% 4. 80%-95% 5. 95%+ spenlj in this type of work.In your state, are you allowed to:13. Practice without referral? 1. Yes 2. No14. Only evaluate without referral? 1. Yes 2. No15. If yes, please estimate the number of patients a month you see without a referral: (Continued)Physical Therapy/Volume 71, Number 3/March 1991 Downloaded from by guest on March 23, 2012
  12. 12. -Appendix.Sectlon Il-Sources (Continued) of lnformatlonThere are many ways a physical therapist may obtain information to make clinical decisions. It is understood that the importance of eachsource may vary with the type of patient being treated. Please consider whether you would use the information sources listed below when youare making decisions about a patient who would be fairly typical of your usual case load.Use the following code to indicate the importance of each source: 1. Very valuable; I almost always rely on this source. 2. Valuable; I rely on this source frequently. 3. Of limited value in most cases; I sometimes use this source. 4. Of very little value; I almost never use this source. 5. This source is not available to me.16. Generally, the information in the patients medical history17. Specifically, progress notes18. Specifically, the medical examination19. Specifically, physicians orders20. Specifically, special test results21. Specifically, x-ray films (you read yourself)22. The information in the medical referral23. The information I find during my own assessment24. The information I can find in textbooks and journal articles25. The information I can get through direct communication with the patients physician26. The information I can get by talking to the patients friends and/or relations27. The information I can get from other physical therapists28. The information I can get directly from the nurse on the floor29. The information I can get from other health care professionals working with the patientSectlon IllThe following statements represent aspects of different styles of clinical decision making. They do not all necessarily apply to each person, asthey are designed to depict a broad variety of processes. The terms "assessment" and "evaluation" are interchangeable.As you read the statements, you will know whether they are characteristic of the way you think and do things in the clinical setting. There areno correct or incorrect answers.If you relate strongly to the statement, you will strongly agree with it (1).If you relate to the statement, but it is not highly characteristic of you, you will agree with it (2).If you do not relate to the statement, but you know you do this occasionally, you will disagree with it (3).If you do not relate to the statement at all, you will strongly disagree with it (4). Strongly Strongly Agree Agree Disagree Disagree - -30. A number of ideas come to mind as soon as I see the referral. 1 2 3 431. 1 sometimes forget one thing in one evaluation and something else in another, but I usually pick 1 2 3 4 them up later.32. 1 usually begin with some general questions about the patients history and go to specific items 1 2 3 4 later.33. Sometimes things about the patient come together when I wake up. 1 2 3 434. 1 use my physical assessment to check out my initial ideas about the patients problems. 1 2 3 435. During the assessment, I check appropriate areas in detail and do the others superficially. 1 2 3 436. Throughout the assessment, I keep a mental check list to be sure I am doing everything I need 1 2 3 4 to do.37. The most important source of information on which I base my treatment decisions is my objective 1 2 3 4 assessment.38. The specific diagnosis is not important; I make treatment decisions from what I see. 1 2 3 439. Once I have a picture of the patients problems, I go on collecting information to confirm the 1 2 3 4 findings.40. My competence as an assessor is determined to a great extent by my knowledge base. 1 2 3 441. What I want to know is related to functional outcomes. 1 2 3 4 Physical Therapy /Volume 71, Number 3 /March 1991 Downloaded from by guest on March 23, 2012
  13. 13. -Appendix. (Continued)42. 1 plan my assessments in a systematic manner so as not to forget anything.43. During the assessment, I use the information I am gathering to decide on the next step. Strongly Agree 1 Agree 2 2 3 3 Strongly Disagree Disagree 4 444. When I am reading the medical chart, I sometimes ask myself, How will this person relate to me, 2 3 4 and how can I relate to him or her?45. There is certain information I need in all instances, but I do not always go about getting it in the same order.46. The first thing I do is acquaint myself as quickly as I can, within time constraints, with the medical history.47. An expert clinician is one who does not quake at the knees when he or she sees a new patient.48. 1 obtain information about the patient from other health care professionals.49. Ideally, I would like to know all about the patients pathology to make my work more precise and rapid.50. 1 go on the premise that the patient and his or her environment are the most important sources of information.51. Sometimes interesting things about the patient come to me in strange places such as the shower.52. 1 think best when I can sit down, line things up, and look at them.53. 1 start to make judgments about the patients problem as I observe him or her walking in the door.54. Early in the assessment, I try to rule out some of my initial ideas or concerns.55. 1 usually consider the cost when selecting treatment.56. As I work through a patient assessment, I gradually build a picture of the patients problems.57. 1 want the referral to be specific about tissue involvement and pathology.58. What I really like about clinical work is the challenge of deciding what is wrong.59. 1 generally follow a systematic assessment protocol.60. When I get a referral, I get a mental image of the patient.61. If I have a question about the patient, I do not hesitate to call the physician.62. 1 want the physician to tell me about potential complications and precautions.63. It bothers me that in busy clinics, the quickest and shortest way of making a decision is often taken.64. 1 inherently know the patients problems without going into miniscule details in the assessment.65. The c?ssentialthings I need to make clinical decisions are the patients problems, the goals, and the specific constraints I have to work under.66. 1 sequence my evaluation according to the cues I get from the patient.67. Experience is an essential component of effective clinical decision making.68. As I read the referral, I try to think about the physical therapy problems.69. 1 prefer to complete my evaluation before making decisions about treatment.70. When developing the problem list, I tend to focus on a few pieces of information that I consider critical.71. When receiving a specific referral, if I do not agree with the physicians orders, I will call him or her to talk about it.72. Good assessors are those who follow a very specific process and use it each time.73. While assessing a patient, I often consider a number of different possible problems at the same time.74. 1 wail until I have some information on each of the patients major complaints before attempting to look ior interrelationships among the symptoms.75. The patients chart is the most important source of information, because it contains the most objective data.76. When the actual patient does not match my mental image, I have to reassess the patient right then.77. 1 like to use a standard assessment form.Physical Therapy/Volume 71, Number 3 /March 1991 201 / 3 3 Downloaded from by guest on March 23, 2012
  14. 14. References ers to clinical decision making.J Med Educ. Statistical Analysis. Canterbury, United King- 1986;61:727-735. dom: University of Canterbury; 1980. HSIU1 Hoganh RM. Judgment and Choice. New 12 Bork CE. The Influence of Cognitive Style Repon 41.York, NY: John Wiley & Sons Inc; 1980:l-10, Upon Clinical Evaluation. Buffalo, NY: State 22 Dennis JK. Decisions made by physiothera.155-184. University of New York at Buffalo; 1980. Doc- pists: a study of private practitioners in Victo-2 Elstein AS,Shulman LS, Sprafka SA. Medical toral dissertation. ria. Australian Journal of Physiotherapy.Problem Solving: An Analysis of Clinical Rea- 13 Payton OD. Clinical reasoning process in 1987;33:181-191.soning. Cambridge, Mass: Harvard University physical therapy. PLys Ther 1985;65:924-928. 23 Browning C, Thomas S, Oates J. ClinicalPress; 1978:1045, 273-302. 14 Thomas-Edding D. Clinical problem solv- decision making and clinical competence. Pre-3 Kahneman D, Slovic P, Tversky A, eds. Judg- ing in physical therapy and its implication for sented at the International Health Sciencesment Under Uncertainty: Heuristics and Bi- curriculum development. In: Proceedings of Education Conference; July 1-5, 1988; Sydney,ases. New York, NY: Cambridge University the 10th International Congress of the World Australia.Press; 1983. Confederationfor Physical Therapy; May 17- 24 McKenney JL, Keen PGW. How managers4 Barrows HS, Tamblyn RM. Problem-Based 22, 1987; Sydney, Australia. Pages 10G104. minds work. Harvard Business Review. May-Learning: An Approach to Medical Education. 15 Cunningham G. Clinical Decision Making June 1974;52:79-91.New York, NY: Springer Publishing Co Inc; in Manipulative Therapy: The Efect of Ante- 25 Hayes-Roth B, Hayes-Roth F. A cognitive1980: chaps 1, 2. cedent E~amination n Palpation Findings. o model of planning. Cognitive Science.5 Gale J, Marsden P. Medical Diagnosis: From Melbourne, Australia: Lincoln Institute of 1979;3:275-310.Student to Clinician. Toronto, Ontario, Can- Health Sciences; 1982. Graduate research pa- 26 Horn JL. A rationale and test for the num-ada: Oxford University Press Canada, 1983: per. ber of factors in factor analysis. Psychometrika. 117-154. 16 McPhate M. Relationship Between Assess- 1965;30:179-185.6 Groen GJ, Patel VL. Medical problem- ment Data and Clinical Decision Strategy in 27 Zwick WR, Velicer WF. Comparison of fivesolving: some questionable assumptions. Med Manipulative Therapy Examination. Mel- rules for determining the number of compo-Educ. 1985;19:95-100. bourne, Australia: Lincoln Institute of Health nents to retain. Psycho1 Bull. 1986;99:432442. Sciences; 1984. Graduate research paper. 28 Twomey LT. The physiotherapist. Med J7 Muzzin LJ,Norman GR, Jacoby LL, et al.Manifestations of expertise in recall of clinical 17 Walker DA. A Survey of Treatment Selec- Aust. 1983;30:422424.protocols. In: Proceedings of the 21st Confer- tion and Subjective Certainty at Dtferent 29 Ross AR, Robens LW, Olson L. The doctor-ence on Research on Medical Education; No- Stages of Clinical Asessment. Melbourne, Aus- physiotherapist relationship: the physiothera-vember 8-10, 1982; Washington, DC Pages tralia: Lincoln Institute of Health Sciences; pists perspective. Physiotheram Canada. 163-167. 1984. Graduate research paper. 1980;32:219-223.8 Hammond KR,McClelland GH, Mumpower 18 Schenkman M, Butler RB. A model of mul- 3 0 Hammond KR,Hamm RM, Grassia J, Pear-J. Human Judgment and Decision Making. tisystem evaluation, interpretation, and treat- son T. Direct comparison of the efficacy ofNew York, NY: Praeger Publishers; 1980. ment of individuals with neurologic dysfunc- intuitive and analytical cognition in expen tion. Phys Ther. 1989;69:538-547.9 DeGroot AD.Perception and memory ver- judgment. In: IEEE Transactions on System,sus thought: some old ideas and recent find- 19 Harris BA, Dyrek DA. A model of onho- Man and Cybernetics. New York, NY: Institute ings. In: Kleinmutz B, ed. Problem Solving. paedic dysfunction for clinical decision making of Electrical and Electronics Engineers;New York, NY: John Wiley & Sons Inc; 1966: in physical therapy practice. Phys Ther. 1987;SMC-17(No.5):l-14. 19-50, 1989;69:548-553. 31 Payne J. Contingent decision behavior. Psy- 10 Iarkin J, McDermott D, Simon DP. Expert 20 Echternach JL, Rothstein JM. Hypothesis- chol Bull. 1982:92:382402.and novice performance in solving physics oriented algorithms. Phys Ther 1989;69:559-problems. Science. 1980;208:1335-1342, 564. 11 Johnson SM, Kum ME, Tomlinson T, Howe 21 Dowie R. The Referral Process and General KR. Students stereotypes of patients as barri- Medicine Outpatient System, First Report: ACommentariesFollowing are two commentaries on "ExpertDecision Making in PbysicalTherapy-A Survey of Practitioners."The accuracy of diagnosis and the for the improvement in performance ceived by their peers to be experts ineffective selection of treatment ap- of clinicians and for the education of an attempt to clarify the nature ofproaches are vital elements in suc- physical therapy students in these information-processing phases and tocessful patient management. Studies processes. describe the cognitive style prefer-that attempt to elucidate the methods ences of expert physical therapy prac-of expert decision making in these May and Dennis have reported the titioners. It is implied that theimportant areas can provide guidance results of a survey of clinicians per- planned description of "expert behav-34 1202 Physical Therapy/Volume 71, Number 3 /March 1991 Downloaded from by guest on March 23, 2012
  15. 15. Expert Decision Making in Physical Therapy−−A Survey of Practitioners Bella J May and Jancis K Dennis PHYS THER. 1991; 71:190-202.Cited by This article has been cited by 5 HighWire-hosted articles: and Reprints for Authors Downloaded from by guest on March 23, 2012