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MASTERCLASS
KEYWORDS Summary This Masterclass explores how practitioners may develop clinical exper-
Clinical expertise; tise. The terms expert and expertise are initially outlined along with the attributes
Expert practice; of a practitioner with expertise. This is followed by an exploration of the literature
Osteopathy; in relation to three key ways to develop expertise: through experience with pa-
Osteopathic medicine; tients, formal postgraduate education and through direct observation of practice
Professional with a mentor. The theoretical basis of these activities is critically reviewed to
development; highlight their underpinning educational value and pedagogy. It is proposed that
Clinical reasoning critical reflection on practice enhanced by direct observation of practice with a
mentor and formal postgraduate education each provide a potentially powerful tool
for learning and the development of clinical expertise.
2015 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijosm.2015.01.001
1746-0689/ 2015 Elsevier Ltd. All rights reserved.
208 N.J. Petty
Expert and clinical expertise outcomes for masters level learning (Table 1),
provide a helpful overview.3
Dictionary definitions of an expert refer to some- Narrowing down to the particular of clinical
one who is very knowledgeable about, or skillful expertise, the literature provides a broad array of
in, a particular area.1 This raises the issue of who characteristics of a practitioner summarised in
decides the level of knowledge and skill needed Table 2. The broad range of attributes include
and what criteria would determine whether patient-centred practice, critical evaluation and
someone is an expert. The complexity of osteo- understanding of their practice knowledge, and an
pathic practice (and other healthcare practice) ability to learn in and from their practice. A recent
may not lend itself to a list of performance in- grounded theory study suggests that some of these
dicators on which to determine whether someone characteristics may be found in experienced
is an expert. Perhaps the notion of someone osteopaths.4,5
being an expert is, like beauty, in the eye of the The last characteristic in Table 2, the capability
beholder; it is a concept constructed by the to learn in, and from, practice (that is, to learn
onlooker. The term expert suggests a static and from experience) is considered essential to main-
final position, however new knowledge is tain expertise.8,10,35 To learn in, and from, prac-
constantly being created, so how often would tice requires practitioners to be capable of and
someone considered an expert need to be re- disposed to critically examining, evaluating,
validated? Because of these difficulties in the creating, developing and transforming their prac-
term expert, the use of expertise has generally tice knowledge and clinical practice.10,29,32,33,35 It
been used in this paper, except where accuracy to is the questioning and challenging of practice
the literature demands otherwise. Expertise has knowledge that leads to its transformation.36 The
been referred to as the proficiency and judgement practitioner therefore needs to be critically
acquired through clinical experience and clinical reflective and reflexive.32 The requirement to
practice.2 Expertise relates to a persons charac- learn in, and from, practice embraces lifelong
teristics, skills and knowledge with a sense of it learning and highlights the importance of critical
being fluid and changing. Clinical expertise is evaluation skills.27
described here as the ability of the practitioner to
effectively integrate their practice knowledge
with the patients clinical presentation, values and Development of clinical expertise
preferences to maximize the therapeutic
encounter for the patient. The developmental process by which practitioners
enhance their clinical practice expertise is a
contentious issue in the literature. Clinical prac-
Attributes of practitioners with clinical tice experience with patients, formal post-
expertise graduate education and having mentors in practice
were each considered instrumental in the profes-
In considering broadly the characteristics of sional development of clinical experts.8 These as-
expertise, the United Kingdom Quality Assurance pects provide a framework for this section and are
Agency (QAA) for Higher Education learning discussed in turn.
Reflection on Maintain
confirmatory practice
Circularity of experience knowledge
Interpretation of Reflection on
Expectations
experience contradictory Adapt
experience practice
knowledge
experience
Exposure to
alternative
practice
knowledge
Figure 1 Circular nature of experience and reflection on learning. (Adapted from Dewey51, Eraut53, Fish and
Coles29, Jarvis61). rejection, acceptance.
18% for sports, 4% for education and less than 1% transformation of practice knowledge may require
for professions. More specifically, musculoskeletal help from other practitioners. They may reveal
physiotherapy practitioners with better patient blind spots in practice knowledge59 and alternative
outcomes for people with low back pain, were not views and paradigms that facilitate a more radical
distinguished by years of experience.50 Recent change.54,55 This may lead to more complex and
research in osteopathy also suggested that there is comprehensive understanding of practice knowl-
no qualitative relationship between practitioners edge with integration of knowing, acting and
level of clinical experience (years in clinical being, embodied and embedded in intersubjective
practice) and attributes of clinical expertise.4,5 practice.57,60
The influence of experience on learning has
been explored by Dewey51 who posited that every Reflection on experience
experience modifies the person and the quality of The importance of reflection to experiential
future experiences. So, for example, each expe- learning demands exploration. From the litera-
rience an osteopath has of performing a spinal ture, a conceptual model of the relationship be-
manipulation or carrying out a patient case history, tween experience and reflection is shown in Fig. 1.
will influence the practitioner and their subse- The circular nature of experience suggests that
quent experiences of manipulation and history experience that confirms expectations may not
taking. This notion is beginning to be borne out by trigger as much reflection as a contradictory
studies exploring experience driven neuro- experience. A confirmatory clinical experience,
plasticity highlighted in this journal by Esteves and accepted as such by the practitioner, may confirm
Spence.52 This meaning making process may create and strengthen existing practice knowledge. A
or modify their practice knowledge (or personal confirmatory clinical experience, rejected as such
theories), which may then modify them as practi- by the practitioner however, may trigger reflection
tioners, and influence their future clinical experi- and lead to modification of practice knowledge.
ence.29,53 The degree of change to their practice The relationship between experience and reflec-
knowledge would thus depend on the degree to tion is illustrated by the following example. When
which they consciously reflected and theorised on presented with a person complaining of chronic
the experience. The experience itself would, in low back pain, the practitioner may expect the
turn, be influenced by the practitioners hidden, persons pain and disability to respond to hands-on
taken for granted assumptions and expect- manual therapy directed to the postural/structural
ations54e56 and this would be influenced by their and biomechanical clinical findings. If the person
clinical perspective or frame of reference54,55; we responds as expected this may confirm and rein-
tend to experience what we expect to experience. force the practitioners beliefs and practice
The potential for learning may therefore be knowledge. Alternatively, the practitioner may
limited as the practitioner may be trapped within critically reflect on the experience and consider
their existing understanding51,57; theories-in-use whether alternative treatment may have had a
may be self-sealingb.58 More radical better and quicker response, this critical explora-
tion may then lead to new insights and learning.
b
In the same way, a contradictory clinical experi-
Self sealing refers to the situation where our theories limit
ence may be embraced, not noticed, ignored or
what we do and therefore limit our opportunities to see
something different. rejected by a practitioner.62e64 A contradictory
A Masterclass in developing clinical expertise 211
clinical experience that is ignored or rejected, may how questioning and critical a practitioner is of
result in little change to practice knowledge; this their clinical experience;
may occur because of the risk of error, uncertainty how open a practitioner is to changing their
or gap in practice knowledge, personal discom- practice knowledge; and
fort,58,65 or reluctance to make the intellectual the degree to which a practitioner is exposed
effort required to reflect.10 Where a practitioner to alternative views and perspectives.
embraces a contradictory clinical experience, this
may result in critical reflection towards their prac-
tice knowledge with subsequent modification. Using Routinisation with experience
the same example as above, if the patient with low Experience not only creates and modifies practice
back pain does not respond as expected and fails to knowledge, it also affects clinical behaviour and
improve, the practitioner may chose to ignore this action. With repetition, actions can become more
and continue to treat in the chosen way or make automatic, fluid and skillful.10,61 For example,
some minor modification to the treatment, with palpation requires motor skills that can become
little learning. Alternatively, the practitioner may automatic and highly skilled with practice.46
embrace this contradictory experience and criti- Automatic actions enhance time efficiency as
cally reflect on their decision making process that well as the cognitive attention required to perform
may highlight missed cues, leading to an enhance- the action. For example, a habitual way to palpate
ment in their practice knowledge. In medical diag- the spine enables the practitioner to concentrate
nostic reasoning, for example, a mismatch between on feeling the paraspinal soft tissues and joint
patient information and the illness scripts and mobility.52 Automatic actions thus facilitate the
memory of previous patients held by expert practi- application of practice knowledge (through cogni-
tioners is thought to trigger an active engagement in tion, metacognition and reflection) enabling
clinical reasoning.17,18 conscious, deliberate patient-centred practice
Thus confirmatory and contradictory clinical that enables the practitioner to learn from expe-
experience that is arrested and examined,66,67 de- rience; this is highlighted in Table 3. Patient-
velops, tests and generates practice knowledge.32 centred practice is used here to denote the
The capability to learn from experience depends conscious, deliberate, creative, individualised and
not on years of experience,66e68 but rather on: collaborative clinical care of patients.8e12 Practi-
tioners developing in this way may have a
the degree to which a practitioner reflects on conception of clinical practice as uncertain, un-
clinical experience; predictable and problematic and a disposition to
Table 3 The nature of practitioner-centred and patient-centred clinical practice (adapted from Eraut10,69 and
Jarvis61).
212 N.J. Petty
critically reflect and learn from their clinical knowledge may devalue a practitioners own
practice, thus enhancing their practice knowledge knowledge gleaned from clinical experience.
with experience.
If, however, clinical actions are not accompa-
nied by conscious use of practice knowledge Influence of work setting
(through cognition, metacognition and reflection), Work settings that value efficiency and patient
then there is a loss of conscious regulation and through-put rather than effectiveness and quality
critical control, so that practice may become of clinical practice10,62 may impede learning from
routinised10,69; the process is summarised in Table experience in a number of ways identified in
3. There may be limited capability to learn from Table 4.
such practitioner-centred clinical practice (the
routine use of examination procedures, treatment Formal education
techniques and management strategies for patients
regardless of their presentation). Practitioners In the UK, university masters courses in musculo-
developing in this way, may have a conception of skeletal physiotherapy have a central aim to
clinical practice as certain, predictable and un- develop the clinical expertise of practitioners.
problematic and may not be disposed to critically These courses are approved by the Musculoskeletal
reflect and learn from their clinical practice, thus Association of Chartered Physiotherapists (MACP)
limiting their practice knowledge. and must comply with the Educational Standards
Document of the International Federation of Or-
Nature of clinical practice thopaedic Manipulative Physical Therapists
The nature of clinical practice may limit the op- (IFOMPT).73 These courses have a minimum of 200 h
portunity to learn from experience.58,69 The of theory, 150 h of practical skill development and
practitioner: 150 h of mentored clinical practice. Research has
demonstrated that practitioners completing these
has to make clinical decisions for complex and courses gained enhanced confidence, clinical
uncertain problems; this may limit accurate reasoning, criticality, ability to engage with evi-
and specific feedback on clinical decisions.10 dence based practice, ability to learn and career
needs to be confident, committed and deci- development and were more patient-cen-
sive with patients, but at the same time needs tred.72,74,75 Some of these elements were found
to be uncertain and critical towards their within a theoretical model of the learning transi-
clinical practice and practice knowl- tion (change in attitude, knowledge and behaviour)
edge.10,58,69 Maintenance of this balance may of musculoskeletal physiotherapists completing a
be difficult. MACP approved MSc,38,76 this is shown in Fig. 2. This
may not value their own knowledge from clin- research study showed that at the start of the
ical experience.70 The emphasis on evidence course, participants typically held uncritical prac-
based practice and the use of propositional tice knowledge and tended towards routine,
Table 4 Ways in which the practice setting can inhibit learning from experience.
Practice setting may inhibit practitioners learning by:
promoting the use of routines and habits in practice.
limiting time for cognitive and metacognitive processing.
promoting superficial reflection on actions and solutions through single loop learning rather than deep
reflection that might question the premises on which action was taken through double loop learning.58
engendering the use of pattern recognition* and a trial and error approach at the expense of reflective
deliberation and an abductive reasoning** approach to patient management.32,71
limiting time and opportunity to critically reflect on clinical experience.
inhibiting any change to practice as the process of change often requires time.
promoting lone working with patients and prevent practitioners working together and learning from each
other.10,72
promoting therapist centred practice.
* It is not suggested here that the use of pattern recognition is a sign of therapist centred practice; rather that time constraints in
an efficiency driven workplace may hinder an abductive approach where this may be needed.
**Abductive reasoning involves the generation of new ideas and hypotheses to help explain phenomena in the data, in this
context, the patients presentation.71
A Masterclass in developing clinical expertise
The learning experience
Critical understanding of
practice knowledge
Hidden received practice You know exactly why youve
knowledge Enhance knowledge and Critical evaluation of practice done each test and for what
Embrace reason.
Id accept what was said. I skill through didactic knowledge It was such a great experience,
didnt really question things Youve got clinicians who are to have somebody watching me
teaching challenging you about your Patient centred practice
I needed to be taught, to and questioning what Im I now use the evidence from
practice, and asking why are doing
listen to people with the patient rather than
you doing it like that?
Therapist centred, routine expertise telling me what I research evidence or
clinical practice should be doing. theoretical knowledge to
Going back to really basic
Id do the subjective and ask the things like what is palpation Defend guide my treatment.
patient routine questions. Id I expected the course to be I didnt feel able to share my
and what is a mobilization and
not really take information from more taught because that thinking in the whole group Learning in & from practice
what do we actually think were
my subjective into the objective. was the way I was being situation and instead got into a I treat each problem and see
doing?
Id do a routine objective taught on weekend clinical small group and it was there what it does for the overall
examination. courses. that I was able to discuss picture. Each patient then
things more openly and I felt adds to your knowledge and
less threatened. experience
Moderating factors
conception of clinical practice 29
epistemology of practice knowledge 77
conception of teaching and learning 78
achievement motivation 79
locus of control 80
self efficacy in practice knowledge 81
professional self esteem 81,82
emotional control 83,84
learning relationships 85
learning style 86
Figure 2 Explanatory theory of the learning transition experienced by practitioners completing a Master of Science degree in musculoskeletal physiotherapy.29,77e85
Reproduced by kind permission of Elsevier from Petty et al.76
213
214 N.J. Petty
practitioner-centred clinical practice. The learning may offset the financial costs for osteopaths
transition varied between participants and depen- working in private practice.
ded on a host of moderating factors. At the end of
the course, participants enhanced their practice in Mentors in practice
terms of three inter-related aspects: they gained a
critical understanding of practice knowledge that The notion of a mentor facilitating the development
facilitated more patient-centred practice, which of a practitioners clinical expertise is consistent
led to a capability to learn in and from practice with the literature related to situated learning; in
(Fig. 3). This development towards clinical exper- this context, learning in and from prac-
tise was primarily facilitated by critical evaluation tice.9,10,29,32,57,68,87 Someone with expertise guid-
of practice knowledge, and was particularly ing a less experienced practitioner is well rehearsed
powerful when facilitated by a mentor in clinical in the literature9,88,89 and the role of the mentor is
practice; this involved the direct observation of summarised in Table 5. It is argued here, that
practice with patients with subsequent question- mentorship that involves direct observation with
ing, discussion and critical feedback. This highly patients may be a powerful method of enhancing
challenging experience necessitated high levels of clinical expertise. The value of direct observation
support from the mentor. From the perspective of of practice, highlighted in Table 6, may be due to
osteopathy, a recent grounded theory study reso- every aspect of practice being observed, which is
nates with the above theory. Osteopaths with then followed by immediate and specific feedback
formal postgraduate education demonstrated a of performance and discussion. Even practitioners
range of attributes associated with clinical exper- of similar levels of knowledge may benefit from
tise, such as adopting a more critical and reflective observing each other in clinical practice.
stance towards practice knowledge, norms and Critical dialogue of practice knowledge creates
traditions; adopting a person-centred approach opportunities for individuals to experience
towards patient management; and were comfort- contradiction that may trigger
able with the ambiguity and uncertain terrain of learning.57,58,62e64,94,98 Unlike confirming experi-
professional clinical practice.4,5 These rewards ence which may lead to minimal learning,
Figure 3 The learning outcome of the Master of Science degree in musculoskeletal physiotherapy. The direction of
development towards clinical expertise involved three developmental aspects: critical understanding of practice
knowledge led to patient centred practice, which in turn led to a capability to learn in, and from, clinical practice.
The smaller arrowheads indicate that learning in and from practice enhanced patient centred practice, which in turn
enhanced critical understanding of practice knowledge. Reproduced by kind permission of Elsevier from Petty, Scholes
& Ellis.76
A Masterclass in developing clinical expertise 215
contradictory experiences can lead to a powerful model demonstrating a higher level of practice
learning transition with significant cognitive and that identifies areas for further development in
emotional dissonance.98 Critical dialogue of prac- the observing practitioner.
tice knowledge with the mentor exposes practi- Direct observation of practice may initially be
tioners to alternative views and perspectives that resisted by practitioners as they may feel vulner-
can free them from their own circular experience able to negative judgement of their practice and a
and understanding.51,57,58 The less experienced loss of respect from their colleagues. While lone
are guided to a higher level of practice knowledge working in a clinic room with patients may protect
and understanding through cognitive scaffolding the practitioner from any criticism, it prevents
and structuring.99 This process may lead to a them from being encouraged and supported and
transformation of practice knowledge that is more misses the opportunity to share and learn from
discriminating, integrated, differentiated, open, colleagues; and thus make it difficult to develop a
dependable and justified.54,91 This highlights the high level of clinical expertise. Mentorship with
need for the mentor to challenge, question and direct observation of practice will, however, be
offer new knowledge that contradicts the mentees challenging. For practitioners in sole practice set-
current knowledge. The mentee, in turn, needs to tings, geographical distance may limit access. To
be prepared to face contradictory knowledge and successfully implement mentorship, it would be
consider alternative points of view. imperative to use a mentee-centred approach and
Opportunity for the practitioner to observe the that a collaborative, respectful relationship is
practice of those with higher levels of expertise developed between mentee and mentor. If this can
may also be of benefit; observational learning has be achieved, mentorship would appear to offer a
been highlighted as a powerful process9,10,81 The potentially powerful and economical method of
observer may gain confidence seeing similar ac- enhancing the clinical expertise of practitioners.
tions to their own as well as seeing alternative While the American Osteopathic Association has a
ways of working. The observed may act as a role well established mentor exchange programme
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