1991; 71:190-202. PHYS THER. Bella J May and Jancis K Dennis Survey of Practitioners A -- Expert Decision Making in Physical Therapy http://ptjournal.apta.org/content/71/3/190 found online at: The online version of this article, along with updated information and services, can be Collections Professional Issues Clinical Decision Making in the following collection(s): This article, along with others on similar topics, appears e-Letters "Responses" in the online version of this article. "Submit a response" in the right-hand menu under or click on here To submit an e-Letter on this article, click E-mail alerts to receive free e-mail alerts here Sign up by guest on March 23, 2012 http://ptjournal.apta.org/ Downloaded from
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1991; 71:190-202.PHYS THER. Bella J May and Jancis K DennisSurvey of Practitioners
A−−Expert Decision Making in Physical Therapy
http://ptjournal.apta.org/content/71/3/190found online at: The online version of this article, along with updated information and services, can be
Collections
Professional Issues Clinical Decision Making
in the following collection(s): This article, along with others on similar topics, appears
e-Letters
"Responses" in the online version of this article. "Submit a response" in the right-hand menu under
or click onhere To submit an e-Letter on this article, click
E-mail alerts to receive free e-mail alerts hereSign up
by guest on March 23, 2012http://ptjournal.apta.org/Downloaded from
Four hundred American and 384 Australian pkysical therapists, nominated by their peers as expert clinicians, were studied to evaluate whether a particular cog- nitive style was prevalent among expert clinicians, to identzb preferred sources of information for clinical decision making, and to determine the similarities and
Physical therapists are assuming in- creasing independence in making patient care decisions. Understanding the dimensions of expert decision making will help current practitioners improve their skills and educators prepare students more effectively. It seemed appropriate to begin an in- vestigation of expert behavior by ask-
Bella J May Jancls K Dennis
ing the experts themselves what they do or believe they do.
dflerences between American and Australian therapists. Results were based on usable surucy responses from 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 the preferred sources of information in both countries. The physician's referral and communications with other health care personnel were reported to be of limited value as sources of information by most respondents. Overall, both groups re- sponded most positively to the receptive style of data gathering and the systemtic style of in formation processing Therapists working primarily with neurologically impaired patients responded most positively to the preceptive style of data gather- ing and the intuitive style of information processing. Therapists working primarily with patients with orthopedic disorders responded most positively to the systemtic style of information processing. /May BJ, Dennis JK Expert decision making in physical therapy4 survq of practitioners. Phys Ther 1991; 71:190-206.1
There has been considerable research into clinical decision making, information-processing strategies, and differences between expert and nov- ice behaviors in the past two decades. Research has been done in many fields, including medicine, education,
B May, EdD, PT, is Professor, Department of Physical Therapy, School of Allied Health Sciences, Medical College of Georgia, Augusta, GA 30912-0800 (USA). Address all correspondence to Dr May.
nursing, and physical therapy, and the findings generalize across areas of c
study. Decision making is influenced by knowledge, the way experience has structured that knowledge, the type or format of the decision task, the limitations in human information processing, and the social and contex- tual elements of the decision.'-l4
Decision making has generally been found to include (1) the use of critical cues or forceful features for promot- ing the recognition of specific clinical
J Dennis, MAppSci, PT, is Assistant Professor, Department of Physical Therapy, School of Allied patterns and (2) the early generation
Health 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 World Confederation for Physical Therapy, Sydney, Australia, May 17-22, 1987.
mati0n.~.*,5 Preliminary evidence sug- gests that physical therapists use
This article was submitted Februaly 15, 1983, and was accepted September 24, 1990.
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similar reasoning processes.12-'7 Cur- rent research does not support the popular belief that clinicians collect a complete, routine database before deciding about the patient's problems. Experts, when compared with novices in the same field, exhibit a superior structuring of knowledge into clini- cally relevant patterns that are un- locked by key cues in the decision environment. Patterns stored in mem- ory enable the expert to recognize meaningful relationships and generate likely hypothe~es.7~9.~~,~~.17 Recently published models1*20 attempt to help practitioners organize key pathologi- cal concepts as a guide to decision making. I'sychological research indi- cates that human information process- ing is subject to bias introduced by the presentation of the task and by strategies used for selective attention and interpretation of the environ- ment.3 If the patient referral, for ex- ample, contains a specific diagnosis, the diagnosis has been shown to be a biasing factor in both medicine in England2:l and physical therapy in A~stralia.;!Z~~3
Cognitive style, which can be defined as an individual's preferred way of thinking and organizing information, has also been studied for its effect on decision making. McKenney and Keenzqdeveloped a paradigm of cog- nitive style that was used by Bork12 in a study of cognitive style influences on decision making by physical ther- apy students. McKenney and Keen'sz4 paradigm reflected four styles of cog- nition, two related to the data- gathering phase and two to the information-processing phase of deci- sion making. The data-gathering styles were defined as (1) receptive, a style generally characterized by suspending judgment until all possible data have been collected, paying attention to detail, anti attending to the implica- tions of each piece of data individu- ally, and (2) preceptive, a style charac- terized by moving from one section to another, seeking and responding to cues and patterns as a guide to data gathering. The information-processing styles were defined as (1) systematic, characterized by a consciously me- thodical approach, defining problems
and constraints early, performing an ordered search for information, and completing one step before progress- ing to the next, and (2) intuitive, char- acterized by keeping the total prob- lem in mind and considering alternatives simultaneously. The intui- tive person may move from one thing to another, relying on cues and hunches. The results of Bork'sl2 study of physical therapy students suggested that cognitive style influenced clinical evaluation performance. The ability to operate in the intuitive mode was associated with a better performance in history taking and physical assess- ment, whereas students who operated primarily in the preceptive mode were less likely to accurately deter- mine a simulated patient's problems. In nursing, Hayes-Roth and Hayes- Roth25 suggested that systematic deci- sion making might be effective in solving simple problems but that op- portunistic decision making, that is, responding to the stimuli as they oc- curred, might be more effective in complex situations. Few studies have specifically examined the relationship of cognitive style preference to deci- sion making.
A study of expert clinicians in the United States and Australia was under- taken as the first stage in the process of describing expert behaviors. The study was designed as a preliminary investigation into the nature of data- gathering and information-processing phases of expert clinical decision making. A second purpose was to compare the reported decision- making processes of therapists in a country with direct client access to physical therapy (Australia) with the reported decision-making processes of therapists in a country with limited opportunity for direct client access (United States). Specific questions addressed by the study were:
1. What are important information sources for expert physical thera- pists in the United States and Australia?
2. Is there a particular cognitive style preference among expert physical
therapy practitioners in each country?
3. Is cognitive style preference influ- enced by country of practice, sex, or major practice area?
Method
Subjects
Subjects were selected through a nomination process. Elected national, state, section, or special interest group officers holding comparable positions in both countries were asked to nom- inate individuals whom they consid- ered to be expert clinicians and who were involved in direct patient care activities at least 25% of the time. Over 800 nominations, which in- cluded 700 individual names, were received from US officers. All individ- uals named more than once and a random sample of the remaining nominees were used to obtain a sam- ple of 404 individuals. In Australia, over 500 nominations, which included 384 individual names, were received and became the group selected to receive the questionnaire.
Procedures
Survey instrument development. We developed an instrument to gather data on expert physical thera- pists' preferred sources of informa- tion and to measure the experts' self- perception of their decision-making behaviors, focusing on cognitive style preference. The instrument evolved from a multistep process that in- cluded interviews, categorization of the interview statements and scoring procedure, pilot testing, and final con- struction of the instrument.
Interviews. We tape-recorded inter- views with eight physical therapists working in Georgia in different prac- tice settings. Interviews were con- ducted by both researchers, with one doing the questioning and the other making notes and monitoring the tape recorder. The purpose of the inter- views was to develop a set of "real- world statements reflecting the char- acteristics of the different cognitive
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styles described by McKenney and Keen2* Respondents were first asked to describe their clinical decision- making processes and then asked to recall specific situations that illus- trated simple decision making and difficult decision making. An unstruc- tured format was used to provide re- spondents with the opportunity to describe their decision-making pro- cesses in their own words.
Categorization. We then screened the interview statements, identifying some that matched the cognitive style descriptions and others that did not fit. The latter appeared to be state- ments of affect or belief (eg, state- ments 63 and 67 of the Appendix) or statements about specific knowledge requirements for decision making (eg, statement 55 of the Appendix). To offset the limitations of the small and geographically discrete interview sample, we added statements gath- ered from our collective experience. The first draft of the survey contained six logically derived components: one for each of the four cognitive styles, one defined as affect, and another defined as knowledge.
Scoring. We developed individual scores by averaging the responses to items within each category (affect, knowledge, receptive, preceptive, sys- tematic, and intuitive).
Pilot test. A sample of 21 practicing physical therapists in the United States and 20 physical therapists in Australia from different practice settings was used to evaluate the pilot survey in- strument, which contained three sec- tions. The first section requested de- mographic information, such as sex and years since graduation. The sec- ond section asked respondents to in- dicate the value of sources of infor- mation, using a four-point numerical scale ranging from "very valuable" to "of no value," with a fifth point if the information was not available. The third section required responses to 55 statements on a four-point scale rang- ing from "strongly agree" to "strongly disagree." Respondents were also asked to comment on the clarity of the items.
We performed a reliability analysis for each category, followed by a factor analysis. We eliminated some state- ments and moved others to different categories if the factor analysis indi- cated a better fit and if the statement had face validity in the new category. We retained 48 items, which were randomized for inclusion in the final survey instrument. At the end of this phase, the alpha value for each cate- gory was above .6, with one category (systematic) above .7.
We decided to proceed with the study, but to perform more reliability and factor analyses before analyzing the final data. Comments on clarity were used to revise all three sections. The final survey instrument was simi- lar in structure to the pilot question- naire and is depicted in the Appendix.
Data Anaiysis
Responses to the survey instrument were coded as indicated on the ques- tionnaire. Data analysis included the following.
Demographics. Frequencies were calculated to provide a description of the two samples. The years since graduation were collapsed into three major categories for general descrip- tive purposes (ie, 0-10, 11-20, 20+), but five categories (ie, 0-5, 6-10, 11- 15, 16-20, and 20+), were retained for analyses of variance (ANOVAs) related to cognitive style. Places of employment included private practice, hospitals, rehabilitation centers, and other areas, as listed in Section I of the questionnaire (Appendix). We identified six major practice-area groups for the purpose of analysis. General orthopedics, manual therapy, and sports physical therapy were combined to form an orthopedics group; adult and pediatric neurology were combined to form a neurology group. General practice, geriatrics, and cardiopulmonary physical therapy remained as initially established. The sixth group, education, comprised physical therapy educators and practi- tioners whose professional role was primarily patient education (ie, child-
birth educators and consultants to industry).
Sources of information. Frequen- cies were computed for each source of information by country, and fre- quency tables, cross-tabulated with place of employment and major prac- tice area, were then generated. Chi- square analysis was not performed because the numbers in some prac- tice groups were extremely small and we preferred to retain qualitative dif- ferences at this level.
Cognitive style preference. We reevaluated category reliability for the combined sample and for each coun- try separately. Each category was scored by calculating the mean score of the items in the category. The scores of subjects who responded to fewer than 75% of the items in a cate- gory were dropped from the calcula- tions of that category. The scores of subjects who responded to 75% or more, but less than loo%, of the items were calculated as the mean of the items answered. We then per- formed a principal components analy- sis using the parallel-analysis method to determine whether the instrument was actually measuring different fac- t o r ~ . ~ ~ Parallel analysis is reported to be the most consistently accurate method for determining the number of major components to retain2'
Analysis of variance. Before per- forming the ANOVAs, open responses ("other") were reviewed individually and either assigned to another re- sponse or dropped from the analysis for that variable. The two national samples were analyzed separately us- ing a one-way ANOVA to identify within-nation differences in cognitive style attributable to sex, years since graduation, place of employment, or major practice area. The Tukey's Hon- estly Significant Difference (HSD) Test procedure was used to identlfy differ- ences between groups at the signifi- cance level of .05. For each category of cognitive style, two-way ANOVAs were used to compare the means of the Australian and American therapists by sex, years since graduation, place
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Percentage of 0 0 time spent in 0-1 0 11-20 20 + 0-1 0 1 1-20 20 + patient care
0%-25% 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 area.
Results
We examined the data for a response set effect within the two countries. There was greater variance in the Aus- tralian therapists' responses, indicating greater heterogeneity in the sample, as compared with the American thera- pists' responses.
samples are comparable in composi- tion (except for the education group, in which childbirth educators and consultants to industry were mainly represented in the Australian therapist sample). Approximately half of both samples were employed in private practice (US therapists, 49%; Austra- - Table 1. Major Practice Areas
Demographics
Usable responses were received from 348 (86%) of the American nominees and from 290 (76%) of the Australian nominees. Fifty-six percent of the American respondents and 76% of the Australian respondents were female. Figure 1 outlines the experience char- acteristics of each sample, showing years since graduation and percentage of time currently spent in direct pa- tient care. Table l depicts the distri- bution of the respondents across ma- jor practice areas for each country and indicates that the two national
lian therapists, 52%). Hospitals em- ployed 29% of the US therapists, com- pared with 18% of the Australian therapists, and rehabilitation centers employed 11% of the US therapists, compared with 2 1% of the Australian therapists. Of the remaining places of employment, 5% of the US therapists worked in a school system, 4% in community care, and 2% in physical therapy education; 7% of the Austra- lian therapists worked in community/ day care centers and as consultants to industry and 2% in physical therapy education. Different practice charac- teristics and health care structures made the samples less comparable in terms of this variable.
Sources of Information
There was a great deal of similarity in the value placed on various sources of information between the two coun- tries. Not surprisingly, therapists in both countries and in all types of practices valued their own assessment more than any other source of infor-
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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 5 0 6 0 7 0 8 0 90 100
Percentage of Respondents
Figure 2. value of physicians' orders (
mation (US therapists, 88%; Australian therapists, 89%).
Physicians' orders were generally con- sidered of limited value by therapists in both countries (US therapists, 58%; Australian therapists, 53%). A greater percentage of Australian therapists compared with American therapists reported that physicians' orders were not available (12% versus 4%, respec- tively) (Fig. 2), because referral is not required for treatment in Australia. The value of physicians' orders varied with area of practice; more Australian therapists (60%) involved in cardio- pulmonary care, for example, valued physicians' orders than did American therapists (46%). The percentage of Australian therapists working in ortho- pedics and neurology who valued physicians' orders (28% and 25%, respectively) was considerably lower than was that of American therapists (46% and 45%, respectively), and more Australian therapists than Ameri- can therapists reported the nonavail- ability of physicians' orders.
;ompared for American and Australian physical
The reported value of direct commu- nication with the physician is illus- trated in Figure 3. Most Australian therapists found direct communica- tions with the physician of value (56%430%); the responses from American therapists were similar (58%-68%), except for therapists working in geriatrics. In geriatrics, the majority of American therapists found direct communications with the physi- cian of limited value (53%).
The reported value of other sources of information was somewhat practice- and employment-specific. Most respondents valued the patient's past medical history (75% overall); however, 20% of the therapists in pri- vate practice and 14% in home health care did not have it available. Overall, 26% of American therapists and 57% of Australian therapists found radio- graphs a valuable source of informa- tion. Sixty-seven percent of American cardiopulmonary therapists, but only 34% of the orthopedic therapists, found radiographs they read them- selves quite valuable.
therapists by major practice area
Principal Components Analysis
Seven factors were identified. We compared the items in each factor for congruence with the logical categori- zation that we had previously im- posed. Although the reliability of the cognitive style categories had been satisfactory in the pretest, regrouping some items and eliminating others in accordance with the principal compo- nents analysis strengthened the statis- tical basis for the survey instrument b
without altering the logical premises on which it was based. We retained the four categories of cognitive style (receptive, preceptive, systematic, and intuitive) and identified two other categories (physician dependency and holism), which will not be reported in this study. The seventh factor iden- tified minor components, including some universal value statements, and was not retained. Our final categories, their alpha values, and the related instrument items for both national samples are shown in Table 2.
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Flgure 3. Value of direct communication with the physician compared for American and Australian physical therapists by major practice area.
Analyses of Variance
The one-way ANOVA indicated that cognitive style preferences were not influenced by years since graduation, except for Australian therapists gradu- ated for 5 years or less, who re- sponded significantly less positively to the receptive category (F=3.51, df=4, P< .Ol). 'fie one-way ANOVA also re- vealed differences related to place of employment. Private practitioners in both the United States and Australia identified significantly less positively
with the preceptive style than those employed in hospitals. The private- practitioner group also responded significantly more positively to the systematic style and less positively to the intuitive style than those em- ployed in rehabilitation centers. Other comparisons were not significant.
Effects of major practice areas within countries. Differences in means of the five major practice groups in both countries are illus- trated in Figure 4. The education
group is not reported in detail be- cause its composition was not compa- rable between countries. The Tukey's HSD Test procedure identified the following groups to be significantly different at the .05 level. Some of the differences were shared between countries, whereas others were country-specific. In the United States, the cardiopulmonary physical therapy group responded more positively to the preceptive style than the orthope- dics and geriatrics groups, the ortho- pedics group responded more posi-
tively to the systematic style than the general practice and cardiopulmonary physical therapy groups, and the gen- eral practice group responded more positively to the systematic style than the neurology group. In Australia, the general practice group responded more positively to the preceptive style than the orthopedics group; the neu- rology group responded more posi- tively to the intuitive style than the orthopedics group, although the mean response was not in the posi- tive range; and the orthopedics group responded more positively to the sys- tematic style than the geriatrics group. In the combined sample, the orthope- dics group responded more positively to the systematic style than the neu- rology and general practice groups, and the neurology group responded more positively to the preceptive style than the orthopedics group.
' 4
0 i - 0 ; - a : Q, : > i .- C . .- . C : 9) 3 - 0 :
s i 3 0 + .- C (II : 0 i .- . c . C .
g ; 2 - 9 : 5 - . 9 ; . Q, i
" I
i 9) 1
Results of the two-way ANOVAs are reported in Tables 3 and 4. There
and Australian physical therapists by major prac
z Receptive Preceptive Systematic Intuitive Receptive Preceptive Systematic Intuitive
Cognitive Style Category
General
0 Orthopedics
Cardiopulmonary
Neurology
Geriatrics
A .......-------..----------.-----.---......--..--.-------.------------------,----...A..
0 6 fi 0 4
8 I I I I
were no significant differences for country or sex for receptive data gath- ering or between countries for sys- tematic information processing. Fe- male physical therapists in both countries reported significantly greater identification with the precep- tive mode of data gathering than male physical therapists, and the US sample overall responded significantly more positively to this category than the Aus- tralian sample. Male physical therapists in both countries responded signifi- cantly more positively to the systematic mode of information processing than did female physical therapists. Ameri- can female physical therapists re- sponded positively to the intuitive cate- gory, but the two-way interaction was not significant. American physical ther- apists overall had a greater affinity for the intuitive category than the Austra- lian physical therapists.
'0 P u
0
rn 8
#J
I I I I
Analysis by major practice area showed significant d8erences in all
:tice area.
categories. The Australian orthopedics group responded least positively to the preceptive category, but the inter- active effect was not significant. The neurology groups in both countries did not respond positively to the sys- tematic approach, nor did the geriat- rics group in Australia. Major practice area was significant for the receptive category, with the orthopedics and cardiopulmonary physical therapy groups in both countries responding more positively to this style than the geriatrics and education groups. Country effects remained the strong- est predictor of identification with the intuitive style. The Australian neurol- ogy group had the most positive iden- tification with the intuitive style; an interactive effect was also noted for this group.
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- Table 3. Analysis-of-Variance Summay for Relationship Between Cognitive Style Catego y, Sex, and County
Preceptive
Source
Sex
Country
Sex x country
Residual
Receptive
Source
Sex
Country
Sex x country
Residual
Systernat~c
Source
Sex
Count?/
Sex x country
Residual
Intuitive
Source
Sex
Country
Sex x country
Residual
Discussion
Sources of Information
Physicians' orders. More than half of the therapists in both countries considered the physicians' orders of limited value, which may reflect the therapists' levels of independence or the con1:ent of the referral letters. We expected that a group of expert clini- cians capable of specifying patients' problems (diagnoses) and making independent treatment decisions would find physicians' orders of lim- ited value; however, it would be inter- esting to determine what therapists expect from the referral. In Australia, Twome!Ps suggested that the patients' radiographs, the results of special tests, and a request for physical ther- apy were all therapists required when
treating patients with vertebral prob- lems or similar nonspecific diagnoses. Our results are congruent with stud- ies in Australiazz and Canada29 that have demonstrated dissatisfaction with the information received from medi- cal practitioners about the patients' medication and overall health status.
Value of direct communication. The value placed on direct communi- cation with the physician was not sur- prising. Considering that Australian physical therapists have direct access, however, it is worthy to note that di- rect communication with physicians is equally, if not more, important to them as compared with American physical therapists. The higher value placed on direct communications by the Australian therapists in cardiopul- monary care may reflect a more di-
rect involvement with acute respira- tory care. Dennisz2 reported 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 varied strategies to maintain and strengthen direct communications. The clinicians also wanted to educate physicians about the skills and values of the physical therapist.
Other sources of information. The much higher values reported by the cardiopulmonary physical therapy groups in both countries may reflect the use of radiographs for treatment decisions, whereas the orthopedics groups may use radiographs to rule out diagnostic alternatives. Therapists in both countries showed consider- able flexibility in using sources of information based on availability.
Cognitive Style Preferences
Overall. The total sample's identilica- tion with receptive data gathering and systematic information processing suggests a response set based on valu- ing the scientific approach and believ- ing it is appropriate in physical ther- apy evaluation, but it may also reflect actual practice. Positive response was strongest for the receptive category. Statistically, the most strongly positive items in the subscale were collecting information to confirm findings, checking out ideas, and gradually building a picture of the patient's problems. Researchers suggest that expert decision makers are subject to logical errors, including a redundancy phenomenon, in which clinicians con- tinue gathering data to substantiate findings after there is sufficient evi- dence for a conclusion.3~22 Efforts at cost containment may not be compati- ble with the receptive approach (for example, cost of procedures, duplica- tion of tests), and clinicians may need to review their own cognitive style preferences in relation to the de- mands of the health care system. Re- dundancy in evaluation may require further investigation. The statistical differences between countries are interesting, but we believe they are
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Table 4. Analysis-of-Variance Summary for Relationship Between Cognitive Style Category, Major Practice Area, and Country
Preceptive
Source
M PAa
Country
MPA x country
Residual
Receptive
Source
M PA
Country
MPA x country
Residual
Systematic
Source
M PA
Country
MPA x country
Residual
Intuitive
Source
M PA
Country
MPA x country
Residual
more efficiently. Educationally, there are important implications for the relationship between cognitive style and clinical decision making. With an understanding of a student's cognitive style preference, faculty can guide the student to select more effective learn- ing strategies. Faculty can also struc- ture case studies and learning experi- ences to elicit desired approaches to decision making.
Future Studies
Considerably more study is needed on the effects of cognitive style prefer- &
ence and the physical therapy task on decision making. Hammond et abo suggest that performance is most ac- curate when task attributes are matched with cognitive attributes. We hesitate to suggest that therapists choose their respective practice areas because they are attuned to different cognitive styles; rather, we believe that most clinicians, faced with a dif- ferently structured problem type, uti- lize a different cognitive strategy. This hypothesis could be the subject of further investigation. We also plan to use the scale with new graduates to compare their cognitive style prefer- ences with those of expert groups.
Conclusions
"Major practice area. A study of expert decision-making
due to the greater heterogeneity of raises the question of whether patient behaviors in the United States and
the Australian sample. care tasks in different areas of physical Australia revealed an overall prefer-
therapy differ in these dimensions. ence for one's own assessment as a
Differences by major practice Our profession espouses the scientific source of information, for the recep-
area. All subscales showed effects for method and analytical thinking but tive style of data gathering, and for
practice area. These findings are con- may also need to consider the influ- the systematic style of information
gruent with literature suggesting that ence of task structure on cognitive processing. Significant differences
problem structure evokes cognitive strategies. were found for major practice areas
behavior.*,30.31 Hammond et a13O de- 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 effects
ing, which may explain our findings, clinical practice may help clinicians were also found between American
If 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- Acknowledgment compose into discrete parts, and, if pects of our activities into conscious measurement is perceptual, it favors awareness, we are better able to de- would like to thank Harry Davis intuitive processing. Tasks with fewer termine our own strengths and weak- of the Medical College of and sequential cues, which can be nesses and lhus reduce the potential D~~~~~~~~ of ~ ~ ~ ~ ~ ~ ~ h , statistics, decomposed into discrete parts and for error As our understanding of the and Cornputen for his invaluable as- measured objectively, favor an analyti- decision-making process increases, so sistance in research design and data cal (systematic) approach. This finding will our ability to make decisions analyses.
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4. If you have completed a post-entry-level master's 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 facility
10. 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
There are many ways a physical therapist may obtain information to make clinical decisions. It is understood that the importance of each source may vary with the type of patient being treated. Please consider whether you would use the information sources listed below when you are 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 patient's medical history
17. Specifically, progress notes
18. Specifically, the medical examination
19. Specifically, physician's orders
20. Specifically, special test results
21. Specifically, x-ray films (you read yourself)
22. The information in the medical referral
23. The information I find during my own assessment
24. The information I can find in textbooks and journal articles
25. The information I can get through direct communication with the patient's physician
26. The information I can get by talking to the patient's friends and/or relations
27. The information I can get from other physical therapists
28. The information I can get directly from the nurse on the floor
29. The information I can get from other health care professionals working with the patient
Sectlon Ill
The following statements represent aspects of different styles of clinical decision making. They do not all necessarily apply to each person, as they 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 are no 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 4
31. 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 patient's 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 4
34. 1 use my physical assessment to check out my initial ideas about the patient's problems. 1 2 3 4
35. During the assessment, I check appropriate areas in detail and do the others superficially. 1 2 3 4
36. 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 4
39. Once I have a picture of the patient's 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 4
41. What I want to know is related to functional outcomes. 1 2 3 4
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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.
44. When I am reading the medical chart, I sometimes ask myself, How will this person relate to me, 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 patient's 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 patient's 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 patient's 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 patient's problems without going into miniscule details in the assessment.
65. The c?ssential things I need to make clinical decisions are the patient's 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 physician's 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 patient's major complaints before attempting to look ior interrelationships among the symptoms.
75. The patient's 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.
Strongly Agree
1
Strongly Agree Disagree Disagree
2 3 4
2 3 4
2 3 4
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1 Hoganh RM. Judgment and Choice. New York, NY: John Wiley & Sons Inc; 1980:l-10, 155-184.
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Commentaries
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Statistical Analysis. Canterbury, United King- dom: University of Canterbury; 1980. HSIU Repon 41. 22 Dennis JK. Decisions made by physiothera. pists: a study of private practitioners in Victo- ria. Australian Journal of Physiotherapy. 1987;33:181-191. 23 Browning C, Thomas S, Oates J. Clinical decision making and clinical competence. Pre- sented at the International Health Sciences Education Conference; July 1-5, 1988; Sydney, Australia. 24 McKenney JL, Keen PGW. How managers' minds work. Harvard Business Review. May- June 1974;52:79-91. 25 Hayes-Roth B, Hayes-Roth F. A cognitive model of planning. Cognitive Science. 1979;3:275-310. 26 Horn JL. A rationale and test for the num- ber of factors in factor analysis. Psychometrika. 1965;30:179-185. 27 Zwick WR, Velicer WF. Comparison of five rules for determining the number of compo- nents to retain. Psycho1 Bull. 1986;99:432442. 28 Twomey LT. The physiotherapist. Med J Aust. 1983;30:422424. 29 Ross AR, Robens LW, Olson L. The doctor- physiotherapist relationship: the physiothera- pists' perspective. Physiotheram Canada. 1980;32:219-223. 30 Hammond KR, Hamm RM, Grassia J, Pear- son T. Direct comparison of the efficacy of intuitive and analytical cognition in expen judgment. In: IEEE Transactions on System, Man and Cybernetics. New York, NY: Institute of Electrical and Electronics Engineers; 1987;SMC-17(No. 5):l-14. 31 Payne J. Contingent decision behavior. Psy- chol Bull. 1982:92:382402.
Following are two commentaries on "Expert Decision Making in Pbysical Therapy-A Survey of Practitioners."
The accuracy of diagnosis and the for the improvement in performance ceived by their peers to be experts in effective selection of treatment ap- of clinicians and for the education of an attempt to clarify the nature of proaches are vital elements in suc- physical therapy students in these information-processing phases and to cessful 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 the important areas can provide guidance results of a survey of clinicians per- planned description of "expert behav-
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