dfa

1. Expert Decision Making in Physical Therapy−−A
Survey of Practitioners
Bella J May and Jancis K Dennis
PHYS THER. 1991; 71:190-202.
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found online at: http://ptjournal.apta.org/content/71/3/190
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2. Research Report
Expert Decision Making in Physical Therapy-
A Survey of Practitioners
Four hundred American and 384 Australian pkysical therapists, nominated by Bella J May
their peers as expert clinicians, were studied to evaluate whether a particular cog- Jancls K Dennis
nitive style was prevalent among expert clinicians, to identzb preferred sources of
information for clinical decision making, and to determine the similarities and
dflerences between American and Australian therapists. Results were based on
usable 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 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 information 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
Key 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 the
creasing independence in making do or believe they do. findings generalize across areas of c
patient care decisions. Understanding study. Decision making is influenced
the dimensions of expert decision There has been considerable research by knowledge, the way experience
making will help current practitioners into clinical decision making, has structured that knowledge, the
improve 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 information
seemed 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 critical
B 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 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.~.*,5Preliminary evidence sug-
gests that physical therapists use
This article was submitted Februaly 15, 1983, and was accepted September 24, 1990.
22/190 Physical Therapy /Volume 71, Number 3 /March 1991
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3. similar reasoning processes.12-'7 Cur- and constraints early, performing an therapy practitioners in each
rent 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 patient's 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 Method
cally relevant patterns that are un- to another, relying on cues and
locked by key cues in the decision hunches. The results of Bork'sl2 study Subjects
environment. Patterns stored in mem- of physical therapy students suggested
ory enable the expert to recognize that cognitive style influenced clinical Subjects were selected through a
meaningful 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 group
published models1*20 attempt to help associated with a better performance officers holding comparable positions
practitioners 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. I'sychological research indi- primarily in the preceptive mode ered to be expert clinicians and who
cates that human information process- were less likely to accurately deter- were involved in direct patient care
ing is subject to bias introduced by mine a simulated patient's 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, were
and 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 a
ample, contains a specific diagnosis, portunistic decision making, that is, random sample of the remaining
the 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 included
A~stralia.;!Z~~3 specifically examined the relationship 384 individual names, were received
of cognitive style preference to deci- and became the group selected to
Cognitive style, which can be defined sion making. receive the questionnaire.
as an individual's preferred way of
thinking and organizing information, A study of expert clinicians in the Procedures
has 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 to
nitive 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 Keen'sz4 phases of expert clinical decision perception of their decision-making
paradigm reflected four styles of cog- making. A second purpose was to behaviors, focusing on cognitive style
nition, two related to the data- compare the reported decision- preference. The instrument evolved
gathering 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 of
sion making. The data-gathering styles physical therapy (Australia) with the the interview statements and scoring
were 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 access
been 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 therapists
tions 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 one
to another, seeking and responding to pists in the United States and doing the questioning and the other
cues and patterns as a guide to data Australia? making notes and monitoring the tape
gathering. 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 cognitive
Physical Therapy /Volume 71, Number
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4. styles described by McKenney and We performed a reliability analysis for birth educators and consultants to
Keen2*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 source
trated 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 with
tured 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 performed
cesses 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 and
Categorization.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 the
descriptions and others that did not study, but to perform more reliability Cognitive style preference. We
fit. The latter appeared to be state- and factor analyses before analyzing reevaluated category reliability for the
ments 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 was
statements about specific knowledge The final survey instrument was simi- scored by calculating the mean score
requirements 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 to
To 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 of
ered from our collective experience. Responses to the survey instrument subjects who responded to 75% or
The first draft of the survey contained were coded as indicated on the ques- more, but less than loo%, of the
six logically derived components: one tionnaire. Data analysis included the items were calculated as the mean of
for 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 instrument
Scoring. 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 accurate
knowledge, receptive, preceptive, sys- tive purposes (ie, 0-10, 11-20, 20+), method for determining the number
tematic, and intuitive). but five categories (ie, 0-5, 6-10, 11- of major components to retain2'
15, 16-20, and 20+), were retained
Pilot 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 responses
and 20 physical therapists in Australia employment included private practice, ("other") were reviewed individually
from 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 analysis
strument, which contained three sec- the questionnaire (Appendix). We for that variable. The two national
tions. 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 identify
and years since graduation. The sec- General orthopedics, manual therapy, within-nation differences in cognitive
ond section asked respondents to in- and sports physical therapy were style attributable to sex, years since
dicate the value of sources of infor- combined to form an orthopedics graduation, place of employment, or
mation, using a four-point numerical group; adult and pediatric neurology major practice area. The Tukey's 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 category
statements on a four-point scale rang- sixth group, education, comprised of cognitive style, two-way ANOVAs
ing from "strongly agree" to "strongly physical therapy educators and practi- were used to compare the means of
disagree." Respondents were also tioners whose professional role was the Australian and American therapists
asked to comment on the clarity of primarily patient education (ie, child- by sex, years since graduation, place
the items.
Physical Therapy /Volume 71, Number 3 /March 1991
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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 Australian
Results 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 Australian
set effect within the two countries. samples were employed in private therapists. Of the remaining places of
There was greater variance in the Aus- practice (US therapists, 49%; Austra- employment, 5% of the US therapists
tralian therapists' responses, indicating worked in a school system, 4% in
greater heterogeneity in the sample, community care, and 2% in physical
as 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 to
Demographics industry and 2% in physical therapy
Practice Area Unlted States Australia education. Different practice charac-
Usable responses were received from teristics and health care structures
348 (86%) of the American nominees General practice 75 (22%) 52 (18%) made the samples less comparable in
and 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 in
acteristics of each sample, showing EducationC 10 (3%) 19 (6%) the value placed on various sources
years since graduation and percentage Total 348 290 of information between the two coun-
of time currently spent in direct pa- tries. Not surprisingly, therapists in
tient care. Table l depicts the distri- aGeneral orthopedics, manual therapy, sports both countries and in all types of
bution of the respondents across ma- physical therapy. practices valued their own assessment
jor 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
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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 Respondents
Figure 2. value of physicians' orders (;ompared for American and Australian physical therapists by major practice area
mation (US therapists, 88%; Australian The reported value of direct commu- Principal Components Analysis
therapists, 89%). nication with the physician is illus-
trated in Figure 3. Most Australian Seven factors were identified. We
Physicians' orders were generally con- therapists found direct communica- compared the items in each factor for
sidered 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 the
percentage of Australian therapists (58%-68%), except for therapists cognitive style categories had been
compared with American therapists working in geriatrics. In geriatrics, the satisfactory in the pretest, regrouping
reported that physicians' orders were majority of American therapists found some items and eliminating others in
not 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 b
The value of physicians' orders varied The reported value of other sources without altering the logical premises
with area of practice; more Australian of information was somewhat on which it was based. We retained
therapists (60%) involved in cardio- practice- and employment-specific. the four categories of cognitive style
pulmonary care, for example, valued Most respondents valued the patient's (receptive, preceptive, systematic, and
physicians' orders than did American past medical history (75% overall); intuitive) and identified two other
therapists (46%). The percentage of however, 20% of the therapists in pri- categories (physician dependency and
Australian therapists working in ortho- vate practice and 14% in home health holism), which will not be reported
pedics 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, including
respectively) was considerably lower of Australian therapists found radio- some universal value statements, and
than 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 related
more Australian therapists than Ameri- cardiopulmonary therapists, but only instrument items for both national
can 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
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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 Respondents
Flgure 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 Tukey's
cognitive style preferences were not significantly more positively to the HSD Test procedure identified the
influenced by years since graduation, systematic style and less positively to following groups to be significantly
except for Australian therapists gradu- the intuitive style than those em- different at the .05 level. Some of the
ated for 5 years or less, who re- ployed in rehabilitation centers. Other differences were shared between
sponded significantly less positively to comparisons were not significant. countries, whereas others were
the 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 therapy
vealed differences related to place of within countries. Differences in group responded more positively to
employment. 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 Q
Preceptive 30, 46, 53, 60, 64, 70, 76 2.07 0.20 .60 2.22 0.28 .56
Receptive 34, 36, 39, 40, 56, 58, 73 1.47 0.02 .60 1.53 0.06 .65
Systematic 42, 45, 59, 66, 69, 72 2.28 0.48 .74 2.36 0.43 .69
Intuitive 31, 33, 51, 52 2.47 0.09 .57 2.79 0.22 .62
Physical Therapy/Volume 71, Number 3/March 1991 195/ 27
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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 Category
Flgure 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 orthopedics
general practice and cardiopulmonary country o r sex for receptive data gath- group responded least positively to
physical 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. The
positively to the systematic style than male physical therapists in both neurology groups in both countries
the 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 practice
than the orthopedics group; the neu- physical therapists, and the US sample area was significant for the receptive
rology group responded more posi- overall responded significantly more category, with the orthopedics and
tively to the intuitive style than the positively to this category than the Aus- cardiopulmonary physical therapy
orthopedics group, although the tralian sample. Male physical therapists groups in both countries responding
mean response was not in the posi- in both countries responded signifi- more positively to this style than the
tive 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 the
In 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; an
rology and general practice groups, not significant. American physical ther- interactive effect was also noted for
and 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 area
reported in Tables 3 and 4. There showed significant d8erences in all
28/196 Physical Therapy /Volume 71, Number 3 /March 1991
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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 varied
Preceptive
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. The
Receptive 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. Therapists
Systernat~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 sample's 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 positive
Discussion 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 patient's
Physicians' orders. More than half have demonstrated dissatisfaction with
problems. Researchers suggest that
of the therapists in both countries the information received from medi-
expert decision makers are subject to
considered the physicians' orders of cal practitioners about the patients'
logical errors, including a redundancy
limited 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 substantiate
the 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 at
cians 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 (for
independent 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 need
ited value; however, it would be inter- rect communication with physicians is
to review their own cognitive style
esting 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 require
radiographs, the results of special placed on direct communications by
further investigation. The statistical
tests, and a request for physical ther- the Australian therapists in cardiopul-
differences between countries are
apy were all therapists required when monary care may reflect a more di-
interesting, but we believe they are
Physical Therapy /Volume 71, Number 3 /March 1991
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10. more efficiently. Educationally, there
are important implications for the
Table 4. Analysis-of-VarianceSummary for Relationship Between Cognitive Style relationship between cognitive style
Category, Major Practice Area, and Country
and clinical decision making. With an
understanding o a student's 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
Residual
Receptive 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. We
Systematic 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. This
Intuitive 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 and
due to the greater heterogeneity of raises the question of whether patient
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 source of information, for the recep-
Our profession espouses the scientific
area. All subscales showed effects for method and analytical thinking but tive style of data gathering, and for
practice 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 differences
problem structure evokes cognitive strategies. were found for major practice areas
behavior.*,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 effects
ing, which may explain our findings, were also found between American
clinical practice may help clinicians
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 ~ ~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 data
cal (systematic) approach. This finding will our ability to make decisions
analyses.
30 / 198 Physical Therapy/Volume 71, Number 3 /March 1331
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11. -
Appendix.
1. sex:
Clinical Decision-Making Questionnaire
Sectlon I--Demographics
Please 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-levelmaster'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
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. No
14. Only evaluate without referral? 1. Yes 2. No
15. If yes, please estimate the number of patients a month
you see without a referral:
(Continued)
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12. -
Appendix.
Sectlon Il-Sources
(Continued)
of lnformatlon
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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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
4
44. 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 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?ssentialthings 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.
Physical Therapy/Volume 71, Number 3 /March 1991 201 / 3 3
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Commentaries
Following are two commentaries on "ExpertDecision 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-
34 1202 Physical Therapy/Volume 71, Number 3 /March 1991
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15. Expert Decision Making in Physical Therapy−−A
Survey of Practitioners
Bella J May and Jancis K Dennis
PHYS THER. 1991; 71:190-202.
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