The question of whether clinical reasoning expertise should be perceived as a skill, or a state is a complex issue that has reverberations on medical expert education. The phenomenon of context specificity (CS) and the situativity theory (ST) represent theoretical perspectives that oppose the viewpoint of professional expertise as a transferable and static trait, and both find reflections in the physical therapy field. Physical therapy practice involves active collaboration with the patient, and the client’s preferences for the use of imaging or treatment options that minimize unwanted physical contact with the provider exemplify the field’s connection to CS/ST.
One example of CS and ST in physical therapy is that patients’ perspectives of diagnostic procedures might interfere with physical therapists’ knowledge. There are interpersonal differences in learning styles and abilities; sometimes, patients’ misconceptions might cause the ordering of additional tests or necessitate additional patient education that delays decision-making and treatment plan realization (Grasha, 1995). CS has emerged from Elstein’s theoretical discussions and means that factors influencing diagnostic and therapeutic processes extend beyond “the clinical content of a case,” and ST further anatomizes it (Rencic et al., 2016, p. 215). For instance, patients with low back pain may take time to request unnecessary imaging tests, assuming that their physical therapist cannot recommend effective treatments without scans (Hoffmann et al., 2022). Such suggestions hinder the physical therapist’s ability to prioritize guideline knowledge, such as the absence of imaging as a routine diagnostic recommendation for low back pain (Crowell et al., 2022; Hoffmann et al., 2022). Instead of relying on their knowledge, professionals might have to dedicate time to client education or investigate the clinical case further to assess such requests or argue that imaging will bring no benefit.
Physical therapy patients’ inability to proceed with some treatments for psychological reasons also illustrates the connection between CS/ST and physical therapy. Specifically, as recent qualitative research suggests, female patients might give preference to exercise-based treatments rather than manual therapy due to the fear of getting naked (Bastemeijer et al., 2021). The situativity theory (ST) seeks to explain CS and argues that direct clinician-related factors, such as knowledge, do not solely predict clinical reasoning outcomes (Rencic et al., 2016).
The distributed cognition concept within the ST theory emphasizes that interactions between the physician and other professionals, environments, and patients interfere with the clinician’s own expertise (Rencic et al., 2016). The aforementioned example illustrates both concepts; physical therapists’ knowledge regarding manual treatments being more effective in relieving certain symptoms encounters barriers in the form of the client’s preferences. In certain cases, manual therapy could be a better choice, such as pain that is strong enough and needs to be reduced quickly. Due to psychological constraints, patients might still prefer exercise-based treatments, so clients’ preferences become another factor besides the clinician’s knowledge to affect the chances of positive outcomes.
To sum up, as a discipline, physical therapy involves some manifestations of the CS concept and the ST theory when it comes to patients’ participation in decision-making. Physical therapy clients’ frequent desire to undergo imaging procedures prior to receiving treatment for lumbago exemplifies how patients’ knowledge levels interact with the clinician’s expertise in decision-making processes. In a similar manner, some patients’ preference for therapies that account for their psychological barriers to physical interaction with treatment providers is indicative of the interplay of factors in treatment decisions.
References
Bastemeijer, C. M., Van Ewijk, J. P., Hazelzet, J. A., & Voogt, L. P. (2021). Patient values in physiotherapy practice, a qualitative study. Physiotherapy Research International, 26(1), 1-10. Web.
Crowell, M. S., Mason, J. S., & McGinniss, J. H. (2022). Musculoskeletal imaging for low back pain in direct access physical therapy compared to primary care: An observational study. International Journal of Sports Physical Therapy, 17(2), 237-246. Web.
Grasha, A. F. (1995). Teaching with style: The integration of teaching and learning styles in the classroom. Essays on Teaching Excellence: Toward the Best in the Academy, 7(5), 1-6. Web.
Hoffmann, T., Bakhit, M., & Michaleff, Z. (2022). Shared decision making and physical therapy: What, when, how, and why? Brazilian Journal of Physical Therapy, 26(1), 1-10. Web.
Rencic, J., Durning, S. J., Holmboe, E., & Gruppen, L. D. (2016). Understanding the assessment of clinical reasoning. In P.F. Wimmers & M. Mentkowski (Eds.), Assessing competence in professional performance across disciplines and professions: Innovation and change in professional education (pp. 209-235). Springer.