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International Journal of Osteopathic Medicine (2015) 18, 207e218


Becoming an expert: A Masterclass

in developing clinical expertise
Nicola J. Petty*

Centre for Health Research, School of Health Sciences, University of Brighton,

Aldro Building, 49 Darley Road, Eastbourne BN20 7UR, United Kingdom

Received 14 August 2014; revised 6 January 2015; accepted 19 January 2015

KEYWORDS Summary This Masterclass explores how practitioners may develop clinical exper-
Clinical expertise; tise. The terms expert and expertise are initially outlined along with the attributes
Expert practice; of a practitioner with expertise. This is followed by an exploration of the literature
Osteopathy; in relation to three key ways to develop expertise: through experience with pa-
Osteopathic medicine; tients, formal postgraduate education and through direct observation of practice
Professional with a mentor. The theoretical basis of these activities is critically reviewed to
development; highlight their underpinning educational value and pedagogy. It is proposed that
Clinical reasoning critical reflection on practice enhanced by direct observation of practice with a
mentor and formal postgraduate education each provide a potentially powerful tool
for learning and the development of clinical expertise.
2015 Elsevier Ltd. All rights reserved.

Introduction doctoral research study exploring learning transi-

tions of musculoskeletal physiotherapists under-
The aim of this Masterclass paper is to explore how taking the aforementioned course, and from
osteopaths and health practitioners may develop supervision of research students from a range of
their clinical expertise and perhaps become known healthcare professions exploring this topic area.
by others as an expert. My knowledge in this area This is not a definitive and comprehensive
has come from over ten years experience as a rendering of the subject, rather the perspective of
course leader of a musculoskeletal physiotherapy the author as an educationalist and researcher and
postgraduate course that was primarily focused on long ago practitioner, who has been exploring this
developing expertise of practitioners, from topic for a number of years. It is hoped that this
paper will help guide practitioners who wish to
* Tel.: 44 0 1273 641806; fax: 44 0 1273 643944. develop their clinical expertise and facilitate
E-mail address: expertise in others.
1746-0689/ 2015 Elsevier Ltd. All rights reserved.
208 N.J. Petty

Expert and clinical expertise outcomes for masters level learning (Table 1),
provide a helpful overview.3
Dictionary definitions of an expert refer to some- Narrowing down to the particular of clinical
one who is very knowledgeable about, or skillful expertise, the literature provides a broad array of
in, a particular area.1 This raises the issue of who characteristics of a practitioner summarised in
decides the level of knowledge and skill needed Table 2. The broad range of attributes include
and what criteria would determine whether patient-centred practice, critical evaluation and
someone is an expert. The complexity of osteo- understanding of their practice knowledge, and an
pathic practice (and other healthcare practice) ability to learn in and from their practice. A recent
may not lend itself to a list of performance in- grounded theory study suggests that some of these
dicators on which to determine whether someone characteristics may be found in experienced
is an expert. Perhaps the notion of someone osteopaths.4,5
being an expert is, like beauty, in the eye of the The last characteristic in Table 2, the capability
beholder; it is a concept constructed by the to learn in, and from, practice (that is, to learn
onlooker. The term expert suggests a static and from experience) is considered essential to main-
final position, however new knowledge is tain expertise.8,10,35 To learn in, and from, prac-
constantly being created, so how often would tice requires practitioners to be capable of and
someone considered an expert need to be re- disposed to critically examining, evaluating,
validated? Because of these difficulties in the creating, developing and transforming their prac-
term expert, the use of expertise has generally tice knowledge and clinical practice.10,29,32,33,35 It
been used in this paper, except where accuracy to is the questioning and challenging of practice
the literature demands otherwise. Expertise has knowledge that leads to its transformation.36 The
been referred to as the proficiency and judgement practitioner therefore needs to be critically
acquired through clinical experience and clinical reflective and reflexive.32 The requirement to
practice.2 Expertise relates to a persons charac- learn in, and from, practice embraces lifelong
teristics, skills and knowledge with a sense of it learning and highlights the importance of critical
being fluid and changing. Clinical expertise is evaluation skills.27
described here as the ability of the practitioner to
effectively integrate their practice knowledge
with the patients clinical presentation, values and Development of clinical expertise
preferences to maximize the therapeutic
encounter for the patient. The developmental process by which practitioners
enhance their clinical practice expertise is a
contentious issue in the literature. Clinical prac-
Attributes of practitioners with clinical tice experience with patients, formal post-
expertise graduate education and having mentors in practice
were each considered instrumental in the profes-
In considering broadly the characteristics of sional development of clinical experts.8 These as-
expertise, the United Kingdom Quality Assurance pects provide a framework for this section and are
Agency (QAA) for Higher Education learning discussed in turn.

Table 1 Documented learning outcomes of Masters level 7 learning.3

Typically holders will be able to:
 deal with complex issues systematically and creatively, make sound judgements in the absence of complete
data, and communicate their conclusions clearly to specialist and non-specialist audiences
 demonstrate self-direction and originality in tackling and solving problems, and act autonomously in planning
and implementing tasks at a professional level
 continue to advance their knowledge and understanding, and to develop new skills to a high level

And holders will have:

 the qualities and transferable skills necessary for employment requiring:
 the exercise of initiative and personal responsibility
 decision-making in complex and unpredictable situations
 the independent learning ability required for continuing professional development
A Masterclass in developing clinical expertise 209

Table 2 Attributes of a practitioner with clinical expertise.

Patient-centred practice.4e9
Conscious, deliberate and creative practice.10e12
Instant or rapid interpretation through pattern recognition.6,13e15
Detect inconsistencies or links between bits of clinical data and in relation to what they know from
Activation and verification of illness scripts.16e18
Holistic view of problematic clinical situations.19,20
More options in clinical decision making, including the option not to treat.21
Education and coaching considered equally important to their skills.4,5,22
Spend time trying to understand the clinical problem (c.f. novices spend time trying out different solutions).23
Appropriate and rapid navigation between clinical action (chains of practice) and understanding (integrated net of
understanding). This is suggested to explain the intuitive dimension of expertise.13,24,25
Critical evaluation of practice knowledge.9e11,15
Understanding of clinical practice with integration of knowledge.8,13,15,26e31 Similar to connoisseurship - awareness
and understanding of what has been experienced.28
Reflective, reflexive and self evaluative.8,9,11,14,15,32
Dynamic, negotiated, and situated.4,5,13,33
Ability to explain and justify clinical decisions.32
Learning in and from practice.4,5,8,10,13,21,27,29,34,35

Clinical experience find solutions to indeterminate problems that

require continuous experimentation.45 Further-
Expert level has been considered to develop from more in this model, expert practitioners are
progressive accumulation of knowledge and skills considered to be arational,a where intuition is
through experience, however this is a controver- considered to guide action.6,37 This is also difficult
sial issue.6,37 Progressive accumulation of knowl- to accept since patient-centred care requires
edge and skills assumes a conception of clinical deliberative action.10,46
practice as a mix of knowledge and skill divorced Within medicine, expert diagnostic reasoning
from clinical practice (technical rationality as has been theorised to develop through three
described by Fish and Coles,29) which seems inad- stages: novice (knowledge that explains causal
equate. Despite this, two research studies have pathophysiological processes, for example causes
found that experienced practitioners (osteopaths of posterior leg pain), intermediate (encapsulation
and physiotherapists) viewed practice as the of biomedical knowledge into diagnostic labels, for
relatively simple application of knowledge and example nerve root compression) and expert
skills.5,38 Furthermore, the assumed progression of (illness script formation that emphasizes enabling
skill through the stages6 (novice, advanced conditions of a disease, for example lack of exer-
beginner, competent, proficient and expert level) cise).16e18 Clinical experience is considered vital
has not been identified amongst teachers,39,40 to the development through each of these
nurses,41 students,42,43 or engineers.30 According stages.16e18
to Benner, 6(p32), 37 the expert nurse: has an The proposal that 10 years (or 10,000 h) of
intuitive grasp of each situation and zeroes in on deliberate practice develops expertise46,47 has
the accurate region of the problem without been disputed. Deliberate practice accounted for
wasteful consideration of a large range of un- one-third of the reliable variance in performance
fruitful, alternative diagnoses and solutions . in chess and music with the proposal that age,
the expert operates from a deep understanding of intelligence and genetics may also be influential.48
the total situation . Highly skilled analytic abil- Furthermore, a meta-analysis49 of 88 studies
ity is necessary for those situations with which the concluded that while the amount of deliberate
nurse has had no previous experience. Benners practice was important in determining perfor-
notion of an expert nurse may also relate to an mance, it was not as influential as first thought.
expert osteopath. However, while the description Deliberate practice accounted for 26% of the
mirrors higher levels of motor skill performance44 variance in performance in games, 21% for music,
and skilled behaviours under conditions of rapid
decision making,10 it does not reflect the advanced a
cognitive abilities used in clinical practice10,44 to Arational refers to being without conscious analytical
decomposition and recombination.37 p36
210 N.J. Petty

Reflection on Maintain
confirmatory practice
Circularity of experience knowledge

Interpretation of Reflection on
experience contradictory Adapt
experience practice
Exposure to

Figure 1 Circular nature of experience and reflection on learning. (Adapted from Dewey51, Eraut53, Fish and
Coles29, Jarvis61). rejection, acceptance.

18% for sports, 4% for education and less than 1% transformation of practice knowledge may require
for professions. More specifically, musculoskeletal help from other practitioners. They may reveal
physiotherapy practitioners with better patient blind spots in practice knowledge59 and alternative
outcomes for people with low back pain, were not views and paradigms that facilitate a more radical
distinguished by years of experience.50 Recent change.54,55 This may lead to more complex and
research in osteopathy also suggested that there is comprehensive understanding of practice knowl-
no qualitative relationship between practitioners edge with integration of knowing, acting and
level of clinical experience (years in clinical being, embodied and embedded in intersubjective
practice) and attributes of clinical expertise.4,5 practice.57,60
The influence of experience on learning has
been explored by Dewey51 who posited that every Reflection on experience
experience modifies the person and the quality of The importance of reflection to experiential
future experiences. So, for example, each expe- learning demands exploration. From the litera-
rience an osteopath has of performing a spinal ture, a conceptual model of the relationship be-
manipulation or carrying out a patient case history, tween experience and reflection is shown in Fig. 1.
will influence the practitioner and their subse- The circular nature of experience suggests that
quent experiences of manipulation and history experience that confirms expectations may not
taking. This notion is beginning to be borne out by trigger as much reflection as a contradictory
studies exploring experience driven neuro- experience. A confirmatory clinical experience,
plasticity highlighted in this journal by Esteves and accepted as such by the practitioner, may confirm
Spence.52 This meaning making process may create and strengthen existing practice knowledge. A
or modify their practice knowledge (or personal confirmatory clinical experience, rejected as such
theories), which may then modify them as practi- by the practitioner however, may trigger reflection
tioners, and influence their future clinical experi- and lead to modification of practice knowledge.
ence.29,53 The degree of change to their practice The relationship between experience and reflec-
knowledge would thus depend on the degree to tion is illustrated by the following example. When
which they consciously reflected and theorised on presented with a person complaining of chronic
the experience. The experience itself would, in low back pain, the practitioner may expect the
turn, be influenced by the practitioners hidden, persons pain and disability to respond to hands-on
taken for granted assumptions and expect- manual therapy directed to the postural/structural
ations54e56 and this would be influenced by their and biomechanical clinical findings. If the person
clinical perspective or frame of reference54,55; we responds as expected this may confirm and rein-
tend to experience what we expect to experience. force the practitioners beliefs and practice
The potential for learning may therefore be knowledge. Alternatively, the practitioner may
limited as the practitioner may be trapped within critically reflect on the experience and consider
their existing understanding51,57; theories-in-use whether alternative treatment may have had a
may be self-sealingb.58 More radical better and quicker response, this critical explora-
tion may then lead to new insights and learning.
In the same way, a contradictory clinical experi-
Self sealing refers to the situation where our theories limit
ence may be embraced, not noticed, ignored or
what we do and therefore limit our opportunities to see
something different. rejected by a practitioner.62e64 A contradictory
A Masterclass in developing clinical expertise 211

clinical experience that is ignored or rejected, may  how questioning and critical a practitioner is of
result in little change to practice knowledge; this their clinical experience;
may occur because of the risk of error, uncertainty  how open a practitioner is to changing their
or gap in practice knowledge, personal discom- practice knowledge; and
fort,58,65 or reluctance to make the intellectual  the degree to which a practitioner is exposed
effort required to reflect.10 Where a practitioner to alternative views and perspectives.
embraces a contradictory clinical experience, this
may result in critical reflection towards their prac-
tice knowledge with subsequent modification. Using Routinisation with experience
the same example as above, if the patient with low Experience not only creates and modifies practice
back pain does not respond as expected and fails to knowledge, it also affects clinical behaviour and
improve, the practitioner may chose to ignore this action. With repetition, actions can become more
and continue to treat in the chosen way or make automatic, fluid and skillful.10,61 For example,
some minor modification to the treatment, with palpation requires motor skills that can become
little learning. Alternatively, the practitioner may automatic and highly skilled with practice.46
embrace this contradictory experience and criti- Automatic actions enhance time efficiency as
cally reflect on their decision making process that well as the cognitive attention required to perform
may highlight missed cues, leading to an enhance- the action. For example, a habitual way to palpate
ment in their practice knowledge. In medical diag- the spine enables the practitioner to concentrate
nostic reasoning, for example, a mismatch between on feeling the paraspinal soft tissues and joint
patient information and the illness scripts and mobility.52 Automatic actions thus facilitate the
memory of previous patients held by expert practi- application of practice knowledge (through cogni-
tioners is thought to trigger an active engagement in tion, metacognition and reflection) enabling
clinical reasoning.17,18 conscious, deliberate patient-centred practice
Thus confirmatory and contradictory clinical that enables the practitioner to learn from expe-
experience that is arrested and examined,66,67 de- rience; this is highlighted in Table 3. Patient-
velops, tests and generates practice knowledge.32 centred practice is used here to denote the
The capability to learn from experience depends conscious, deliberate, creative, individualised and
not on years of experience,66e68 but rather on: collaborative clinical care of patients.8e12 Practi-
tioners developing in this way may have a
 the degree to which a practitioner reflects on conception of clinical practice as uncertain, un-
clinical experience; predictable and problematic and a disposition to

Table 3 The nature of practitioner-centred and patient-centred clinical practice (adapted from Eraut10,69 and
212 N.J. Petty

critically reflect and learn from their clinical knowledge may devalue a practitioners own
practice, thus enhancing their practice knowledge knowledge gleaned from clinical experience.
with experience.
If, however, clinical actions are not accompa-
nied by conscious use of practice knowledge Influence of work setting
(through cognition, metacognition and reflection), Work settings that value efficiency and patient
then there is a loss of conscious regulation and through-put rather than effectiveness and quality
critical control, so that practice may become of clinical practice10,62 may impede learning from
routinised10,69; the process is summarised in Table experience in a number of ways identified in
3. There may be limited capability to learn from Table 4.
such practitioner-centred clinical practice (the
routine use of examination procedures, treatment Formal education
techniques and management strategies for patients
regardless of their presentation). Practitioners In the UK, university masters courses in musculo-
developing in this way, may have a conception of skeletal physiotherapy have a central aim to
clinical practice as certain, predictable and un- develop the clinical expertise of practitioners.
problematic and may not be disposed to critically These courses are approved by the Musculoskeletal
reflect and learn from their clinical practice, thus Association of Chartered Physiotherapists (MACP)
limiting their practice knowledge. and must comply with the Educational Standards
Document of the International Federation of Or-
Nature of clinical practice thopaedic Manipulative Physical Therapists
The nature of clinical practice may limit the op- (IFOMPT).73 These courses have a minimum of 200 h
portunity to learn from experience.58,69 The of theory, 150 h of practical skill development and
practitioner: 150 h of mentored clinical practice. Research has
demonstrated that practitioners completing these
 has to make clinical decisions for complex and courses gained enhanced confidence, clinical
uncertain problems; this may limit accurate reasoning, criticality, ability to engage with evi-
and specific feedback on clinical decisions.10 dence based practice, ability to learn and career
 needs to be confident, committed and deci- development and were more patient-cen-
sive with patients, but at the same time needs tred.72,74,75 Some of these elements were found
to be uncertain and critical towards their within a theoretical model of the learning transi-
clinical practice and practice knowl- tion (change in attitude, knowledge and behaviour)
edge.10,58,69 Maintenance of this balance may of musculoskeletal physiotherapists completing a
be difficult. MACP approved MSc,38,76 this is shown in Fig. 2. This
 may not value their own knowledge from clin- research study showed that at the start of the
ical experience.70 The emphasis on evidence course, participants typically held uncritical prac-
based practice and the use of propositional tice knowledge and tended towards routine,

Table 4 Ways in which the practice setting can inhibit learning from experience.
Practice setting may inhibit practitioners learning by:
 promoting the use of routines and habits in practice.
 limiting time for cognitive and metacognitive processing.
 promoting superficial reflection on actions and solutions through single loop learning rather than deep
reflection that might question the premises on which action was taken through double loop learning.58
 engendering the use of pattern recognition* and a trial and error approach at the expense of reflective
deliberation and an abductive reasoning** approach to patient management.32,71
 limiting time and opportunity to critically reflect on clinical experience.
 inhibiting any change to practice as the process of change often requires time.
 promoting lone working with patients and prevent practitioners working together and learning from each
 promoting therapist centred practice.
* It is not suggested here that the use of pattern recognition is a sign of therapist centred practice; rather that time constraints in
an efficiency driven workplace may hinder an abductive approach where this may be needed.
**Abductive reasoning involves the generation of new ideas and hypotheses to help explain phenomena in the data, in this
context, the patients presentation.71
A Masterclass in developing clinical expertise
The learning experience

Antecedent conditions Expectations Learning contradiction

Reaction to contradiction Learning outcomes

Critical understanding of
practice knowledge
Hidden received practice You know exactly why youve
knowledge Enhance knowledge and Critical evaluation of practice done each test and for what
Embrace reason.
Id accept what was said. I skill through didactic knowledge It was such a great experience,
didnt really question things Youve got clinicians who are to have somebody watching me
teaching challenging you about your Patient centred practice
I needed to be taught, to and questioning what Im I now use the evidence from
practice, and asking why are doing
listen to people with the patient rather than
you doing it like that?
Therapist centred, routine expertise telling me what I research evidence or
clinical practice should be doing. theoretical knowledge to
Going back to really basic
Id do the subjective and ask the things like what is palpation Defend guide my treatment.
patient routine questions. Id I expected the course to be I didnt feel able to share my
and what is a mobilization and
not really take information from more taught because that thinking in the whole group Learning in & from practice
what do we actually think were
my subjective into the objective. was the way I was being situation and instead got into a I treat each problem and see
Id do a routine objective taught on weekend clinical small group and it was there what it does for the overall
examination. courses. that I was able to discuss picture. Each patient then
things more openly and I felt adds to your knowledge and
less threatened. experience

Moderating factors
conception of clinical practice 29
epistemology of practice knowledge 77
conception of teaching and learning 78
achievement motivation 79
locus of control 80
self efficacy in practice knowledge 81
professional self esteem 81,82
emotional control 83,84
learning relationships 85
learning style 86

Figure 2 Explanatory theory of the learning transition experienced by practitioners completing a Master of Science degree in musculoskeletal physiotherapy.29,77e85
Reproduced by kind permission of Elsevier from Petty et al.76

214 N.J. Petty

practitioner-centred clinical practice. The learning may offset the financial costs for osteopaths
transition varied between participants and depen- working in private practice.
ded on a host of moderating factors. At the end of
the course, participants enhanced their practice in Mentors in practice
terms of three inter-related aspects: they gained a
critical understanding of practice knowledge that The notion of a mentor facilitating the development
facilitated more patient-centred practice, which of a practitioners clinical expertise is consistent
led to a capability to learn in and from practice with the literature related to situated learning; in
(Fig. 3). This development towards clinical exper- this context, learning in and from prac-
tise was primarily facilitated by critical evaluation tice.9,10,29,32,57,68,87 Someone with expertise guid-
of practice knowledge, and was particularly ing a less experienced practitioner is well rehearsed
powerful when facilitated by a mentor in clinical in the literature9,88,89 and the role of the mentor is
practice; this involved the direct observation of summarised in Table 5. It is argued here, that
practice with patients with subsequent question- mentorship that involves direct observation with
ing, discussion and critical feedback. This highly patients may be a powerful method of enhancing
challenging experience necessitated high levels of clinical expertise. The value of direct observation
support from the mentor. From the perspective of of practice, highlighted in Table 6, may be due to
osteopathy, a recent grounded theory study reso- every aspect of practice being observed, which is
nates with the above theory. Osteopaths with then followed by immediate and specific feedback
formal postgraduate education demonstrated a of performance and discussion. Even practitioners
range of attributes associated with clinical exper- of similar levels of knowledge may benefit from
tise, such as adopting a more critical and reflective observing each other in clinical practice.
stance towards practice knowledge, norms and Critical dialogue of practice knowledge creates
traditions; adopting a person-centred approach opportunities for individuals to experience
towards patient management; and were comfort- contradiction that may trigger
able with the ambiguity and uncertain terrain of learning.57,58,62e64,94,98 Unlike confirming experi-
professional clinical practice.4,5 These rewards ence which may lead to minimal learning,

Figure 3 The learning outcome of the Master of Science degree in musculoskeletal physiotherapy. The direction of
development towards clinical expertise involved three developmental aspects: critical understanding of practice
knowledge led to patient centred practice, which in turn led to a capability to learn in, and from, clinical practice.
The smaller arrowheads indicate that learning in and from practice enhanced patient centred practice, which in turn
enhanced critical understanding of practice knowledge. Reproduced by kind permission of Elsevier from Petty, Scholes
& Ellis.76
A Masterclass in developing clinical expertise 215

Table 5 The role of the mentor.

The mentor provides:
 high level challenge toward uncritically assimilated taken-for-granted assumptions, beliefs, values,
expectations, perceptions, judgements, actions and perspectives.9
 questions the learners practice knowledge.33 Questioning can trigger reflection and reveal understanding,
as well as promote collaborative construction of knowledge.90
 critical dialogue to promote collaborative interpretations and critique, and evaluation to promote
deliberation and reflection.9
 practice knowledge broken down into its constituent parts. Each part is then made more complex
and more distinguishable by being refined, differentiated and elaborated through critical evaluation.86
 guidance for cognitive organisation to remain at the level of principles for flexible and creative clinical
practice and to facilitate integrative development of understanding with further experience.86
 opportunity for knowledge to become more discriminating, integrated, differentiated, open,54 dependable
and justified.91
 high levels of support9 to counterbalance the learning transition that may involve less fluid and more
difficult practice, disorientation, vulnerability, and even alienation with strong feelings of anxiety, stress,
and irritability.10,92,93,94

contradictory experiences can lead to a powerful model demonstrating a higher level of practice
learning transition with significant cognitive and that identifies areas for further development in
emotional dissonance.98 Critical dialogue of prac- the observing practitioner.
tice knowledge with the mentor exposes practi- Direct observation of practice may initially be
tioners to alternative views and perspectives that resisted by practitioners as they may feel vulner-
can free them from their own circular experience able to negative judgement of their practice and a
and understanding.51,57,58 The less experienced loss of respect from their colleagues. While lone
are guided to a higher level of practice knowledge working in a clinic room with patients may protect
and understanding through cognitive scaffolding the practitioner from any criticism, it prevents
and structuring.99 This process may lead to a them from being encouraged and supported and
transformation of practice knowledge that is more misses the opportunity to share and learn from
discriminating, integrated, differentiated, open, colleagues; and thus make it difficult to develop a
dependable and justified.54,91 This highlights the high level of clinical expertise. Mentorship with
need for the mentor to challenge, question and direct observation of practice will, however, be
offer new knowledge that contradicts the mentees challenging. For practitioners in sole practice set-
current knowledge. The mentee, in turn, needs to tings, geographical distance may limit access. To
be prepared to face contradictory knowledge and successfully implement mentorship, it would be
consider alternative points of view. imperative to use a mentee-centred approach and
Opportunity for the practitioner to observe the that a collaborative, respectful relationship is
practice of those with higher levels of expertise developed between mentee and mentor. If this can
may also be of benefit; observational learning has be achieved, mentorship would appear to offer a
been highlighted as a powerful process9,10,81 The potentially powerful and economical method of
observer may gain confidence seeing similar ac- enhancing the clinical expertise of practitioners.
tions to their own as well as seeing alternative While the American Osteopathic Association has a
ways of working. The observed may act as a role well established mentor exchange programme

Table 6 Value of direct observation of clinical practice.

Nature of practice knowledge Direct observation of clinical practice
Embedded within action and rarely discussed, Can trigger articulation and critical evaluation of
debated or critically appreciated.29 knowledge embedded within action.58
Hidden like an iceberg from practitioners so Awareness raised through comprehensive, direct and
they are unaware of what informs their clinical specific feedback of performance by another.10,22,88,96
Tacit or difficult to articulate10,95,97; for example Enables aspects that cannot be articulated to be shared in
palpation findings other ways, for example comparing palpation findings.
Outside the control of the practitioner10 and as Comes under the control of the practitioner10 and so
such cannot be changed.58 can be changed.58
216 N.J. Petty

(, 2. Sackett DL. Evidence-based medicine. Seminars Perina-

the recent initiative to develop and pilot a sup- tology 1997;21:30.
3. Quality Assurance Agency for Higher Education. Frame-
portive mentoring programme for UK osteopathy work for higher education qualifications in England, Wales
graduates100 may prove fruitful. and Northern Ireland. 2008. Retrieved 5.8.14 from:
4. Thomson OP, Petty NJ, Moore AP. Clinical decision-making
Conclusion and therapeutic approaches in osteopathy - a qualitative
grounded theory study. Man Ther 2014;19:44e51.
Just as the more you know, the more you know you 5. Thomson OP, Petty NJ, Moore AP. A qualitative grounded
dont know is a truism, so the notion of an expert is theory study of the conceptions of clinical practice in
osteopathy- a continuum from technical rationality to
a chasing after the wind.101 The best that can be
professional artistry. Man Ther 2014;19:37e43.
hoped for is a developing expertise that will 6. Benner P. From novice to expert, excellence and power in
continue as a lifelong process. Once accepted that clinical nursing practice. California: Addison-Welsey;
learning is a necessary and continuous process for 1984.
practitioners, the next question of importance is 7. Jensen GM, Gwyer J, Shepard KF, Hack LM. Expert practice
in physical therapy. Phys Ther 2000;80:28e43.
how best to learn and develop. The literature sug-
8. Martin C, Siosteen A, Shepard KF. The professional devel-
gests that passively gaining years of experience will opment of expert physical therapists in four areas of
not automatically lead to the development of clinical practice. In: Jensen GM, Gwyer J, Hack LM,
expertise and expert practice. A practitioner has to Shepard KF, editors. Expertise in physical therapy prac-
actively and critically engage with their practice, tice. Boston: Butterworth Heinemann; 1999.
9. Titchen A. Critical companionship: a conceptual frame-
seeking out and embracing contradictory experi-
work for developing expertise. In: Higgs J, Titchen A, ed-
ences and challenging confirmatory experiences in itors. Practice knowledge and expertise in the health
order to use these as vehicles to learn and enhance professions. Oxford: Butterworth Heinemann; 2001. p.
their practice knowledge. Critical reflection on 80e90.
practice is fundamental to this. In addition, direct 10. Eraut M. Developing professional knowledge and compe-
tence. London: Routledge Falmer; 1994.
observation of practice and mentorship provide
11. Higgs J, Titchen A. Knowledge and reasoning. In: Higgs J,
practitioners with a potentially powerful process in Jones M, editors. Clinical reasoning in the health pro-
which to share knowledge and gain alternative and fessions. 2nd ed. Oxford: Butterworth Heinemann; 2000.
broader ways of working that can lead to higher p. 23e32.
levels of clinical expertise. 12. Johns C. Becoming a reflective practitioner. 2nd ed. Ox-
ford: Blackwell; 1998.
13. Benner P. Using the dreyfus model of skill acquisition to
describe and interpret skill acquisition and clinical
Conflict of interest judgement in nursing practice and education. Bull Sci
Technol Soc 2004;24:188e99.
14. Glaser R. Expert knowledge and processes of thinking. In:
None declared.
McCormick R, Paechter C, editors. Learning and knowl-
edge. London: Paul Chapman; 1999. p. 88e102.
15. Milidonis MK, Godges JJ, Jensen GM. Nature of clinical
Ethical approval practice for specialists in orthopaedic physical therapy. J
Orthop Sports Phys Ther 1999;29:240e7.
16. Schmidt HG, Norman GR, Boshuizen HPA. A cognitive
I confirm that all research authored by me and perspective on medical expertise: theory and implica-
cited in this Masterclass paper was conducted with tions. Acad Med 1990;65:611e21.
appropriate permission from the University of 17. Schmidt HG, Rikers RMJP. How expertise develops in
Brighton Research Ethics and Governance medicine: knowledge encapsulation and illness script for-
mation. Med Educ 2007;41:1133e9.
Committee. 18. Boshuizen HPA, Schmidt HG. The development of clinical
reasoning expertise. In: In Higgs J, Jones MA, Loftus S,
Christensen N, editors. Clinical reasoning in the health
Funding professions. 3rd ed. Amsterdam: Elsevier; 2008.
19. Benner P, Tanner CA, Chesla CA. Expertise in nursing
None declared. practice: caring, clinical judgment, and ethics. New York:
Springer; 1996.
20. Higgs J, Jones M. Clinical reasoning in the health pro-
fessions. 2nd ed. Oxford: Butterworth-Heinemann; 2000.
References 21. McEwen IR. Paediatric expert practice. In: Jensen GM,
Gwyer J, Hack LM, Shepard KF, editors. Expertise in
1. Oxford Dictionary [accessed 9.8.14] http://www. physical therapy. Boston: Butterworth Heinemann; 1999. p. 247e52.
A Masterclass in developing clinical expertise 217

22. Jensen GM, Gwyer J, Hack LM, Shepard KF. Expertise in learning and problem solving in complex work activities.
physical therapy practice. Boston: Butterworth Heine- Learn Instr 1995;5:319e36.
mann; 1999. 46. Ericsson KA. The influence of experience and deliberate
23. Sternberg RJ, Horvath JA. A prototype view of expert practice on the development of superior expert perfor-
teaching. Educ Res 1995;24:9e17. mance. In: Ericsson KA, Charness N, Feltovich PJ,
24. Eraut M. Non-formal and tacit knowledge in professional Hoffman RR, editors. The Cambridge handbook of exper-
work. Br J Educ Psychol 2000;70:113e36. tise and expert performance. Cambridge: Cambridge
25. Kinchin IM, Cabot LB, Hay DB. Using concept mapping to University; 2006. p. 683e703.
locate the tacit dimension of clinical expertise: towards a 47. Ericsson KA, Th Krampe R, Tesch-Romer C. The role of
theoretical framework to support critical reflection on deliberate practice in the acquisition of expert perfor-
teaching. Learn Health Soc Care 2008;7:93e104. mance. Psychol Rev 1993;100:363e406.
26. Boshuizen HPA. Medical education: or the art of keeping a 48. Hambrick DZ, Oswald FL, Altmann EM, Meinz EJ, Gobet F,
balance between science and pragmatics. In: Campitelli G. Deliberate practice: is that all it takes to
McCormick R, Paechter C, editors. Learning and knowl- become an expert? Intell 2014;45:34e45.
edge. London: Paul Chapman; 1999. p. 185e97. 49. Macnamara BN, Hambrick DZ, Oswald FL. Deliberate
27. Caney D. Competence e can it be assessed? Physiotherapy practice and performance in music, games, sports, edu-
1983;69:302e4. cation, and professions: a meta-analysis. Psychol Sci 2014;
28. Eisner EW. The art of educational evaluation, a personal 25:1608e18.
view. London: Falmer; 1985. 50. Resnik L, Jensen GM. Using clinical outcomes to explore
29. Fish D, Coles C. Developing professional judgement in the theory of expert practice in physical therapy. Phys
health care. Oxford: Butterworth-Heinemann; 1998. Ther 2003;83:1090e106.
30. Sandberg J. Understanding human competence at work: 51. Dewey J. Experience and education. New York: Touch-
an interpretative approach. Acad Manage J 2000;43: stone;; 1938/1997.
9e25. 52. Esteves JE, Spence C. Developing competence in diag-
31. Tynjala P. Towards expert knowledge? A comparison be- nostic palpation: perspectives from neuroscience and ed-
tween a constructivist and a traditional learning environ- ucation. Int J Osteopath Med 2013;17:52e60.
ment in the university. Int J Educ Res 1999;31:357e442. 53. Editorial Eraut M. The many meanings of theory and
32. Rolfe G. Beyond expertise: reflective and reflexive nursing practice. Learn Health Soc Care 2003;2:61e5.
practice. In: Johns C, Freshwater D, editors. Transforming 54. Mezirow J. Transformative dimensions of adult learning.
nursing through reflective practice. Oxford: Blackwell California: Jossey-Bass; 1991.
Science; 1998. p. 21e31. 55. Mezirow J. Learning as transformation, critical perspec-
33. Billett S. Knowing in practice: re-conceptualising voca- tives on a theory in progress. San Francisco: Jossey-Bass;
tional expertise. Learn Instr 2001;11:431e52. 2000.
34. Daley BJ. Novice to expert: an exploration of how pro- 56. Schutz A. The phenomenology of the social world. Lon-
fessional learn. Adult Educ 1999;49:133e47. don: Heinemann Educational Books; 1972.
35. Kennedy MM. Inexact sciences: professional education and 57. DallAlba G, Sandberg J. Unveiling professional develop-
the development of expertise. Rev Res Educ 1987;14: ment: a critical review of stage models. Rev Educ Res
133e67. 2006;76:383e412.
36. Cranton P. Understanding and promoting transformative 58. Argyris C, Schon DA. Theory in practice, increasing
learning. 2nd ed. San Francisco: Jossey-Bass; 2006. professional effectiveness. San Francisco: Jossey-Bass;
37. Dreyfus HL, Dreyfus SE. Mind over machine: the power of 1974.
human intuition and expertise in the era of the computer. 59. Luft J. Of human interaction. California: National Books;
New York: Free; 1986. 1969.
38. Petty NJ, Scholes J, Ellis L. The impact of a musculoskel- 60. DallAlba G. Understanding professional practice: in-
etal masters course: developing clinical expertise. Man vestigations before and after an educational programme.
Ther 2011;16:590e5. Stud High Educ 2004;29:679e92.
39. Huberman M. Professional careers and professional 61. Jarvis P. The practitioner-researcher. Developing theory
development: some intersections. In: Guskey TR, from practice. San Francisco: Jossey-Bass; 1999.
Huberman M, editors. Professional development in edu- 62. Eraut M. Knowledge creation and knowledge use in pro-
cation, new paradigms and practices. Teachers College, fessional contexts. Stud High Educ 1985;10:117e33.
Columbia University; 1995. p. 193e224. 63. Schon DA. The reflective practitioner, how professionals
40. Mevarech ZR. Teachers paths on the way to and from the think in action. Aldershot: Ashgate Arena; 1991.
professional development forum. In: Guskey TR, 64. Titchen A, Ersser SJ. Explicating, creating and validating
Huberman M, editors. Professional development in edu- professional craft knowledge. In: Higgs J, Titchen A, edi-
cation, new paradigms and practices. Teachers College, tors. Practice knowledge and expertise in the health pro-
Columbia University; 1995. p. 151e70. fessions. Oxford: Butterworth Heinemann; 2001. p. 48e56.
41. Rischel V, Larsen K, Jackson K. Embodied dispositions or 65. Gamble J, Chan P, Davey H. Reflection as a tool for
experience? Identifying new patterns of professional developing professional practice knowledge and exper-
competence. J Adv Nurs 2008;61:512e21. tise. In: Higgs J, Titchen A, editors. Practice knowledge
42. Beaty E, Morgan A. Developing skill in learning. J Open and expertise in the health professions. Oxford: Butter-
Distance Learn 1992;7:3e11. worth Heinemann; 2001. p. 121e7.
43. Marton F, DallAlba G, Beaty E. Conceptions of learning. 66. Boud D, Cohen R, Walker D. Using experience for learning.
Int J Educ Res 1993;19:277e300. Buckingham: The Society for Research into Higher Educa-
44. Johns C, Freshwater D. Transforming nursing through tion & Open University; 1993.
reflective practice. Oxford: Blackwell; 1998. 67. Criticos C. Experiential learning and social transformation
45. Engestrom Y, Engestrom R, Karkkainen M. Poly- for a post-apartheid learning future. In: Boud D, Cohen R,
contextuality and boundary crossing in expert cognition: Walker D, editors. Using experience for learning.
218 N.J. Petty

Buckingham: The Society for Research into Higher Educa- 84. Goleman D. Emotional intelligence. London: Bloomsbury;
tion & Open University; 1993. p. 157e68. 1996.
68. Usher RS, Bryant I. Re-examining the theory-practice 85. Harris TA. Im ok-youre ok. London: Pan Books; 1973.
relationship in continuing professional education. Stud 86. Kolb DA. Experiential learning. Englewood Cliffs: Pren-
High Educ 1987;12:201e12. tice-Hall; 1984.
69. Eraut M. Editorial continuity of learning. Learn Health Soc 87. Billett S. Workplace participatory practices. Con-
Care 2005;4:1e6. ceptualising workplaces as learning environments. J Work
70. Usher RS. Beyond the anecdotal: adult learning and the Learn 2004;16:312e24.
use of experience. Stud Educ Adults 1985;17:59e74. 88. Fish D, Twinn S. Quality clinical supervision in the health
71. Blaikie N. Approaches to social enquiry. Cambridge: Pol- care professions. Principled approaches to practice.
ity; 1993. Edinburgh: Butterworth-Heinemann; 1997.
72. Stathopoulos I, Harrison K. Study at Masters level by 89. Daloz LA. Mentor, guiding the journey of adult learners.
practising physiotherapists. Physiotherapy 2003;89: San Francisco: Jossey-Bass; 1999.
158e69. 90. Graffam B. Deriving better questions: creating better
73. Rushton A, Petty N. The course approval board of the clinical instruction. Clin Teach 2008;5:98e102.
manipulation association of chartered physiotherapists. 91. Cranton P. Individual differences and transformative
Man Ther 2002;7:222e8. learning. In: Mezirow J, editor. Learning as trans-
74. Green A, Perry J, Harrison K. The influence of a post- formation, critical perspectives on a theory in progress.
graduate clinical masters qualification in manual therapy California: Jossey-Bass; 2000. p. 181e204.
on the careers of physiotherapists in the United Kingdom. 92. Eraut M. Editorial, learning to change and/or changing to
Man Ther 2007;13:139e47. learn. Learn Health Soc Care 2004;3:111e7.
75. Rushton A, Lindsay G. Defining the construct of masters 93. Griffiths D. In: Griffiths D, editor. Psychology and medi-
level clinical practice in manipulative physiotherapy. Man cine. London: British Psychological Society and Macmillan;
Ther 2010;15:93e9. 1981. p. 296e322.
76. Petty NJ, Scholes J, Ellis L. Masters level study: learning 94. Scholes J. An exploration of role transition in students
transitions towards clinical expertise in physiotherapy. converting from enrolled nurse (general) to registered
Physiotherapy 2011;97:218e25. general nurse. Unpublished DPhil. Sussex University; 1995.
77. Belenky MF, Clinchy BM, Goldberger NR, Tarule JM. 95. Fish D. Appreciating practice in the caring professions.
Womens ways of knowing. 10th ed. New York: Basicbooks; Oxford: Butterworth-Heinemann; 1998.
1986. 96. Jones MA. Orthopedic expert practice. In: Jensen GM,
78. Ng KC, Murphy D, Jenkins W. The teachers role in sup- Gwyer J, Hack LM, Shepard KF, editors. Expertise in
porting a learner-centred learning environment: voices physical therapy practice. Boston: Butterworth Heine-
from a group of part-time postgraduate students in Hong mann; 1999. p. 264e70.
Kong. Int J Lifelo Learn 2002;21:462e73. 97. Titchen A, Ersser SJ. The nature of professional craft
79. Dweck CS. Self-theories: their role in motivation, per- knowledge. In: Higgs J, Titchen A, editors. Practice
sonality and development. Philadelphia: Psychology Press; knowledge and expertise in the health professions. Ox-
2000. ford: Butterworth Heinemann; 2001. p. 35e41.
80. Weiner B. Achievement motivation and attribution the- 98. Scholes J. Developing expertise in critical care nursing.
ory. Morristown: General Learning; 1974. Oxford: Blackwell; 2006.
81. Bandura A. Self perceived self efficacy, the exercise of 99. Tharp RG, Gallimore R. Rousing minds to life: teaching,
control. New York: WH Freeman and Co;; 1997. learning, and schooling in social context. Cambridge:
82. Fennell M. Overcoming low self-esteem, a self help guide Cambridge University; 1988.
using cognitive behavioural techniques. London: 100. Institute of Osteopathy. 2014 Retrieved 29.12.14 from
Constable and Robinson; 1999.
83. Hopson B. Transition: understanding and managing per- attachments/THES/117264/Invitation%20to%20Tender%
sonal change. In: Griffiths D, editor. Psychology and 20Mentoring%2009%2006%202014.pdf.
medicine. London: British Psychological Society and Mac- 101. Bible Holy. New international version. Ecclesiastes, vol. 4.
millan; 1981. p. 323e48. Colorado Springs: International Bible Society; 1991. p. 4.

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