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INTRODUCTION

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If you chase two rabbits, both will escape.

—Author Unknown

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By three methods we may learn wisdom: First, by reflection, which is noblest; Second, imitation, which is easiest; and third by experience, which is the bitterest.

—Confucius

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*Mr. Ketterman's Case

Mr. Ketterman appears to have a relatively short life expectancy. What is my role as his physical therapist? Should I provide any care at all? If so, what kind of care? How safe would treating him be? Does he need referral to others? So many questions! (See Appendix for Mr. Ketterman's Health History)

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Physical therapists are responsible for making many types of decisions with and for their patients. These decisions are elementary components of every aspect of the patient management model discussed in Chapter 1; for example, physical therapists are required to develop a diagnosis and prognosis and to select interventions. The decisions range from thoughtfully considered decisions developed over time, such as an appropriate discharge destination for a patient following an inpatient course of care, to moment-by-moment decisions, such as movements required during a treatment session. Over the century of our profession's history, physical therapists have grown both in the capability and desire to make these clinical decisions. Early in the profession, physicians wrote detailed treatment prescriptions that covered all but the most mundane clinical decisions required of physical therapists. We were viewed as technical assistants who could neither diagnose a patient's impairments or functional limitations nor develop a plan of care. In the 21st century, we view ourselves as autonomous practitioners with significant responsibility for the judicious care and successful outcomes for our patients. Thus, the types of clinical decisions made and the characteristics of the clinical reasoning processes are of great interest to practitioners who wish to improve their approach to practice.

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The science that supports theories of clinical reasoning in physical therapy is built upon studies of cognitive processing in nonmedical fields,1 medical problem solving,2,3,4,5,6 and expert practitioners in nursing,7,8,9 occupational therapy,10 and physical therapy.11,12,13,14,15,16,17,18,19,20,21,22 Expert practitioners provide researchers with the opportunity to study the combination of knowledge and skill acquisition along with the cognitive and metacognitive processes of clinical reasoning.

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The most recent attempts to understand the clinical reasoning of experts in contrast to novices have been conducted in the practice environment as the importance of the contextual nature of clinical reasoning has emerged.23 Grounded theory qualitative case studies have also emerged as the research method of choice for studying the expertise of health care practitioners8,13,24 as contrasted with earlier research on physician decision making that used standardized stimuli with research subjects in an artificial setting. ...

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