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EXPERTISE IN PHYSICAL THERAPY PRACTICE ISBN-13: 978-1-4160-0214-7

SECOND EDITION ISBN-10: 1-4160-0214-6

Copyright © 2007, 1999, by Saunders, an imprint of Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any from or
by any means, electronic or mechanical, including photocopying, recording, or any information
storage and retrieval system, without permission in writing from the publisher.
Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in
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Notice

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment, and drug therapy may become necessary
or appropriate. Readers are advised to check the most current information provided (i) on
procedures featured or (ii) by the manufacturer of each product to be administered, to verify the
recommended dose or formula, the method and duration of administration, and contraindications.
It is the responsibility of the practitioner, relying on their own experience and knowledge of the
patient, to make diagnoses, to determine dosages and the best treatment for each individual
patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the
Publisher nor the Author assumes any liability for any injury and/or damage to property arising
out of or related to any use of the material contained in this book.

The Publisher

ISBN-13: 978-1-4160-0214-7
ISBN-10: 1-4160-0214-6

Publishing Director: Linda Duncan

Editor: Kathryn Falk
Developmental Editor: Andrew Grow
Publishing Services Manager: Melissa Lastarria
Project Manager: Kelly E. M. Steinmann
Designer: Ellen Zanolle

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1
The dedicated life is the life worth living. You must give
with your whole heart.
Annie Dillard, The Quotable Woman, Running Press, 1991

To the therapists who have shared their lives with us and

who lead the life worth living.
About the Authors

Gail M. Jensen, Ph.D., P.T., FAPTA, is Dean of the Graduate School and
Associate Vice President for Faculty Development in Academic Affairs, Professor,
Department of Physical Therapy, School of Pharmacy and Health Professions,
and Faculty Associate, Center for Health Policy and Ethics, Creighton University,
Omaha, Nebraska. She has a Bachelor of Science in Education from the
University of Minnesota, and a Master’s Degree in Physical Therapy and a
Doctor of Philosophy Degree in Educational Evaluation and Curriculum from
Stanford University. Her research interests, publications, and presentations span
the areas of clinical reasoning, development of expertise, qualitative research,
interprofessional education, and assessment. She has served on several editorial
boards and is the deputy editor for Physiotherapy Research International and asso-
ciate editor for Physiotherapy Theory and Practice. She is co-author of the Handbook
of Teaching for Physical Therapists (with K. Shepard, 2nd ed., 2002) and Educating
for Moral Action: A Sourcebook in Health and Rehabilitation Ethics (with R. Purtilo, C.
Royeen, 2005). Over the past 10 years, she has been involved in initiating feder-
ally funded interdisciplinary grants supporting an academic–community part-
nership with the Native American communities in northeast Nebraska that has
led to self-sufficient rehabilitation clinical services and ongoing interdisciplinary
education. She received the American Physical Therapy Association’s (APTA’s)
Golden Pen Award and is a Catherine Worthingham Fellow of the APTA.
Jan Gwyer, Ph.D., P.T., is Professor and Doctor of Physical Therapy Division,
Department of Community and Family Medicine, School of Medicine, Duke
University, Durham, North Carolina. She holds a Bachelor of Science degree
from the Medical College of Virginia and Master’s and Doctor of Philosophy
degrees from the University of North Carolina at Chapel Hill. She has held sev-
eral leadership roles in the APTA, serving on the board of American Physical
Therapy Specialists, on the Clinical Instructors Education Board, and on the
board of directors of the APTA. She has served on the Project Advisory Group
for the Guide to Physical Therapist Practice and as a member consultant to the
Clinical Research Agenda. In 1998 she received the APTA Lucy Blair Service
Award. She also has written in the areas of clinical education, career patterns,
and workforce issues in physical therapy.
vii
viii About the Authors

Laurita M. Hack, D.P.T., Ph.D., M.B.A., FAPTA, is Professor and Director of the
Ph.D. Program, Department of Physical Therapy, College of Health Professions,
Temple University, Philadelphia, Pennsylvania. She received a Bachelor of Science
in Biology from Wilmington College; a Master of Science degree in Physical
Therapy from Case Western Reserve University; a Master of Business Adminis-
tration in health care administration from the Wharton School, University of
Pennsylvania; a Doctor of Philosophy degree in Higher Education from the
University of Pennsylvania; and a doctor of physical therapy degree from MGH
Institute of Health Professions.
She serves as a site team leader for the Commission on Physical Therapy
Education and has served on the Central Panel of the Commission. She has
served as president of the APTA’s Community Home Health Section, of the
Section on Health Policy, and of the Education Section, and as chief delegate of
the Pennsylvania chapter, all components of the APTA. She is the recipient of
the Carlin-Michels Award for Achievement from the Pennsylvania chapter and
the APTA’s Lucy Blair Service Award and the Baethke-Carlin Award for
Teaching Excellence. She has also been named a Catherine Worthingham
Fellow of the APTA. She has owned and managed a large physical therapy
practice that included outpatient care, home care, and a membership-based
exercise center. Throughout her career, she has written and lectured on many
health services issues in physical therapy.
Katherine F. Shepard, Ph.D., P.T., FAPTA, is Professor Emeritus, Founding
Director, Ph.D. Program in Physical Therapy, Department of Physical Therapy,
College of Health Professions, Temple University, Philadelphia, Pennsylvania.
She received a Bachelor of Arts in Psychology from Hood College, a Bachelor
of Science in Physical Therapy from Ithaca College, and Master of Arts in
Physical Therapy and Sociology and a Doctor of Philosophy degree in
Sociology of Education from Stanford University. Her professional career in
physical therapy spans more than 40 years, and she has published extensively
in the areas of social science research related to physical therapy education and
practice. She is co-author of the Handbook of Teaching for Physical Therapists (with
G. Jensen, 2nd ed., 2002). She has taught graduate courses in qualitative
research in the United States, Sweden, and South Africa. She is the recipient of
the APTA Baethke-Carlin Award for Teaching Excellence, the APTA Golden Pen
Award for outstanding contributions to physical therapy, and the APTA Lucy
Blair Service Award. She is a Catherine Worthingham Fellow of the APTA and
has been named the Mary McMillan Lecturer for 2007.
Contributors

IAN EDWARDS, Ph.D., P.T.

Lecturer, School of Health Sciences (Physiotherapy), Physical Therapist,
Brian Burdekin Clinic, University of South Australia, Adelaide, South
Australia

ANN JAMPEL, P.T., M.S.

Center Coordinator for Clinical Education, Physical Therapy Services,
Massachusetts General Hospital, Boston, Massachusetts

MARK A. JONES, M.APP.SC., P.T.

Program Director, Senior Lecturer, Postgraduate Coursework
Masters Programs in Physiotherapy, School of Health Sciences,
University of South Australia, Adelaide, South Australia

ELIZABETH MOSTROM, P.T., Ph.D.

Professor, Director of Clinical Education Program, Physical Therapy School
of Rehabilitation and Medical Sciences, Central Michigan University,
Mount Pleasant, Michigan

MICHAEL G. SULLIVAN, P.T., D.P.T., M.B.A.

Director, Physical and Occupational Therapy, Massachusetts General
Hospital, Boston, Massachusetts

LINDA RESNIK, Ph.D., P.T., O.C.S.

Assistant Professor (Research), Department of Community Health,
Brown University, Providence, Rhode Island; Research Health Scientist,
Providence VA Medical Center, Providence, Rhode Island

ix
Foreword to the Second
Edition

This second edition of Expertise in Physical Therapy Practice is a useful tool for the
reader who is being introduced to the topic, as well as the one who has worn thin
the pages of the first edition. From the earliest times, “expertise” in the health
care professions has been characterized as excellence in the exercise of both the
art and the science of practice. This book demonstrates how physical therapists
can continue to develop so that both aspects can be realized in today’s health care
environment. It is an essential resource for all who want not only to practice
physical therapy but also to continue to develop their expertise to its full potential.
The authors of Expertise in Physical Therapy Practice sound the encouraging
note that the knowledge, skills, and decision-making abilities used by expert
clinicians can be identified, nurtured, and taught. The authors’ studied atten-
tion to how and why experts do the right thing at the right time is both timely
and important: timely because individual expertise is under siege today, owing
to a growing tendency to emphasize efficiency and measure therapeutic suc-
cess largely, or even solely, on the basis of pooled data; and important because
efficiency and outcomes measures are valid indicators of one dimension of
therapeutic success—but a success that risks becoming vacuous and skeletal
without the nourishment of human interaction. In short, this book has given
thought to when and how a more adequate criterion of effectiveness is
achieved, and the second edition provides additional strategies for successful
applications in education and practice. It puts people back into the health pro-
fessions, both as professionals and as patients.
Edmund Pelligrino, a health professional and humanities scholar, reminds
us that the idea of a “profession” is that “one professes something.” Health pro-
fessionals profess something that goes straight to the heart of society’s values
by selling themselves as vehicles of healing and comfort! This, then, is what
health professionals in general say they will do and are charged by society—
and given license by it—to do. The technical competence of each profession
must be combined with development and use of skills and other conduct that
heals and comforts.
As the authors of Expertise in Physical Therapy Practice aptly highlight with
their writing and examples the rehabilitation professions pose an interesting

xi
xii Foreword to the Second Edition

question about what effectiveness in the health professions entails. The tradi-
tional notions of healing and comfort were conceived in a time when the health
professional (i.e., physician) was viewed in a priestly role as knowledgeable and
powerful—the sole means to healing and comfort for the suffering of injury or
illness. The art of medicine included an acknowledgment that it could not do
everything to heal or alleviate suffering, but up to that point the power was in
the physician’s hand. In contrast, the rehabilitation professions were born in dif-
ferent times and places: partially in the ravages of war, when the human will to
survive and thrive was far more central an agent of healing and comfort than the
availability of health professionals or health care technology; partially in a secu-
larized, individualized society that equated independence with well-being; and,
at least partially, in cultures that had developed an understanding of human
rights that gave the patient power to place a claim on the society for help. The
idea of how the skills of healing and comforting should be applied had to be
expanded, and the rehabilitation professions were one healthy offspring of the
mating of tradition with these new social forces.
An expert clinician in the rehabilitation professions today is less priest than
teacher, less parent than coach, less stranger than advocate. The effective rehabil-
itation professional can help heal (e.g., boost) a patient’s flagging morale through
instruction in exercise techniques designed to improve function; can help heal
decreased self-esteem caused by the sudden onslaught of illness or injury by pro-
viding reassurance of the person’s worth; and can help “cure” disabling social
attitudes toward people challenged by impairment through advocacy, involve-
ment in policy, and political action. “Comfort” (com + forte = with strength) can
be more long-lasting if directed toward the ultimate goal of the patient’s reinte-
gration into her or his community of support and meaning than if directed solely
toward the (also important) goals of reversing dysfunction. For example, a phys-
ical therapist may provide comfort through instruction about how to avoid work
injury or by helping the patient endure work hardening after injury.
In viewing expert clinicians as those who effectively adapt more traditional
approaches to healing and comforting while facing the demands of modern
social conditions, the authors of this book help us to understand how physical
therapists can continue to be relevant and how they also can become expert
agents of transformation. The authors contribute to our understanding of spe-
cific developmental tasks clinicians have to undertake to become experts. Their
definition of expert practice as being able to do the right thing at the right time
acknowledges the deep well of information that always has been available in
clinical experience within a given time and social and cultural context. They
have bothered to tap it and show that there is much to sustain the rehabilitation
professions—and individual professionals within them—today.
As an ethicist, I also am informed by their work regarding implications for a rel-
evant professional ethic. A traditional health professions ethic justifiably empha-
sizes its ethical role as one that needs constraints on abuses of power. Students of
ethics will recognize the ethical duties/principles such as do not harm, act to ben-
efit the patient, be faithful to reasonable expectations, and be truthful as socially
mandated guidelines that reflect society’s anxiety about its dependence on physi-
cians’ knowledge, skills, and conduct.
 Foreword to the Second Edition xiii

But just as the study reported in this book shows an evolving model of the
health professional and patient relationship, so, too, does it make good sense to
include such insights in our understanding of physical therapists’ ethical man-
dates. Insights from their stories enrich our appreciation of how story and
viewpoint provide data for ascertaining a caring course of action in the years
ahead. Such a course does not include the dumping of constraints embodied in
traditional duties and principles, but the traditional ethic is malnourished as
the sole approach.
In summary, in this second edition the authors leave intact fundamental con-
cepts and illustrative material that skillfully introduces clinicians and educa-
tors to the whats, whys, and wherefores of expertise in physical therapy
practice. At the same time, these well-established and respected physical ther-
apy leaders have continued to listen skillfully and with due care to the stories
of physical therapy professionals and to interact with the leading researchers
and writers in this area across the health professions. Drawing on these essen-
tial resources, they have updated their initial contribution to make this second
edition fully relevant to the ever-developing demands of professionalism in
physical therapy today.

RUTH B. PURTILO, Ph.D., P.T., FAPTA

Director and Professor, Ethics Initiative
MGH Institute of Health Professions
Boston, Massachusetts

xiii
Foreword to the First Edition

The debate never seems to end, the arguments never seem to illuminate, and,
in the end, the issues never seem to be resolved. When it comes to understand-
ing what makes some practitioners better than others and to agreeing on a def-
inition of a clinical expert, calm discussions give way to passions that rise to
levels achieved not even in gothic romance novels. No wonder the questions
remain. How do members of health care professions best provide their ser-
vices? What is the “magic” of the successful practitioner? What is the nature of
the expert practitioner, and how can we obtain more expert practitioners? The
debate is often characterized by assaults on motives, and some discussants seek
refuge by claiming they speak on behalf of patients. Who can argue with those
who are cloaked with the best interests of those not participating in the debate?
The problem, however, lies not in the questions, but in the false premises that
often are used in these discussions.
We have heard people defend the artistry of the health care professional
while they demean the science that is the right of patients who deserve the best
care possible. They characterize science and quantification as being antithetical
to humanistic practice and argue for vague, undefined constructs that obscure
rather than define. Others argue that some practitioner skills are intuitive—
almost genetically endowed—and are, therefore, either present or not. Some
view the use of evidence and concerns for outcomes as non–patient focused
behaviors and therefore, at best, as a technical requirement for reimbursement
rather than an appropriate practice mode. Still others take refuge under the
banner of unproven expertise to facilitate self-promotion and deflect inquiry
and accountability. The outrage of self-appointed experts when they are denied
the center stage is an ugly sight and as incongruous as Madonna singing lyrics
that compare her to a virgin.
Until the pioneering work of the authors of this book, serious inquiry into the
nature of expertise has been rare—and thoughtful discussion of how we can learn
from our experts has been even more rare. The time has come for us to face the
truth. Expertise in physical therapy can be studied and understood, just it has been
in other professions and, I add with bemusement, just as it has been in the arts.
A book that takes a scholarly look at expertise is long overdue in physical therapy.

xv
xvi Foreword to the First Edition

Science can be used to study expertise, and a variety of research methods can
be used to understand how experts function and how to enhance practice by
mimicking some of their behaviors. But first we must define what it means to
be an expert. We should realize that factors such as the numbers of courses
taken, the number of continuing education courses taught, or the reverence of
colleagues do not really identify an expert. In my view, true expertise means
that a practitioner can do something better and data exist to support this con-
tention. Wouldn’t we all want experts to treat our ailments? Of course. But
unless they provide better care, what would be the point?
The authors of this book have long been proponents of studying expertise.
Once they were lonely voices; now others are beginning to see the benefit of
research into the nature of practice and what differentiates more effective ther-
apists from less effective therapists. In other words, who are these experts, and
what are they doing? Studying something does not mean that we will under-
stand it today or even in the immediate future—only that the journey toward
understanding has begun. And studying expertise does not mean that we
dehumanize this very human trait, but rather that we can use all of the research
techniques available to us to capture the essential elements that can be under-
stood, shared, and nurtured.
One of the most remarkable things I have ever seen on television was the
master class of the cellist Pablo Casals. An elderly man at the time, he sat
curved around his cello, holding his bow loosely but waving it as needed to
illustrate a movement, underscore a point, or celebrate the achievement of a
student. The master’s instructions were being codified and passed on to a new
generation. Casals was deliberate and communicated directly. He carried his
remarkable burden with grace. What was the burden? It was the burden of the
expert who is committed to his craft. Like any true expert, he not only excelled,
but he also knew that he had a responsibility to understand the source of his
own greatness so that he could attempt to pass on what was important, so that
he could turn his students’ attention toward the essential and away from the
trivial or irrelevant.
Artisans have always been known for their ability to train future genera-
tions, yet so many physical therapists recklessly dichotomize practice into “sci-
ence” and “art.” This dichotomy allows them to hide behind the canard that
artistry cannot be codified or studied. Thankfully, the authors of this book—
and the authors of the articles on which they base much of their work—did not
share in this fatalistic excuse that delays the development of more experts and
in the end denies our patients the best possible care. The invocation of art is
designed to provide a seemingly attractive substitute for meaningful discus-
sion. Too many of us respond to this image much as a moth is attracted to a
light bulb—and with equal effect. If you found out tomorrow that you had a
malignancy, would you seek out an oncologist known for his or her artistic flair
in applying treatments? Would you want a practitioner who likes to deviate
from known protocols because this allows expression of individualism? As for
me, I would go with the expert—and I define the expert as the practitioner
known to achieve the best outcome.
 Foreword to the First Edition xvii

Our need to understand and enhance expertise is particularly acute today

because physical therapy finds itself among the health professions being chal-
lenged to provide evidence that our services meaningfully change people’s
lives. Now that we are under fire and some of us believe the job market is
shrinking, I suspect we will see fewer therapists taking shelter under the spe-
cious claim that our results and practice behaviors cannot be studied. As can be
seen from the primary research cited in this book, some techniques—such as
qualitative methods that can be used in isolation from, in coordination with, or
as precursors to quantitative methods—allow us to study more than can be
imagined by those who would argue rather than engage in inquiry. When
debate is stilled or illuminated by the power of data, knowledge grows, under-
standing increases, and new questions arise. As a result, we move forward.
Some see today’s focus on outcomes and evidence as automatically turning
practitioners’ attention away from the individuality of patients and their
unique needs. I believe this phenomenon occurs only when we fail to under-
stand the nature of outcomes data and the role of expertise and individual-
ism—individualism of both the patient and the therapist. David Sackett, who is
often referred to as the father of evidence-based medicine, argues that expertise
and individual characteristics of the patient and the practitioner are very
important. He contends that evidence-based practice “is the conscientious,
explicit, and judicious use of current best evidence in making decisions about
the care of individual patients” (1).
He appears to be defining some of the characteristics of an expert. Experts,
he contends, should be explicit in their use of evidence, they should know what
is the best evidence, and they should make decisions about individual patients.
Outcomes data and some related research usually focus on groups, but as
Sackett clearly indicates, when it comes to evidence-based practice, the issue is
the application of information to specific patients. Often, data on outcomes are
designed to examine results in the aggregate and to judge how therapists and
facilities compare with other therapists and facilities or with established stan-
dards. Groups of patients are considered, not the individual characteristics of
those who may have been better served by physical therapy than others were.
Although outcomes data are important in today’s world of health care
accountability, in my view data do little for the therapist who is dealing with
specific patients. The most useful data for the expert and for the application of
evidence in practice are those which can be used by specific types of therapists
on identifiable patients. That is why we need data that can be applied by ther-
apists in specific settings to specific patients, and our research community
should generate these data. Data, however, are insufficient. Who can best use
the data? Who can be the role model for the application of science in practice?
Our experts should be able to do both!
If any doubt exists about how expertise and evidence-based practice are
complementary, consider another observation by Sackett: “External clinical evi-
dence can inform, but can never replace individual clinical expertise, and it is
this expertise that decides whether the external evidence applies to the patient
at all, and if so, how it should be integrated into a clinical decision” (1).
xviii Foreword to the First Edition

Evidence without clinical expertise is as useful as a supercomputer in a rain-

forest: The sight might be impressive, but it isn’t useful. Sackett and other pro-
ponents of evidence-based practice realize that expertise is the key. Evidence in
the hands of an expert is a powerful tool. We, however, must first know what
defines an expert and how we can develop enough experts to serve our patients.
This book turns us away from hero worship and false prophets who proclaim
expertise based on pretense and self-promotion, and turns us toward experts
whose expertise is based on evidence of achievement—experts whose creden-
tials can be externally verified. Within the profession of physical therapy, many
are experts, but they remain an untapped resource. With this volume, we turn
toward this valuable commodity and seek to exploit it for the benefit of us all.

JULES ROTHSTEIN, Ph.D., P.T., FAPTA†

Professor and Head, Department of Physical
Therapy, College of Health and Human
Development Sciences and Professor,
Department of Bioengineering,
University of Illinois College of Medicine,
Chicago; Chief, Physical Therapy Services,
University of Illinois Hospital, Chicago;
Editor, Physical Therapy, American Physical
Therapy Association, Alexandria, Virginia

REFERENCE 1. Sackett DL, Richardson WS, Rosenberg, et al. Evidence-Based Medicine: How
to Practice and Teach EBM. New York: Churchill Livingstone, 1997.

† Decreased.
Preface

This book is about expertise that is grounded in physical therapy practice. It is

a reflection of clinical practice that is built from our observations and in-depth
discussions with expert therapists about how they think, why they think it, and
why they do what they do, rather than being a description of what clinical tech-
niques they choose to apply to particular patients at particular times. Our
approach is not without risk because much of the previous work in physical
therapy centers on the application of clinical techniques. We believe there is
tremendous value in the in-depth interpretative description of expert physical
therapists in practice, especially at a time when changes in the health care sys-
tem cause some to question the value of reflection and decision making in
health care practice. We pose a grounded theory of expert practice in physical
therapy that provides the profession with our first comprehensive understand-
ing of the multiple dimensions of expertise. These insights include how expert
practitioners develop, what knowledge they use, where they acquire that
knowledge, how they think and reason, how they make decisions, and how
they perform in practice. This book is a useful tool for validating elements of
expert practice; generating new ideas for practice and education; and stimulat-
ing conversation and debate among faculty, clinicians, policy makers, and stu-
dents in physical therapy and across the health professions.
Our book is also about collaboration and learning from one another on several
levels. The initial level of observation and data collection begins by collaborating
with colleagues in practice. We learned a great deal from them as we studied
them working in the trenches of clinical practice. We began our observational
work of physical therapy in the late 1980s, when three of us merely watched a
therapist work with a patient. That initial 20-minute observation fueled a 3-hour
debriefing discussion that led to multiple projects and funded research through
the 1990s, as we continued to be fascinated by what physical therapists actually
do in practice. What we found were practice elements that were broader, deeper,
more profound, and more interconnected than we could have imagined.
Collaboration among a community of scholars is a central aspect of qualitative
research. Insightful qualitative research is seldom accomplished working alone.
Good conceptualization and theory development in qualitative research demands

xix
xx Preface

collaboration. Analysis and interpretation of data are very much a collaborative

act. Our team of four researchers met extensively throughout the project to dis-
cuss, listen, analyze, agonize, and challenge to move the work forward. Working
together requires more dialogue, more patience, more compromise (and some-
times more frustration) than individual research, but the whole is astonishingly
greater than the sum of the parts. The quilt patterns at the beginning of each chap-
ter and the resultant quilt are an appropriate metaphor for this work. Each indi-
vidual pattern provides a visual display of each chapter’s focus. Together, the 15
quilt blocks become a unit—a quilt with a clear design and purpose, representing
the fullness of clinical practice.
When we wrote these words in the first edition of this book, we had no plans
for writing a second edition. Our thoughts were that the first edition met our goal
of sharing our findings about expert practice in physical therapy. We found, how-
ever, that as we continued to discuss elements of expert practice and ideas for pro-
fessional development with our colleagues through publications, presentations,
workshops, and conversations, we all continued to learn through this reflective
process. Our work in expertise, grounded in physical therapy practice, has been
enriched through our interactions and thoughtful comments from our colleagues.
Our work appears to serve as a common ground for clinicians to discuss and learn
from the expertise that is part of everyday practice. Although individual thera-
pists carry the responsibility for practice, it is this community of practice in phys-
ical therapy that is critical to the profession’s growth. Our work in expertise in
physical therapy appears to serve as a common ground for clinicians to discuss
and learn from the expertise that is part of everyday practice. This is a generative
time for physical therapists as the profession moves rapidly toward having the
Doctor of Physical Therapy (DPT) as the primary, and eventually only, prepara-
tion for practice. The responsibilities that accrue to a doctoring profession mean
that, now more than ever, the profession must acknowledge the fundamental
importance of development of expertise. We believe this edition extends the con-
versation on expertise and professional development by presenting new applica-
tions of our work to research, teaching, and practice in physical therapy.

G.M.J.
J.G.
L.M.H.
K.F.S.
Acknowledgments

The completion of this book was made possible through the support and encour-
agement of a number of individuals. First and foremost are the expert clinicians
who patiently gave of their time; allowed us to interrupt their lives repeatedly to
observe, interview, and videotape their interactions with patients; and thought-
fully shared their insights and reflections about their professional journeys and
how they view clinical practice. We are also grateful to their patients and families
who allowed us to observe and videotape their treatment sessions.
This research effort could not have been done without the financial support of
the Foundation for Physical Therapy, and we are grateful for the funding of our
research. We also appreciate the seed money provided by the Dean’s Incentive
Funds at Temple University. Our time and efforts also were supported by our
respective institutions and department colleagues at Creighton University, Duke
University, and Temple University. To our consultants, Arthur Elstein, Ph.D.; Lee
Shulman, Ph.D.; Anna Richert, Ph.D.; and John Hershey, Ph.D., we owe great grat-
itude for helping us to see different views. Their conceptual and theoretical
insights were invaluable to our work. We are grateful to our other contributors
who shared their research on expertise with us. All of these contributors have
challenged us to think more deeply about expert practice in physical therapy.
We thank Marion Waldman and Kathy Falk for their guidance and support
of the second edition of this book. We are extremely grateful to Andrew Grow,
our developmental editor, who has patiently prodded and enthusiastically sup-
ported our efforts in this revision.
We also thank our friends and families for their support, encouragement,
and endurance of our writing time. Special thanks to Judy Gale, Jack Hershey,
Sarah Hershey, and Rose Lopopolo, and in memory of Herbert L. Gwyer.

xxi
 Part I

Studying Expertise:
Purpose, Concepts,
and Tools
One of the recurring themes in our research and writing on expertise in phys-
ical therapy practice is the central role of context. Context includes under-
standing more about the human behavior and interactions, relationships, and
belief systems that are part of physical therapy and expertise in physical ther-
apy practice. We continue to assert that it is the uncovering and understanding
of the contexts of physical therapy practices that are essential parts of our grow-
ing knowledge base in physical therapy. The role of qualitative research meth-
ods is critical in further exploring the context of physical therapy practice
through description, explanation, understanding, and theory development. As
we planned this second edition, we wished to continue to place our work in the
larger context of the profession and professional life, research and theory devel-
opment in expertise research, and the role of qualitative methods.
There has been tremendous growth and change in health care and the profession
in the last few years from a stronger focus on health and wellness in a highly com-
petitive health care environment to the acceptance of the role of the doctor of phys-
ical therapy degree for entry into the profession. Chapter 1 provides a critical
reflective look at the current and future context of professional life across education,
practice, and health care. In Chapter 2 we work to make meaningful connections
between expertise research and theory and physical therapy. We explore the unique
contribution of expertise research in physical therapy to expertise research across
professions. We also embrace along with others the importance of seeing expertise
as a continuous process, not a state of being, as an ultimate goal for professional
development. In Chapter 3, we conclude this section with a succinct chronology of
the conceptual models and theory development that underlies our work.
 Crazy Quilt — An unstructured melding of
diverse colors and textures, unified by embroidery
and embellishments.

1 Professional Life: Issues

of Health Care, Education,
and Development

CHAPTER OVERVIEW Growth in Scholarship, Evidence-Based

THE CURRENT CONTEXT OF PHYSICAL Practice, and Outcomes Measurement
THERAPY PRACTICE Development of Professional Core Values
Professional Development over One’s
PHYSICAL THERAPISTS’ PRACTICE
Career
DESCRIBING PHYSICAL THERAPY
VISIONS FOR THE FUTURE
SERVICES
OVERVIEW OF THE BOOK
PHYSICAL THERAPISTS’ EDUCATION
CONTINUED MATURATION OF THE
PROFESSION

3
4 PA RT I ■ Studying Expertise: Purpose, Concepts, and Tools

THE CURRENT P hysical therapy (PT) can be traced as far back as the ancient Greeks, who
CONTEXT OF emphasized the healing properties of the sun’s warmth and the value of exer-
PHYSICAL cise for producing sound minds in sound bodies. The profession of physical
THERAPY therapy, however, is a product of the twentieth century. Many of the defining
PRACTICE events of the twentieth century allowed, and even fostered, its growth. Major
strides in public health standards and the adoption of medical innovations
have allowed people to benefit from rehabilitation services. Catastrophes such
as world wars and epidemics have helped create a need for physical therapy,
and social movements of the twentieth century can be credited with recogniz-
ing the needs of people with disabilities. All of these things contributed to
nearly a century of continued growth for the practice of physical therapy.
Physical therapy appeared to have escaped the almost regular cycles of surplus
and shortage that have plagued medicine, and especially nursing, and has been
generally in demand with a continuous upward trend, as events in the external
environment conspired to create continual need (1).
Events of the late 1990s, however, created shifts that did change the demand
for physical therapy for a period. The federal government, in its role as a major
reimbursement source for health care services, made changes in its reimburse-
ment for long-term care services in the Balanced Budget Act of 1997, which took
effect in 1999. The response from the health care market was swift. Within days
of the date the law went into force, skilled nursing facilities and outpatient
practices began to limit their use of physical therapy. Within a few short months
there was an almost complete freeze in the market for physical therapists and
physical therapist assistants. The predictions that the demand for physical ther-
apy would diminish, although based on entirely different reasons, appeared to
be true (2).
These changes in the health care market, although not yet fully documented,
were accompanied by all of the predictable changes in physical therapy.
Physical therapists, and especially physical therapist assistants, reported
decreased work hours and reductions in salary (3). Educational programs
reported declines in applicant pools. These declines were sharp enough to
result in a reduction in the number of physical therapist assistant programs (4).
Yet indicators of recovery began within 5 years, and, as we move to the middle
of the first decade of the twenty-first century, by all anecdotal accounts the
demand for physical therapists has returned.
What lessons can be learned from this period? We have learned that changes
in health care markets can have a swift and furious impact on the organization
of care and the role of health care providers. Yet we have also seen a resilience
in physical therapy demonstrated by the ability to return to a state of demand
in 5 years. Only time will tell whether this temporary decline in demand will
fade in its importance as the overall trend in the need and demand for physical
therapy increases or whether it signals a different level of growth.
Physical therapy is practiced in the context of the health care market. All
signs indicate that there continue to be concerns over the growth of health care
as a portion of our economy. These concerns are fueled on one side by increas-
ing demands for monies to be spent in other sectors and the perspective that
we have not achieved the health care outcomes (e.g., decreased mortality and
 CHAPTER 1 ■ Professional Life: Issues of Health Care, Education, and Development 5

morbidity) that might be reflected by the current level of investment. There

continue to be many suggestions that limits should be placed on the growth of 1
health care and that more accountability must be demanded from professions
that have previously been relatively autonomous.
Almost all of health care in the United States is paid for by third parties:
employers, through their role as manager of benefits for their employees, and
the federal government as an employer and as a source of health insurance for
defined populations. The past 25 years have seen major changes in the expec-
tations placed on health care providers by these third-party reimbursement
sources. Most of these changes have been focused on decreasing costs through
increased controls over the decisions made by individual health care providers.
In response to these increased controls, practitioners have modified their
behavior, with a general reduction in the amount of services provided, as mea-
sured by lengths of stay (5).
Known loosely as managed care, these changes have primarily resulted in a
greater emphasis on using policies predetermined by the reimbursement
sources and their agents (i.e., insurance companies) for decision making and
much less reliance on decisions made by individual health care practitioners
themselves. Managed care has many other features, many of which are focused
on reducing costs to payers (e.g., employers, insurance companies, and gov-
ernmental agencies). Although these cost-control strategies abound and
become more complex with each new attempt to design appropriate incentives
for payment, they are based on the belief that care can be more efficient if
provided in a more uniform manner.

PHYSICAL Who is the typical physical therapist dealing with these clinical realities?
THERAPISTS’ Analyzing simple descriptive data reveals that the typical therapist is a woman
PRACTICE who is white, in her 30s, educated as a therapist with a bachelor’s degree, and
working in either a hospital or an outpatient practice. Identifying the “average”
therapist is deceptive, however, particularly when health care is changing at an
ever more rapid pace. Instead, the range of possibilities that more fully
describes the multifaceted practitioners of today must be examined (6).
The face of physical therapy is really more diverse than can be seen in simple
modal statistics. Although the average age is in the late 30s, the rapid expansion
of new entrants into physical therapy between 1985 and 2000, followed by a
decline in the number of graduates through at least 2010, means that there are
several age-based cohorts making up the distribution of therapists. Although
most physical therapists are women, more than 30% are men; although most are
white, almost 8% are from ethnic groups normally underrepresented in physical
therapy (6). Based on the demographics of enrolled students, the numbers of
entrants from underrepresented groups is growing (4).
Career patterns of physical therapy as a predominantly female profession
reflect attempts to meet the dual responsibilities faced by women in today’s
society—career and family. To retain a license to practice physical therapy, one
must meet variable state government requirements, which might include
annual continuing education courses or documentation of continued active
practice. Both of these requirements present challenges for women who wish
6 PA RT I ■ Studying Expertise: Purpose, Concepts, and Tools

to interrupt their careers to raise children. Historically, the profession has

experienced a significant rate of attrition that has been higher for women than
for men (1).
Perhaps most markedly, describing a model site for practice is nearly impos-
sible. In a profession whose members were once almost exclusively in the
employment of hospitals, remarkable shifts occurred in the 1980s and 1990s
and continue today. Many therapists choose to own or work in practices owned
by physical therapists. There has also been a fairly rapid shift in the ownership
of practices to corporately held chains and health care systems (7). Major
changes in the provision of care to acutely ill patients have occurred. Rapidly
declining lengths of stay have moved those patients, whose physiologic ability
to heal has not changed, from acute care hospitals to other sites of care, such as
skilled nursing facilities and homes. To meet the demands of managed care,
hospitals have redefined themselves and formed partnerships with these other
sites, creating larger systems through mergers, acquisitions, and alliances.
Physical therapists have responded to these changes by following the patient.
Therapists have changed their employers and their employment relationships
to continue to gain access to patient care.
Additionally, therapists have identified “niche” markets, with a focus on
specific patient populations, such as women’s health and prevention.
Concurrently, there has been an increase in the acceptance of self-pay as a form
of reimbursement (8). All of these changes mean that a great deal of diversity
exists in both current practitioners and current practice of physical therapy.
Until very late in the twentieth century, not enough physical therapists were
available to meet the needs of the patient population of the United States. In
response, the number of educational programs preparing new therapists
increased, the average size of graduating classes grew, and reliance on interna-
tionally educated therapists and on other providers (e.g., physical therapist
assistants, athletic trainers, and occupational therapists) also increased.
The changes at the end of the 1990s, documented earlier, which include
actual reductions in care and perceptions of uncertainty and volatility, have
resulted in the need for new analyses of this situation. Any study of the balance
of supply and demand for a particular occupation is always subject to being
quickly rendered obsolete as market forces respond to the very changes being
predicted in the study. At best, these studies are snapshots; what is most
needed to help guide health personnel decisions is real-time video. Such
research, however, can help identify the factors that contribute to balance by
asking questions such as, “What is the demand or need for physical therapy?”
“What controls the supply of physical therapists and their substitutes in the
labor market?” and “How are practitioners distributed, both geographically
and by specialty?”
What will the twenty-first century reveal about physical therapy? How will
the work of physical therapists be transformed? The answers to these questions
can be found in the profession of physical therapy and in the external environ-
ment of physical therapy practice. Today’s environment is changing so rapidly
that details of such changes cannot be accurately illustrated in the confines of
printed text. Yet, no matter the specifics of change, the overall impact is that
 CHAPTER 1 ■ Professional Life: Issues of Health Care, Education, and Development 7

care must be provided more efficiently, more quickly, more accurately, more
cheaply, and with more accountability. 1
DESCRIBING As in many other health care professions, models of disability have been used in
PHYSICAL physical therapy to help describe who we are treating and why. In the past,
THERAPY patients have been described almost exclusively by their diagnoses. For example,
SERVICES a system of classifying diseases, known most commonly as the International
Classification of Diseases (ICD), was developed and has been used in the United
States as the principal means of categorizing patients for reporting and reim-
bursement (9). This classification was based primarily on the types of diagnoses
of pathology usually made by physicians. When the major goal of health care
intervention is removal of the disease, this system works relatively well. However,
it is increasingly clear that describing patients based on disease entities is insuffi-
cient for making a prognosis and predicting resource allocation. Disease-based
classifications may also not be useful in identifying the full range of a patient’s
needs. As the ability to prolong people’s lives improves and the number of people
with chronic diseases and people living with permanent sequelae increases, this
system begins to not work as well. Instead of concentrating on the precipitating
event, health care practitioners should focus on the results of the event.
In response to these concerns, disablement models have been proposed
(10,11). One such model is the Nagi model, as adapted and promulgated in the
American Physical Therapy Association’s (APTA) Guide to Physical Therapist
Practice (Figure 1-1) (12). Although the initial disease, syndrome, or traumatic
event begins the cascade of decision making, it is only the beginning.
Disablement models recognize that each disease results in certain impair-
ments to systems or organs, that these impairments can lead to a decrease in
functional ability, and that this decline in function can result in disability or a
reduction in the ability to fully engage in one’s role in society. The models also
identify physical, psychological, and social factors that either can diminish or
increase impairments, functional limitation, and disability. All of these disabil-
ity models are rooted in the context of the biopsychosocial model for under-
standing health, illness, and well-being that has been put forth by the World
Health Organization (WHO) (13). WHO has also sponsored the development of
a new means of classification in health care, the International Classification of
Functioning, Disability, and Health, known as the ICF. This classification differs
from the ICD by adding emphasis on chronic conditions versus acute, by focus
on function rather than disease, and by recognizing the impact of the environ-
ment on people with disabilities (14).
By adopting such models and systems for classification for describing care,
health care practitioners are able to focus on the ongoing needs of patients in
the context of the patients’ lives. Prognosis and resource allocation become
clearer, and the fact that, in addition to physicians, many participants in health
care (e.g., other health care providers, insurance companies) make decisions
about classification of patients by impairment, limitation, or disability becomes
evident. The adoption of a disability model to provide a context for thinking
about health care changes everything about how relationships to patients and
colleagues are defined. For example, the label stroke does not define very much
 8 PA RT I ■

Biological Factors Demographic Factors

Congenital Conditions Age, Sex,
Genetic Predispositions Eductaion, Income

Pathology/ Functional
Pathophysiology
Impairment Disability
Limitations

Comorbidity Psychological
Health Habits Attributes
Personal Behaviors (motivation, coping)
Lifestyles Social Support

Physical and Social Environment

Medical Care Medications/Therapies Rehabilitation

Mode of Onset and Duration
Studying Expertise: Purpose, Concepts, and Tools

Prevention and the Promotion of Health, Wellness, and Fitness

Figure 1–1 ■ The Nagi Model for the Process of Disablement. (Adapted from Guccione A. Physical therapy diagnosis and the relationship
between impairments and function. Phys Ther 1991; 71:499–504.)
 CHAPTER 1 ■ Professional Life: Issues of Health Care, Education, and Development 9

about the rehabilitation programs that are designed with and for patients who
have had a stroke. Identifying the impairments and functional limitations of 1
defined groups of patients who have had a stroke, however, can clearly iden-
tify the prognosis and the resource allocation needed to meet that prognosis.
The adoption of such a model has helped create the Guide to Physical
Therapist Practice (12), which identifies patterns of care for groups of patients
who benefit from the intervention of physical therapists and provides a com-
mon language for physical therapists to use in describing and documenting
care that actually reflects our contributions to the health and wellness of our
patients. The ICF, which is compatible with the assumptions used in the Guide,
has extended this ability to converse across the world (15).

PHYSICAL Education in physical therapy has progressed through four distinct phases in
THERAPISTS’ the nine decades of the profession’s history: 1) postgraduate specialty training
EDUCATION (1920s to 1950s) to 2) baccalaureate programs (1950s to 1980s) to 3) master’s
level programs (1970s to 1990s), and most recently to 4) doctoral programs
(1990s to present). This last period has also seen the rapid shift from master’s
level programs to doctoral level programs.
Today, of the 214 physical therapist educational programs, more than 40%
are at the doctoral level. Surveys of the remaining master’s degree programs
indicate that more than 90% of all physical therapist educational programs will
be at the doctoral level by 2013. This represents a much more rapid shift from
master’s to doctoral level than from baccalaureate to master’s, which took
almost 25 years (4).
The type of student attracted to a career in physical therapy has also changed.
In the first phase, almost everyone who entered the profession was female and
had previously received training as a nurse or teacher. In the second phase, the
majority of entrants were women who chose physical therapy while in high
school and were educated at the baccalaureate level (16). In the beginning of the
third phase, a higher number of applicants had previous employment and career
experience and represented an increasing diversity in sex, race, and age (17,18).
The fourth phase has also coincided with a decrease in the size of applicant pools,
with fewer nontraditional students represented. However, the changes in the
health care market that signify an increase in the demand for physical therapists
have also caused an increase in the size of applicant pools.
The most typical format of professional education for the 214 accredited pro-
grams in physical therapy is a 2- to 3-year program of education at the master’s
degree level, with a number of 3-year postbaccalaureate professional doctoral
degree programs emerging.
Although applicants to physical therapy programs share a comprehensive
background in basic science and social science prerequisites similar to that of
medical school applicants, they also bring diversity to the professional educa-
tion curriculum through their areas of study and life experiences. The curricula
for preparation of physical therapists in programs across the country are
planned to achieve a required set of outcome expectations for graduates, as
articulated in the Evaluative Criteria for Accreditation of Physical Therapist
Educational Programs developed by the Commission on Accreditation in
10 PA RT I ■ Studying Expertise: Purpose, Concepts, and Tools

Physical Therapy Education. These evaluative criteria provide the assurance

that a minimum level of clinical competence can be anticipated for graduates of
all accredited programs. The evaluative criteria used for accrediting educa-
tional programs are reviewed continuously for currency of the practice expec-
tations for new entrants to the profession (19). A nationwide consensus project
to develop curricular content and practice expectations for postbaccalaureate
curricula in physical therapy has helped lend consistency to the curricular
development process in many schools (20).
The curriculum content in physical therapy educational programs is pre-
sented in both didactic and clinical formats. Faculty members in the academic
setting prepare students for phases of clinical education conducted under the
supervision of clinical education faculty in a variety of practice settings that
reflect current physical therapy practice. The didactic content includes current
information in the following areas: basic sciences of anatomy, physiology, his-
tology, pathology, and neuroscience; clinical sciences of kinesiology, arthrology,
human development, motor control, and pathokinesiology; medical sciences of
surgery, medicine, radiology, pharmacology, and nutrition; social sciences of
psychology, sociology, ethics, research, and teaching/learning theory; and phys-
ical therapy sciences of examination, evaluation, diagnosis, prognosis, interven-
tions, and outcome assessment. Didactic and clinical phases of the curriculum
usually are integrated to allow progression of the student through successively
more complex performance challenges with patients. At the conclusion of
the professional education program, graduates must successfully complete a
standardized national licensure examination before being admitted to practice.
Although standards for accreditation and licensure lend consistency to the
preparation of physical therapists, an examination of the variety of educational
programs also would reveal considerable diversity. Diversity among programs
is found in the educational settings of physical therapist programs (ranging
from liberal arts colleges to academic medical centers in universities), the
sequencing and integration of the didactic content, and the length and breadth
of the clinical education component (4).
Certainly, the shift to doctoral level education will mean changes in appli-
cant pools, in faculty responsibilities, and in the physical therapy curricula.
Yet this shift has occurred at the same time that market forces have affected the
size of applicant pools and class sizes. Only time will tell how the shift in PT
education to doctoral level will affect practice.

CONTINUED In the midst of all of these changes in practice setting, models for describing
MATURATION practice, and physical therapist education, the profession of physical therapy
OF THE has also adopted activities that demonstrate a true commitment to patients and
PROFESSION a willingness to accept the accountability required of professionals.

GROWTH IN SCHOLARSHIP, EVIDENCE-BASED PRACTICE,

AND OUTCOMES MEASUREMENT

The amount of research being done to provide insight on the theory and prac-
tice of physical therapy continues to grow, as is documented by the increased
CHAPTER 1 ■ Professional Life: Issues of Health Care, Education, and Development 11

number and quality of journals in the field and the increased number of articles
in other journals that have specific application to physical therapy (21). The 1
spectrum of research approaches and designs also has increased. It is now
much easier to find qualitative work that helps us understand the perspectives
of practitioners and patients at a much deeper level. We are also seeing an
increase in epidemiologic and health services research that helps us learn about
our practices by analyzing large databases and examining population-based
risks. Finally, there has been an increase in the amount of research that is being
done to measure the effectiveness of diagnostic and prognostic tools and inter-
ventions in actual patient populations. All of this expansion means that we
have available to us an almost unmanageable amount of information that can
help us improve care.
Over the past 10 years a new force has been active in the way clinicians think
about and provide their care, which also gives us a means to manage this mas-
sive amount of information. This is the concept of evidence-based practice
(EBP) (22–24). EBP was developed to help clinicians bring the results of current
research (evidence) together with the patient’s values and circumstances, to
make decisions using their clinical expertise, thereby forging a therapeutic
alliance with the patient. The proponents of EBP believe that using the
processes of EBP can improve care. There is a growing body of evidence that
supports this view (25,26).
One of the outcomes of EBP is to engage in careful analyses of individual
research studies. An example of a resource that supports such analyses is the
Hooked on Evidence project of the APTA (27). Another of the outcomes of EBP
is to arrive at conclusions (clinical bottom lines) about preferable modes of
treatment based on a systematic review of the current evidence. The Evidence
in Practice feature in Physical Therapy is an example of such reviews (28). EBP’s
origins are found in the British Commonwealth countries; there are also numer-
ous examples of resources found around the world (29,30).
The assumptions are that by using evidence from research, literature clini-
cians can identify a recommended course of action for similar patients and
that clinicians can expect that a majority of their patients will benefit from
application of these patterns. Because much of physical therapy, as is true
across all health care, does not yet have specific research evidence to support
it, expert opinion also becomes a source of guidance. Therefore, one of the
major evaluative decisions made by clinicians in this mode of practice is to
decide if the patterns apply to a particular patient presenting to the practi-
tioner. This is quite different from the more traditional process of clinical
decision-making, which focused much more on patient differences than on
commonalties.
Choosing an appropriate pattern of care for a patient requires understand-
ing how to classify that patient into a specific group and being assured that the
patterns chosen are based on patients’ full needs, addressing impairment, lim-
itation, and disability. Guide to Physical Therapist Practice (12) offers more than
30 patterns of care for patients with problems in the four systems within the
physical therapist’s scope of practice: neurological, musculoskeletal,
cardiovascular/pulmonary, and integumentary.
12 PA RT I ■ Studying Expertise: Purpose, Concepts, and Tools

Changes in the health care system also have required the development of
what is known as the outcomes movement, which focuses on better measuring
outcomes at all levels, especially those related to functional ability and quality
of life. As health care outcomes become more clearly explicated, practitioners
can be expected to turn increasingly to evidence-based practice. In other words,
learning more about what is actually achieved with interventions encourages
using only those interventions that have clear documentation of success. This
is a laudable goal but one that will take much time to achieve and will depend
heavily on wise clinical input.
All health care practitioners grapple with the issue of how to adequately
identify and measure the outcomes of their work. For outcome measurement to
be successful, such measurement must meet the requirement of all sound mea-
surements: It must be valid. Among other things, these measures must relate to
the world in which patients live, reflect the roles patients have chosen in their
lives, and be both sensitive and specific enough to provide information that
helps validate our diagnostic and prognostic decisions. This is a difficult task
that is made even harder when the process of care is not fully understood.
A clear understanding of how therapists interact with patients to make indi-
vidual decisions during the course of care is essential for capturing the full pic-
ture of all outcomes addressed by care (whether disease related, impairment
based, or related to functional limitations), for identifying the variables that
affect these decisions, and for developing measures that capture all aspects of
care. The absence of such an understanding forces therapists to rely on gross
measures that may easily miss the most important contributions they make to
patients’ lives.
For example, most physical therapists consider teaching patients to make
good decisions about their own behavior one of the most important things ther-
apists do. If research does not focus on the long-term effects of physical ther-
apy, the effects of patient education on lifelong health cannot be measured. As
another example, although most therapists believe that their individual inter-
ventions are different from each other because they provide different physio-
logic and anatomic benefits, developing specificity of intervention selection
and intensity of service guidelines is impossible if all interventions are identi-
fied simply as physical therapy.
The trend toward better understanding outcomes also moves closer to evi-
dence-based practice. Evidence-based practice requires health care practition-
ers to look to many sources of evidence to determine their choices in clinical
decision making. These sources certainly include quantitative studies on effi-
cacy, especially controlled clinical trials. Research should be designed to help
improve decisions to define options and the results of specific choices. Another
source of evidence is documentation of best practice based on expert opinion,
such as the Guide. Evidence gathered in a systematic way on a case-by-case
basis from each patient is also a source of guiding information for evidence-
based practice (31). Therapists participate in evidence-based practice when
they reflect on each patient and what can be learned from that patient about
subsequent patients. This is in contrast to therapists who make decisions
because of expediency, lack of knowledge, personal comfort with a type of
 CHAPTER 1 ■ Professional Life: Issues of Health Care, Education, and Development 13

intervention, or any other reason that does not arise from what is learned about
patients and their responses to interventions. 1
DEVELOPMENT OF PROFESSIONAL CORE VALUES
There is a continued call across health professions for a set of core competen-
cies that are seen as critical for reform of health professions education. The 2003
Institute of Medicine report, “Health Professions Education: A Bridge to
Quality,” proposes these five core competencies for all health professions: pro-
vide patient-centered care, work in interdisciplinary teams, use evidence-based
practice, apply quality improvement, and use informatics (32).
In 2002 the APTA undertook a project to identify the core values that under-
lie physical therapists’ behaviors as professionals committed to the welfare of
their patients and clients. Two of the authors of this text were among the group
convened to review the work that had been done in identifying these core val-
ues and to prepare a document for review across the profession. After wide-
spread dissemination, the APTA Board of Directors adopted the Core Values.
These value statements have since been integrated into normative descriptions
of physical therapy education and into accreditation standards, as seen in
Box 1-1 (19,20,33,34).

BOX 1–1 The Seven Core Values

(Continued)
14 PA RT I ■ Studying Expertise: Purpose, Concepts, and Tools

BOX 1–1 The Seven Core Values—Cont’d

From Bezner J. Board perspective: getting to the core of professionalism, PT Mag.

2004;12(1).

PROFESSIONAL DEVELOPMENT OVER ONE’S CAREER

Informal and formal opportunities for continued development over a thera-
pist’s career have increased in the past 25 years and are expected to grow in the
future. Self-directed, nonmandatory opportunities for professional develop-
ment have significantly expanded, with continuing education courses available
on a wide range of topics, in a variety of settings, and delivered both in person
and through distance communication techniques.
The American Board of Physical Therapy Specialties of APTA sponsors a cer-
tification process for physical therapists who have specialized their practice in
one of seven areas: 1) cardiopulmonary therapy, 2) clinical electrophysiology,
3) geriatrics, 4) neurology, 5) orthopedics, 6) pediatrics, or 7) sports. This rigor-
ous program of self-assessment and standardized testing has been successful,
with more than 6,000 board-certified specialists currently practicing (35).
Additional opportunities for continued professional development in a men-
tored, planned clinical format, termed “residency,” exist for physical therapists
who have selected a specialty area of practice. Residency training requires the
therapist to be in residence for at least 6 months at a residency-training site for
a combined program of didactic and clinical advanced education. There are
18 residency programs in four clinical areas: geriatrics, neurology, orthopedics,
and sports (36).
More formalized, advanced programs provide opportunities for physical
therapists to update and deepen their clinical knowledge base by earning an
advanced master’s or doctoral degree. There are more than 75 such programs
in physical therapy departments (37) in the United States, with many more
available in related basic and behavioral science fields.
 CHAPTER 1 ■ Professional Life: Issues of Health Care, Education, and Development 15

The past 10 years have also seen the growth of programs termed transitional-
Doctor of Physical Therapy (DPT) programs. These programs are available for 1
practicing physical therapists and are therefore an opportunity for professional
development. They are also designed to help practicing therapists match the
level of current entry level, so they can be seen as part of entry-level prepara-
tion. There are more than 60 such programs, with almost 10,000 therapists
enrolled or graduated from such programs (38).
Fellowship programs have also developed to further practice, research, and
educational skills for therapists who have already completed doctoral degrees,
residencies, or specialization. There are 15 fellowship programs in four clinical
areas: hand therapy, movement science, orthopedics, and sports (39).

VISIONS FOR The APTA has set forth its view of what the future should be for physical ther-
THE FUTURE apy in what is termed Vision 2020:
By 2020, physical therapy will be provided by physical therapists who are
doctors of physical therapy, recognized by consumers and other health care
professionals as practitioners of choice to whom consumers have direct access for
the diagnosis of, interventions for, and prevention of impairments, functional
limitations, and disabilities related to movement, function, and health.
APTA has identified that, to reach this Vision, physical therapists will be doc-
tors of physical therapy who practice in an autonomous manner through direct
access to their services, using EBP principles, adhering to professional core val-
ues, and thereby being practitioners of choice among health care consumers (40).
The growth that has been achieved in physical therapy practice and educa-
tion has resulted only because of the work of leaders in physical therapy prac-
tice. Health care practitioners should continue to seek the judgment of such
people to respond to the challenges in practice and education that lie ahead,
especially if the vision described is to be achieved. The decisions that are made
regarding where and how therapists practice will influence the ultimate ability
of physical therapy to contribute to the care of patients. The ultimate answer to
the economic analysis of surplus versus shortage depends on society’s percep-
tion of its need for physical therapy and the translation of that need into
demand. The choices therapists make regarding appropriate clinical care deter-
mine how many therapists are needed and where they need to practice. The
advocacy exerted with patients, payers, and policymakers will affect the
demand for this care. Professional expectations for quality can set the necessary
limits on the cost reductions that can be derived from the system. The quality
of education of new practitioners will determine these practitioners’ ability to
meet these challenges. Given the incredible rate of change in the health care
system and the remarkable advances in physical therapy, perhaps it has never
been more important to understand how our colleagues achieve expertise.

OVERVIEW OF In the intervening years since we first presented our research on expertise in
THE BOOK physical therapy, much has changed, but much has remained the same. We
believe that the lessons we learned, and the work that has built on research, can
continue to provide useful perspectives for the future.
16 PA RT I ■ Studying Expertise: Purpose, Concepts, and Tools

The remaining chapters of Part I, Studying Expertise: Purpose, Concepts,

and Tools, set forth a description of the research done in many fields to explain
and define expertise, followed by a review of the specific research techniques
used in our study of expert clinicians. The chapters in this section are designed
to explain the theory and processes that guide reflections and research on
expertise.
Part II, Portraits of Expertise in Physical Therapy, presents the cases and
detailed stories of 12 expert clinicians in four clinical areas of practice. These
chapters (4–7) deal with real clinicians and their patients as the clinicians make
good decisions, make mistakes, learn from their mistakes, teach others, and
reflect on their practice. Chapter 8 contains the synthesis of our cross-case
analysis for the four clinical specialty areas and tells the greater story of what
we learned from the 12 therapists that defines what it means to be a physical
therapist striving to be the best clinician possible. The section closes with a
postscript on our experts over the intervening years since they last shared their
reflections with us.
We are excited by the addition of Part III, Lessons Learned and Applied,
which sets forth the work of four groups of researchers and practitioners who
have built on the premise of our work. In Chapter 9, Resnick connects concepts
of expert practice to patient outcomes by using data from large databases.
Edwards and Jones, in Chapter 10, add an international dimension with their
work examining clinical decision-making in therapists in a variety of clinical
settings in Australia. In Chapter 11 Mostrom updates her contribution from the
first edition, adding elements about patient-centered reasoning and the role of
the practice community. Chapter 12 is a presentation by Sullivan and Jampel
about the application of what we know about expertise to the development of
a practical system for professional development and recognition in practice.
Part IV, Pursuing Expertise in Physical Therapy, offers our views about how
the work done explaining and understating expertise in physical therapy can
be applied to future research (Chapter 13), education (Chapter 14), and practice
(Chapter 15). We see the growth of physical therapy and the understanding of
expertise in clinical practice as a grand journey. We invite the reader to join us
on this journey, which started with profound respect for the work done by
physical therapists and with inquisitiveness about how the best therapists
think. Our collective journey has not ended; it continues because of the won-
derful therapists we have met who have shown us an exciting, adventurous
path toward high-quality, compassionate, and efficacious care.

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CHAPTER 1 ■ Professional Life: Issues of Health Care, Education, and Development 17

6. American Physical Therapy Association. Physical therapist member demographic profile 1999–2004.
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14. International Classification of Functioning, Disability, and Health. Available at:
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15. Reed G, Harwood K, Brandt D, et al. International Classification of Functioning, Disability, and
Health: A manual for health professionals. American Physical Therapy Association Annual
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Alexandria, VA: APTA; 1979.
17. American Physical Therapy Association. 1993 active membership profile report. Alexandria, VA:
APTA; 1994.
18. Pinkston D. A history of physical therapy education in the United States [PhD dissertation].
Cleveland, OH: Case Western Reserve University; 1978.
19. Commission on Accreditation for Physical Therapy Education. Evaluative criteria for accredita-
tion of education programs for the preparation of physical therapists. Alexandria, VA: Commission on
Accreditation for Physical Therapy Education; 2005.
20. American Physical Therapy Association. A normative model of physical therapist professional edu-
cation, Version 97. Alexandria, VA: APTA; 1997.
21. Miller PA, McKibbon KA, Haynes RB. A quantitative analysis of research publications in phys-
ical therapy journals. Phys Ther. 2003;83:123–131.
22. Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-based medicine, ed 3. New York:
Churchill Livingstone; 2005.
23. Bury T, Mead J. Evidence-based health care: a practical guide for therapists. Oxford: Butterworth-
Heinemann; 1998.
24. Geyman JP, Deyo RA, Ramsey SD. Evidence-based clinical practice. Boston: Butterworth-
Heinemann; 2000.
25. Mikhail C, Korner-Bitensky N, Rossignol M, et al. Physical therapists’ use of interventions with
high evidence of effectiveness in the management of a hypothetical typical patient with acute
low back pain. Phys Ther. 2005;85:1151–1167.
26. Ring N, Malcolm C, Coull A, et al. Nursing best practice statements: An exploration of their
implementation in clinical practice. J Clin Nurs. 2005;14(9):1048–1058.
27. American Physical Therapy Association. Hooked on evidence. Available at: http://www.hooke-
donevidence.com/. Accessed February 2, 2006.
28. Smith B, Cleland J. Clinical question: Is radiologic examination necessary for a 9-year-old girl
with a knee injury? Phys Ther. 2004;84(11):1092–1094.
29. www.nettingtheevidence.org.uk. A ScHARR introduction to evidence based practice on the internet.
Available at: http://www.shef.ac.uk/scharr/ir/netting/. Accessed February 2, 2006.
30. PEDro. Physiotherapy evidence database. Available at: http://www.pedro.fhs.usyd.edu.au/
index.html. Accessed February 2, 2006.
18 PA RT I ■ Studying Expertise: Purpose, Concepts, and Tools

31. McEwen I (ed). Writing case reports: a how-to manual for clinicians, ed 2. Alexandria, VA: APTA;
2001.
32. Greiner A, Knebel E (eds). Health professions education: a bridge to quality. Washington, DC:
Institute of Medicine of the National Academies, National Academies Press; 2003.
33. American Physical Therapy Association. Professionalism in physical therapy: core values.
Alexandria, VA: APTA; 2003.
34. Bezner J. Board perspective: getting to the core of professionalism. PT Mag. 2004;12(1).
35. American Physical Therapy Association. American Board of Physical Therapy Specialties. Available
at: http://www.apta.org/AM/Template.cfm?Section=ABPTS1&Template=/TaggedPage/
TaggedPageDisplay.cfm&TPLID=42&ContentID=14391. Accessed February 2, 2006.
36. American Physical Therapy Association. Residencies. Available at: http://www.apta.org/AM/
Template.cfm?Section=Residency&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=
118&ContentID=15371. Accessed February 2, 2006.
37. American Physical Therapy Association. Post-professional degrees. Available at: http://
www.apta.org/AM/Template.cfm?Section=Post_Professional_Degree &TEMPLATE=/CM/
ContentDisplay.cfm&CONTENTID=27838. Accessed February 2, 2006.
38. American Physical Therapy Association. Transition-DPT programs. Available at: http://
www.apta.org/AM/Template.cfm?Section=Post_Professional_Degree&CONTENTID=28221&
TEMPLATE=/CM/ContentDisplay.cfm. Accessed February 2, 2006.
39. American Physical Therapy Association. Fellowship web site. Available at: http://www.
apta.org/AM/Template.cfm?Section=Residency&CONTENTID=28129&TEMPLATE=/CM/
ContentDisplay.cfm. Accessed February 2, 2006.
40. American Physical Therapy Association. Vision 2020. Available at: http://www.apta.
org/AM/Template.cfm?Section=About_APTA&TEMPLATE=/CM/ContentDisplay.cfm&
CONTENTID=19078. Accessed February 2, 2006.
 Moon over the Mountain — A traditional
folk pattern with the brilliant moon illuminating
the land below.

2 Understanding Expertise:
Connecting Research and
Theory to Physical Therapy

CHAPTER OVERVIEW DIMENSIONS OF DEVELOPING EXPERTISE

COMING TO TERMS: TERMS AND Knowledge: What Do Experts Know?
CONCEPTS IN EXPERTISE Clinical Reasoning and Judgment: How Do
Novice–Expert Differences Experts Solve Problems?
Novice Development toward Professional Skill Acquisition: How Do Experts Acquire
Competence and Expertise Skills?
Novice Learning Reflection: How Do Experts Learn from
Practice?
THEORIES OF EXPERTISE: MAKING
Professional Formation: What Is the Role of
MEANINGFUL CONNECTIONS
Enculturation?
THEORIES OF PROFESSIONAL EXPERTISE
Expertise as Mental Processing
Expertise as Knowledge and Clinical
Reasoning
Expertise as Everyday Practice

19
20 PA RT I ■ Studying Expertise: Purpose, Concepts, and Tools

What is our fascination with expertise? We are quick to claim that we want to
facilitate rapid development of novice practitioners toward professional compe-
tence and expertise, yet the focus on evidence-based practice has led to contin-
ued debate about the relative importance of “expert opinion” as an important
source of evidence (1,2). This debate has been fueled, in part, by our own mis-
conceptions of expert opinion, what counts as evidence, the dimensions of
expertise and expert practice, and the assumption that research and theory on
expertise and expert practice can be applied across health professions.
In the first edition of this book, we provided a basic overview of the litera-
ture on expertise and proposed a prototypical model of expertise. In this
revised chapter, we take a bolder stand to explicitly make meaningful connec-
tions between theory, research, and physical therapy. We believe that the con-
tinued growth and acceptance of the Doctor of Physical Therapy (DPT) degree
in physical therapy education signals a readiness of the profession to under-
stand and use theoretical work in our thinking, in deliberations, and across set-
tings (education, research, and practice).
This chapter begins with “coming to terms” with the terms and concepts.
Why is this important? We use this introduction to lay the foundation for the
importance and practical relevance of research in expertise for the profession of
physical therapy. In this section, we explore the meaning of expertise, novice
and expert differences, and novice development as it relates to contemporary
definitions of professional competence. The middle section of the chapter
focuses on an overview of predominant theories in expertise research. One of
our challenges in this chapter is finding the right balance between sharing the
research and supporting literature in a way that is relevant, is practical, and
contributes to the physical therapy knowledge base. We hope we have found
the right balance that will inform education and practice and facilitate the pro-
fession’s intellectual growth. We believe that exposure to the breadth of exper-
tise research and theory is important because it helps us understand how
expertise research in physical therapy (3–16) contributes to the identity of the
profession of physical therapy among other professions.
Finally, we conclude the chapter with a revised prototypical model of exper-
tise that highlights the core dimensions of developing expertise. In this revised
chapter, we embrace, along with others (17,18), the assumption that expertise
should be seen as a continuous process, not as a state of being, because the ulti-
mate goal of studying expertise is enhancing the professional development of
novices and lesser-skilled practitioners.

“COMING TO What does it mean to be an expert? What is the relationship between profes-
TERMS”: sional competence and expertise? Why have we continued to see research and
TERMS AND discussion about expert practice in physical therapy? These are questions we
CONCEPTS IN will begin to address in this section.
EXPERTISE The simple definition of an expert is as follows: “an expert is capable of
doing the right thing at the right time” (19, p. 308). In research on expertise
there are several variations on this definition of an expert. An expert can be
defined as someone who performs at the level of an experienced professional,
such as a master or grandmaster in chess or a clinical specialist in medicine
CHAPTER 2 ■ Understanding Expertise: Connecting Research and Theory to Physical Therapy 21

(20,21). Experts also can be defined as top performers who excel in a particular
field, such as elite athletes or musicians. Finally, experts can also be seen as
those who achieve at least a moderate degree of success in their occupation
(22). Another view or conception of expertise is that it is not just a cluster of
attributes such as knowledge and problem-solving skills or high-level perfor-
mance; expertise needs to be seen as a process rather than a static state or label
2
(23). This does not mean that the process of moving toward expertise is based
merely on the gathering of years of experience. Without learning mechanisms
or reflection used to mediate improvement from experience, there will be little
acquisition of expertise (17). If our definition or conception of expertise is seen
more as a process than a state to be achieved, then we begin to see the critical
importance of learning in the context of professional development. This
includes broadening our discussion to additional considerations such as under-
standing expert–novice differences to facilitate novice development, profes-
sional learning, and the development of professional competence.

NOVICE–EXPERT DIFFERENCES
In more than 40 years of expertise research, there remains strong consensus in
how experts differ from novices (18–26). The case examples in this chapter
highlight key characteristics and differences in how a novice and an expert may
handle a patient case.
CASE EXAMPLE
The patient is a 70-year-old man who is referred to physical therapy with right
hip pain and a diagnosis of osteoarthritis of the hip.
1. Experts bring more knowledge to bear in solving problems within their
clinical specialty area or domain of practice. This knowledge is highly
organized, accessible, and integrated.
NOVICE: Forms immediate working hypothesis that the patient’s primary
problem is osteoarthritis of the hip, given the patient’s age and history
of arthritis.
EXPERT: Knows that hip pain may be referred from the low back and asks
specific, directed questions in the patient interview to obtain a better
understanding of the symptom patterns with activity and with rest.
Given the presentation of pain in the L3 dermatome and relief the
patient experiences with sitting, the expert is suspicious of an L3 spinal
problem.
2. Experts figure things out. They solve problems more efficiently and mon-
itor, adapt, and revise their approaches to problems with ease.
NOVICE: Does not discover the patient’s symptom of radiating pain down
the leg with specific lumbar movements and thinks the hip is the main
problem.
EXPERT: Immediately shifts thinking in the physical examination process
to include the lumbar spine and works quickly examine the hip.
22 PA RT I ■ Studying Expertise: Purpose, Concepts, and Tools

3. Experts continue to learn through experience by monitoring their actions

and evaluating ongoing efforts of problem solving. These actions are
called higher-order (metacognitive) skills or reflective processes.
NOVICE: Uses an evaluation framework and emphasizes data collection.
A novice’s thinking process is governed by application of rules.
EXPERT: Thinks about and interprets the evidence as the evaluation pro-
gresses. When a special clinical test turns out negative and does not seem
to fit with the working hypothesis, an expert reevaluates the techniques
used to perform the test. An expert draws on a rich background of clini-
cal knowledge by recalling experiences with patients who had, for exam-
ple, initial diagnoses of hip pain but who, in fact, had spinal problems.
4. Experts continually develop skills through intense, focused, deliberate
practice.
NOVICE: Has learned hip mobilization treatment techniques in the labora-
tory, practiced a few times, and feels fairly confident to do these with
patients.
EXPERT: Has engaged in long hours of self-directed study, worked with
mentors, and constantly practiced to learn and refine mobilization skills.
An expert continually works to learn more and perfect manual skills.
5. Experts are insightful and investigate not only the stated problem but also
factors that may affect the specific problem. Discovering these factors and
issues is part of what is called clarifying the context of the problem.
NOVICE: Focuses on the hip problem and gathers limited contextual data.
Limited insight is gained into other aspects of the patient’s life.
EXPERT: Listens to the patient intently and with focus. An expert gathers
data on the patient’s family, beliefs about exercise, fears about loss of
mobility, and concerns that can affect the patient’s outcome throughout
the evaluation.
Although there is strong evidence supporting the distinguishing aspects of
experts from novices, how does this knowledge translate into more effective
education or training? This is where we begin to see expanded discussions
about the importance of professional learning as it relates to novice develop-
ment and an expanded definition of professional competence.

NOVICE DEVELOPMENT TOWARD PROFESSIONAL COMPETENCE

AND EXPERTISE

In professional education, we are concerned about novice development

toward professional competence and development of expertise. In physical
therapy, the profession’s vision for increased autonomy brings with it increased
responsibility and therefore greater accountability (27). In both academic and
clinical settings there will continue to be increasing emphasis on demonstrating
accountability for competent performance. For educational programs, this
 CHAPTER 2 ■ Understanding Expertise: Connecting Research and Theory to Physical Therapy 23

means we must be able to demonstrate that our graduates are competent and
ready to begin practice. In practice, this means we must continue to show that
professionals remain competent over time. Therefore when we talk about
expertise we must also consider the steps or stages toward the development of
expertise that include novice development and demonstration of professional
competence. Concerns with the health care system place increasing emphasis
2
on accountability for competent performance, and in turn our discussions in
professional education and practice must also consider the interrelationships of
competence, novice development, and expertise (28,29).
In medicine there have been two well-known models of professional com-
petence described. In 1985 Norman (28) performed a methodological review
and proposed the following categories as components of professional compe-
tence in medicine: clinical skills (patient interview and examination), knowl-
edge and understanding, interpersonal attributes, problem solving and clinical
judgment, and technical skills. More recently, Epstein and Hundert (29) pro-
posed this expanded definition of professional competence for medicine:
Professional competence is the habitual and judicious use of communication,
knowledge, technical skills, clinical reasoning, emotions, values and reflection
in daily practice for the benefit of the individual and the community being
served. (p. 226)
Epstein and Hundert argue that competence builds on a foundation of basic
clinical skills, scientific knowledge, and moral development (29). Dimensions of
professional competence include the traditional elements of cognition and tech-
nical skills, but they also require integrative skills and behaviors involving con-
text, relationship, affective/moral, and habits of mind (Table 2-1) (29,30).

Table 2–1. Dimensions of Professional Competence

Dimension Examples, skills, or behaviors
Cognitive Core knowledge, basic communication, information management, problem solving,
generating questions, learning from experience
Technical Physical examination skills, procedural skills
Integrative Integrating scientific, clinical, and humanistic judgment; applying clinical reasoning
strategies; managing uncertainty; linking basic and clinical knowledge
Context Varying contexts of clinical delivery, use of time
Relationship Communication skills, handling conflict, teamwork; teaching
Affective/moral Tolerance for ambiguity, emotional intelligence, respect, caring, responsiveness to
patients and society
Habits of mind Observations of one’s own thinking (metacognitive skills), critical curiosity, recognition
and response to cognitive and emotional biases, willingness to acknowledge and
correct errors

Adapted from Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA 287. 2002;226–235.
24 PA RT I ■ Studying Expertise: Purpose, Concepts, and Tools

A critical assumption here is that professional competence is developmental

and context dependent.
Competence means connecting the person and his or her abilities with the per-
formance of tasks in a specific clinical context. So, rather than seeing competence
as simple possession of knowledge, skills, and attitudes that are presumed to
work for most patient situations, Epstein and Hundert would see that caring for
a patient with similar physical symptoms in different delivery settings requires
different skills and abilities. They further assert that scientific, clinical, and
humanistic judgments are all essential parts of clinical reasoning. This expanded
view of professional competence requires us to also reconsider the traditional
approaches to assessment of learning such as multiple-choice examinations,
objective structured clinical examinations, or standardized patient assessments.
They propose consideration of new learning assessment formats that also con-
sider assessing clinical reasoning, expert judgment, management of ambiguity,
professionalism, time management, learning strategies, and teamwork (29).

NOVICE LEARNING
What can teachers and schools do with curricula, classroom settings, and teach-
ing methods to enhance student learning? The National Academy of Sciences,
National Academy of Engineering, Institute of Medicine, and National Research
Council, in their book, How People Learn (24), took several key findings from
research on expertise integrated with research on learning to generate recom-
mendations for teaching and learning. A central premise of this book is critical
examination of key research findings along with application of these findings to
classroom practices and learning behavior. In Table 2-2 we highlight key princi-
ples from research on expert knowledge and demonstrate an application to
teaching and learning environments in physical therapy. One of the challenges
for educators in an age of rapid development and transfer of information is deci-
sions about time, content, and learning experiences in the curriculum. The
research evidence here on learning supports providing novices with learning
experiences that help them build a scaffold or conceptual understanding of their
knowledge, that facilitate linking basic science concepts to clinical signs and
symptoms, and that demonstrate the importance of understanding the condi-
tions or context of the situations or problems they are trying to solve.

THEORIES OF As we have stated before, one of the most compelling reasons for understand-
EXPERTISE: ing expertise and expert practice is that we want to prepare students for the pro-
MAKING fession in ways that will facilitate the development of expertise. The primary goal
MEANINGFUL of a profession is service to society, which involves broad and complex knowl-
CONNECTIONS edge not readily available to the public. A profession is a practice that is
grounded in bodies of knowledge that are created, tested, elaborated, refuted,
and transformed by the profession. The profession needs both research and the-
ory development. “Professions change, not because the rules of practice change
or policies change, but they should change because of the process of knowledge
growth, criticism, and new understandings that come through research and the-
ory development” (31). One of the challenges in physical therapy has been the
 CHAPTER 2 ■ Understanding Expertise: Connecting Research and Theory to Physical Therapy 25

Table 2–2. Principles of Experts’ Knowledge and Implications for Teaching

and Learning
Principle Expert–novice difference Learning strategy for novice development
Meaningful patterns Experts recognize features or Provide novices with learning experiences
2
of information patterns not recognized that enhance ability to link what they
by novices know to meaningful patterns (e.g., link
basic science concepts to specific clinical
signs and symptoms of a patient case)
Organization of Knowledge for experts is not a Consider building conceptual
knowledge list of facts or formulas but is understanding as a critical element in
organized around core concepts curriculum design; teach for depth and
and “big ideas” not breadth of knowledge
Context and access Experts do not have to search Design learning experiences that help
to knowledge through everything to know students learn about the conditions of
and identify relevant knowledge application to specific cases or problems
(not just the automatic application of
information from a textbook)
Fluent retrieval Experts work toward understanding Instruction and testing should also focus
the problem rather than jump on fully understanding the problem and
to solution strategies and engage the situation, not just on accuracy
in a process of problem solving
Adaptive expertise Experts use metacognitive strategies Help novices understand that an expert is
and the ability to self-monitor not someone who knows all of the
own level of understanding; answers; help develop metacognitive
recognize their limits of knowledge skills through teaching and assessing
and take steps to remedy self-awareness; promote intellectual
humility

Adapted from Brandsford J, Brown A, Cocking R (eds). How People Learn: Brain, Mind, Experience and School. Washington,
DC, National Academy Press; 2000.

significant focus on the scientific method that assumes the core tenets of the bio-
medical model as the most highly valued forms of knowledge generation. For
example, we are more likely to see support in terms of grant funding and pub-
lication for a quantitative approach to research is which the evidence of clinical
success is quantifiable and measured, such as the effects of a specific interven-
tion on patient outcome. This intervention is more likely to be a modality or
exercise than any consideration of the teaching skill and ability of the therapist.
This quantitative approach is in contrast to more methodologically diverse
approaches, such as qualitative exploration of the patient–clinician interaction
that may have a significant and meaningful impact on patient outcome and
function (32). You might be asking: Why is this knowledge and theory discus-
sion important to understanding expertise? The answer to this question is
twofold: 1) Physical therapy continues to have a paucity of conceptual models,
Exploring the Variety of Random
Documents with Different Content
 MEMORIES OF THE RUSSIAN COURT 271 middle of the
night of August 24 (Russian) ordered, I had to leave for an unknown
destination withiit twenty-four hours. As I was without money and
was really in need of a physician's care, my relatives began at once
to petition every authority for a delay of at least twenty-four hours
more. This was finally allowed, but two soldiers were immediately
placed before my door and I was a prisoner in my uncle's apartment.
Meanwhile my parents and friends continued to make every
preparation for my comfort in exile, and two of my hospital staff, the
director and a nurse, volunteered to go with me. The night before I
left my poor parents stayed with me, none of us going to bed. Very
early on a rainy morning two motor cars filled with police came for
us. They were kind enough to let my parents accompany me almost
to the Finnish side, and they explained that they had come so early
because they feared street demonstrations. At the station we found
a miscellaneous company of alleged counter-Revolutionists including
a few old acquaintances. Among these was former detective
Manouiloff, a tall officer named Groten, the editor, Tanchevsky, and
the curious little Siberian doctor Badmieff, with his equally curious
wife and child and a young maid named Erika whom I came to know
very well. Badmieff was the herb doctor who, it will be remembered,
was supposed to purvey the deadly poisons which I was alleged to
feed to the Tsarevitch. He was a small, round, shriveled man,
excessively old — over a hundred, they said — and in appearance
resembled a quaint carved Buddha out of an antiquarian shop. He
had the smallest, blackest eyes imaginable,
 272 MEMORIES OF THE RUSSIAN COURT set in a face
yellow and wrinkled, and his long, scraggly beard was as white as
cotton. His wife, many years his junior, and his funny little child,
Aida, were as Mongolian in appearance as himself. The maid, Erika,
a girl of about eighteen, was not uncomely with her bright eyes and
short, curly hair. All the "counter-Revolutionists" were herded
together in one carriage, the one farthest from the engine, and in
charge of us was a Jewish official of the Kerensky Government. At
Terioke I parted with my father and mother, the train moving on
quickly to the Finnish town of Belieovstrov. Here we were met by an
enormous crowd of soldiers and working people, all hostile,
demanding to see the dangerous counter-Revolutionists. Especially
they demanded to see me, but I shrank back in my seat, fearing
every moment that the shower of stones against the carriage would
break the windows. But quickly the conductor's whistle was blown
and the train moved beyond the reach of the mob. Worse was to
come. When we reached Rikimeaki we found waiting us a larger and
a still more furious crowd. Our carriage was unfastened from the
train and the mob rushed in yelling that we must all be given up and
killed. "Give us the Grand Dukes!" they shouted. "Give us Gourko!" I
sat with my face buried in the shoulder of my nursing sister fearing
that my end had come. My fears were not imaginary, for several
ruffians pitched on me shouting that they had found Gourko in
women's clothes. Frantically the sister explained that I was not
General Gourko but only a woman ill and lame. Refusing to believe
her,
 MEMORIES OF THE RUSSIAN COURT 273 they demanded
that I be stripped, and I have no doubt that this would have
happened had not a motor car opportunely dashed up carrying a
sailor deputation from the Helsingfors Soviet. These men pushed
their way into the carriage, and without ceremony booted the
invaders out. One man, a tall, slender youth named Antonoff, made
a speech at the top of his voice, commanding the mob to disperse
and to leave things in the hands of the Soviet. So authoritatively did
he speak that the crowd obeyed him and allowed our carriage to be
attached to another train bound for Helsingfors. Antonoff remained
with us, and in the friendliest fashion sat down beside me and bade
me to be of good cheer. He did not know why we had been sent
away from Petrograd, but the Soviet at Helsingfors, of which he was
a member, had received a telegram, he thought directly from
Kerensky, saying that we were being sent on, and when we arrived
were to be placed under arrest. Doubtless there would be
explanations, and after that we would surely be released. To my
mind the thing seemed not quite so simple. Kerensky had sent us
from Petrograd, but not to be imprisoned in Helsingfors. What he
desired was that the mobs, notified of our arrival from his office,
would kill us before we ever reached Helsingfors at all. No doubt he
hoped at the same time to dispose of General Gourko and the Grand
Dukes left in Petrograd. But Gourko was too clever for Kerensky, and
made good his escape to Archangel, where he took refuge with the
British Occupational Force. As for the Grand Dukes, they were, for
some reason, at this time left undisturbed by the Revolutionists.
 274 MEMORIES OF THE RUSSIAN COURT It was night
when we reached Helsingfors and we found the station practically
deserted. The main body of the prisoners were taken away into the
darkness, but Antonoff said that I and the nurse should spend the
night in a hospital adjoining the station. We climbed several flights of
steep stairs and passed through wards crowded with blue-gowned
sick soldiers and sailors, not one of whom offered us the slightest
rudeness. A skilled Finnish nurse undressed me and put me to bed,
but unhappily not for long. Scarcely had I composed myself to sleep
when the door opened, the lights flashed up, and Antonoff, red and
very angry, entered the room. He had gone to the Soviet authorities,
confident that he could persuade them to let me remain in the
hospital, at least until word came from Petrograd of our exact status.
But they refused his request and ordered him to take me at once to
the ship on which the other prisoners were confined. There being no
appeal I dressed and limped down the long stairs to the street
where a dense mob had assembled, shouting, threatening, crowding
dangerously around the motor car. It is a horrible thing to hear a
mob shrieking for one's blood. One feels like a cornered hare in the
face of yelping hounds. With the strength of desperation I clung to
the arm of Antonoff, who for all I knew might yield suddenly and
throw me to the crowd. Unworthy thought, for the man held me
firmly, all the time demanding that the people give room and let us
reach the car. When they saw me in the car their fury seemed to
redouble. "Daughter of the Romanoffs," they yelled, "how dare she
ride in a motor car? Let her get out and walk." Standing
 MEMORIES OF THE RUSSIAN COURT 275 up in the car
Antonoff repeated his commands that the mob disperse, and slowly
at first and then more rapidly we got away. We reached the distant
water front, and I was taken from the car to a ship. Picture my
astonishment when I found myself standing on the deck of the Polar
Star, the light and beautiful yacht on which I had so often sailed in
Finnish waters with the Imperial Family. With all the Imperial
property the Polar Star had been confiscated by the Provisional
Government, and it was but another sign of the changing times that
the yacht had later been taken away from the Provisional
Government and was now the property of the Soviets, being the
Zentrobalt, or headquarters of the Baltic fleet. From the deck I was
hurried past the open door of the main dining salon, once a place of
ceremony and good living, now a dingy, disordered apartment where
crowds of illiterate workmen gathered to dispose of the rest of
Russia's ruined fleet and the future of our unhappy country.^ At
least a hundred of these men were in the salon when I passed it
first, and during the five days I spent on the yacht their voices
seemed to go on In endless orations, ceaseless wrangling, twenty-
four hours at a stretch. It was like nothing I can describe, like an ill-
disciplined lunatic asylum. I was herded with the other "counter-
Revolutionists" far below decks in what I conjectured had been the
stokers' quarters. The stifling little cabins were filthy, like all the rest
of the yacht, and they simply swarmed with vermin. It was so dark
that night and day the electric lights burned, and I was thankful for
that because 'Finland had not then separated from the old Russian
Empire.
 276 MEMORIES OF THE RUSSIAN COURT somehow the
bright light seemed to be a kind of protection against the swarm of
grimacing, obscene sailors who infested the place, amusing
themselves with discussions as to when and how we were likely to
be killed. During the whole of the first night Antonoff stood guard
over us and warned the sailors that no murder could be done
without authority from the Soviet. Over and over again they
suggested that he leave the place, but he always replied firmly that
he was responsible for the prisoners and could not go. Finally
towards morning the sailors left, and afterwards we learned that
their blood lust towards us was not merely simulated. They had
gone directly from the yacht to the Petropavlovsk, the flagship of the
fleet, and had killed every one of the old officers left on board.
Antonoff left us early in the morning, left us expecting to return, but
he never did return nor did we ever see or hear of him again. Such
sudden disappearances were common enough even in those early
days of the Russian Revolution, before murder became the fine art
into which it has since developed. Five days we remained on the
Polar Star, very miserable in our vermin-infested quarters below
decks, but mercifully allowed part of each day in the open air. They
might have allowed us longer time on deck had it not been for the
hostile crowds that constantly thronged the quays. My time was
spent in the shelter of the deckhouse near the main salon, a spot
where in the old days the Empress and I loved to sit with our books
and work. Here five years before, when the Empress Dowager
visited the yacht, I had taken a photograph of her with her arm
around the shoulders of the Emperor, both
 MEMORIES OF THE RUSSIAN COURT 277 smiling and
happy in the sparkling light of the fjord. Every corner of the yacht
had been exquisitely clean and white in those days. Dirty as the
yacht's present crew appeared, I cannot say they starved their
prisoners or were cruel to them. We had soup, meat, bread, and tea,
luxurious fare compared to Peter and Paul. Our worst condition was
suspense of mind as to our ultimate fate. At every change of guard
we begged news from Petrograd, but always we received the same
answer. The Kerensky Government gave no reason or justification for
our arrest. Two of the sailors were especially friendly to me because,
as they explained, they came from Rojdestino, our family estate near
Moscow. "If we had known that you were going to be brought here,"
they said, "we might have done something. But now it is too late."
That night I found in my cabin a tiny note, ill-spelled and badly
written, warning me that all of us were about to be transferred to
the Fortress of Sveaborg in the Bay of Helsingfors. "We are so sorry,"
the note concluded. Although it was unsigned, I knew the note must
have been sent in kindness by one of the men from my old home.
But at the prospect of another imprisonment my heart turned sick
with dread. Next evening came Ostrovsky, head of the Helsingfors
Okhrana, accompanied by several members of the main committee
of the Soviet. Ostrovsky was a very young man, scarcely eighteen I
should judge, but he had fierce eyes and all the assurance of a born
leader. Turning to my nurse, to Mme. Badmieff, Erika the maid, and
her little Mongolian charge Aida, he said roughly that they were free
but that all the rest would
 278 MEMORIES OF THE RUSSIAN COURT be taken at once
to the fortress. In a sudden panic of alarm I threw myself into the
arms of my nursing sister and begged her to accompany me. But
she too was fear-stricken and drew back while all the men laughed
heartlessly. "What's the difference?" asked Ostrovsky brutally.
"You're all going to be shot anyhow." At which the dauntless Erika,
putting Aida into her mother's arms, came over to me and tucking
her hand under my arms said: "I'm not afraid. I'm going wherever
the doctor goes and I'll stand by you both." I gave the trembling
nurse a small box containing all the trinkets I had brought with me,
gave her messages to my father and mother, and followed my fellow
unfortunates to the deck, down a slippery gangplank to waiting
motor boats on which we traveled the half hour's journey from the
yacht to the fortress.
 CHAPTER XX SVEABORG before the War was one of three
principal naval stations of the Russian Empire, the other two being
Kronstadt and Reval, Sveaborg occupies a number of small islands in
the Bay of Helsingfors. The bay itself, shaped like a rather narrow
half moon, is so enclosed by these wooded islands that in winter the
salt water freezes solidly. In summer the islands are green and lovely
and a few of them, not under military control, are used by the Finns
as pleasure resorts. Even in the darkness and in the unfortuitous
circumstances of our arrival I could see that the main island might
be a very attractive place. Up a steep hill we panted, past a white
church surrounded with trees, and at last reached the place of our
confinement, a long, dingy, one-storied stronghold. A young officer
and several very dirty soldiers took our records, and Erika and I were
pushed into a small cell with two wooden bunks covered with dust
and alas, nothing else. The place smelled as only old prisons do
smell, and the only air came in through a small window high in one
of the walls. Wrapping ourselves in our coats, we lay down on the
hard planks and tried to sleep. In the early dawn we got up, our
backs aching and our throats choked with dust, but the Irrepressible
Erika laughed so heartily and sneezed so comically that I found it
impossible to lament our surroundings. The 279
 28o MEMORIES OF THE RUSSIAN COURT place was a
dreadful hole just the same, no proper toilet facilities at hand, and of
course no opportunity of washing, to say nothing of bathing. We had
to pay for our food at the rate of about ten rubles a day, at that time
no small amount of money. The food was not very bad except that
Stepan, the commissary, used to wipe our plates with a disgustingly
dirty towel which he wore around his neck, the same towel being
used in a laudable attempt to wipe the dust from our bunks.
Climbing on the bunks, we had a view through the window of a new
building going up, the workmen being women as well as men. At the
same time we got a glimpse of the detective Manoulloff who, ever
pessimistic, held up three fingers as an expression of his belief that
we had only that many days to live. We, however, ventured the
guess that we would not remain at Sveaborg more than a month. It
was a mere hazard but it turned out a fortunate one. We remained
just about a month. It was a queer life we lived during that month,
surrounded by tipsy and irresponsible men whose officers seemed to
fear them too much to insist upon discipline. The officers, especially
one fine young man, did everything they dared to make us
comfortable. After the first ten days our plank beds were furnished
with green leather cushions which might have made sleep a comfort
if they had not persisted in slipping from under us about as soon as
we dozed off. Somewhat later, a week perhaps before our liberation,
these cushions were replaced by real mattresses stuffed with
seaweed, wonderfully luxurious by comparison with the bare boards.
The prisoners were exercised every day in the open under Sveaborg
guards and the
 MEMORIES OF THE RUSSIAN COURT 281 gaze of a crowd
of Finnish Bolshevists. These people seemed at first immensely
div^erted by the pomposity of the Siberian doctor Badmieff who, in
his long white robe, tall cap, and white gloves was certainly a
curious spectacle. Soon they tired of him and turned their stolid,
expressionless eyes on the other prisoners with what intentions we
could only conjecture. Badmieff continued to be a center of interest
in the prison. Erika, his faithful disciple, demanded the privilege of
attending him, and this was granted. Every day he sat cross-legged
like the Buddha he so much resembled, dictating endless medical
treatises to Erika. In the evenings he used to put his lamp on the
floor at the foot of his bunk, strew around it flowers and leaves
brought from outside, burn some kind of ill-smelling herbs for
incense, and generally create what I assumed to be the occult
atmosphere of his beloved Thibet. Erika, scantily clad, always
attended these seances and gradually they appeared to hypnotize
the sailors, who thought highly of the doctor's professional powers.
Indeed towards the end I often heard them swearing that whoever
left the fortress, they would at least keep their highly esteemed
tovarish Badmieff and his Siberian-Thibetan lore. In sad contrast to
the condition of Dr. Badmieff was that of the poor editor. Glinka
Janchevsky, who being without money was treated with the utmost
contempt. Housed in a wretched cell covered with obscene
drawings, the miserable man spent most of his time lying on his
wooden bed wrapped up, head and all, in his overcoat. He used to
creep to our cell door with a glass of hot water in his hand begging
for a pinch of tea and,
 282 MEMORIES OF THE RUSSIAN COURT if we had it, a
little sugar. Every day he used to ask pathetically: "When do you
think we shall be let go?" Like all journalists, he was famished for
news, and whenever I got hold of a stray newspaper I used to read
it to him from the first column to the last. The vacillating conduct of
the Bolshevist sailors toward the prisoners of Kerensky I can only
ascribe to the increasingly bitter conflict going on between the weak
Provisional Government and the Bolsheviki. The sailors hated us
because we were "bourgeois," but they spared us because Kerensky
desired our destruction. The officers good-naturedly brought me
flowers from outside, an occasional newspaper, and even letters
from people in Helsingfors who knew my history and pitied my fate.
Sometimes I was even invited to tea with the officers, and twice I
was taken out of prison, ostensibly for examination, but really to
attend services at the little white church on the island. The guards
were rough and kind by turns, sometimes uttering horrible threats
against all the prisoners, sometimes bringing me a handful of the
wild flowers they knew I loved to have near me. Discipline was lax,
and we never knew from one day to another what might befall. For
example, the padlock to my cell got lost and for several nights the
door was left unlocked. One can imagine how I slept ! On one of
these unguarded nights the cell was invaded by a group of drunken
and lustful men. Erika and I fought them, screaming at the top of
our lungs, until a few sober and better-minded sailors came to the
rescue. A day or two later, when a rumor spread that we were all to
be hanged, I among the first, I for one felt less terror than relief.
Any 
 MEMORIES OF THE RUSSIAN COURT 283 thing, even
hanging, seemed better than this lunatic prison where the guards
drank, played cards, and wrangled all night, and where the men's
attitude towards Erika and myself, the only women, was by turns
dangerously savage and dangerously friendly. Besides the Kerensky
prisoners the fortress sheltered eight or nine prisoners charged with
crimes ranging from theft to murder. Some of these whom we
encountered in the exercise yard looked like very decent men,
shining perhaps by contrast with the rowdy Revolutionists I had seen
in the course of two imprisonments. For these unfortunates and for
the guards we bought cigarettes, thus establishing more cordial
relations. Nobody knew or could guess what was going to happen to
us. One day appeared the president of the Helsingfors Soviet, a
black-eyed Jew named Sheiman, who assured us that we were to be
sent back to Petrograd, and that we might as well have our things
ready by nine o'clock that night. Nothing happened that night, nor
did we, for some reason, expect anything. The next day Sheiman
came again with his bodyguard of soldiers and sailors, and told us
that his Soviet refused for a time to release us. It appeared that
telegrams had arrived from Kerensky and from Cheidze, the
Georgian leader in the Petrograd Soviet, urgently demanding our
return. The Helsingfors Soviet might have obliged Cheidze, but they
would not honor any demand of Kerensky's, so there we were. The
Provisional Government and the Petrograd Soviet sent over several
deputies, Kaplan, a small, blackbearded man, who smilingly told us
that there was no possible hope for us; Sokoloff, the famous, or
rather
 284 MEMORIES OF THE RUSSIAN COURT Infamous, author
in the first instance of Order No. i which was principally responsible
for the break-up of the army; and Joffe, the little Jew, who, a few
years later, became influential enough to be included among the
delegates to the Genoa Conference. After their visit, I don't know
why, prison discipline became still further relaxed. We had visitors
and the attention of physicians if we needed it. We were informed
that henceforth we would not be regarded as prisoners at all, but
only as persons temporarily detained. Two hours a day after this we
were allowed in the open air, and I became very friendly with the
Finnish women carpenters at work on the new building on our
island. These good souls brought me bottles of delicious milk, and
one day the building foreman, a Moscow Russian, invited me to his
house to tea, and here I, a poor prisoner, was treated with such
deference that I was actually embarrassed. Not one of the family
would eat with me or even sit down in my presence. At this time
Erika and I were given a more commodious cell furnished with the
seaweed mattresses of which I have spoken. But to our horror we
found the walls covered with the most frightful scrawls and pictures.
The sailor guards, however, brought water and sponges and with
many apologies washed off the disgusting records as well as they
could. I was thankful for this a few days later when all unexpectedly
I received a visit from my dear mother. It had been some days after
our parting at the frontier before she and my father learned that I
was in prison. Immediately they had gone to Helsingfors to appeal to
General Stachovitch, the Governor of Finland. But he
 MEMORIES OF THE RUSSIAN COURT 285 advised them to
avoid trouble for themselves, perhaps for me also, by going quietly
back to Petrograd. My parents gave him money for me, which I
never received, and despite the Governor's advice they stayed on in
Helsingfors in faint hope of seeing me. Dr. Manouchine, my mother
told me, had returned from a long visit in the Caucasus and was
doing what he could to get me released. My mother also gave me
news of the last struggle to maintain the army, the conflict between
Korniloff and Kerensky, ending, as everyone knows, in the death of
Korniloff. These two were about equally hated by the Sveaborg
sailors who would gladly have murdered them both. They had begun
to speak with unbounded admiration of Lenine and Trotzky,
especially of Lenine, who they declared was the coming saviour of
Russia. Bolshevism was in the air, and for a moment it assumed a
really benevolent aspect. I remember a deputation of Kronstadt
Bolshevists who came to Sveaborg to inspect us and to review our
entire case. Some of these men were very civil to me, asking many
questions about the Imperial Family and the life of the Court. At
parting one said to me naively; "You are quite different from what I
thought you'd be, and I shall tell the comrades so." The very next
day another deputation came and, characteristic of the confused
state of the public mind, these men were as brutal as the others had
been kind. They stormed down the prison corridors roaring: "Where
is Viroubova? Show us Viroubova !" I cowered in my cell, but when
the guard came and admonished me, for my own safety, to show
myself to the men I gathered courage to speak to
 286 MEMORIES OF THE RUSSIAN COURT them. Totally
unprepared to see the terrible Viroubova merely a crippled woman in
a shabby frock, the men suddenly quieted down and made civil
response to my words. "We didn't know that you were ill," said one
of the men as they prepared to move on. Although we did not know
it at the time, our fate really hung on the outcome of a Congress of
Soviets which was then being held in Petrograd, and to which both
Sheiman and Ostrovsky were delegates. Sheiman returned to
Helsingfors and visiting my cell told me that both Trotzky and
Lounacharsky were insistent on the release of Kerensky's prisoners.
That evening, he said, would be held a secret session of the
executives of the Helsingfors Soviet at which he would urge the
recommendation of Trotzky and Lounacharsky. If the executives
agreed the question would then be referred to the entire Soviet,
made up principally of sailors of the old Baltic fleet. That evening I
was invited to tea in the officers' quarters, and while sitting there the
telephone rang. "It is for you," said the officer who answered the
call. I picked up the receiver and heard Sheiman's voice saying
briefly: "The executive has voted unanimously for the release of the
prisoners." There was little sleep for me that night, but tired as I
was by morning, I greeted happily the unkempt cook and his messy
breakfast plate. All day I waited with the dumb patience only
prisoners know, and at early evening I was rewarded by the
appearance of Sheiman and Ostrovsky. "Put on your coat and follow
me," said Sheiman. "I have resolved to take you, on my
 MEMORIES OF THE RUSSIAN COURT 287 own
responsibility, to the hospital." To my nursing sister, who had spent
the afternoon with me, he gave orders to go to Helsingfors and wait
for further directions. At the prison gate Sheiman signed the
necessary papers, and hurrying me past two gaping Bolshevist
soldiers, he led the way down a bypath to the water. Boarding a
small motor launch manned by a single sailor, we started off at high
speed for Helsingfors. There was one bad moment when we
approached a low bridge occupied by a strong guard, but at
Sheiman's directions, uttered in a short whisper, I lay down flat in
the launch and we passed unchallenged. The first stars were shining
in the clear autumn sky as we reached the military quay of the town.
We ran in under the lee of a huge warship and stepped ashore.
There was a motor car waiting and the chauffeur, who evidently
knew his business, started his engine without a word or even a turn
of his head. Sheiman spoke only one sentence. "Tovarish Nicholai,
drive to — " naming a street and number. At once we were off, my
head fairly swimming at the sight of electric lights, shaded streets,
and people walking up and down. Turning into a quiet street we left
the car, all three of us shaking hands with the discreet driver. Bidding
Ostrovsky find my nurse and my small luggage, Sheiman conducted
me to the door of the hospital where a nice clean Finnish nurse took
me in charge and put me to bed in one of the freshest, airiest, most
comfortable rooms I have ever occupied. "Take good care of this
lady," were the last words of the President of the Helsingfors Soviet,
"and let no
 288 MEMORIES OF THE RUSSIAN COURT one intrude on
her." His words and tlie assured smile of the nurse were good
soporifics and I fell almost instantly into a deep sleep. Two days
later, September 30 (Russian), Sheiman came to see me with the
news that Trotzky had ordered all the Kerensky prisoners back to
Petrograd, and that he, Sheiman, had personally seen to it that my
nurse and my aunt, who was at that time in Helsingfors, were to
accompany me. Sheiman himself, and also Ostrovsky, who was
unfortunately very drunk, went with us in the train which left
Helsingfors that same night about half past ten. It was an
unpleasant journey, the prisoners being in a state of wild
excitement, and many of the red-badged officers more or less tipsy.
With my aunt and the nurse I sat in a corner of a dirty compartment
praying for the day to come. At nine in the morning we reached
Petrograd, and Sheiman, still solicitous of my welfare, escorted the
three of us to the Smolny Institute, once an aristocratic school for
girls, now the headquarters of the Petrograd Soviet. Here I had the
happiness once more to embrace my mother, who, with relatives of
other prisoners, waited our arrival. Many Soviet authorities were in
the place, among others Kameneff, a small red-bearded man, and
his wife, a sister of the renowned Trotzky. Both of the Kameneffs
were extremely kind to us, seeing that my companions and I had tea
and food, and expressing the hope that I should soon be out of
trouble. Kameneff telephoned Kerensky's headquarters asking leave
to send us home, but as it was a holiday nobody answered the call.
"Well, go home anyhow," said Kameneff, leaving the telephone, but
Sokolov stopped
 MEMORIES OF THE RUSSIAN COURT 289 us long enough
to make us understand that the prisoners all had to appear the next
day before the High Commission in the Winter Palace. I never saw
the Kameneffs agam even to thank them for their kindness, but I
read in the Kerensky newspapers that I was on terms of intimacy
with them and was therefore a Bolshevist. It was even stated that I
was a close friend of the afterwards notorious woman commissar
Kolantai, whom I have never seen, and that Trotzky was a familiar
visitor in my house. Thus ended my second term of imprisonment.
First I was arrested as a German spy and intrigant, next as a
counter-Revolutionary. Now I was accused of being a Bolshevist and
the name of Trotzky instead of Rasputine was linked with mine.
Hardly knowing what next was in store for me, I reported at once to
the High Commission. Here I was told that their inquiries concerning
me were finished, and that I had better see the Minister of the
Interior. At this ministry I was informed that I was in no immediate
danger but that I would remain under police surveillance. I asked
why, but got no satisfactory answer. Later I learned that the
tottering Provisional Government wanted to send me and all the
"counter-Revolutionists" to Archangel, but this move Dr. Manouchine,
who was still very influential, was determined to prevent. From my
uncle's house, where I had first taken refuge, I moved to a discreet
lodging in the heart of the city and from this place I never once in
daylight ventured out. This was in late October, 19 17, and the
Bolshevist revolution had begun in deadly earnest. Day after day I
sat listening to the sound of rifle shots
 290 MEMORIES OF THE RUSSIAN COURT and the putter of
machine guns, the pounding of armored cars over the stone
pavements, and the tramp, tramp, tramp of soldiers. Russia was
getting ready for the long promised constitutional convention which
turned out to be a Communist coup d'etat. Once in a while the
husband of my landlady, a naval man, came to my lodgings, and it
was he who gave me news of the arrest of the Provisional
Government, the siege of the Winter Palace, and the ignominious
collapse of Kerensky while women soldiers fought and died to hide
his flight ! The scenes in the streets, as they were described to me,
were appalling, and soon it was decided that my retreat was too
near the center of hostilities to be at all safe. About the end of
October I was taken by night to a distant quarter of the town to the
tiny apartment of an old woman, formerly a masseuse in my
hospital. Here came our old servant Berchik, keen to protect me
from danger, and here we stayed for a month, when my mother
found me a still safer lodging on the sixth floor of a house in the
Fourtchkatskaia, a cozy little apartment whose windows gave a
pleasant view of roofs and church steeples. There for eight months I
lived like a recluse, once in a great while venturing to go to church,
well guarded by Berchik and the nurse. The Bolshevik Government
seemed successfully established, and its policy of blood and terror
and extermination was well under way. Yet in my hidden retreat it
seemed to me that, for a time at least, I was forgotten, and my
troubles were all over.
 CHAPTER XXI PARADOXICAL though it may appear, the last
months of 1917 and the winter of 1918, spent in a hidden lodging in
turbulent Petrograd, were more peaceful than any period I had
known since the Revolution began. I knew that the city and the
country were in the hands of fanatic Bolshevists and that under their
ruthless theory of government no human life was at all secure. Food
and fuel were scarce and dear, and there was no doubt that things
were destined to grow worse long before they could, in any
imaginable circumstances, grow better. The wreck of the army was
complete, and while the war still waged in western Europe we, who
had had so much to do with defiance of German militarism, were
completely out of the final struggle. The peace of my soul was partly
born of ignorance, I suppose, the ignorance of events shared by
everyone not immediately in contact with the world catastrophe. I
was free, I lived in a comfortable apartm.ent, my dear father and
mother came daily to see me, and two of my faithful old servants
lived with me and were ready to protect me from all enemies. Also,
because the mind cannot fully realize the worst, I believed that the
Russian chaos was a temporary manifestation. I thought I saw signs
of a reaction in favor of the exiled Emperor. In this I was certainly
encouraged by two of the oldest and most prominent Revolutionists
known to the outside world, 291
 292 MEMORIES OF THE RUSSIAN COURT Bourtseff, a
leader among the old Social Revolutionaries, and the novelist Gorky.
It was in December, 19 1 7, if I remember correctly, that I learned
that Gorky was anxious to meet me, and as I preferred to keep my
small corner of safety as free from visitors as possible, I made an
appointment with the novelist in his own home, a modest apartment
on the Petrograd side of the Neva, not far from the fortress. Gorky,
whose gaunt feautures are familiar to all readers, is said to be a
sufferer from tuberculosis, but as he has lived many years since the
first rumors of this disease were circulated, there may be some
reason to doubt his affliction. That he is a sick man none can doubt,
for his high cheek bones seem almost to pierce his colorless skin and
his darkly luminous eyes are deeply sunken in his head. For two
hours of this first interview I sat in conversation with Gorky, strange
creature, who at times seems to be heart and soul a Bolshevist and
at other times openly expresses his loathing and disgust of their
insane and destructive policies. To me Gorky was gentle and
sympathetic, and what he said about the Emperor and Empress filled
my heart with encouragement and hope. They were, he declared,
the poor scapegoats of the Revolution, martyrs to the fanaticism of
the time. He had examined with care the private apartments of the
palace and he saw clearly that these unhappy ones were not even
what are called aristocrats, but merely a bourgeois family devoted to
each other and to their children, as well as to their ideals of
righteous living. He expressed himself as bitterly disappointed in the
Revolution and in the character of the Russian proletariat. Earnestly
he
 MEMORIES OF THE RUSSIAN COURT 293 advised me to
live as quietly as possible, never reminding the Bolshevist authorities
or any strangers of my existence. My duty, he told me, was to live
and to devote myself to writing the true story of the lives of the
Emperor and Empress. "You owe this to Russia," he said, "for what
you can write may help to bring peace between the Emperor and the
people." Twice afterwards I saw and talked with Gorky, showing him
a few pages of my reminiscences. He urged me to go on writing,
suppressing nothing of the truth, and he even offered to help me
with my work. But writing in Russia was at that time too dangerous
a trade to be followed with any degree of confidence, and it was not
until I was safely beyond the frontiers that I dared begin writing
freely and at length. I wish to say, however, that It was principally
due to Gorky's encouragement and to the encouragement of an
American literary friend, Rheta Childe Dorr, that I ventured to
attempt authorship, or rather that I undertook to present to the
world, as they really were, my Sovereigns and my best beloved
friends. My casual acquaintanceship with Gorky was naturally seized
upon by certain foreign journalists as evidence that I had gone over
to the Bolsheviki, and much abuse and scorn were hurled against "?
e. How little those writers knew of Gorky and his half-hearted
support of the Lenine policies ! He held an important office under
the Communists, it is true, and his wife, a former actress, was in the
commissariat of theatricals and entertainments. But no man in
Bolshevist Russia has ever been permitted more freedom of thought
and speech than Gorky. He has done things which would have
brought
 294 MEMORIES OF THE RUSSIAN COURT almost any other
man to torture and death, I know, for example, that he sheltered
under his roof at least one of the Romanoffs, and that the man was
finally assisted by him across the Finnish frontier. Gorky interested
himself also in the fate of several of the Grand Dukes, Nicholai
Michailovitch, Paul and George, who were arrested and later shot to
death in Peter and Paul. Gorky did everything in his power to save
these men, in whom personally he had no interest whatever. He
simply believed their murder to be unjustified, and it is said that he
actually induced Lenine to sign an order for their release and
deportation, but the order was signed too late, and the men were
brutally executed. At Christmas, 19 17, I had a great happiness,
nothing less than letters and a parcel of food from the exiles in
Tobolsk. There were two parcels in fact, one containing flour, sugar,
macaroni, and sausage, wonderful luxuries, and the other a pair of
stockings knit by the Empress's own hands, a warm scarf, and some
pretty Christmas cards illuminated in her well-remembered style. I
made myself a tiny Christmas tree decorated with bits of tinsel and
holly berries and hung with these precious tokens of affection and
remembrance. Nor was this the only Christmas joy vouchsafed me
after a year of sorrow and suffering. Under the escort of my good
old servant Berchik I ventured to attend mass in the big church near
the Nicholai station, a church built to commemorate the three
hundredth anniversary of the Romanoff succession. After the service
an old monk approached me and invited me to accompany him into
the refectoire of his monastery. I followed
 MEMORIES OF THE RUSSIAN COURT 295 him, a little
unwillingly, for one never knew what might happen. Entering I saw,
to my astonishment, about two hundred factory women who almost
filled the bare and lofty room. The old monk introduced me to the
women, and to my bewilderment their leader came forward bowing,
and holding in her outstretched hands a clean white towel on which
reposed a silver ikon. It was an image of Our Lady of Unexpected
Joy, and the kind woman told me that she and her fellow workers
felt that after all that I had unjustly suffered in the fortress I ought
to have from those who sympathized with me an expression of
confidence and good-will. She added that were I again in trouble I
might feel myself free to take refuge in the lodgings of any one of
them. Overcome with emotion, I could utter only a few stammering
words of thanks. I kissed the good woman heartily, and all who
could approached and embraced me. Knowing that I longed for
more tangible expressions of gratitude, the good old monk pressed
into my hands a number of sacred pictures and these I gave away,
as long as they lasted, to my new friends. No words can tell how
deeply I felt the kindness of these working women who, out of their
scanty wages, bought a silver ikon to give to a woman of whom they
knew nothing except that she had, as they believed, been
persecuted for others' sake. I needed the assurance that in the cruel
world around me there were those who wished me well, for in the
first months of the new year came one of the bitterest sorrows of
my life, the death of my deeply loved and revered father. He died
very suddenly, and without any pain, on January 25, 19 18, leaving
the world
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