Wisdom in Practice: Conceptions, Perspectives and Development

Helders, in a 2003 editorial, acknowledges the continued interest in measurement of patient outcomes and at the same time calls for investigations of the patient care process itself (1). ‘‘You have to know and understand the care process itself in order to improve it.’’ As we continue to grapple with increased pressures for evidence in support of physical therapy interventions (treatment), we need to carefully examine our assumptions underlying physical therapy interventions and ask ourselves critical questions: What is a physical therapy intervention? To what extent, if any, is the physical therapist part of the intervention? What meaningful evidence do we seek in support of considering the therapist part of the interventions? If we assume that physical therapy interventions are defined by reimbursement guidelines and coding schemes as procedures, modalities and techniques, we limit our ability to create a dynamic theoretically responsive knowledge base. I offer this critical reflection on our work as physical therapists by drawing a page from another applied field, teaching. One of my mentors, Dr Lee Shulman, President of the Carnegie Foundation, in a recent book of essays on teaching, reflects on his work on investigating the knowledge base in teaching (2). He argues there are several areas of knowledge in teaching, including content knowledge, knowledge of pedagogy (teaching), curriculum knowledge, knowledge of learners and knowledge of the organizational context, and he proposed a new category of knowledge / pedagogical content knowledge. Pedagogical content knowledge (PCK) is a special amalgam of content and pedagogy that is unique to teaching. Shulman asserted that it is insufficient to merely distinguish between a teacher having content knowledge and knowledge of teaching methods, that there was something else happening in the actual act of teaching and that PCK represented a signal of a missing component in theories of teaching. The concept of PCK then became a symbol much like a new piece of furniture in the living room and as such created many opportunities for changing the landscape in educational research (2). We need a new piece of furniture in our physical therapy living room. While there are many categories of our knowledge base in physical therapy from foundation sciences to clinical and applied sciences, we perhaps overlook or take for granted what might be uniquely ours as physical therapists. If we accept the assumption that the therapist is indeed part of the physical therapy intervention, then we could also argue in similar fashion that there is specific knowledge embedded in the minds, thoughts, actions and interactions of therapists as they interact, touch, teach, facilitate movement through manual techniques, exercise and guide their patients toward improving function. Just as with PCK and teaching, is there part of our knowledge base that is uniquely the province of physical therapists and a special form of professional understanding? How would we discover and uncover such knowledge? I suggest that this is best done by putting on our research agenda serious investigations of the wisdom of practice. The practical wisdom and knowledge of practitioners of both experts as well as promising young novices is an important source of such knowledge (3). What counts as evidence in support of good practice cannot only come from randomized, controlled clinical trials of technical interventions. We need to remember that good science begins with observations, which lay the theoretical foundation and determine the conceptual parameters of the discipline. Qualitative research is an essential tool for this exploration (4). As a profession, we are theory poor, lacking conceptual models and frameworks that assist in linking theory and practice (5). I urge us to look around our living rooms of practice and see if we can describe a new piece of furniture that is uniquely ours.