The Second Leg:The Second Leg:Clinical ExpertiseClinical Expertise

June 14, 2007June 14, 2007

Clinical Expertise DefinedClinical Expertise Defined

Clinical expertise:Clinical expertise: the ability to use the ability to use clinical skills and past experience to clinical skills and past experience to rapidly identifyrapidly identify each patient's unique health state and each patient's unique health state and

diagnosisdiagnosis individual risks and benefits of potential individual risks and benefits of potential

interventionsinterventions personal values and expectations personal values and expectations

APA EBPP DefinitionAPA EBPP Definition

Relevant issues:

1)Experts v. novices

2)Heuristics and biases

3)Cookbook formulation

4)Competency v. adaptive knowledge

Components of Clinical Components of Clinical ExpertiseExpertise

Assessment, diagnostic judgment, systematic case formulation, and treatment planning

Clinical decision making, treatment implementation, and monitoring of patient progress

Interpersonal expertise Self-reflection and life-long learning Evaluation of research evidence in basic and

applied psychological science Understanding individual and cultural differences

and their effects on treatment Seeking available resources Having a cogent rationale for clinical strategies

Clinician BiasesClinician Biases Motivated reasoning: people more Motivated reasoning: people more

skeptical when processing skeptical when processing information they don’t want to information they don’t want to believe (Ditto et al, PSPB, 2003) believe (Ditto et al, PSPB, 2003)

fake saliva test indicating presence of a pancreatic enzymefake saliva test indicating presence of a pancreatic enzyme

Evidence Evidence that that

Clinical Clinical Skills are Skills are ImportantImportant(N=248 (N=248

consecutivconsecutive patients)e patients)

(Wahner-(Wahner-Roedler, et al., Roedler, et al., J Eval Clin PracJ Eval Clin Prac, ,

(2007).(2007).

Clinician “semantic space” of DSM-II-R Axis I and Axis II disorders

Herkov & Blashfield (1995) – hierarchical structure of diagnoses in personality disorder

Shedler & Westen (American Journal of Psychiatry, 2004)Clinician concepts of PDClinician concepts of PD

National sample of 797 experienced psychiatrists National sample of 797 experienced psychiatrists and clinical psychologists (18.1 postgrad years)and clinical psychologists (18.1 postgrad years)

Pick a patient or respond to a ‘hypothetical’Pick a patient or respond to a ‘hypothetical’ Sort statements into 8 piles from least descriptive Sort statements into 8 piles from least descriptive

(0) to most descriptive (7)(0) to most descriptive (7)

Blashfield and Flanagan Blashfield and Flanagan JNMD, 1998JNMD, 1998

““age= 38, gender = female, marital status = single.” (*1*)age= 38, gender = female, marital status = single.” (*1*)““A 38-year-old woman was brought to an emergency room after attempting to kill A 38-year-old woman was brought to an emergency room after attempting to kill

herself by jumping in front of a subway train. (*2*)herself by jumping in front of a subway train. (*2*) The woman had flat affect The woman had flat affect and spoke matter-of-factly during the interview. She said that the driver of the and spoke matter-of-factly during the interview. She said that the driver of the subway train had been her lover and that a major fear of these drivers was subway train had been her lover and that a major fear of these drivers was that someone would leap in front of their train in a suicidal act. (*3*) that someone would leap in front of their train in a suicidal act. (*3*) This This lover had recently stopped seeing the woman after his wife learned of his lover had recently stopped seeing the woman after his wife learned of his affair and the wife had physically beaten up the patient in a nightclub. (*4*)affair and the wife had physically beaten up the patient in a nightclub. (*4*)

The patient is an obese women of at least 250 pounds who works at a mortuary. The patient is an obese women of at least 250 pounds who works at a mortuary. She has been employed at the mortuary since the death of her mother.(*5*) She has been employed at the mortuary since the death of her mother.(*5*) Her mother and father were divorced when the patient was 15. Initially, the Her mother and father were divorced when the patient was 15. Initially, the father won custody, but, when the patient kept running away from him, she father won custody, but, when the patient kept running away from him, she was permitted to live with her mother. (*6*)was permitted to live with her mother. (*6*) She and her mother were very She and her mother were very close. The mother contracted cancer, and the patient took care of her until close. The mother contracted cancer, and the patient took care of her until her death. Then the patient requested a job with the mortuary that buried her her death. Then the patient requested a job with the mortuary that buried her mother. (*7*)mother. (*7*)

Until recently, the patient had had no social life outside the mortuary. However, Until recently, the patient had had no social life outside the mortuary. However, while riding the subway, she became fascinated with the voice of one driver while riding the subway, she became fascinated with the voice of one driver and was determined to learn about this man. (*8*)and was determined to learn about this man. (*8*) She took leave from her She took leave from her job and managed to learn who the driver was, what his schedule was, and job and managed to learn who the driver was, what his schedule was, and where he lived. She approached him and they became lovers. (*9*)”where he lived. She approached him and they became lovers. (*9*)”

Previous distributions of PD diagnoses

Diagnosis when presented in steps

Therapist (Treatment) SkillsTherapist (Treatment) Skills(Bennett-Levy et al (2006) (Bennett-Levy et al (2006) Behavioural and Behavioural and

Cognitive TherapyCognitive Therapy))

DeclarativeDeclarative MethodsMethods TechniquesTechniques

ProceduralProcedural ““When-then”When-then” ““How-to” (e.g., reflection, empathy)How-to” (e.g., reflection, empathy)

ReflectionalReflectional Key to skill developmentKey to skill development

Expert and Novice TreatersExpert and Novice Treaters(Eells et al, (2005), (Eells et al, (2005), JCCPJCCP))

Expert, experienced, and novice txExpert, experienced, and novice tx Expertise in psychotherapy is “ill structured” Expertise in psychotherapy is “ill structured”

rather than “well-structured” as in chessrather than “well-structured” as in chess Psychodynamic and CBTPsychodynamic and CBT ““Think aloud” case formulations of standard Think aloud” case formulations of standard

casescases Experts’ formulations were more elaborated, Experts’ formulations were more elaborated,

comprehensive, complex, and systematiccomprehensive, complex, and systematic Experts treatment plans more directly tied to Experts treatment plans more directly tied to

case formulationscase formulations Effect size medium-largeEffect size medium-large

QuestionQuestion

If you were doing a study evaluating the If you were doing a study evaluating the relationship between therapist expertise relationship between therapist expertise and therapy outcome, how would you and therapy outcome, how would you measure expertise?measure expertise?

If you were doing a study evaluating the If you were doing a study evaluating the relationship between therapist expertise relationship between therapist expertise and the therapy experience (viewed by the and the therapy experience (viewed by the patient), how would you measure patient), how would you measure expertise?expertise?

What does the literature What does the literature say…say…

About the relative importance of About the relative importance of therapist, treatment, and patient therapist, treatment, and patient variables in predicting outcome?variables in predicting outcome?

Is there any empirical data on the Is there any empirical data on the implications of therapist expertise implications of therapist expertise findings for education and training?findings for education and training?

How can supervision be structured to How can supervision be structured to enhance development of expertise?enhance development of expertise?

Research NeedsResearch Needs(APA, 2005)(APA, 2005)