On Mastery

By Seth Peterson, PT, DPT, OCS, FAAOMPT

“I don’t know how they can sleep at night.” I was getting chewed out in a hallway in my first year of residency training. My mentor was speaking in general terms, but it was painfully clear that “they” meant me. I had just seen an 11-year-old girl with an ankle sprain. I had given her a painful balance exercise in standing (because the evidence showed it was more effective) and we had talked about pain neurophysiology, which was cutting-edge at the time. Her problem with what she’d just witnessed was that, despite me applying “evidence-based care,” she hadn’t really seen me apply that care to the individual. She hadn’t seen me think.

Looking back, my lack of thinking about the interventions was made worse by the fact that I was doing so much thinking about the simple things. While my mentor was thinking about the words used to greet someone and deciding what mattered to that person on that day, I was focused on how to sequence an ankle examination. I was focused on the basics—and the basics were something they did unfailingly well. Using the conscious competence learning model, you could say I was at a stage of “conscious incompetence” while they were well into the “unconscious competence” stage. Another way to say it is they had “mastered” the basics, while I was just beginning to grasp them.

Mastery is a topic I’ve continually returned to over the course of my career. I’ve always loved seeing people who are amazing at what they do. I loved watching Kobe Bryant, even though I grew up in Minnesota and regretfully call myself a Timberwolves fan. But it’s not just sports. I love watching violinists, chess masters, and even those viral videos of restaurant workers who can chop vegetables in the blink of an eye. I think I just love marveling at what human beings can accomplish.

In 2020, I did a short podcast series called Masters in Motion in which I interviewed a list of 12 living physical therapists that were influential figures in the 20th century. I emphasized clinicians since I was disturbed by what I saw as some of the best physical therapists leaving the clinic for other roles. I thought (as I still do) that such an exodus is problematic for the profession. I’ll admit that my orthopedic background also influenced my choices. Nonetheless, I was able to interview people like Stanley Paris and Shirley Sahrmann. I wanted a historical record of the careers of these physical therapists, but I also wanted insights into how they developed their expertise. I wanted to know if there were things about their journeys that we could all implement.

There were a few common themes, but one of them was pretty striking. Although these were people who had achieved a lot in their careers, they were still integrating new knowledge into their practices. For example, Michael Moore and Gregg Johnson, both still seeing patients in their 70s, talked about going to continuing education courses and learning new things. When discussing their fears about the next generation, many of them said they didn’t see the same passion in new physical therapists. Almost without exception, that passion was ignited by seeing another physical therapist do something amazing. This pattern may be best exemplified by the following quote from Tim Fearon:

“I found myself exceedingly bored and I found the profession to be exceedingly boring. Then I went and saw Stanley Paris…and I realized after being in Stanley’s class for a day that the problem wasn’t the profession, the problem was me—the professional who wasn’t professional. Stanley said more in one day than I learned in all my years of PT school. Then I remembered Rick Bowling and Dick Erhardt, thinking, ‘You heard it in this class, but you saw it there.’ That’s what I want. I want to be that guy that makes a change with patients.”

Episode after episode, this pattern emerged. Clinicians who witnessed someone at a later stage in their development making a change with a patient in front of their eyes. This recognition of a high level of skill in someone else lit a fire in them that lasted their entire careers. Just like what happened after Roger Bannister broke the 4-minute mile, seeing someone do things you can’t do yourself opens your eyes to what is possible. If that person is in the same field as you, it signals that you still have work left to do.

How Excellence Affects Us

One of the concepts in psychology that I’m most interested in is that of “flow.” The term was coined by researcher Mihály Csíkszentmihályi to describe what he was observing with high-performing individuals in a variety of professions.¹ It is a mental state associated with a pleasant feeling (sometimes referred to as being “in the zone”) that occurs when there is immense focus on the task, a loss of reflective self-consciousness, a sense of control over the situation, and a sense of time distortion.¹ It’s Lebron James seeing movement on the basketball court before it even happens and making the perfect pass without even thinking. It’s the absorption that an artist feels when totally focused on their work. But it’s also just as common—if not more so—at work. One longitudinal study found workers experiencing flow were 500% more effective.²

Oddly enough, occupational therapists have already written about flow in their own profession. In 1994, occupational therapists in a study reported experiencing a “flow” state about 5 times per week and described the feeling as being “happy,” “creative,” “excited,” and “proud,” among other things.³ The experience most often happened when an intervention was being applied.³

The thing is, if the task you are doing is perceived as easy, it is impossible to attain a flow state. What you have is a state in which you are bored. If it is too challenging, you can end up in a state of frustration. The experience of flow seems to be present when the task is challenging enough to warrant a high level of focus, but not so challenging that the individual lacks a sense of control. It also requires knowledge about the task and the ability to gain feedback. I would argue that “master clinicians” are more likely to attain flow states during their workday since they are more likely to be adept at gaining feedback on what is working, have knowledge about where to start, and probably have greater mental bandwidth to focus on the present moment. That being said, it is clear that flow can be achieved no matter what stage one is in their career.

Now, let’s look at the other side of the coin. Early in their careers, physical therapists often report suffering from “imposter syndrome,” in which people doubt their competence and have a sense that they will be exposed as “frauds.”⁴ While it might seem like a good idea to assure physical therapists that their job isn’t that hard, I believe this has the potential to backfire. For one, we know that there is a negative relationship between perceived over-qualification and work-related well-being.⁵ In other words, feeling that your job is easy makes you feel less satisfied, not more satisfied. Instead, work climates that encourage seeking of mastery make employees more likely to stay at their jobs.⁶ People want to be challenged to improve, to have something to strive for. The process of ongoing improvement can be intrinsically rewarding. In fact, one of the recommended ways to manage imposter syndrome is to encourage more intrinsic motivation, particularly through structured mentorship.⁷

What Mastery Looks Like

Mastery in physical therapist practice is probably different than what you’re imagining. A study by Linda Resnik and Gail Jensen explored the idea of expertise in physical therapy based on patient outcomes, finding those with the best outcomes had certain characteristics.⁸ They were more reflective, they delegated less often, used collaborative clinical reasoning, and promoted patient empowerment.⁸ They also tended to be humbler and had a love of clinical care.⁸

A more recent qualitative paper by Michelle Kleiner and colleagues identified several characteristics of a “good” physical therapist: responsive, ethical, communicative, caring, competent, and collaborative.⁹ One thing that stands out is that the emphasis here, like the research by Resnik and Jensen, identified mostly relational skills as being hallmarks of “goodness.” However, note that “competence” is still one of the key factors. I’m sure we all know physical therapists who are “nice,” yet lose patients when they exhibit poor handling of a painful body part or think all scapular pain is coming from the rhomboid muscle. Now think back to the physical therapists you’ve seen who you recognize as exhibiting expertise. Chances are, they also demonstrated great relational skills, although they may not have consciously recognized it.

The Death of Expertise

Despite the fact that striving toward mastery can be intrinsically rewarding and has the potential to improve patient care, there seems to be an undercurrent of doubting expertise in physical therapy. Some will make the case that it is only the rote application of science that matters, that being a physical therapist is not challenging, it can be easily figured out, and everyone gets similar results with their patients. In fact, as the critics say, those claiming to be experts are no different from anyone else—only more arrogant.

This sentiment is eerily similar to that discussed by Tom Nichols in his book “The Death of Expertise,” expanded from an earlier paper.¹⁰  In it, Nichols makes the argument that the sentiment of “anti-intellectualism” has permeated through life in the United States.¹⁰ Among other things, he blames the educational emphasis on self-esteem for contributing to widespread overconfidence in one’s abilities.¹⁰

There is of course the problem of who declares themself an expert. In a 2023 viewpoint in The New England Journal of Medicine entitled “Protecting the Legitimacy of Medical Expertise,”¹¹ the authors highlight a 1902 Supreme Court Case in which the Court found in favor of The American School of Magnetic Healing, which was initially prohibited from distributed mailers claiming to offer “cures.”¹¹ In the Court’s opinion, Justice Peckham wrote that the school’s “fraud” was merely a matter of opinion, since cures could not be objectively proven.¹¹ While this idea has since been beaten back, it is a stark reminder that medical nihilism can exist at the highest levels of American society.

We found a similar problem in our review of continuing education courses in orthopedic and sports physical therapy.¹² Despite low back pain being one of the world’s most challenging conditions to prevent, there was a course (approved by state associations) claiming all low back pain could be blamed on one muscle: the quadratus lumborum.¹² No doubt, there are still physical therapists out there teaching courses that are complete nonsense. So, what is a person to do? How do you actually recognize mastery and move in that direction?

What Might a Path to Mastery Look Like?

I’ve had a while to consider this question, and I keep returning to decision-making research. In that field, there is a certain tension between psychologists and economists. Economists are always striving for efficiency and effectiveness. They might argue for the “maximization” of choice, i.e., finding the “best.” Psychologists sometimes argue that the constant pursuit of “best” is sometimes impossible and can be detrimental to mental well-being in situations where “best” is undiscoverable. Instead, psychologist Herbert Simon has argued that we should be simply looking for “good enough,” as most organisms do, and recognize better when it comes along.¹³ Over time, you can continually improve, much like someone learning to improve their practice and moving up the rung of expertise.

When you attend a course or listen to someone speak, I think a good approach is to ask “what is this person doing that is better than what I’m currently doing?” Maybe how they handle the patient’s neck while providing overpressure looks more comfortable. Maybe it’s how the person uses their words to guide a patient. Maybe you see this person provide the gentlest manual therapy technique. Maybe you notice them soften their voice and dim the lights when seeing a person with a headache. I would urge people to look for the simple things. Look for what Kleiner and Resnik have identified as hallmarks of expertise. Does this individual have those traits? It’s also possible that someone can be amazing in certain domains, but mediocre in others. Take what they do well and ignore the rest.

In writing, there is an idea that someone needs to write until they “find their voice.” However, there is a growing recognition that “your voice” is just a mishmash of things other people have done that you have assimilated into your own style. Maybe clinical practice—and developing mastery—is a bit like that. We don’t need to be aspiring to one “ideal,” but we do need to be aspiring to “better,” whatever that looks like to you.

There is danger in pretending that mastery doesn’t exist. Not only do I believe this idea is wrong, but it sacrifices long-term career fulfillment in order to create a short-term boost in someone’s self-esteem. If there is a more widespread nihilism, it could also lead to physical therapists providing sub-optimal care or even leaving the profession altogether. I also don’t think “mastery” is some endpoint to be achieved. Yo-Yo Ma once said he was halfway through a “perfect concert,” something to which he had always aspired, before realizing it was the most boring concert he’d ever done. You could say that he “mastered” the cello, but that he also realized there was no such thing as perfect. Yo-Yo Ma wasn’t saying that skill was an illusion or that his years spent chasing perfection were wasted, just that he got there and realized that a different approach was better. I think physical therapy is the same. There is no such thing as “perfect” or the “best.” But it seems to me very obvious that “better” is everywhere around us—if you look for it.

REFERENCES

1. Csikszentmihalyi, Mihaly (1990). Flow: the psychology of optimal experience (First ed.). New York: Harper Collins. p. 39. ISBN 9780061339202.
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4. Furtado M. Assessment of Academic Resilience as a Non-Cognitive Variable in Entry-Level Doctor of Physical Therapy Students. J Allied Health. 2022;51(3):189-197.
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7. Hoang, Queena (January 2013). “The Impostor Phenomenon: Overcoming Internalized Barriers and Recognizing Achievements”. The Vermont Connection. 34, Article 6.
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10. Lederman, Norman G.; Lederman, Judith S. (2014-01-17). “The Death of Expertise”. The Federalist. 25 (6): 645–649. Bibcode:2014JSTEd..25..645L. doi:10.1007/s10972-014-9398-8. S2CID 146447547. Retrieved March 25, 2017.
11. Baron RJ, Coleman CH. Protecting the Legitimacy of Medical Expertise. N Engl J Med. 2023;388(8):676-678. doi:10.1056/NEJMp2214120
12. Peterson S, Weible K, Halpert B, Rhon DI. Continuing Education Courses for Orthopedic and Sports Physical Therapists in the United States Often Lack Supporting Evidence: A Review of Available Intervention Courses. Phys Ther. 2022;102(6):pzac031. doi:10.1093/ptj/pzac031
13. Simon, Herbert A. (1956). “Rational Choice and the Structure of the Environment” (PDF). Psychological Review. 63 (2): 129–138. CiteSeerX 10.1.1.545.5116. doi:10.1037/h0042769. PMID 13310708. S2CID 8503301