Below is the text from a talk I recently gave via Skype at the PPS Graham Session this weekend in Charleston, SC. I unfortunately was unable to attend due to a last minute military deployment. Many thanks to Steve Anderson and the Graham meeting participants (and as I understand it, was record attendance and a terrific meeting) for allowing me to be there virtually via Skype to deliver my talk. As always, it's a genuine privilege to be in the same room (whether face-to-face or virtually) with friends and colleagues who are members of the greatest profession on Earth.
John
Delivered via Skype on Saturday, Jan 14 at the recent PPS Graham Session in Charleston, SC
Despite positive reforms in physical therapy education in recent years including the transition to a doctoral level education, clinical education has lagged. Physical therapy clinical education remains a highly fragmented and ill equipped system, marked by an inefficient 1:1 student to instructor format consisting of several short duration clinical affiliations, which leads to disjointed, highly variable, and non-collaborative learning. If we are going to be a meaningful contributor to health care reform and more importantly, play a prominent role in the reform process, we must hurriedly wake up from our delusions of grandeur, embrace the fact that we have a deep chasm in clinical education that must be closed, and wholeheartedly distance ourselves from the status quo.
The current physical therapy clinical education system leans heavily on a ‘barter arrangement’ completely dependent on the altruism of clinical practices at the sheer mercy of the academic program. For example, the short duration of the average clinical affiliation combined with the Interns’ limited skill set mitigates their potential to become a productive, value added member of the staff. Clinical resources are inefficiently expended to help the Interns learn the various systems, documentation standards, billing procedures, etc., only to have the student move on to their next clinical affiliation immediately after their useful assimilation into the practice. In short, the indirect costs for clinical practices to provide clinical education under the current model are steep and bothersome. Other than altruism, it is curious how academic programs have been successful in affiliating with clinical practices at all. Yet, in our typical peace gene like fashion, we oblige the “predatory” behaviors of academic programs who have duped us into believing that it is our professional duty to provide free clinical education for students while the academic program rakes in substantial tuition dollars during clinical affiliation semesters for which the academic program provides virtually no services!
Before I offend those of you in the audience who are on faculty in an academic program (ok, I probably already have!:)), think about this with me for a moment in practical terms. As educators in entry-level academic programs, we sit in many a faculty meeting debating the pedagogical pros and cons of adding “ABC” content, taking away “DEF” content, dedicating more time to topic “X”, less time to topic “Y”, etc. In fact, many of our curricular “experts” even get passionately defensive when making such arguments. You should see some of the heated debates that ensue when it comes to determining what content should be included in the didactic phase of physical therapy education! As a result, our students tend to progress through a highly organized and systematic curricula during this phase, evidence by a detailed schedule and syllabus. Nothing is left to chance. For example, it’s no mystery to the student as to what books they need to buy, what time they need to be where for what class, and what content to review prior to each class. We diligently measure student performance through countless rigorous written and practical exams. What strikes me as most odd then is why we don’t appear to be bothered by the lack of a clinical education curriculum that you can "touch and feel". For example, can a single DCE in the country tell me what content their students are learning on week 4 of their clinical education experience? How about week 18? What about week 23? Unfortunately, the default strategy for clinical education hinges on a “hope and prayer” strategy in which we send our students out into widely disparate learning experiences with little to no connectivity between clinical sites or even to the academic program. We then sit back and “hope and pray” that our students have a good experience. Think about the lunacy of our current 1:1 model with me for just a moment. Even the most highly capable clinical faculty do not have the depth and breadth of knowledge and experience necessary for a comprehensive clinical education experience. By the way, if we are to achieve meaningful reform in clinical education, clinical faculty must have the same faculty status and privileges of full time core faculty, if not higher!
Complicating matters, there are only 3 prerequisites for qualifying as a clinical instructor in our current model. First, you must have a PT license. Second, you must have a heart rate and pulse. Third and final, you must not be in a coma. If you meet these 3 criteria, you will be inundated with requests from DCEs around the country to affiliate with their program. Lest you doubt me, just ask any DCE how many contracts he or she attempts to manage under the current system. Most will answer somewhere between 250-500 contracts, yet the program is only able to assign 1 or 2 students each year per location in most cases. Therefore, the DCE inefficiently spends countless hours managing affiliation agreements with practices that take very few students in aggregate over time. As a result, the clinical education sites are rarely connected to each other in an organized way and frequently even remain at an arm's length from the academic program, tethered only by the clinical affiliation agreement. You don’t have to be an ISO 5000 certified quality engineer to understand that quality assurance across this many educational experiences is impossible.
Fundamentally, the potential transformation of physical therapy clinical education is dependent upon the ability of academic institutions and clinical practices to align themselves in a symbiotic relationship that delivers mutual benefit and value for all stakeholders. The medical model of clinical education has long proven useful in the training of residency-trained physicians. Interns would train collaboratively in group settings rather than a far more narrow learning experience that occurs when you only have 1 clinical faculty member. We should foster the development and evaluation of a standardized internship curriculum that leverages online learning management systems and team-based learning to deliver a consistent learning experience regardless of location. In other words, we need to “crowd source” clinical education so that the full “universe” of knowledge is available to them, not an isolated slice. One could even envision a matching process whereby students are competitively matched to specific residency programs…the right student to the right clinical education experience at the right time, the results of which would further incentivize quality and standardization and create a win/win/win proposition for students, educational programs, clinical practices, and most importantly, the patients to whom we provide care.
Finally, it’s an outrage that our graduates currently have debt that is completely out of proportion with their ability to recoup their investment. As it currently stands, there is no compelling economic argument to pursue a career as a physical therapist because of the inability to achieve a return on investment that justifies the necessary debt burden of the average student. Unfortunately, academic programs are in a negative incentive situation when it comes to such reform because students currently pay tuition to their academic institution while completing their clinical rotations, creating a veritable cash cow for the academic program, yet the academic program provides few services during this period. In fact, I routinely advise students that when their DCE calls them during their clinical affiliation to check in on how things are going, they should make the DCE stay on the phone for at least 100 hours to even begin recouping the value of the investment of tuition dollars the students have poured into the program.
We must disruptively innovate within clinical education to attract the best applicants into our profession, many of whom currently pursue careers in medicine instead. Similar to the medical model, students should attend physical therapy academic programs for didactic learning experiences, graduate once that component is finished, sit for licensure, and immediately begin a formal internship/residency lasting a minimum of 1 year. Interns would receive a modest stipend in exchange for receiving a high quality standardized training program delivered under the auspices of a credentialed graduate medical education system that adheres to rigorous accreditation and quality standards. Migrating the preponderance of clinical education to the post professional, post licensure setting would shorten the typical academic program by 1/3 (2 years rather than 3), trimming tuition accordingly.
In summary, we can no longer justify clinical education being relegated to 2nd class citizen status, and surely such a low view is inadequate for the contemporary Vision 2020 physical therapist. We are starting to see some innovative internship models emerging, such as those at the University of Pittsburgh, MGH Institute of Health Professions, the US Army-Baylor Doctoral Program in Physical Therapy, and Rocky Mountain University, among others. However, the rate at which the transformation is happening is far too slow. Fundamental reform of clinical education is critical for guiding the future of physical therapist education, and the immediate possibilities for such reform are real and tangible. In doing so, clinical education can be transformed into a collaborative and highly effective experience that will serve to elevate the role of the physical therapist in our health care system. Disruptive innovation is needed…and needed fast!
