Our CEU Approval Process is Broken

For all the progress we have made towards EBP, we would be sadly mistaken if we think our day of arrival is imminent. Course descriptions like the one below truly sadden me (www.barrettdorko.com). Poetry as an EBP alternative anyone?

Manually Managing Pain: The Use of Simple Contact for Neural Tension and Chronic Pain
Instr:  Barrett Dorko, PT
Simple Contact is an increasingly popular manual care technique that emphasizes the reflexive reaction of the body to gentle touch at specific sites. It begins with the premise that the body's own corrective processes are generally sufficient to produce enough mechanical force to reduce pain and normalize function. Since this process is unconsciously motivated, technique must support and encourage the patient's ongoing activity. This program provides instruction in manual care designed to assist in the correction of dysfunction secondary to abnormal neurodynamics and increased sympathetic tone. All lectures are supplemented with reference lists and essays written and previously published by the instructor. Exercise and stretching regimes to maintain correction are also demonstrated and provided in written form.

Among others, John Barnes certainly falls in this fringe camp as well. Well aware that some physical therapists are sufficiently gullible, I still find it hard to believe that individuals actually spend their own or their company's hard earned dollars attending these courses. The truly sad part is that CEU approval committees within our state professional associations are inclined to approve this garbage. By the way, I am entirely at a loss to figure out what these committees do. Do they ever reject anything? As far as I'm concerned, their sole purpose is collecting non-dues revenue for the professional association. I can hear the mantra now - "but it would be mean spirited not to include everyone". I have a hard time figuring out sometimes whether our primary professional objective is to be sensitive and all inclusive, or march towards a culture of EBP. To say the CEU approval process in the physical therapy profession is broken is as self-evident as the fact that there is standing water in New Orleans! My glass is always half full, and I will feel better tomorrow, but this makes me want to go back to bed.

Speaking of New Orleans (and other areas decimated by Katrina), our thoughts and prayers are extended to the countless individuals who have lost loved ones and/or experienced enormous loss of physical property. We had some friends that lived just blocks away from where the levy broke - their entire house under water. Stories like this are repeated hundreds of times over. The personal stories of loss circulating 24 hours a day around the news outlets give us all room to pause and reflect about what matters most in life. If you live in an area where evacuess are being sheltered, I hope you will take the time to pitch in as you are able. I have included a link below to the American Red Cross for those wishing to make a financial donation. We will recover, but I think there are few who would argue that we have just witnessed the largest natural disaster in our nation's history.

John

Comments

[Anthony Delitto]

After publishing the piece on remembering Jules, I thought I would remind you of something Jules wrote back in 2001 entitled Are You Financing a Sham?

http://www.ptjournal.org/September01/SeptemberEdNote.cfm

[Selena Horner]

The reasons that Dorko and others can have those types of courses approved for CEU are probably because:

1) the professionals registering for the course(s) as a majority are not demanding any type of evidence published in peer-reviewed literature or a list of references initially provided prior to registration as an importance that has to be met when we register, pay and attend any type of CEU

2) probably as a majority, professionals get interested in the semantics that they read with the course descriptions and don't really sit back and do any deep thought and questioning of the plausibility of what was just read and then some follow up investigating/searching to substantiate some of the claims made

3) money... some of the companies that "produce" (can't think of a better term) CEU may not really care about the actual quality or any proof that the course has a solid foundation from which what is being taught was built

4) and, technically, do we in our profession actually measure or somehow track how our outcomes change? Meaning - if I participate in a clinically relevant CEU, is anyone measuring my outcomes to see if my outcomes improved? Is the goal of continuing education just to snag hours OR is the goal of continuing education to actually impact the provision of our services to potentially improve efficiency and effectiveness?

[Jon Newman]

I take quite an interest in this post on multiple levels. I enjoy this blog as the posts are typically insightful. I also enjoy Barrett Dorko's thoughts on the treatment of pain for which we cannot detect pathology with confidence. Your characterization of me as being therefore gullible is Ad Hominem and I take exception to that.

You seem upset about the CEU system for which much course work could be criticized yet you pick on one person. That I don't actually mind as it your blog and you can do what you want. What confounds me is that you seem to disparage poetry therapy, a type of bibliotherapy, and yet you just engaged in it and do so regularly as evidenced by this blog. I'm willing to bet you even feel a bit better after posting. My personal opinion is that PT could use more in the way of medical humanities and learning what it has to teach us. What that has to do with what Dorko teaches as a 'technique' however is an extrapolation but you seem to equate the two(similar to how you link him to John Barnes).

Instead of trying to sully him with associations, why not just refute his basic premise? It seems much more constructive and maybe someone as gullible as I would benefit.

My understanding is that you've been invited to do just that on rehabedge on more than one occasion. If you didn't know, you do now.

[Carole Oser]

I just want to respond about the hurricane relief effort. We have donated to multiple agencies as we cannot imagine the conditions these people have had to contend with. We have offered to house people in our home. I encourage everyone to donate whatever they can to our own people. Remember the people and animals when you donate. I feel very fortunate right now. It is often easy to look at what you do not have until everthing is gone.

Carole

[Britt Smith]

John Childs,
Thank you for the post on CEUs. We at the Colorado Chapter of the APTA are trying to adopt a system of ranking courses sponsored by the chapter in terms of evidence for the courses presented. I have proposed a system like the SORT document from the American College of Family Physicians. We would like to get away from just ‘fund-raising’ with the courses and move towards promotion of EBP.
Comments to Jon Newman: First, It seems that EBP or EBM are not incompatible with the various approaches you propose in medicine: “Bibiotherapy” or “poetry therapy.” The proponents of these approaches to care should start to test the hypothesis that the interventions are, or are not, effective in treatment of a patient population. Not testimonials (John Barnes loves those from patients and PTs alike). I am not familiar with either form of care, but I don’t think the evidence that John Childs might “even feel a bit better after posting” will get very far with the Cochrane Library folks. Let’s see Barrett Dorko or John Barnes produce something substantial in the literature besides poetry (and I don’t think they’re listed in any registry of poets): Case Studies, Series of Case Studies, or, heaven forbid, an RCT, say compared to a sham treatment or head-to-head with another more orthodox approach. What I’ve read of some of these courses, I’m not sure that the presenters even approach biological plausibility for the interventions (e.g. bio-energy approaches?).
There is a movement in medicine, the ‘medical humanities and learning’, called ‘narrative based medicine,’ which seeks to affirm the substantial contribution narration or story telling plays in the history of, and practice of, medicine. Trish Greenbaugh, a prominent proponent of EBM from England, has edited a book by the same title (BMJ publishing) in 1998. The book is a good read, particularly, the chapter by the late Stephen Jay Gould on his own experience of illness and the process the diagnosis and prognosis from his considerable scientific perspective. Medicine is rich with narrative forms and we are immersed in narration every day we practice, through our patients’ histories and stories and our interpretation of the experience. Indeed, we are better clinicians if we are better story tellers (communicators); however, patients come to us for treatment, assurance and information and they rely on our skills & knowledge as well as our empathy and care. The communication is an attribute that is indispensable, but we must have something to say, with veracity and timeliness. The patient is best serviced by our being informed clinicians, not good poets and story-tellers.
Evidence-based medicine and practice is a narrative form. It is about asking an answerable question to the patients’ problems, finding the evidence for the answer and assessing and acting on the evidence: Incorporating the evidence in the patients’ care or informing the patients themselves. Simple story structure. I can cite several sources from the humanities that would support asking a question and seeking an answer (The evidence based form of practice):

I roamed the countryside searching for answers to things I did not understand.
Leonardo da Vinci (1452 - 1519)
You don't ask the right questions, you don't get the right answers. A question asked in the right way often points to its own answer. Asking questions is the ABC of diagnosis. Only the inquiring mind solves problems.
Edward Hodnett
The wise man doesn't give the right answers, he poses the right questions.
Claude Levi-Strauss
Good questions outrank easy answers.
Paul A. Samuelson
The real object of education is to have a man in the condition of continually asking questions.
Bishop Creighton
Judge of a man by his questions rather than by his answers.
Voltaire (1694 - 1778)
I would like to beg you, dear Sir, as well as I can, to have patience with everything unresolved in your heart and try to love the questions themselves as if they were locked rooms or books written in a very foreign language.…the point is to live everything. Live the questions now. Perhaps then, someday far in the future, you will gradually, without even noticing it, live your way into the answer.
Rainer Marie Rilke, Letters to a Young Poet

Selena is right. PTs are culpable for not seeking evidence and outcomes for the courses presented: Do the courses change my skill or knowledge set (measureable)? Do the courses improve my patient outcomes (measureable)? Do the presenters give adequate acknowledgement of the history of the intervention or is it plagiarism? Do the presenters present any scientifically valuable information for effectiveness (even biological plausibility) or or is the genre science fiction or fantasy?
Thanks, Britt

[Jon Newman]

Hi Britt,

I don't think I proposed anything about bibliotherapy or its relation to EBM. If you re-read my post you'll find that I found it confounding that John used "poetry therapy" (a particular type of bibliotherapy) to describe Barrett's course work (which is not poetry therapy or bibliotherapy) in a negative light yet uses bibliotherapy himself (as well as you). Strange how it can be a negative thing and a positive thing at the same time but more on that later. As long as we are on the subject of bibliotherapy and you seem to be in a position of influence I'd like to know why you think bibliotherapy is "incompatible" with EBM. There are 184 hits on Medline last I looked suggesting evidence of at least some level. Perhaps it might help if you expound on your concept of EBM a bit more.

A quick digression here. The fact that you bring up bio-energy fields is a good indication that John's associating trick is working as no pre-newtonian concepts are entertained in any course work I've been exposed to.

Back to the 'bad and good at the same time' issue. You mention "indeed, we are better clinicians if we are better story tellers (communicators)" but later say "The patient is best serviced by our being informed clinicians, not good poets and story-tellers." So now which one makes me a better clinician...being well informed or being a better story teller? Can't I be both? In the interest of evidence, why does being a better story teller or poet "work" (i.e. make us better clinicians)? Why does listening to another's narrative help that story teller (from an evidenced based perspective)?

jon

[Jon Newman]

Correction: Britt, I misread your post thinking you stated bibliotherapy "is incompatible" (not "is not incompatible") with EBM which I thought to be a bold statement. Sorry for any confusion that mistake caused.

jon

[John Childs]

Jon:

I appreciate your response. However, I have no intention of engaging in a back and forth discussion with Barrett (or anyone else similarly misinformed) on this topic. I have mistakenly gone down this path before on Rehab Edge, only to be reminded that the individuals on the other side of the issue are often far removed from anything that remotely resembles an EBP mindset. Discussion is pointless, analogous to the endless loops I frequently encountered writing programs in my first computer science class in college. Nothing personal, but you get nowhere fast debating pseudointellectuallism. Efforts are better directed toward individuals who are not so open minded to think that practice variation is a good thing and that we can all be right (most of our blog audience).

On a related note, the reason there is so much back and forth discussion at Rehab Edge is because
they cater to individuals wanting to share their exerpience
(hey, I didn't make this up - it's their tagline - despite this idea being the very antithesis of what EBP is all about). Back and forth discussions are also an incredible time sink. Given the low yield, it's simply not worth the opportunity cost - a book that I don't get to read with my kids, a missed snuggle time with my son, etc.

Incidentally, this is the reason we started the blog. High quality evidence can often specifically inform clinical practice without the need for incessant debate over obtuse theoretical
arguments that likely have absolutely no implications for improving the care of our patients. In fact, except in instances where we have no data available, we don't want to hear about one's experience. The blog is not about free speech. It's about channeling information that actually matters and can be used for the proverbial patient sitting in front of you tomorrow morning. Data, balanced within the framework of compassion and consideration of patient values, is king. There's plenty of high quality data currently already available that is not being reflected in our care. Achieving behavior change based on what we know to be fact is a formidable enough task. No EBP practitioner has time leftover for pedantic debates about issues that have never been shown to matter.

Jules Rothstein expresses my sentiments perfectly (or would it be more correct to say that I am probably reflecting here some of what I learned from him) in one of his editorials in Physical Therapy from 2001 (see previous comment from Tony Delitto who reminded us). I rest my case here, but thanks for sharing.

John

[Selena Horner]

Britt brings up a great point in regard toward steps in the right direction for clinicians who have a desire to play the CEU circuit. A case study or a series of case studies at least indicates a very reasonable attempt in my mind to bring the material into a peer-reviewed process.

To play the devil's advocate, for a clinician who's sole role is patient care and the stresses that go along with that kind of position at this day in age with a major focus on productivity there really isn't going to be administrative support within most organizations to assist that clinician, I would say there would be a high amount of fear for the clinician to potentially overcome (especially if that clinician has zero contacts known personally to be of assistance - it is difficult and takes a bit of courage to attempt to communicate to someone you don't know), there really isn't a "teamwork" kind of attitude between the clinical world and the academia world so there really isn't that much assistance to help a clinician progress along to have any study potentially published, and from a clinician's view - why go through the hassle of also learning the whole process involved with submitting (trying to do the right thing, but of course if you've never submitted there will be a ton of unknowns along with potential failure if submitted incorrectly).

So, technically, the whole idea of CEU rating or ranking or whatever does kind of loop right back to the whole process of having something published in a peer-reviewed journal. There are what I would view as definite barriers to clinicians out in the field who may be doing great and wonderful things but generally speaking I'd assume that those clinicians may not have the ability to team up with someone who has the knowledge and experience in submission to work with. I don't view it as an excuse per say, but enough of a barrier that some may just not want to even attempt OR if the clinician did attempt, there wasn't a positive, helpful experience gained.

[Jason Silvernail]

Well, less in the way of "sharing" and more in the way of "clarifying"...

It is a mistake to link Barrett Dorko's work and theories to John Barnes'. In fact, Dorko is a very vocal opponent of the Myofascial Release community as well as modes of care that are not biologically plausible.

Dorko's work (I haven't been to his course) centers around the rather large amount of basic science literature surrounding neurodynamics, neuromodulation, and ideomotor movement. I cannot defend the lack of outcome studies for his approach, but it should be noted that data at the level of outcomes research is the only place his approach is lacking. To equate it with energy medicine, reiki, or myofascial release is incorrect, and misleading to those who might get a better appreciation of the physiology of pain by reading his work.

I do agree that simply "sharing" uninformed views repeatedly over and over on a discussion board is not as valuable as far as changing practice as this blog, at least for me.
I do agree that the CEU system has run horribly amok, as well. Of note is that most other CE systems for other professionals shares similar downfalls. I don't believe we can tu quoque our way out of the obvious changes that need to be implemented, and holding CEU courses to some standard is a good start. The question becomes, what is an acceptable standard? Presence of outcome studies? At least one RCT? Or do we fall back to biologic plausibility? As bad as the CEU system is now, by creating standards for it, might we be making the problem worse?
In this case, specifically enriching some providers at the expense of others? Kickbacks for those on the approval committee?
J

[John D. Childs]

Jason:

I always appreciate your thoughts. You are correct that many of the same problems exist throughout our healthcare system.

To clarify, I am not linking Dorko with Barnes, other than to suggest that they both have been teaching for a long time and have had ample opportunity to contribute to the peer-reviewed literature. What has emerged? Absolutely zilch. How about starting with a case report? An RCT would cause me to experience an arrthymia, perhaps even MI resulting in suden death.

Cries of biologic plausibility are entirely insufficient (and completely irrational for that matter) in light of higher level studies that can accurately inform decision-making. There are many examples of effective interventions whose biologic plausibility may not be immediately clear. Perhaps even more relevant to the discussion here, there are countless examples of interventions that appear to be biologically plausible, yet are shown to be absolutely ineffective in outcomes studies. Biologic plausibility does not equate to biologic certainty. In fact, trials with negative results (yet whose interventions are biologically plausible) are far more common than trials demonstrating positive effects for the intervention of interest. This is exactly why outcomes study trump biologic plausibility any day of the week.

This crowd (Barrett is not the only one - it's a rampant problem in continuing education) routinely discounts higher level studies in deference to biologic plausibility. For example, Barrett like to speak of spinal manipulation as being almost a violent act. Arguments like this are preposterous (and even laughable when pondering for more than a few seconds). Much of the problem emanates from the dilemma that folks like Barrett and John Barnes would find themselves in should they adopt a more evidence-based perspective in their teaching - it would cost them financially and diminish their professional stature. However, any EBP practitioner would be the first to applaud such a transformation. However, I harbor virtually no hope that something like this would ever happen. The stark reality of our capital enterprise is this - where the potential for profit conflicts with informed decision-making, profits wins virtually 100% of the time.

Although there will always be "takers" (I've been there myself before, having to walk out of a couple of courses), I am optimistic that our programs are graduating professionals (we're by no means there yet) who will be less and less tolerant of the non-sense communicated across much of the continuing education circuit. Change is on the horizon.

John

[Jason Silvernail]

So I think the next pertinent question is, How might we change the CEU approval process to make it lean more toward providing education that is based in evidence and helps to reduce the variability of practice?

As usual, John, you make great and insightful points. I agree with everything you said. But regarding the issue of CEU reform, I have some concerns that cover more "rubber-meets-the-road" areas. I think we can all agree the CEU process is broken, but what's the fix? If we were to implement standards, where could we start such an endeavor? Any suggestions from anyone as to what a "good start" would look like?

I'm thinking of the IOC (Int'l Olympic Committee) and all the fraud and kickbacks that go into "deciding" who gets to host the Olympics. We can all remember the recent scandals. If we have standards for CEU provision, especially at the professional/ national level, aren't we creating our own little IOC?

Here again, we can agree to reject the craniosacral, reiki, and therapeutic touch, but what about other courses that aren't so easy to place into our neat little categories of "Based in Evidence" and "Not Based in Evidence". How much evidence is needed to justify charging and providing a course? One case series? One case report? One RCT, two?
Where, essentially, do we draw the line to make it a fair system?
Any takers on that one?
:)

J

[Selena Horner]

The levels of evidence that are commonly seen in medical journals could be used or adapted:

General Description of Levels of Evidence

Level I: Randomized trials or meta-analyses in which lower limits of the confidence interval for the treatment exceed the minimal clinically important benefit

Level II: Randomized trials or meta-analyses in which lower limits of the confidence interval for the treatment overlap the minimal clinically important benefit

Level III: Nonrandomized concurrent cohort studies (studies with one group receiving the treatment and a concurrent group not receiving the treatment)

Level IV: Nonrandomized historic cohort studies (a study where outcomes from patients receiving a treatment are compared with a historic group with different treatment method)

Level V: Case series without controls

Cut and pasted from Medscape and this reference: Guyatt GH, Cook DJ, Sackett DL, Eckman M, Pauker S. Grades of recommendation for antithrombotic agents. Chest 1998;114(suppl):441S-4.

Maybe instead of the hours of the continuing education course determining the value, the level of evidence determines the value. If there is no evidence, there is no defined value. (Just because something has no defined value doesn't mean that the course can't be taught - it just indicates that the folks taking the course don't receive any credit for the experience or knowledge gained.) The greater the amount of evidence, the greater the value. As evidence for the various courses occurs, well, the value should alter to reflect the changing evidence.

Is it the time spent in continuing education courses OR is it the quality/value of the continuing education course that is more relevant? It also has to be kept in mind that the probability of having a lot of high quality levels of evidence in physical therapy are going to be quite low. So... there has to be some way such that the level of evidence is determined keeping that in mind while at the same time fitting in such that it is reasonable for therapists to meet state regulated requirements (which means that quality and value may need to be tossed out the window because "hours" is typically what is probably defined as what needs to be met or maybe there could be some sort of way to come up with some calculation of sorts determining the "hours" granted). And then from a political view and from a monetary view - what party will be responsible for reviewing the information provided to determine the value and how much will it cost?

[Jason Silvernail]

Selena-
I see where you're going, but you have essentially paraphrased my real nuts and bolts question in your last statement.

If we use your proposed system, just for the sake of the argument, then where do courses reviewing basic science or literature relevant to our practice that does not include a testable intervention fall?
For example, if we used your system, we could not get CEUs for:
1. anatomy reviews via cadaver lab
2. current data in soft tissue healing mechanisms
3. courses covering the physiology of pain
4. Clinical Instructor certification via the APTA
5. Pharmacology
and funnily enough:
6. Statistics and concepts of Evidence Based Medicine
:)
Are these not important things for PTs to know? Do they not deserve study?

If I stand to make a good bit of money by teaching a course, would I not be well advised to bribe the committee responsible for determining appropriateness? How about conflicts of interest, let's say a prominent lecturer or researcher is also on that committee? Even if I were teaching Therapeutic Touch, could I get my course approved if I covered the large amount of evidence regarding the physiology of pain and possible mechanisms of pain relief to be wrought with manual care? How much evidence and how much technique could I teach to be correct and qualify?

I'm honestly not trying to be argumentative, but seeking to go beyond the rather obvious statement that the system is broken, and address possible mechanisms of relief. It seems to me these "devil in the details" questions are why the system is the way it is now (ie quantity, not quality of courses).

Isn't any proposed mechanism of determining quality just the Thought Police? As much opinion as fact to base the decision? How is that fair and/or moving us forward?
J

[Selena Horner]

Well, courses like 1, 3,& 6 would predominantly be "refresher" courses. Maybe "refresher" courses fall into the current type of system we now have. Those types of courses aren't proporting to offer an approach to interventions.

Courses like 2 & 5 could potentially have some type of level of evidence. Medications always have to go through clinical trials and current data on tissue healing indicates some type of study occurred, hence it wouldn't be current.

So, instead what you do is... set it up similar to what the NATA does. I just submitted my CEU online with them and I should remember the specifics, but they have I think 4 different sections in which CEU can be gained. No, it's not the perfect system either because quality of the course isn't considered.

I was mainly addressing the CEU geared toward practitioners that offer treatment approaches. But, yes, there is a whole realm of type of CEU - reviewing manuscripts, authorship, presenting, attending APTA CSM or annual conferences.

I don't view determining quality necessarily as "thought police." If the specific criteria are set and a course meets the preset criteria, well, it seems kind of black and white to me. The problem is in having a panel of some sorts actually agree upon the criteria. But I would tend to think that once something like that was hashed out, a potentially simple "met" and "not met" check box system for the defined criteria along with evidence provided for anything in the "met" category might be a good start. The course instructors for that matter could fill out a form like that and let the "thought police" verify that what was provided is adequate and then establish the level of quality/CEU.

I think something with criteria would move us forward a lot better than what is currently in place.

[Jason Silvernail]

I agree.
The issues surrounding who sets the criteria, who determines what fits what criteria, who enforces this, and who stands to gain/lose from such decisions monetarily, are important issues that I hope do not get lost in the shuffle.

Given the low overall membership of professional associations, and the most common reasons for not joining being financial, will such a CEU rating system raise licensure dues to a greater extent then they provide value to the clinician?

J

[John D. Childs]

Jason/Selena:

Good discussion all the way around. I would defer back to one of Britt Smith's ealier comments with regard to CEU reform. Colorado (where Britt lives) may end up being the model for the rest of the country. He has the right idea for how to operationalize change.

John

[Jon Newman]

Along the same lines as the comments of Jason is that a course that is supplying essentially all RCT and systematic review data is providing information that is not difficult to interpret or apply to practice and hardly warrants a course. At least not one I'm interested in spending my time and money on when I can do lit searches or look at sites like this one and rehabedge for free and from the comfort of my own home.
It's the application of basic sciences that require interpretation and, for me, makes for an interesting course. In a sense, those who keep up with the literature would subsequently be 'punished' by being forced to go to what is easily accessible and interpreted.

Selena,
I would disagree that a course in pain physiology is a "refresher" course. It seems to me that there is no standard pain curriculum in PT school and much our understanding of pain physiology has been done in the last 10 years--much of it is not taught while I was in PT school I would wager that many PTs' understanding of pain physiology begins and ends with gate theory and that they equate pain with wound state or biomechanics which would be an error (although they are associated).

[Jon Newman]

Sorry about that last sentence, I was distracted. It should have read:

...the last 10 years--much of it was not taught while I was in PT school. I would wager that many PTs' understanding of pain physiology begins and ends with gate theory and that they equate pain with wound state or biomechanics which would be an error (although they are associated).

[Debby Heiss]

I have to step into this discussion for 2 reasons: 1) Ohio has approved Barret's course from 12/04 to 12/05; and, 2) I am well aware of the CEU approval process in Ohio. You are correct that the system is flawed if these courses can be approved, but it is not necessarily all at the level of the CEU approver. First, because of concerns about the quality of the CEU approval process, the Ohio PTA changed the way courses were approved. We now have 2 paid reviewers who are PTs with strong clinical and education backgrounds - they do an incredible job - and I am often told about the content/nature of the courses that were turned down. It is amazing what people will try to sell as a CEU course. Second, we worked very hard in the past 3-4 years to revise our policies, procedures, and application requirements to be more stringent. Effective Jan 05, applicants are required to provide at least 5 references published within the past 7-10 years to support the course content - these can include textbooks as well as journal articles. Presenter must provide their qualifications to teach the material (abbreviated CV).
So, how could this course by Mr. Dorko be approved?
Well, we have wanted to make the criteria even more stringent but we are limited by our state practice act (and directions from our board) as well as the difficulty in evaluating the quality of the course beyond what is provided on paper. Mr. Dorko most likely could produce 7-10 references - maybe they would be from the neural tension literature, I don't know. Not all areas of PT practice lend themselves to randomized controlled trials, so where do we define the cut off for the quality of evidence as others have alluded?
So, please be patient, our CE approval process is one of the most rigorous - but we have limitations. It takes a concerted effort on many fronts to elevate the practice of physical therapy. In addition, if we want to discuss educational issues - I am aware of a number of programs that teach myofascial release, craniosacral therapy, etc... so, this problem is much bigger than CE courses.
However, I love this blog and it encourages me that things are changing.

[Jon Newman]

I've been to a one day course by Barrett Dorko. The course manual had 42 citations in the reference list. Although I suspect that some of the references you'd have no problem disparaging as non-educational.

Along the the lines of some of the previous suggestions one could label the type of course. Some examples would be

1. Basic science course
2. Outcomes course
3. Theoretical perspectives
4. Technique mastery

I think there is value in all of these types of courses. The usefulness in labeling would help a consumer avoid going to a theoretical perspectives course when what they wanted was an outcomes course. I think this makes sense and solves much of the 'problem' unless your intent is to define what is education is in a 'big government' sort of way.

jon

[John Childs]

Debbie:

Thanks for you input. CE courses are indeed just one small aspect of the problem. There are not enough hours in the day to begin a discussion regarding the quality of our educational programs, some (perhaps many) of which employ a woefully ill prepared faculty. An eternal optimist, our profession continues to evolve for the better, but we have a long ways to go.

Part of the problem with the CE process is that we have become deluded into thinking that having a reference list somehow equates to evidence-based practice. This is pure non-sense, when the bulk of the references consist of textbooks, other non-peer-reviewed literaure, or primarily evidence based on biological plausibility. The term evidence-based practice has been so overused that it has lost its meaning entirely.

An all out assault on all fronts is required to achieve behavior change that is consistent with current best evidence, a far cry from what is currently modeled in many of our educational programs and CE courses. I have personally given up gentle persuasion. Leadership is about understanding the future, then inviting others to come along and join. An eternal optimist, more are more leaders are stepping up and showing the way. Naysayers are welcome to sit on the sidelines. However, you will become an isolated fringe of the profession and get left behind.

Life is short, so we'd better get busy.

John

[Jon Newman]

High re-definition of ebm is no better than low re-definition. Regardless, what EBM has to do with the CEU process is confusing to me.

Are you suggesting that every CE course has to be about EBM? What about ethics courses; a requirement for liscensure in WI?

Isn't EBM something that happens in the clinic more so than in the classroom?

jon