How productive are our academic programs???

This paper published in the mose recent issue of PTJ is a really nice barometer on the state of scholarly activity in PT academic programs in the US. The message is not surprising, primarily we still have a long ways to go. We can tell all sorts of stories about why and why not, but the bottom line is that a very small number of programs are generating the overwhelming majority of scholary activity, with plenty of programs (roughly 50%!!!) doing next to nothing.

We must do better, and the only way it will happen is to see consolidation or elimination of lower tier programs, expansion of the better ones, or creation of new and innovative mega programs. It's simple math, economies of scale, and environment. As long as we continue to train students "red hat society" style (ie, average class sizes of 30-40), we severely limit our opportunity to evolve as a profession. We should be seeing 100+ students per class. If top tier programs will take the lead and solve the tution crisis by graduating students after the didactic phase of training same as medical school (CAPTE, it's coming one way or the other), which effectively cuts tuition by 1/3, the small programs (except perhaps for underserved areas where right or wrong there might be a niche) will dry up as well they should, not to mention solving virtually every other problem in PT education at the same time (need for expansion of residency training, compliance issues in our current pre-profession clinical education model, and a whole host of others.).

Per usual, just laying out the issues here for the sake of generating discussion, whether you agree or not. I suspect the first volley will be educators coming to the defense of their sub-par PT academic programs and how they do everything else so well (in particular being nice to students and making sure they dress professional and wear a pressed, short white jacket in the clinic). We can figure out from the number of comments should how many academicians will hide behind the transparency of a blog and do their venting in a closed community like the Education Section listserv where they will find many consoling colleagues in their educational AA circle.

Admittedly pointed as usual but never personal. Thoughts?

John

Comments

[David G]

I'll bite. As a current PT student at a Division I school (we didn't make the top 14 I'm sad to say), I am exposed to and can learn from some great researchers and teachers. It was my choice to attend here based on two factors - cost, and where I am thinking about going (eventually into teaching and research).
I ruled out two schools I was accepted to not because they were poor quality, but because I wasn't going to have the opportunity that I have had here (and it would have cost me at least 2x as much).

But what the other schools offer that mine currently does not is service learning, to our detriment I think (we are only exposed to patients in clinicals and once or twice each quarter in the 2nd year).

Just because a school is not producing academic work does not mean they suck and should either get their act together or get out. Isn't EBP the big thing, the buzz word, the Great Idea, the One Thing? If they are
doing EBT and making sure we are doing EBP, and are passing on the idea
of giving a damn about those who can't afford healthcare, are they any
less of a program than one who generates research and teaches it, but doesn't pass on other things? Doesn't the APTA code of conduct or whatever it is called recommend such a thing? (which begs the question, how many APTA members either do that, or even know that the document
exists?). Sorry, but I would have to disagree with you. You can't judge
a program based on how many times their articles have been cited. I think they should be judged based on the quality of the student (research is important, yes, but not as the sole criteria).

(as a side note, in the publish or perish atmosphere of DivI, the ability for a PT to practice to any good extent is virtually nil due to teaching and research expectations, at least with an n=1 where n is the number of schools I have observed).
David G, SPT

[Carina Lowry]

Well,

I have a few comments. First I do not agree with you David that those programs not putting out the research take better care of their students. I have been affiliated with 3 of the programs on the top 15 list in one way or another (as student, affiliated faculty, or clinician volunteer). I have seen first hand that these programs are very student-based erstwhile pumping out research. As these authors alluded to, it is critical that it starts at the top with specific expectations for research and publishing.

I also disagree with you John that we should have 100+ students per class. This is not only pragmatically difficult, but also may contribute to poor learning on behalf of the student. I know that even with a class size of 40, teaching manual skills and manipulation is difficult without clinicians from the community coming in to volunteer their time to teach or teaching through a fellowship program. I am fairly certain that CAPTE recommends one instructor per 10-15 students when teaching manipulation. Therefore if we want our students to have the best manual skills, it is essential that we have community involvement with the fellows and manual therapists to support the faculty teaching manips. Otherwise it will continue to be the same story--50% of the schools out there do not teach manipulation. Only 2 of 6 programs in Chicago teach manips at entry level.

So class size aside, I also think it is extremely important that a distinction is made as to clinical research versus benchwork research. Each has its own difficulties and each is important in it's own way. Yet I think that it is very important that a true academic publish in BOTH clinical research and basic science research. Our profession should acknowledge the basic science researchers in our profession...the work can sometimes take many years to fully study and publish anything even remotely comprehendable. That said, 75% of the programs had less than 5 publications over 5 years...which means that we need a culture change in our academic institutions and maybe even more collaboration. I do find it interesting the point the authors made of if the program is affiliated with a medical school or institution that there was greater percentage of publications. This tells me that we need research farms in our academic settings, and we need it soon.

Carina

[John Childs]

Carina:

I appreciate your concerns regarding class size, teaching skills, etc., however I envision the vast majority of clinical hands-on content being shifted to post-professional clinical education. When physicians graduate from medical school, they essentially know how to do a basic physical exam and have some very general practice-related skills. For all practical purposes, they are clinically incompetent for any single area of practice, hence why residency training pursued at such high rates. We need the same model in PT, and I think we'll see it happen in the next 10 years. The days of 1:1 clinical education model that relies on very fragmented networks of loosely affiliated clinics (the average program maintains 300+ contracts for 30-40 students!!!...this is patently absurd) has to stop. We need post-professional, group-oriented, standardized, collaborative clinical education a la the medical residency model. Until we have this, we will not see a dent in the gross practice variation that exists in PT.

John

[Richard Zaruba]

I'll make a couple comments about medical education. I have taught in the medical school curriculum, particularly in the first two years of the curriculum and I am familiar with the content of the next two. The first two years are straight didactic with some brief clinical observations, the second two years are a cross between didactic and clinical, and this includes exposure and basic practice for evaluation and treatment in several different areas during their rotations. The Medical School curriculum is not four years of didactic education. There is a significant clinical component to medical education before a physician receives their MD degree. Our current PT curriculum is actually very similar to the Medical School curriculum that is in place for the degree phase.
What I believe is lacking in our current model of physical therapy education are the internship and residency phases of the education. This is my own opinion, but I believe we should look to expanding our education to include an emphasis on advanced training and with a scope of practice similar to what is being considered in Ontario (http://www.opa.on.ca/pdfs/in_the_news_app_in_ontario.pdf) as well as developing programs dedicated to training individuals to conduct the appropriate research for our field to grow. This would allow physical therapy to truly provide comprehensive care in primary care practice as well as justify the effectiveness and need for our services.
I also agree with Carina in the idea that the expansion of programs to 100+ would actually reduce the quality of the students produced. I strongly believe that putting quality before quantity in education is paramount to achieving continued advancement.

Rich

[John Childs]

Rich:

Good comments, and I appreciate the fact that medical school is not 4 years of didactic. The point is that physicians (at least the 95% of them that pursue residency training) do not pretend competence in their particular profession until after completing a residency, which implicitly suggests that their clinical training during medical school is not intended as such. Rather, it's much more competency focused, as opposed to our model of "once your licensed you're good to go at anything in PT". This is just not a tenable presumption in light of the rapid maturity of our profession and growing evidence to support our practice. We're a long, long ways from being the technician who got patients up out of bed to walk.

I agree completely with you regarding the need for expanded residency training, so long as it's post-professional. Academic programs rake students over the coals by forcing them to pay tuition to an educational institution that delivers virtually no services during the last 1/3 of their program, primarily the clinical education component. We have to get a handle on tuition and eliminate all of the compliance issues associated with students billing 3rd party, Medicare, etc. Care needs to be provided by licensed personnel, however green they may be.

I continue to disagree that large class sizes will equate to worse education. There is simply no data to support this, particularly in a collaborative learning model that is beyond the 100 students sitting behind a desk getting Power Pointed to death. Obviously faculty sizes would be much larger to accommodate the scale. The fact that medicine has only 110 programs with roughly 6 times the number of physicians (or some ballpark multiple to this), while we have 200+ programs just doesn't pass any common sense test that I am aware of.

Great discussion and one worthy of good debate.

John

[John Ware]

John,
Given that current health care practice is not by and large outcomes/results driven, don't you think that the derth of medical schools may be due to the medical educators' efforts to control the numbers of doctors in order to keep salaries up? I don't want PT schools to come at it from a labor union sort of approach, as the medical schools apparently do, to limit PT's into the market.

I tend to agree with you, though, that class size doesn't matter when it comes to didactic learning. This is a red-herring perpetuated by public school educators and unions to keep the demand for teachers strong and reduce their workload.

Throughout my education, I've had good and bad of both large and small classes. It's the instructor that makes the difference, not the size of the class.

[Carina Lowry]

John et al.

Well, I agree with you that the basic science can be taught in large classroom scale. However I still think that the problem may lie when the student gets out into the clinic to perform their residency and can't perform a thorough enough hands on evaluation to determine if the problem is a shoulder vs cervical problem. I am sorry to say but I see this quite often in family practice medicine referrals who are supposed to have a basic skill set as well as orthopedes who are supposedly more advanced with "expert skills" in differential diagnosis.

The problem I see is multiple fold:

1. The average PT student has no clue (or relatively no clue) as to which area of practice they want to pursue directly out of PT school. Thus they may be "residency trained" in an area they don't continue to practice in. There needs to be, in my humble opinion, a certain quality of clinical experience before a clinician pursues residency/fellowship.

2. If we truly want to state that manipulation should be an entry level skill set into the profession, then we should teach it as such. This is one of the basic arguments we use to counter chiro pressure to require 1000's of hours to be able to manipulate. If we do not feel that it is a basic entry level skill, then concede to the chiros and form Masters of Manips programs like they have in Australia so that we can have truly skilled professionals, not people who learned how to do a skill over 2 days. If it is an entry level skill, then treat it as such and provide the faculty necessary to really get our students up to par with manips and place them in clinicals where manip is utilized. From the last numbers I saw, most PT's go into orthopedics, so I would think that having strong orthopedic skills taught would be beneficial here.

3. The residency model in med school is very guru-based from what I have seen at the teaching hospital where I work. It is based upon how the mentor trained the student and this affects their practice--both clinical decision making and surgical technique. I can only see the disaster when we turn these nice little green students out to all of the different theories of how to manage pain (as has been extensively discussed in myofascial pain on this blog).

4. Realize that there are PT's who don't go into orthopedics...and that's ok too. Move them on to something else and offer residencies to their strengths.

5. Realize that some students are best as basic researchers. Encourage them to pursue PhD programs, hopefully one in a medical center with large numbers of faculty publications and strong in the basic sciences.

6. By increasing class size, we increase our numbers and forces. However I am still a little skeptical of the private practice model. I think that if everyone hung a shingle, then we would have the PT on every corner...and thus higher defaults on student loans...similar to another profession.

Just a few more thoughts...

Carina

[Richard Zaruba]

By collaborative model I am assuming that you are referring to the "Patient Centered Learning" model that is now in vogue. There are several draw backs to that model of learning that would need to be addressed. I have taught at the University of North Dakota in the traditional model, during the transition, and after the implementation of this model. There is a notable difference in the student produced by both models. The "Traditional" model produced students with a very strong base in basic sciences from which to draw ideas and reason with. The "PCL" model produces students that are very good at looking up information and applying EBP but sometime lacking the solid base from which to reason through the haystack to find what is relevant. I would love to see a curriculum which implemented the best points of both systems, but no one that I know of has found that combination yet. Regardless of which model is utilized they are both faculty intensive regardless of the size. This is particularly true in the clinical laboratories where regardless of the size of the class one on one instruction is often needed. Also, our field suffers from many of the same problems that other allied health fields do. You can make more money in the clinic with much less hassle and aren’t expected to earn a PhD. The other drawback is that the larger the school which houses the program the greater the pressure to publish and research, and teaching is a “distraction” or “hindrance”. This is an even larger problem when the program is housed in a medical school where the pressure is even greater. The larger schools which would be required for classes of that size are some of the biggest “publish or perish” enforcers. Also prevalent in our current system of education is the disconnection of the faculty from current practice in the clinics, I can name a number of examples where the faculty have not practiced in the clinic for a decade or better, but are the senior faculty directing course/curriculum development. I believe if we could address these issues headway could be made, but even within the medical school system these are overwhelming problems, how would you suggest we address them in a manner which is practical, efficient and possible.

Rich

[Andy Sotirokos]

I've read with interest the recent discussions on the medical model of education and requiring residencies. I completely agree with John when it comes to cutting the last year of tuition out of PT programs. My last year at Pitt ('05) was entirely in the clinic with almost no contact with the university. To their credit, we did get a stipend, but that didn't even allow us to break even on tuition. My problem with the idea is that if we can't ensure quality clinical sites in the current model, where are all these residents going to be training at? I'd even go so far as to question the quality of some of the current residency programs. While some are bound to be better than others, graduates from one institution in particular that some of my classmates and I have come into contact with demonstrate clinical skills surprisingly lacking and with a disapointing use of evidence backed treatments. So I guess my point is residencies are a great idea, but unless you find an adequate number of qualified mentors, does it really make a difference?

[sean]

Carina,
I think you missed part of John's point which you need to do a little reading beetween the lines to get. That is if we close some programs, and expand others, the faculty from the closed clinics will come to the larger ones. Let's assume for argument's sake that they CAN teach manipulation, et al, you just have 8 lab groups of 12-14, instead of 4.
John Childs,
you have a great idea. But until Medicare allows students to treat patients like med students and residents do, your idea is not plausible.
From a personal note, my program was extremely poor regarding ortho treatments. The program director was a neuro researcher and did a very good job as a professor, in addition to participating in research regularly.
Our program was very strong in neuro at the time... which is great if that's what you want to do. I draw from this experience that we really need to have CAPTE rate programs on their areas of focus in addition to accrediting them. Following this up with the standard clinical experience, then providing the opportunity to get paid as a fellow would improve our colleagues immeasurably. but like I said above, we have to get Medicare on board first.

[Jess Brown]

Carina -
I'm not sure that I agree with your first point. The current medical model expects their students to have a good idea of their preferred practice area after the end of their didactic education. I think that it is reasonable that we expect the same of PT students. Also, if an MD decides they wish to pursue another area of practice, they often pursue residency in that other area. I would think that this would be applicable to the PT residency model of the future.

I agree with Sean in that I don't think that any of this is feasible until CMS starts paying facilities for services rendered by PT students.

Any thoughts on how the smaller PT schools are going to accept being closed or merged with larger programs?

[Carina]

Jess--

I think that it would be an interesting study to see how many new grads switch practice areas within the first 3 years. Myself, I switched 3 settings in my first 3 years, and still am unsure that I am really a PT after 4 additional. :-) From what I have seen the average PT switches settings quite often, but we don't actually know if this is because they are trying to find a job or trying to find which setting best fits. So I think to enforce that the PT has to pick one and only one and stay with that may not be reflecting the current state of PT.

Sean--yes, I guess I did miss reading between the lines there. So if you and others are advocating closing programs, how do you set the standards by which to say the program must close down? What criteria would you use?

Carina