Now, we PT students are ready to be interns and take on true application of knowledge in a clinical setting. We all pay a god-awful amount of money for our schooling (well except for Army-Baylor), but why is that some of us will walk away from our clinical internships ready and equipped while some won't feel ready to enter the professional world? I would be pissed if I walked away from three years of training and $100,000-$250,000 deeper in debt (dependent on school) and I didn't feel I got enough training. A student's clinical education is most important part of professional education, whether it is medicine, nursing, PA, or PT. If the clinical education is the most important, then why are PT students given such intricate didactic structure then thrown to the "clinical wolves" to fend for themselves to literally get the most for their money? Some of us travel internationally, some across multiple states, and some just travel down the road to our respective clinical sites. Most of us have never met our Clinical Instructor (CI) before and have no idea what to expect from our CI.
The kicker is that our clinical education faculty has never met our CI either, so it is completely unknown what the learning experience is going to be; well it is known what type of setting, but that is about it. Clinical education faculty don't have time to visit every 200+ sites that many schools "boast" about.
The 1 on 1 model is a failing model. The model especially fails with the much longer clinical internships for Doctor of Physical Therapy students. It doesn't take much time until the student gets "their own" caseload while their CI also has their own caseload. The intern is now a source of revenue for the clinic and the CI is getting nearly double the billable units (this is a whole other bag of worms). How is the PT intern supposed to learn critical clinical reasoning when the intern and CI's mind is too preoccupied with paperwork and each seeing their own patients. Don't get me wrong, learning to juggle patients and paperwork is an important real world aspect of PT, but it doesn't take a year long internship to learn this aspect. Additionally the model fails because the standardization process is a joke; the clinical performance instrument (CPI) basically determines if the PT intern is safe and communicates with patients through a series of very repetitive questions. Also, many can agree that there are PT's that vary on the spectrum of greatness; Shockingly, there are CI's that vary on the spectrum of greatness. Where's the standardization in this?
The PT clinical education model across the nation is due for an overhaul. A doctor level degree deserves a doctor level of education from beginning to end. The wheel does not need to be reinvented, just give it some studs.
16 comments:
Johnny-
I totally agree with your assessment about clinical instructors. From my own experience in my orthopedic rotation (which is the area I want to be the most proficient in) my CI has only been out of school for 1 year. I have been out of school now and working for 1 year and I would never presume to take on a students education at this point. What we really need are certified CI's who are on the level of experience and education that our instructors are. Until schools start to require these credentials we are basically screwed as students. As we strive for PT2020's goals we need to have CIs who are focused on the same goals. My best advice is to treat your first job (as I have) as an extended clinical residency. Dont let pay drive where you work. Get a decent and fair paycheck; but make sure your goal is MENTORSHIP...and make sure your boss and co-workers have the experience and education to help you get that.
Johnny, first of all good on ya' for starting up your blog. I guess you must have more free time after getting out of Texas.
Much of what you wrote in this posting really resonates with me, a non-clinical education faculty for our PT students at that "other" PT program across town from you. The clinical education system, much like the larger health care system, is strained at best and completely broken at in worst-case scenario. Twenty years ago my PT classmates and I had the very same complaints about clinical education being completely hit or miss regarding the quality of the experience and it seems like your generation feels exactly the same way.
Except that now there seems to be so much more at stake. The Class of 2008 is still in the first wave of DPT graduates (now over a decade old) that is going to define how the future of our emerging doctoring profession will function and be perceived. You'll need to be at the top of your game.
I am also not trying to come down on clinicians who agree to give up some of their own finite energy to mentor students. Clinicians are in a difficult position with ever increasing productivity demands and ever decreasing reimbursement rates. So they are not completely at fault. I'm also sure that PT faculty and curricula can do more to prepare students and work with clinical education instructors to ensure as seamless integration of didactic & clinical education as possible.
Bottom line: the classroom needs to look more like the clinic and the clinic more like the classroom in order to optimally prepare the DPT grads that can meet (and exceed) the challenges the lie ahead.
Keep charging forward!
Tim Noteboom
Great points Johnny. In my final clinical my CI was basically there just to co-sign my notes. I had to beg her to do any education with me; and in the end found other PT's in the same clinic to pass on what they had learned.
Understand, though, there really isn't any other model (that I'm aware of) out there to do better. Med students are trained by interns who are trained by senior residents who may be trained by a staff who doesn't even want students.
So, what we find is that those who constantly work to get a good clinical experience are usually only the ones that do get one.
Johnny,
way to get the ball rolling. This is a very difficult area, and as you orthopaedic instructor, it breaks my heart to send students to clinics where their CI's are 10 or 20 years behind the times. I agree with Tim, we should be grateful that these clinicians take the time to take our students in the clinic, and it is time academia gave back a bit for this "free ride." Here at the University of Colorado, we have started giving "Orthopaedic Updates" for clinicians in the community, and if they take our students, the fee is very reasonable (it should be free, but we charge $35 or so). We include a full day, consisting of about 4 hours of lecture and 4 hours of lab to bring clinicians in the community up to speed on what we are teaching our students. I would argue that all PT programs should start some type of clinical instructor training that gives back a bit to the CI's who so graciously volunteer their time. It is exceptionally hard for busy clinicians to stay on top of the literature, and the student/CI team should look at the experience as a trading of information, not a one-way street. Students come armed with the current best evidence (if academia is doing the job properly), and the CI's bring the clinical expertise, how to touch and talk to the patients and help them achieve their goals. The current system is broken. Our students are coming to the clinic using new techniques and speaking essentially a different language than the clinician, and it sets up a potential sitation for conflict. Both the student and the CI have a tremendous amount to offer, but there is a river that flows between them. It is my opinion that it is academia's duty to build a bridge so that the 2 sides can meet in the middle and forge a new path that ultimately moves our profession forward.
Just my 2 cents.
Paul Mintken
Johnny -
Again, kudos to you for starting the dialog. I completely agree that the current system under which we operate is broken and in need of a major overhaul. There are too many students that are paying huge amounts of money that end up with the most vital part of their education lacking. It is easy to point out all the external reasons why this exists, however we have to take some of the onus on ourselves as well. To this, I have to agree with what Jason had to say about those who seek out good internships are the ones that find them. If we come across an internship that is not of the level needed for our profession, it is important for us to voice this to our directors in a mature and professional way. If we want to be treated as medical professionals with the doctor title, it is important we start acting like professionals during our education. Our directors and faculty are much more likely to listen to concerns about our clinical affiliations if they are presented in a professional way. I have heard students in all medical programs, from medical, dental, veterinary, PT, etc ranting about their internships. Ranting among ourselves can be cathartic, but the only real change will come from within the system as we are able to accurately and fairly voice our concerns to our faculty. Johnny, this is a great start to that change! Thank you again for starting the conversation!
Congrats on your blog. I too, took the cue and started a blog of my own. It will be good to have you back in Texas when things are wrapped up. Hopefully we'll see great things to come from your practice. Just wanted to pop in and say hello. Feel free to visit my blog as well at www.texasorthopedics.blogspot.com
There are certainly kinks in the system. It is easy to agree with many of your statements and I commend for starting this discussion. Speaking from the CI side of things, some of us are very interested in taking students, but there are many who are assigned students against their will and desire. This is the main problem as I see it. CI's need to want to be instructors. This is the issue I feel needs to be addressed first and foremost. There is a lot of pressure on clinics to take students and it is very hard to accommodate all of these requests by only utilizing the people who want to take students. Your PT school faculty are there because of desire, not assignment, and that is the same situation as it should be in the clinics. As my clinic's CCCE I have a hard time accepting commitments to take students that I can't be the primary CI for. I am surrounded by several absolutely fabulous clinicians and can learn a lot from simply watching them work. But none of them are interested in taking students for an extended time and I don't want a student's experience to suffer because of this. Part of this is because of the extra work it takes to have a student (and please don't ever think that it's not extra work to take a student, if you spend any time with that student). The other part is because they are clinicians and neither see themselves as clinical instructors, nor have a desire to teach people other than the clients and families they work with.
There is a course out there to credential clinical instructors. I took that course and it's the only course that I have taken since my graduation from PT school in which participants had to take a test to prove their competencies. I fully appreciated this aspect of the course. Credentialed CI's are apparently few and far between and there's nothing that guarantees that a credentialed CI is actually any good at teaching you the skills necessary to be a good clinician at the end of your experience. This course is designed to educate CI's on good techniques of some facets of direct education but more so on communication with both students and schools to foster a better experience, especially if problems exist. We as a profession need to encourage our clinicians to take this type of class and the PT programs need to provide these programs for free or at very reduced prices for clinicians. Most clinicians have a very limited personal or clinic budget for taking CEUs and sadly most people would rather better themselves as clinicians than spend that time and money on learning to lead the future of the profession. How soon we forget what it was like to be a student. Good luck to you!
-Torey Gilbertson, PT, DPT, CCCE
I actually should have made a point on my initial comment. I'm not sure the system needs overhauling. Some of the most outstanding, reputable, published (pick any measure you choose) therapists were trained under this system. Sure there is a degree of exploitation, but unfortunately that is part of an institution that is so deeply intrenched into medical education. I can't forsee a fundamental change unless the end result is shown to be poor therapists. Right now therapists continue to be trained at very high levels throughout the country.
The downside of our current system is the lack of exposure to specialized training like medical residents receive. We are essentially generalists upon graduation. In order to become proficient most of us had to learn on the job and earn board-certification. I would propose condensing the PT didactic curriculum into 2 years followed by 2-3 years of residency, again followed by board certification.
This is more consistent with the medical model of training and would bring us more in line with what we are truly after.
This is a wonderful discussion and one way to create the change that you desire, and is needed is to be an APTA member, and active in the Education section. This is exactly where we need you, and your ideas, and your energy. Many of the points you have brought up are actively being discussed, with groups working hard at improving the education of CIs, the clinical preparation of the students, and the culture of the clinical facilities. Talking is a great start - doing is the next step.
Remember that there are two sides to the coin as well. I may give up taking interns, and one of the reasons? Being fed up with students that really do not want to take an active role in continuing their education
I tell them all at the start that I will not hover, nag them with assignments and tests, etc. They are supposed to be professionals ready to enter the work force, they are paying a ton of money, and should take full advantage of this opportunity. I remind them of the internet and all the sites I use, that I will come in early, stay late, copy articles for them, etc. All they have to do is ask, and show some interest.
8 out of 10 just want to come in, fluff around, get their degree and go make some money. I think we see that same apathetic trend in a high percentage of practicing PT's.
Anonymous notes that one should join the APTA, and I am not sure how that is going to help. I get interns based on reputation as a clinician and CI, I am not in the APTA, nor do I plan on taking any type of CI class. I do know of some PT's that are APTA members, have attended CI related classes, and are clinically inept
It is kind of sad to see that the system works this way. What do you think the solutions are?
i think im going to subscribe for your blog
have a look at my blog regarding physical therapy and rehabilitation protocols of treatment
http://physiophysio.blogspot.com/
Keep it up !
This is very helpful.. thank you guys for covering this up in here.
Johnny,
Thanks for your perspective. I will say that, sadly, the frustrations have not changed since I graduated. I am a DCE in an expansion DPT program in FL so I am currently developing our Clin Ed model. I think we have outlined the problems pretty well...what solutions do we have?
I agree with Tim (Hi Tim!) regarding the integration of the classroom and the clinical. But we have to stay actively engaged when the student leaves the classroom and hits the clinic. I agree with comments about credentialed clinical instructors. I also think APTA membership should be a CI requirement. What about student APTA membership? Does your program require it? Ultimately it is the responsibility of the DCE/ACCE to locate quality clinical learning sites, but when there are problems in the clinic, like the example of the CI who wouldn't teach, who's responsibility is it to communicate that? I would assert that it is the students responsibility to provide that feedback to the University. Just as the faculty needs to communicate about student progress, when the student leaves the classroom it is imperative that they become their own active advocate in their education. Also what motivates a student to choose their clinical site? Is the student doing research into the actual CI they will be assigned? Or are decisions made based on other factors? Again an active role.
Another possible solution, along the lines of what others have said is moving toward residency models. I think that is the next wave of change coming to our educational programs.
Ultimately I think successful transition from classroom to clinic to practice is dependent upon clear communication and active engagement in the process by ALL parties involved: faculty, student, and CI.
I am researching information on Physical Therapy programs and the various types of Clinical opportunities. I plan on attending a graduate school for Physical therapy in the next 2-3 years. This information about the different types of experiences people have when doing their Clinicals will help me decide on which programs to choose and ask this valid question with the programs I meet/interview with. I have heard from students who have done Clinicals in other medical fields and they have expressed that it can be good or it can be boring/ not getting as much out of the experience. One of the bloggers expressed how sometimes he had to push to get educated by some of the Clinical instructors and that is what I will plan on doing if I feel it is getting to stagnant but eventually after so much of that pushing it tends to get old and you stop because it starts feeling uncomfortable. Well thank you for this blog and for the valid points from several of you. This will help me be better prepared on this journey I am about to take soon...
Great post! Let me share you something about the benefits of physical therapy education which include the intrinsic rewards of life as a PTA. In other words, you are helping people each and every day of your career, and having a direct role in. Check this out for the details.
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