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Raising the Bar in Rehab

Structured Learning

Published August 9, 2012 11:31 AM by Lisa Mueller

I've been a clinical instructor to a few students since graduating myself a few years ago. I enjoy teaching and watching students execute skills they studied prior to arriving at the clinical. Over the past year or so, I've read a few physical therapy blogs and discussed with my coworkers the lack of structure for the clinical experience. Students are usually given a series of items to be assessed, including professionalism, safety, clinical judgment and decision making, as well as other qualities needed to be an entry-level physical therapist.

But beyond that, the bulk of the clinical is determined by the instructor and varies significantly between students as a result. The patients and diagnoses a student may encounter, the pace of work and need for efficiency, as well as the interactions with other health care providers, are not usually requirements of the school or necessary for licensure, but rather generally left to the discretion of the clinical instructor.

While having this extraordinary amount of freedom in a clinical certainly has its benefits, it also has some serious drawbacks. If one student works at a busy outpatient orthopedic clinic, seeing 10-12 patients a day with collaboration between physicians, chiropractors and athletic trainers, while another student in a slower setting is the only therapist on site and sees four to five patients a day -- which student do you think will have more opportunities to practice their skills? Which student would likely become more effective at treating common diagnoses? What happens if a student graduates from physical therapy school without having seen a hip or knee replacement -- two diagnoses common to our practice?

Without a standard of minimum experiences a student must have during a clinical, our profession should not be surprised by the variability between therapists. (I'm not even going to address the lack of screening for therapists to become clinical instructors. Currently, any therapist can be an instructor. There needs to be minimum criteria or letters of recommendation or some sort of other qualification process to teach students. Bad clinical instructors will only result in poor outcomes for the student).

I've noticed this pattern, or lack of structure, extend beyond the school years of the physical therapy profession. In the few clinics I've interviewed at or worked for, there seem to be inconsistent training schedules for new staff. It is assumed new physical therapists will be able to use all modality equipment, mold orthotics or perform any other "basic" task with no structured checklist.

Why is our profession hesitant, or unable, to develop criteria for clinical experiences as well as for new staff across all physical therapy settings? What do you think about this topic?



Thanks for sharing your thoughts.  You are right, we certainly cannot all be specialists.  Unifying our efforts would likely create less confusion across the board.  

Lisa Mueller September 24, 2012 10:00 PM

New Standards are being made. To be a practicing therapist now you must have attended an accredited school. You have to get your basic training. No one expects you to be be proficient in every setting as a new student. (Assume is not an acceptable word). I may be mistaken, but I have heard a lot of graduates say they never set foot in an Aquatic environment, so I wouldn't ASSUME that they would be proficient with Aquatic Therapy.  We all learn by experience. I remember becoming a SCUBA Instructor and I was authorized to teach most anything related to being in or under water.

Then someone decided we should specialize, so Cave Diving, Underwater Photography, etc.. came around and now I don't teach those anymore without a specialty certification even though I had the experience to teach those classes. So now APTA is specializing also. My patients come in the door now expecting to receive treatment from a Neuro specialist, Cardiac Specialist, Ortho Specialist, Geriatric Specialist and so on. My point is no one is going to graduate from school and be a specialist in every setting. I believe it is important for us to be versatile in this field and adjust to our patient's needs.  The clinical instructor field is also a specialty as I recall, well at least a certification program exists. How long do we need to go to school to get all this experience across all Physical Therapy Settings?( Lifetime Student ). As for the UK and learning a few things from them, I believe Mr Metz made a good point. UK has 4 four countries with one governing body. We have 50 fifty states to try and unify. Takes a little time, but APTA is trying.

Hang in there and keep up the good work.

Donald Meadows , Acute/Outpatient - LPTA, Traveler September 23, 2012 7:27 PM
Winona MS

 I'm not convinced that the degree that the CI holds is relevant to their structure or abilities.  I had four total clinicals while in PT school, and two of my CI's had B.S. degrees, one MPT, and the other a DPT.  By far, the best CI's were the ones with Bachelor degrees.  It's a difficult question to answer, because if you are in a busy OP clinic seeting 14 patients a day, the therapist rarely has time to teach and take time to explain in depth their clinical reasoning.  If you're in a slow clinic, you have plenty of time, but not the in-depth experience.  I believe that over the course of your 2-3 year program, this balances out. Most PT schools employ a clinicial education coordinator, that solely deals with these issues.  When I would return from each of my clinicals, I would meet with this individual to discuss the effectiveness of the experience.  I think that there needs to be a push to make CCE interact and coordinate better with CI's.

Justin Lowe August 10, 2012 11:09 AM

This issue actually begins at the school the student attends.

There is a difference in educational standards and there are so many PTs practicing who have various degrees from certificated to DPT.  (yes, I have worked under a PT who had a certificate not a degree)

With this type of chaos in degree levels no wonder there is no structure in the clinical sites.  

Jason Marketti August 9, 2012 10:38 PM

The profession is not unified on a national level. Each state has its own standards of practice. It took forever to get all the states to agree to adopt the DPT!

This is one area where the UK has an advantage. All four countries in the UK have one accrediting body and the professional association determines scope of practice, not the individual countries.

As such, education is also standardised and CIs need to become Accredited Clinical Educators (ACE) before they can take on a student.

We could learn a few things by looking at other models like the UK.

Dean Metz August 9, 2012 1:43 PM

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