Top 10 Things Clinical Instructors Need to Know

Like many of you, I've served as a Clinical Instructor for PTA  Students quite a few times over the years.  I enjoy working with students and believe that serving as a CI has at least two benefits.  It demonstrates professional responsibility on the part of the clinician by helping develop the next generation of PTA's.  I think it also has a positive impact on one's clinical development.  Typically at the end of the clinical, I fill out an evaluation form and comment on how the student met certain learning objectives.  The student also  has an opportunity to critique the clinical experience as well as the CI.  I usually receive positive comments indicating that students have had a good clinical experience.  I have never had any complaints.  So I must be a good clinical instructor, right?  

Well, maybe...  But maybe the students' positive post-clinical comments are just an attempt to score a few last minute brownie points...  So I asked the following question via social media: What qualities are most important for an effective Clinical Instructor?  Here is the best answer I received from Jan Spigner, PT, Del Mar College PTA Program Director: The top 4 qualities of Clinical Instructors, as determined by survey of PT and PTA students are Communication skills, Interpersonal skills, Professional skills, and Teaching skills.  (Emery MJ, Wilkinson CP. Perceived importance and frequency of clinical teaching behaviors; survey of students, CI, and CCCE. Journal of Physical Therapy Education. 1987; 1 (1): 29-32.)

OK... before I go any further, I must make a small confession.  There is no "Top 10 List".  That was just a cheap online marketing trick to grab the reader's attention.  Sorry about that...  There is really only one suggestion for you current or prospective Clinical Instructors out there.

What should we really focus on with students during clinical rotations?  Well, the obvious answer is, we should ensure that students can provide safe and effective entry-level patient care.  But we need to get students to think beyond the "how" of data collection and interventions and develop students' ability to ask "why".  I've recently come to the conclusion that we need to do a better job of challenging students to think critically and problem solve.  I have worked in a number of settings over the years and at times have observed clinicians (both PT and PTA) that seem to just go through the motions.  Progressing from yellow to red resistance band is not critical thinking.

The most important time for critical thinking is probably during the first 2-3 treatment sessions after the evaluation.  Clinicians should be asking some very important questions during this time frame.  As PTA's we should be looking and thinking critically at each patient, each intervention, during each treatment session and asking the question: Is this patient improving?  What evidence exists in the medical record of this progress?  What are the patient's goals?  If the patient is not improving, what action is being taken?  Is the supervising PT being apprised of the status?

I hope this gives you something to consider as you treat patients, and as you serve as a Clinical Instructor for PTA students.

The Role of PTA's in APTA Governance

When I started this blog I chose the name PTA Professionals.  There has been some debate in years past about whether or not PTA's are considered professionals.  Merriam-Webster online defines a professional as "characterized by or conforming to the technical or ethical standards of a profession", or "exhibiting a courteous, conscientious, and generally businesslike manner in the workplace".  PTA's are held to high ethical standards, (see "Standards of Ethical Conduct for the Physical Therapist Assistant") and have also  participated in APTA governance activities for many years at the district (local) level, the chapter (state) level, and also at the national level within the PTA Caucus and the APTA House of Delegates (HOD).

This year's APTA HOD will convene June 24-26 in Salt Lake City, UT.   The HOD is the policy making body of the APTA and is comprised of delegates  from each chapter, section, and the PTA Caucus (5  delegates).  The PTA Caucus consists of one PTA representative from each chapter and meets annually prior to the HOD, this year on June 22.  PTA's may not serve as chapter delegates, and PTA Caucus delegates and section delegates are not actually voting members of HOD, although they are permitted to submit motions, participate in debate of motions, and propose amendments.  Your chapter PTA Caucus Delegate and PT Delegates are your link to the APTA HOD.  I encourage you to get to know your delegates and give them your input on upcoming 2013 HOD motions.

This year for the first time ever, APTA members will be able to view the HOD via livestream on the APTA website.  This is a great opportunity for those who have never attended the House in person to experience association governance first hand.  Prior to attending the HOD as the PTA Caucus Representative for Texas, I did not fully appreciate the importance of the work of the HOD.  I applaud APTA for utilizing the available technology.  The HOD is where physical therapy policy begins.  Keep in mind that certain parts of the House can be very tedious.  But a little patience will reveal the great diversity of opinion that exists across the country in our profession.  

Listed below are just a few important APTA policies and guidelines pertaining to PTA's.  They were created by the APTA HOD, and the PTA Caucus played a key role in their development.  You can read them in detail by visiting the PTA page of the APTA website. 

-Minimum required skills of physical therapist assistant graduates at entry level

-Standards of Ethical Conduct for the Physical Therapist Assistant

-PT/PTA Teamwork: Models in Delivering Patient Care

-Procedural Interventions Exclusively Performed by Physical Therapists

I would also like to draw your attention to a pending policy RC 2-12, and its predecessor, RC 3-11 related to utilization of PTA's and other "extenders" of care, i.e. non-licensed personnel.  Just in case you think being an APTA member isn't important, this proposed amendment should convince you otherwise.  In my opinion, these motions propose some potentially critical policy changes affecting the role of PTA's.  This year the HOD is scheduled to receive an interim report on RC 2-12, with the final report and follow up motions to be heard in 2014.

A summary of RC 3-11 can be found here.

source: http://tinyurl.com/mhjl3rj
Information on RC 2-12 Amend: Physical Therapist Responsibility and Accountability for the Delivery of Care, Resolved Paragraph and Proviso

The following is excerpted from the 2012 House of Delegates Minutes and provides the final language for RC 2-12, which was passed at the 2012 House of Delegates. RC 2-12 contains both a position and a charge. As seen in the proviso below, the “position will become effective upon implementation of the necessary initiatives in education, practice, payment, regulation, and research, and adoption of requisite APTA positions, standards, guidelines, policies, and procedures….” The steps to these necessary initiatives are outlined in the charge. Due to the proviso, the position will not be posted as an APTA position on the Policies and Bylaws webpage until it becomes effective.

For complete text on RC 2-12, visit the 2012 House of Delegates Minutes in the House of Delegates community’s Archive folder.

Excerpted from 2012 House of Delegates Minutes:

RC 2-12 AMEND: PHYSICAL THERAPIST RESPONSIBILITY AND ACCOUNTABILITY FOR THE DELIVERY OF CARE, RESOLVED PARAGRAPH AND PROVISO – REPLACEMENT PACKET II

Required for Adoption: Majority Vote

*FINAL - PASSED June 5, Pages 165-331

V-8 PHYSICAL THERAPIST RESPONSIBILITY AND ACCOUNTABILITY FOR THE DELIVERY OF CARE

Whereas, The American Physical Therapy Association (APTA) Vision Statement for Physical Therapy 2020 (Vision 2020) recognizes physical therapists as practitioners characterized by independent, self-determined professional judgment and action; and recognizes that physical therapists have the capability, ability, and responsibility to exercise professional judgment within their scope of practice and to professionally act on that judgment;

Whereas, Current APTA positions, standards, guidelines, policies, and procedures specify the use of specific personnel rather than recognizing the responsibility and accountability that accompany the independent judgment of contemporary physical therapist practice, which is characterized by the autonomous professional;

Whereas, To best meet the needs of the patient/client, it is necessary for physical therapists to maximize the ability to respond to the changes resulting from passage of the Patient Protection and Affordable Care Act, including emerging models of care delivery and expanding numbers of insured consumers seeking care, thereby providing opportunities for physical therapist leadership; and,

Whereas, APTA Standards of Practice for Physical Therapy state that the physical therapist is responsible for the direction of physical therapy service, complies with all legal requirements of jurisdictions regulating the practice of physical therapy, involves appropriate others in the planning, implementation and assessment of the plan of care, and provides or directs and supervises the physical therapy intervention;

Resolved, That the American Physical Therapy Association (APTA) recognizes that physical therapy is provided by, or under the direction and supervision of, a physical therapist. Evaluation remains the complete responsibility of the physical therapist.

Proviso to the Resolved Clause: This position will become effective upon implementation of necessary initiatives in education, practice, payment, regulation, and research, and adoption of requisite APTA positions, standards, guidelines, policies and procedures. Annual interim reports will be provided to the House of Delegates beginning in 2013.

That the American Physical Therapy Association (APTA) explore practice models that are responsive to the needs of society and adaptable to our changing health care environment.

Steps toward the adoption of any practice models shall include:

-determination of changes needed, including: scope, feasibility, timing, and other resources required to adopt any and all new models;

-amendment of requisite APTA positions, standards, guidelines, policies and procedures;

-an interim report to the 2013 House of Delegates and a final report no later than the 2014 House of Delegates;

-approval of any model by the House of Delegates.

*A counted vote via Audience Response System was used to determine the outcome of this motion; the final vote tally was as follows: 351 in favor of adoption - 46 opposed to adoption.

*As requested by the House, the secretary of the APTA Board of Directors has agreed to separate the resolution from the charge.

[Contact: nationalgovernance@apta.org | Last Updated: 08/29/12]

The Elephant in the Room

I recently received an e-mail notification of an upcoming ethics course.  It was titled "Red Lobster, With a Side of Ethics".   Since my PTA license is soon up for renewal, the timing was perfect.  Texas requires all licensees to attend a two-hour of ethic course for PT/PTA license renewal.  

Not a single PT or PTA I know gets excited about attending a mandatory ethics course.   It's just not that exciting.  Ooooooh... but an ethics course at Red Lobster...? Now there's something I can get (a little) excited about.  Plus the course was being presented by three friends/PT colleagues of mine.  So thanks to Dee, Christina, and Jon for providing an INTERESTING ethics course.  The appetizers weren't too bad either! 

It was ironic that less than two weeks later I came across a stunning report that appeared on CBS This Morning.  The report,  "Medicare fraud allegations: National nursing home chain accused of billing for excess care"  covers current Medicare/OIG investigation of Life Care Centers of America for providing excessive therapy services to patients in order to receive a higher level of Medicare reimbursement in the skilled nursing setting.  

According to the report: 
"Medicare reimbursed $4.2 billion to Life Care Centers between 2006 - 2011.  While skilled nursing facilities averaged 35% of treatments for rehab patients at the ultra-high level nationwide in 2008, Life Care Centers had 68% of therapies at the ultra-high level, court records say. Rehab therapy claims have come under increased scrutiny in recent years, with other nursing home chains also have faced accusations of upcoding."

I'm curious to know how many of you are honestly surprised about the current investigation into Life Care Centers, and the LTC industry in general.  Of course Life Care strongly disputes any wrongdoing.  Which begs several questions: How much therapy is too much therapy?  And who is really responsible?  Is it the evil corporation?  The CEO?  The Regional Director?  The facility Director of Rehab?  The staff therapist?

Probably all parties are culpable, but without a doubt, the licensed therapists are!  (These people must not have mandatory ethics courses.)  

The alleged widespread over-utilization issue presents a bit of a stumbling block for a profession that is trying to "Move Forward".  It is the elephant in the room.  Until now I haven't heard much about over-utilization in the news, but more surprisingly, I've never heard it discussed in our state or national professional association meetings. This could be a significant setback for those who are striving to elevate the profession by working to enhance access to physical therapy services.  It wouldn't surprise me if over-utilization will be used to legislatively by direct access opponents.  

Kudos to the whistle blower(s) who made an ETHICAL decision to do the right thing.  Hopefully this case will draw enough attention to the issue that therapists AND corporations will become more ethical and conscientious. 

Patient Access to Physical Therapy - A Personal Experience

Patient Access to Physical Therapy

My parents recently underwent orthopedic surgical procedures.  One had hand surgery to straighten and fuse an arthritic DIP joint of the index finger.  The other had surgery to address painful deterioration of the MTP joints of the first three toes.  

My mother was in a hand cast for 8 weeks and had it removed a little over a week ago.  She now has swelling and stiffness of the entire hand and as expected, diminished strength and muscle atrophy.  Today she asked me multiple questions:  "Should I be stretching it more?  Why are my other fingers so stiff? What can I do for the swelling?  When is my strength going to come back?  When is the feeling going to come back in my index finger?"  My response was, "These are all great questions for a physical therapist who specializes in hand therapy."  Much to my chagrin, my mother received only one session at the surgeon's office for HEP instruction consisting of a few simple range of motion exercises.    

My father had orders to remain non-weight bearing for 6 weeks and is now in a cam boot with instructions to increase weight bearing 40 lbs. per week.  Last week he called to ask when I would be able to to come over and show him how to walk with the walker and maintain the 40 lb. weight bearing limitation.  The only  problem:  they live two hours away.  Again my response was, "This is a great question for your physical therapist!"  But again, you guessed it - no physical therapy ordered.  Today as my parents left our house I had to explain to my dad the proper technique to safely descend the three steps from the porch to the sidewalk.

As of this post, the Texas Physical Therapy Association has made significant progress in achieving "Patient Access to Physical Therapy".  When this legislation passes, patients will have the right to access a physical therapist without the burdensome and unnecessary requirement of obtaining an order from a physician (or from one of the other laundry list of health care providers who are legally allowed to prescribe physical therapy).  House Bill 1039 has passed favorably out of committee and now sits in the House Calendars Committee.

If you are a PT or PTA practicing in Texas, NOW is the time to act.  Please use the House Calendars link above to find out if your representative serves on this committee.  I urge you to call and ask that HB 1039 be placed on the House Calendar.  If you are former or past physical therapy patient, your support of HB 1039 in the form of a telephone call or email would be greatly appreciated.

HB 1039 will serve the best interests of our patients.  Physical Therapists are the most qualified and skilled health care professionals in human movement and function, and patients should have the consult a physical therapist whenever the need arises - just as they have the ability to consult a physician, dentist, or an orthopedic surgeon.  The fact that my parents were not able to consult a physical therapist in a timely manner illustrates the importance of passing this bill, and is also a great example of flaws in the current "gatekeeper" system.  It's time that the Texas legislature recognize the fact that PT's don't need an order from an MD to "Evaluate and Treat" in order to do their job.          

    

"... if you ask a person what their favorite therapy is, they will tell you it is the one that works." -Michael J. Fox

Let's talk for a minute about Evidence-Based Practice (EBP).   What role does the PTA play in the implementation of and utilization of EBP?  The answer to that question may depend on several factors such as the ratio of supervising PT's to PTA's, the frequency with which the supervising PT observes PTA treatment (and vice versa), and the willingness of the PT to discuss changes to treatment options and approaches.  Of course it also depends on the PTA's ability to utilize evidence based resources and then apply those resources in the clinical setting to analyze the current treatment approaches.  It is critical for the PT and PTA to have a good working relationship and to be comfortable questioning one another, while at the same time remaining respectful of the other clinician's experience, values, and knowledge base.  A new grad might be a bit intimidated when questioning someone with 20 years of experience, but they should both be open to new ideas, concepts, and of course, research.  Discussion of current evidence supporting physical therapy interventions should be a routine task in all treatment settings.  I'm sharing what I think is a pretty good intro to EBP in physical therapy.  What experiences do you have in implementing EBP in your practice setting?  It is a team approach?  Do you set aside time each week, or month to review evidence based literature?  I look forward to hearing your comments.

Article taken from http://www.ptwa.org/Content/Legal/EBP.u htm

Evidence-Based Practice and Physical Therapy 
During his address to congress on behalf of people with disabilities, Michael J. Fox said that if you ask a person what their favorite therapy is, they will tell you it is the one that works. Using interventions that work is what evidence-based practice (EBP) is all about. It is not a particularly new concept, as David Sackett originally proposed it for medicine in the early 1990s. Since that time, over 1,000 articles on this topic have been published in medical journals. To quote Sackett, "Evidence-based medicine (EBM) is the integration of best research evidence with clinical expertise and patient values" (Sackett et al., 2000). Importantly, this definition states that clinical decision-making should be based on three components: research, clinical expertise, and patient values. Thus, it is not solely driven by research studies, but also values clinical expertise and the wishes of the patient and family when determining optimal interventions. Furthermore, this definition acknowledges that not all research evidence is equal, and that some research studies should be given greater consideration than others when evaluating therapeutic regimens.
The philosophy of EBM is also relevant to other health care fields, including physical therapy, and in order to be more inclusive, is now often referred to as evidence-based practice (EBP). EBP has generally, although not universally, been endorsed by health care professionals for two major reasons. First, there has been an explosion in information, with a ten-fold increase in professional journals between 1940 and 1993 (Presidentís IT Advisory Committee Interim Report, 1998). At this time, there are more than 23,000 biomedical journals. Second, rapid advances have occurred in information technology over the last decade. In 1997, over 100 million people were using the Internet worldwide, a number that is expected to increase to more than 1 billion by 2005 (Presidentís IT Advisory Committee Interim Report, 1998). Since increasing numbers of biomedical journals can be accessed via the Internet, this has greatly increased the accessibility to research evidence for both clinicians and clients. However, the amount and availability of information can also be daunting. Therefore, guidelines on ways to evaluate the evidence have generally been welcomed. Other reasons for endorsing EBP are the concern that the traditional approach of relying on continuing education courses for keeping clinical knowledge and practice up-to-date does not lead to improvements in clinical performance (Davis, et al., 1999), and the need for greater accountability for reimbursement and liability.

EBP is a five-step process (Sackett et al., 2000). 

Step 1 is to convert the need for information into a clinically relevant, answerable question. What exactly is it that you want to know? One method for formulating the question is referred to as PICO. P refers to the patient or population of interest, I to the intervention, C to the comparison intervention (if one exists), and O to the outcome. An example of how to use the PICO method to refine a question regarding the role of exercise for certain clinical problems is shown below.

P     What individual or patient populations do I have in mind?

            People with post-polio syndrome.

I     What type of exercises am I considering?

            Strength training.

C     How does my intervention compare to the effects of another intervention? What is that other intervention?

            Relaxation exercises.

O     What are the goals of the exercise intervention?

            Increased daily activity level.Putting this all together results in a more refined question. 

"For clients with post-polio syndrome, is strength training better than relaxation exercises for increasing levels of daily physical activity?"

Step 2 is to efficiently find the best evidence. This step is often easier said than done, but all things considered, the Internet has greatly increased the ease with which many clinicians can access and rapidly sort current information. Of the numerous databases available for information, a few are particularly relevant to physical therapy. PubMed is probably the best known database. It is maintained by the National Library of Medicine and is free to the public at http://www.ncbi.nlm.nih.gov/PubMed. Most searches should begin by looking at what is available through PubMed. PubMed allows you to search combinations of key words, such as physical therapy and post-polio syndrome. Depending upon the number of articles retrieved with these key words, one can either expand or narrow the search by removing or adding key words. A search can also be narrowed by limiting it to certain dates, e.g., after 1995, or by types of articles, e.g., review articles. It is not unusual for an initial search to yield thousands of articles, but with further refinement to be reduced to only a few highly relevant ones.
Citations in Nursing and Allied Health (CINAHL) is a database targeting health professionals in these disciplines. Whereas articles on biomedical topics are the primary ones found in PubMed, CINAHL will often include citations covering a broader scope, e.g., special education or physical fitness. Go to http://www.cinahl.com/index.html to access this database. The Cochrane Library is another useful database. It includes some excellent reviews of the current available research on selected medical topics. The address is http://www.cochranelibrary.com/clibhome/clib.htm. Abstracts can be accessed at no charge. The Physiotherapy Evidence Database (PEDro) is designed specifically for physical therapy. The address is http://ptwww.fhs.usyd.edu.au/pedro/. Tips for searching the literature are also available at http://cebm.jr2.ox.ac.uk.
The APTAís Hooked on Evidence Initiative is a new and exciting grass roots effort to systematically find and evaluate research with relevance to physical therapy practice. This effort wasinitiated by the California Research Special Interest Group and has now been extended nationally. People willing to find and review articles are needed. More information about the process involved is available on their website, which can be accessed from the APTA website or https://www.apta.org/hookedonevidence/index.cfm.

Step 3 is to critically appraise the evidence. Surprisingly, there are only three critical questions that you need to ask to appraise most clinical studies. Is the study valid? Are the findings clinically important? Do the findings apply to my client? However, answering each of these three questions requires a systematic analysis. Indeed, a series of factors needs to be considered when appraising the validity, such as was the study retrospective or prospective? Was it randomized? Did it use human or animal subjects? Depending upon the answers to these and other questions, the validity of the evidence, or in other words, how close it is to the truth, is ranked. To appraise the clinical importance of the evidence one needs to consider the magnitude of the effect of the intervention, as well as the probability of the effect generalizing to whole patient populations. To appraise the applicability of the findings, you must compare your client to the subjects used in the study, consider the feasibility and risks and benefits of the intervention, and also determine if it is in line with the clientís preferences. Mastery of step 3 is beyond the scope of this article, but additional information is available on the web at http://cebm.jr2.ox.ac.ukand http://www.fhs.mcmaster.ca/rehab/ebp/.

Step 4 involves applying critically appraised evidence to clinical practice. Of all the steps, this is the one that may be the most difficult. Numerous challenges face health care providers interested in changing their clinical practice based on EBP. These challenges include, but are not limited to, a lack of control over their workload, competing priorities, limited access to the Internet and/or journals, lack of training in information technology and critical appraisal of literature, and a lack of institutional support for EBP. To overcome these obstacles, it helps to remember the ancient proverb, "A journey of a thousand miles begins with one step." Start small. Form a lunchtime journal club to critically appraise relevant clinical studies. Be a "clinician-scientist" by using valid and reliable tests and measures to acquire baseline measurements and evaluate outcomes of your clients. Search for a topic of interest on PubMed or another database. Be part of the APTA Hooked on Evidence Initiative. These are just a few of many possible ways to begin to integrate EBP into clinical practice.

Step 5 is to evaluate the effects of EBP on clinical outcomes. Whether incorporating EBP into physical therapy practice will increase the likelihood that Michael J. Fox and all of our other clients receive interventions that are effective is unknown. The essence of EBP is an argument for critical appraisal of therapeutic interventions. Wisely, the people who developed EBP extended this requirement not only to clinical interventions, but also to EBP itself. Future studies are needed to determine if there is a correlation between the integration of EBP into clinical practice and improvements in outcomes.
In conclusion, EBP is a five-step process that aims to improve health care outcomes by balancing findings from research with clinical experience and patient/family preferences. Extensive information on EBP is available both in print and online. Additional information on how to incorporate EBP into physical therapy practice was presented at the Fall 2002 PTWA Conference. We have the technology for EBP. We have the intelligence to critically appraise evidence. The time is right to incorporate EBP into physical therapy practice.

REFERENCES

1. Davis D, OíBrien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A., 1999, Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA.282:867-74.
2. Presidentís IT Advisory Committee Interim Report, August 1998.
3. Sackett, DL, Straus, SE, Richardson, WS, Rosenberg, W, Haynes, RB, 2000, Evidence-Based Medicine. How To Practice and Teach EBM. 2nd edition. Churchill Livingtone, NY.Ramona Hicks, PhD, PT and
Jeff Coppersmith, MS, PT
 

Jumping on the Blog Bandwagon

Welcome!

Physical Therapy through the eyes of a PTA

There are hundreds, if not thousands of blogs, websites, and various social media pages dedicated to all aspects of physical therapy.  But what I've noticed is almost none are written exclusively from a PTA's perspective.  So... I decided to jump on the blog bandwagon - not in the interest of self promotion, but rather to attempt to provide PTA's and students (and anyone else that might be interested) with information about the profession, continuing education (a.k.a. continuing competence), our association (APTA), government affairs, and any and all things related to physical therapy.  I welcome your comments and suggestions, even your (tactful) criticism.  Want to be a guest blogger?  Send me an article, and if it's half way decent, I'll publish it.

Luke