By: Robert E DuVall, PT, DHSc, MMSc, ATC, CSCS
Board Certified in Orthopaedic and Sports Physical Therapy, Fellow, American Academy of Orthopaedic and Manual Physical Therapy, APTA Orthopaedic Section Nominating Committee, Residency and APTA Fellowship Program Director: SportsMedicine of Atlanta, Inc
I now, more frequently than before, receive inquiries regarding Residency and or Fellowship training. First I would like to express congratulations to those PTs who, before any major health care reform or economic down-turn reasons forced them to pursue essential clinical specialty training, have accomplished ABPTS board certification or Fellowship training. Clearly, many new DPT graduates are now making excellent career plans and decisions in light of the impending health care reform challenges that all healthcare providers will be navigating through in the near future. Likewise, despite many recent reforms in academic entry-level PT education, including transition to the DPT, clinical education has not similarly evolved. Due to the high variability in entry-level clinical education, one could argue that today’s professional PT students entering their internships have adequate didactic preparation, but are not provided a challenging practical internship. More consistent with APTA’s Vision 2020, entry-level internships should meaningfully actualize the students’ didactic preparations. I believe internship should facilitate students to apply what they’ve learned in the classroom and challenge them to further their learning through rigorous critical reasoning processes applied to real case scenarios. Finally, for those PTs with years of clinical experience, for the first time I see greater value and return on their educational investment to be in Residency or Fellowship training over the non-practice oriented t-DPT educational offerings.
Hence, Residency and Fellowship training could serve as professional employment insurance, geared to prepare PTs for value-based payment systems with a special focus on achieving optimal functional outcomes (while preventing healthcare system readmission), all in the most efficient and cost effective manners. Equally important is the need for residency and fellowship specialty training to occur with an emphasis on patient self-referral (direct access) education. Consistent with APTA’s Vision 2020, if Residency and Fellowship programs do not actualize PTs unique body of evidence into practice in autonomous practice environments that are academically free, with no fear of referral source retribution, than how can we expect pre-professional clinical internships to offer students direct access education. I joke when I say that I am afraid that PTs will someday scientifically earn the legal right to offer their services directly to Medicare patients, only because most practicing PTs would not accept Medicare direct access patients for fear it could threaten their physician referral relationships.
I have found that didactic course work in most residency and fellowship programs is admirable with regard to subject matter, but offer little preparation or practical experience with regards to a true and functional autonomous models of practice so that contemporary subject-matter evidence can be immediately applied (Lenfant) to practice without the fear of retribution from sources of referral (Dennis; source of referral effects the clinical judgment of PTs). I believe that practical “delivery model process skills” education is equally, if not more important than content-subject matter focused training programs. The medical literature supports this notion, by revealing that medical students learn more in the clinic than in the classroom (or on the computer). Similarly, the didactic portion of some residency or fellowship programs is much stronger than their practical 1:1 mentored experiences due simply to the percentage of mentored learning experiences that occur as a result of physician referral. Dennis reports, and I have anecdotally found, that clinical judgments are affected by sources of referral, i.e. critical reasoning and the highest levels of critical thinking are suppressed/inhibited, not demanded nor necessary in many referral based case scenarios. I have observed that intuition and innovation in practice are also inhibited due to referral based practice models. Why do the Australian and New Zealand PTs deliver so much practice innovation, while equally delivering on justification? I believe it is the degree of autonomy they have worked hard to earn, and private practice as well as patient self-referral are the key ingredients to their autonomy that drives their intuitive innovation.
So, do Residency and or Fellowship programs need to offer curricula that didactically and practically prepare PTs to uniquely, without fear of referral source retribution, advocate with moral courage (Purtillo), promote and create patient access to PT which, as Shoemaker’s evidence purports, is a slow to evolve model of practice (Direct Access Shoemaker)? I advise prospective applicants to critically examine residency and fellowship curricula to see if the program they are interested in actually offers didactic and practical components in the form of dedicated course/practical learning experiences in autonomous practice and patient self-referral. Are there clinical learning experiences and 1:1 mentored learning in direct access scenarios are in place to address not just the subject matter, but to addresses the delivery and process variables aforementioned. In summary, I recommend that don’t judge a book by its cover, nor residency or fellowship training by its mere subject matter curriculum. I recommend that you ask a few questions about direct access process skills taught in dedicated courses in both the didactic and practical components of the curriculum. Ask for the percentage of direct access patients you will actually see while mentored 1:1. Also ask how much interaction there is between current Fellows and Residents and Residents and Interns, all for the purpose of theoretical/practical integration practice and study opportunities.
Lenfant C. Clinical Research to Clinical Practice: Lost in Translation? The New England J of Med 2003: 349; 868-874.
Dennis JK. Decision Made by Physiotherapists: A Study of Private Practitioners in Victoria. The Australian J of Physiotherapy 1987: 33; 181-191.
Purtilo RB. Moral Courage in Times of Change: Visions for the Future. J of Phys Ther Ed 2000:14; 4-6.
Shoemaker MJ. Direct Consumer Access to Physical Therapy in Michigan: challenges to policy adoption. Phys Ther 2012:92; 236-250.
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