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Research Reports |
G Jull, MPhty, PhD, FACP, is Professor of Physiotherapy, The University of Queensland, Brisbane, Queensland, Australia, and President, Australian College of Physiotherapists
Address all correspondence to Dr Jull at: g.jull{at}uq.edu.au
Continuing education and professional development are hallmarks of professional practice. The concept of the 5-year half-life of knowledge in health care professions is well recognized,1 as is the fact that tertiary professional (entry-level) education does not fully prepare or equip new professionals for lifelong practice. The need for effective continuing professional development is no more evident than in the profession of physical therapy. Physical therapist practice has developed rapidly over recent decades, which genuinely challenges clinicians to provide contemporary management to their patients throughout their working life. Physical therapists around the world have recognized the need and assumed the responsibility for lifelong learning and, in most instances, have avidly embraced continuing professional development. Mandatory continuing education2 exists in many countries and often is linked to continuing professional registration. In recognition of the importance of continuing professional development, researchers continue to study the nature and experiences of, barriers to, and implementation strategies for continuing professional development of physical therapists in order to optimize the education experience.3,4
The research and evidence base of physical therapy has grown enormously, and the face of practice is changing as research informs the development of new assessment and treatment interventions. The efficacy of both new and traditional interventions has been rigorously examined. The Physiotherapy Evidence Database (PEDro)5 lists a notable 10,770 clinical trials of physical therapy interventions. Thus, there is increasing evidence to inform best practice for the management of patients with a variety of disorders. Effective continuing professional development is a potent vehicle to translate this evidence into practice to improve patient outcomes.
Not only do physical therapists need to maintain contemporary knowledge, but many assessment techniques and interventions also require high-level clinical reasoning and practical skills for competent implementation. Certainly, studies confirm that superior outcomes are achieved when it is a skilled practitioner who delivers specific exercises or exercise programs.6,7 Thus, it is reasonable that a popular continuing education format for physical therapists is practically orientated short courses where clinicians stand not only to gain new knowledge but also to learn practically from experts. Yet, few individuals have the skill-acquisition capabilities to be able to instantly perform and perfect complex manual skills. Certainly, Tiger Woods did not pick up a golf club one day and win the US Masters the next. There was significant coaching, practice, and reflection between these 2 events. Thus, in the physical therapy context, it is reasonable to question whether "once-off" short courses are adequate platforms for individuals to acquire the practical skills and clinical reasoning processes necessary to ultimately improve patient outcomes.
The results of a preliminary noncontrolled study investigating this issue by Brennan et al8 showed that outcomes for patients did not improve after a short continuing education course on the management of neck pain. In contrast, improved clinical outcomes were noted in patients treated by course participants who subsequently were selected to be involved in a quality-improvement project involving ongoing audit and feedback of clinical interventions.
Brennan and colleagues’ study8 had limitations, but the outcome clearly raised the question of whether a planned, ongoing education program following a short course could enhance clinical outcomes. This is the substance of Cleland and colleagues’ well-designed prospective randomized trial.9 The effect of ongoing education was investigated after clinicians had attended a 2-day (8 hours) continuing education course on the management of neck pain, following which participants were randomly assigned to receive or not to receive ongoing education. The primary outcome measure was of most clinical relevance, namely improvement in patient outcomes as measured by changes in Neck Disability Index (NDI) scores and pain ratings. The course content was evidence based and included lectures on current best evidence on a classification system for the management of neck disorders and a significant practical component consisting of manual therapy techniques and specific therapeutic exercise for cervical disorders. The ongoing education was a logical and appropriate design and covered theory, practical skills, and clinical application. It consisted of two 1.5-hour educational meetings (4 and 7 weeks after the course) in which the classification system and participant skills were revised and checked by the course instructor. Clinical application was mentored in a 1-hour co-treatment session of a patient by the clinician and instructor in the clinician's normal work setting.
The results of this randomized controlled trial demonstrated that patients with neck pain treated by clinicians who received ongoing education had superior clinical outcomes in terms of changes in NDI scores. No improvement in clinical outcomes was observed in patients treated by those clinicians who did not receive ongoing education. This finding may not be totally unexpected, given Brennan and colleagues’ previous results,8 but ongoing education has not always resulted in superior patient outcomes. This is in evidence in the study by Rebbeck et al,10 who investigated the implementation of guidelines for the management of neck pain associated with a whiplash injury. The disparate findings suggest that the construct and content of the ongoing education may be crucial factors. The effectiveness of individual components of ongoing education could not be evaluated in the study by Cleland et al. The authors discuss these and other limitations, but accepting the results at this point, the study importantly provides evidence to drive change in the current internationally popular method of short, practical continuing education courses without any ongoing education.
There are challenges ahead to determine the best methods of ongoing education to maximize the benefit of short courses. Methods are likely to incorporate a variety of formats to attain diverse goals, such as advancement and improvement of physical therapists’ knowledge and clinical reasoning and technical skills; evidence of translation of research-informed practices to the clinical environment; and, importantly, enhanced clinical outcomes for patients. As highlighted by Cleland et al, the costs of educational methods must be rationalized with, for instance, enhanced patient outcomes and efficiencies in the cost of care. Additionally, there needs to be equity in access to ongoing education following short continuing education courses, which may pose more challenges than encountered in Cleland and colleagues’ study of a relatively confined group of practitioners.
Further research is necessary to determine the most-effective methods of delivery of continuing professional development suitable to a physical therapy context. There is merit in the methods of ongoing education used by Cleland et al. Re-enforcement of knowledge, practice, feedback on performance, and reflection are factors that aid deeper learning. It is my view that a key component of the ongoing education was the co-treatment of a patient by the clinician and instructor, where new knowledge and skills were directly applied in the clinical setting.
Although theory and practice may be very clear in a classroom, workload management and individual patient peculiarities may challenge the clinician's ability to appropriately apply new knowledge and skills gained in a short course in his or her own practice setting. In such circumstances, it often is easier to revert to old ways. Certainly, personal experience is that students of specialty postgraduate course work master's programs rate the value of supervised clinical practice as one of the strongest features of the programs. Costs, time, and accessibility issues for both course participants and instructors will limit this activity in relation to short, non-award continuing education courses, but alternatives can be found for this important "coal face" translation of new knowledge and skills to clinical practice.
Peer mentoring and peer-assisted learning11 with patients should not be undervalued in this context. Course participants may have opportunities to meet and examine patients together as an ongoing education strategy. When distance is an issue, Internet conferencing facilities can be used with minimum cost. Not only are peer-mentoring methods relevant for novice learners, but, as has been witnessed in candidates’ preparation for final examinations for clinical specialization and Fellowship of the Australian College of Physiotherapists, peer-assisted learning with patients is a highly potent method of learning for experienced practitioners as well.
Effective continuing education methods are necessary not only to assist clinicians in maintaining currency in practice, but also for training physical therapists to advance in rapidly changing scopes of practice. In various parts of the world, physical therapists are practicing as specialists, as extended-scope practitioners, or as the first-contact practitioners in the previously traditional medical settings such as hospital emergency departments and hospital orthopedic, pediatric, and neurosurgical clinics.12–14 Health care delivery is changing, and the changes at all levels require effective methods of continuing professional development. Cleland and colleagues’ research is timely, and it is hopefully the beginning of many future studies to evaluate best methods for delivery of effective continuing education for physical therapists.
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