#DPTstudent Chat for Wednesday, June 25th: What should you consider when choosing a clinical rotation?

At some point in your career as a #DPTstudent, you will have to make choices about your clinical rotations. You may have to consider the setting, your CI and the way the clinic practices… the process can be very intimidating. How does your school handle this process? What say do you have in the matter? What can you do if you’re unhappy with your rotation(s)? Should you go to a place where you have an existing relationship or a clinic that does not have a relationship with your school? Are you hesitant or fearful of making any of these decisions?

Join us on Twitter on Wednesday, June 25th at 9 PM EST to share! Follow the hashtag #DPTstudent to see the discussion unfold.

#DPTstudent chat for Wednesday, June 18: Professionalism in a Digital Age

As a PTthinktank reader, you are likely aware that social media sites have made new information easier to share and access. Health professionals, fitness “experts” and the average Joe are now able to disseminate large amounts of information quickly and easily – with content that may or may not be credible.

Drs. Kendra Gagnon and Carla Sabus argue in a recent PT Journal article that physical therapy professionals have an “opportunity – and perhaps a professional obligation” to contribute in meaningful ways to the quality of health-related information on social media websites. In their article, they offer several opportunities and guidelines through which physical therapy professionals can use social media to connect with other providers, patients, and readers around the world.

For this week’s #DPTstudent chat, we’ll be interviewing Kendra and Carla via Google Hangout from 8pm-9pm CST. The live YouTube link will appear on this site on Wednesday evening immediately before the interview. We welcome your comments, questions and discussion on Twitter during the interview regarding social media use for physical therapists and DPT students.

Abstract and link to full-text for APTA members here

View the interview here: http://youtu.be/dQHgoj_kyDE

See you there!
@LauraLWebb

#DPTstudent Chat for Wednesday, June 11, 2014 @ 9PM EST: Should Schools Pay to Place a #DPTstudent in Clinic?

There is a trend emerging in #DPTstudent education of declining reimbursement and less flexibility and options with clinical placements. As a result, some schools are beginning to offer money to clinics in order to persuade them to accept students. In this week’s #DPTstudent chat, we will discuss the implications of this change, good and bad. Should PTs consider it a part of their job to instruct incoming professionals? Does this practice reduce the #DPTstudent to a commodity? Or is it a necessary change given health care reimbursement decline? You tell us!

RESIDENCIES FOR NEW DPT GRADS FROM CLINIC OWNERS PERSPECTIVE

Residencies seem to the hot topic now that I have entered the third and final year of my DPT program. Residencies are designed to help build a specialization as well as foster mentorship and increase clinical reasoning skills. If completing an APTA accredited residency you are eligible to take the OCS, NCS or other specialization designation test sooner. (More details about that here.) Deciding to pursue a residency after graduating from a DPT program is a big undertaking and should be well researched and understood by the student. You can find a great comprehensive list of residencies in different areas of specialization here. The point of this post is not to discuss to many different kinds of residency models but instead to discuss some topics that #DPTstudents should be aware of before diving head first into post DPT residency.

Let me start with a little background on why I decided to ask clinic owners or hiring managers their thoughts on residencies. I was discussing the many options of post DPT graduation residencies with my husband. With a confused look on his face he said, “I don’t understand. You will have just finished 3 years of a doctorate program but you need to do a year or longer residency to land a job that would pay you exactly the same as if you hadn’t done the residency?”  I wasn’t sure how to answer his question. Would I make more if I did a residency? Would I be a better candidate or would I just be considered a silly new grad who happens to be more in debt? Would an employer be willing to help me pay for it? (Please note that there are residencies that pay you as a full time employee and incorporate mentoring hours and clinical hours. In my case, I want to stay in Colorado so I have only been looking into distance based residency programs with weekend hands-on intensives. I also want to begin my career where I  plan to live for the foreseeable future just as a personal choice. Ok, back to the topic!)

I made a short survey and with the power of Twitter I was able to get 35 clinic owners or hiring managers to complete the survey and many offered additional comments. The n=35 is not statistically significant but I think it gives a good insight regardless. This is what they had to say.

Question 1: Does completing a residency increase a new grads chance of being hired?

YES. 66.6% said yes, 33.3% said no. Many of the comments that accompanied this question stated that a residency provides more experience and mentoring (read: “less needy”) and therefor the student would be perceived as a better candidate. However, some of the comments were not along these lines such as “I would not give a residency grad higher priority than I would to a well-informed, motivated and articulate new DPT who has not gone through a residency.”

Question 2: Is the salary higher for a residency grad vs a new DPT grad?

You have a 50/50 shot at making more money as a residency grad. The results were split right down the middle (one person did not answer this question). Many of the comments on this question stated that just because a new PT graduated from a residency program does not mean they are able to bill the patient more for their time. One commenter stated that often times residency grads request a higher salary but the skills they bring have not brought extra value to the clinic. This owner/ hiring manager states “you have to look at what type of value/niche the potential PTs residency brings to the practice and community. We pay people based on the individual value they bring.” It’s all about value.

Question 3: As an employer, do you offer any assistance for an employee wanting to complete a residency?

I was really surprised by the answers and comments on this question. The majority (50%) do not offer any assistance on continuing education including a residency, 30% offer some continuing education budget, and 20% of the respondents host a residency in their clinic. Many of the comments posted on this question simply stated that as a small private practice, this is too big of a financial burden to provide a continuing education budget. One responder said they would support an employee wanting to pursue a residency but there would be pay back stipulations if a certain time commitment of employment was not met.

Question 4: Do you have any other thoughts you would like to share regarding new DPT grads exploring residency programs?

I will let these comments speak for themselves:

I think that we do our profession harm if we imply a residency is the only way to specialize. I think it’s great that it’s an option, but it’s too soon (at least in women’s health) to determine a good cost-benefit analysis.

Therapists who complete the residency programs may have didactic knowledge, however the clinical translation is a value lost on my practice. I would suggest a 2-3 year level of experience prior to attending a residency as a criteria, a new grad is a new grad- residency or otherwise.

I encourage new grads to do a residency is they have the financial means. If they don’t, then I think they should think twice

I think it’s a great idea to explore a residency if you can support yourself on a potential lower salary for awhile.

I think a residency is a fantastic thing to do for the motivated individual to take their practice to the highest level. However, I do not believe that increased pay or anything to that effect should be the motivating factor to pursue a residency.

If you are in a position to attend one, great. The mentoring and experience should be beneficial. But do not think that it is the only path to excellence. As an employer, I would prefer a keen, passionate and well informed new grad over one who has been groomed to follow outdated paradigms and has become a follower of any one particular technique (i.e. McKenzie, Paris or Dry Needling). I much prefer a strong critical thinker who is willing to apply uncomfortable truths about research and evidence into the practice of PT. I do not see this push in residency programs so far.

I found the results and comments posted on my little research study to be very eye opening. I hope this helps you put things into perspective as it did for me. Attending a residency can be very beneficial in many ways, but think twice and ask many questions before jumping in as a residency is not the only way to success.

#DPTstudent chat for Wednesday, 6/4/14: Passing the NPTE Exam!

Congratulations, you’ve just graduated and earned your DPT – now the hard stuff is over, right?  Not so fast! That pesky National Physical Therapy Exam (NPTE) is standing between you and that license!  This week we will discuss strategies, resources, and best practices for passing the big test!

Come join the discussion Wednesday at 8:00pm CST and let’s help set each other up for success!
– @TylerTracy10

#DPTSTUDENT CHAT TOPIC FOR WEDNESDAY, MAY 28, 2014: SAY WHAT?

“Oh, you’re in PT school?” …

… “I’ve had this ache in my right shoulder for the last few months, could you take a look at it?”

… “So that means you’re pretty good at back massages, right?”

… “What exercises do you recommend to build up my calves?”

We’ve all had these encounters by now… well-meaning friends, relatives and innocent bystanders who, upon discovering your acceptance into physical therapy school, suddenly see you as an expert on all things pain-/massage-/exercise-related.

And in some ways, these questions are great! We WANT to be known as experts in the field of neuromusculoskeletal disorders. Other times, however, their questions can be misguided or downright offensive (NO I will not rub your feet!!).

How do you respond to such queries when people find out you are a #DPTstudent? Do you take it as an opportunity to explain what PT’s actually do? What’s your best elevator speech?

This Wednesday, May 28 at 9 PM EST, we are taking a lighthearted approach to a common issue: discussing the craziest things people have said to you when they learn you are a #DPTstudent and how you responded!

See you there.

–@LauraLWebb

Manipalooza from a #DPTstudent Perspective

photo 2-2 (2)There are some experiences as a #DPTstudent that leave you feeling energized, happy, and confident that you absolutely made the right career choice. This was one of those experiences. This past weekend I had the amazing opportunity to attend Manipalooza put on by Evidence in Motion. Manipalooza is a “3-day festival of hands on learning in manipulation, soft tissue techniques, pain management strategies, sports PT, and practice management. Participants will learn the most cutting edge techniques from experts in the PT field.” I can’t possibly fit everything I learned into a blog post but I am going to recap the many highlights of this experience.

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Saturday kicked off with a freestyle rap performed by a CU student on whatever PT topics the audience threw at him. You can see the video here. How someone raps about CT junction manips or G codes is beyond my comprehension but it was amazing and had everyone laughing to start off the morning. After an introduction to the weekend, Dr. Larry Benz kicked off the presentations with one titled “Deliberate Practice: Taking Your Skills from Good to Great”. This presentation focused on how to create a mindset of growth in order to continue to advance. One topic that Larry discussed that I find myself reflecting on again and again is the concept of “normalized discomfort”. This means that you have to fail in order to be able to grow. We must become more comfortable with failure and constructive criticism as we tend to learn the most from it. If we are not challenging ourselves outside of our comfort zone, we will never move closer to where we want to be. I would say that I found the whole weekend challenging and because of his talk, I was able to tell myself “it’s ok that you are struggling with this technique, this is challenging, and you are learning.”

Daphne Scott, leadership extraordinaire, then took to the floor with a presentation called “Change, Willingness…and Love”. Daphne lead the group through an exercise where we took a complaint we had about work or life, and showed us how to analyze and redirect the complaint and turn it into something more productive but to also stop wasting creative energy on blaming ourselves and instead just recommit to your goal. We discussed how change is hard and how upwards of 70% of companies who try to implement change fails.

After the short morning presentations, you had the choice of 3 different sessions: manual therapy of the foot and ankle (ortho track), neuromuscular intervention for chronic ankle instability (sports track), or time management and the illusion of time (business track). TJ and I decided to go to the ortho track, but I wish we could have been at all 3! Some of the techniques we went over I had previously learned in school but it was really nice to see a few modifications as well as get a nice refresher! I was also exposed to several techniques that we did not learn previously.

TJ practicing a rear foot distraction technique
TJ practicing a rear foot distraction technique

 

After lunch I decided to switch tracks (the afternoon classes that were offered were manual therapy of the knee, Eval of athletic movement: the ACL, and Career development: Yours and Theirs) and attend the business track on career development lead by Daphne Scott. It was a small group and Daphne asked all of us to tell her what we wanted to get out of the session. TJ and I were the only DPT students in the room (in fact, there were hardly any students at the event at all! Maybe 8 total for the Saturday session and just the two of us on Sunday!) and it was interesting to hear clinic owners talk about developing their staff. We also talked a lot about passion and spotting the employees who find their position to be a job, a career or a calling. A job is something you do to make money. Scooping ice cream when I was 15 was a job. A career is something you are trained in and have room for advancement but would quit if you won the lottery. My previous profession of an accountant was a career. A calling is what you think you were meant to do and you would still pursue it if you won a few million bucks. For me, this is my future in physical therapy- I am passionate about it so much that even if I were rich I would still be a physical therapist (granted, one that takes super fancy vacations).  I was able to leave that session knowing what I am looking for as far as career development goes and how to be sure that my values align with a potential employer.

regis
A few of my classmates that attended!

 

The Sunday sessions were equally as fun! We kicked off the morning with 4 hours of thoracic and rib cage manual therapy and manipulations taught by Tim Flynn. The afternoon was 4 hours of cervical manips taught by Jason Rodeghero, EIM’s orthopedic residency director. Both sessions integrated clinical reasoning alongside of the manual techniques. What I absolutely loved about all of the lab sessions is how many EIM faculty were there to help! I had personalized attention from at least one -but most times 2 different faculty helped- on every single technique. I was offered advice on how to modify skills based on my size, how to adjust my hand placement, and several times a faculty would place their hands over mine to make sure I was where I was supposed to be. Jason even taught us a little trick to help with speed of manipulations by using a water bottle to practice the small quick movements! I have been doing this with my water bottle every day…but make sure the lid is on tight enough or else you have water all of the floor…not like I did that or anything.

Learned several modifications for this technique in order to perform it on patients bigger than I am (which is everyone)
Learned several modifications for this technique in order to perform it on patients bigger than I am (which is everyone)

I was introduced to some of the techniques in school but I left on Sunday with many more skills in my proverbial PT toolbox and a greater sense of confidence about using my hands on a patient. In fact, I thought to myself many times, “I had no idea this many manual techniques even existed!” As I said before the weekend was challenging. TJ and I would talk through each technique in regards to when you would use it on a patient before practicing on each other. With many of the techniques we struggled at first, but with deliberate practice (Thanks, Dr. Benz!) and amazing faculty there to help us we were successful with all of the techniques before we left. We ended Sunday by attending the complimentary managers reception at the host hotel where we were able to chat with the EIM faculty and other participants.

TJ and I with Dr. John Childs and Dr. Tim Flynn
TJ and I with Dr. John Childs and Dr. Tim Flynn

 

Unfortunately, I had to high tail it back to Wyoming for clinical on Monday, so I missed the last day. However, one of the best parts about Manipalooza is that EIM gives you online access to their Moodle which is an online classroom and I was able to download all of the slides from the sessions I missed!

I would argue that Manipalooza is one of the absolute best conferences a DPT student could attend. The clinical reasoning, hands on labs, and amount of fun is unparalleled. If you want to take your manual skills to the next level before graduation this is the place to go The personalized attention allowed me to leave with a sense of confidence in the skills that I learned. Manipalooza will be an event that I attend year after year. It is just too good to miss!

Thank you again to EIM for such an amazing event!

#DPTSTUDENT CHAT TOPIC FOR WEDNESDAY, MAY 21, 2014: TIME MANAGEMENT AND STUDY TIPS

Congratulations!

You’ve been accepted to physical therapy school and are ready to embark on a great adventure. Or perhaps you have finished your first (or second) year and are looking to fine-tune your approach for the remainder of your time as a #DPTstudent. Whatever the case may be, this Wednesday we are looking for incoming, current and former students to share their study tips and time management strategies that have helped them achieve success.

See you there!

–@LauraLWebb

Data Quality: Garbage In = Garbage Out

Measuring and objectifying observations and phenomena. Numbers. Data. These are the cornerstones of analytics. The presentation and appearance of (apparent) objectivity. Whether in research, health care policy, economics, business, or clinical practice, data is important.

The data doesn’t lie.

But, sometimes the people that interpret it do. Not that they mean to. It’s not done on purpose (except when it is). So, yeah, unfortunately, the numbers can lie. And, they will lie to you if you are not conscientious about assessing them more deeply.

“What gets measured, gets managed.” Peter Drucker

Data Quality

Questions of why this works, or, maybe, more importantly, “does this work as proposed? Does the explanatory model make sense?” are not inherently built into the evidence based approach. Yet, these questions are vital to integrating and understanding outcomes research, while evolving our theoretical models. Such a task mandates metacognition and critical thinking. Failure to critical assess the quality, and potential meaning, of data, will result in improper conclusions.

The evidence hierarchy is sorted by rigor not necessarily relevance –EBP and Deep Models

But, the questions and issues surrounding data quality and interpretation transcend assessing the literature within the context of the evidence based hierarchy. Much like the research literature, the data collected, analyzed, and utilized everyday warrants critical appraisal. It all requires assessment; data encountered inside and outside the clinic, data utilized for decision making and understanding. The concepts of scientific inquiry should be wielded routinely, including assessment of quality, source, and limitations of the numbers. Only then, can proper interpretation and subsequent decision making occur.

Is it accurate?
Is it representative?
Where did the numbers originate?
What do the numbers actually represent?
What conclusions can or can not be concluded from a data set?

The evidence based practice hierarchy is concerned mainly with questions of “what works?” and “what is effective and efficacious?” These are necessary, important, big questions. But, the term “evidence” as utilized by most clinicians and researchers is focused mainly on randomized clinical trials, systematic reviews, and meta analyses of randomized control trials. Outcomes based research. This is a necessary and obvious step forward from purely observational, experienced driven clinical practice and education. Despite the obvious importance of experience (or more accurately deliberate practice) in clinical decision making, analysis based on experience or clinical observation only is prone to errors such as confirmation bias and convenience. Clinical observation alone is limited in it’s ability to ascertain phenomena such as a natural history and regression to the mean. And thus, this issue is related not only to data quality, but proper data interpretation. Understanding data quality assists in assessing “what works”, but also in tackling the complex question of “why does it appear to work?” Both questions are inherent to, and reliant upon, the quality of data.

Numbers, Data, and Objectivity

In attempting to objectively measure the world, has the potential accuracy and quality of data been forgotten? Overlooked even? A number seductively presents the appearance of objectivity and accuracy, but does not guarantee it. Big Data provides an excellent example of data quantity with relatively overlooked quality. Astounding data-sets through avenues such as social media and search engines afford researchers and large companies the opportunity to analyze data-sets that would literally explode your lab top. For example, in 2008-2009, based on web search data Google Flu Trends more accurately and quickly predicted and modeled flu outbreaks than the Centers for Disease Control (CDC). Well, until 2012-2013 when it wasn’t so accurate, over estimating peak trends. In big data are we making a mistake? Tim Harford explores the scientific and statistical problems still present (even when the size of a data set requires it to be stored in a warehouse): 

But a theory-free analysis of mere correlations is inevitably fragile. If you have no idea what is behind a correlation, you have no idea what might cause that correlation to break down. One explanation of the Flu Trends failure is that the news was full of scary stories about flu in December 2012 and that these stories provoked internet searches by people who were healthy. Another possible explanation is that Google’s own search algorithm moved the goalposts when it began automatically suggesting diagnoses when people entered medical symptoms…

Statisticians have spent the past 200 years figuring out what traps lie in wait when we try to understand the world through data. The data are bigger, faster and cheaper these days – but we must not pretend that the traps have all been made safe. They have not…

But big data do not solve the problem that has obsessed statisticians and scientists for centuries: the problem of insight, of inferring what is going on, and figuring out how we might intervene to change a system for the better.

Measurement Matters

Now, just because it can be measured, does not mean it should be measured. Measurement alters behavior. And, the change is not always as envisioned or desired. As soon as a goal is set to alter a metric, incentives apply. This concept transcends clinical care. It applies to business, management, and clinician behavior. Enter the cobra effect.

The cobra effect occurs when an attempted solution to a problem actually makes the problem worse. This is an instance of unintended consequence(s).

So, is the goal to change that specific metric only?  Or, is the actual goal to encourage specific behaviors that appear to directly affect, or are correlated with, that metric. Regardless of the goal, care must be taken in defining success. This requires a clear definition of what is measured and why. Again, deep analysis of data quality and interpretation are necessary to properly interpret results of process changes. Due to the appearance of objectivity in the presentation of numbers, it is easy to make inaccurate or far reaching conclusions. This is especially true when care is not taken to assess all the components of the data:

What does the data actually represent?
Who or what measured it? Who or what entered it?
How was it initially assessed and subsequently interpreted?
What other data needs to be considered or measured?

Now, even with reliable and accurate data input, inaccuracy can occur. The wrong conclusions can be “output” because of the misinterpretation regarding what the data is representing or signifying. Wrong numbers = wrong analysis = wrong conclusion = wrong interpretation = misguided application.

Steer away from subjectivity

The complexity of even the simplest data sets is astounding. Ever present are questions such as: Is the data valid? Does the data represent the assumed construct or principle? What potential bias is involved? Is it reliable between people; between subsequent measurements? Is it actually measuring what we think it’s measuring? Can it answer the questions we are posing? Measured and presented data is rarely as simple as a concrete number.

The attempted objectification and simplification of subjective, individualized, complex phenomena such as happiness, satisfaction, engagement, or pain may be tragically flawed. Commonly, over reaching conclusions are based on assumptions of accurate and/or complete representation. The data presented is merely a measurement, a number produced via the tool chosen.

A tool misused produces data that’s unusable

That tool may, or may not, accurately convey the construct it was initially designed to represent. In the case of patient report questionnaires, the individual filling out the tool will always be biased; influenced by the environment, their expectations of what should be conveyed, influences from others (explicit and implicit), as well as complex incentives depending on their needs, goals, and expectations. Further, most data encountered on daily basis, including clinical outcome measures (whether patient performance or patient report), is not collected in controlled environments with explicit processes. Bias will always affect reporting and recording. Questions of the accuracy, reliability, and validity apply not only to the tool, but also to the person recording the measurement. It quickly becomes complicated. The Modified Oswestry Disability Index never seems so messy when presented as a straight forward percentage.

Compare the stark contrast between how an outcome measure is collected within a research trial vs. everyday clinical practice. In order to minimize both error and affects of bias, outcomes in a trial are collected by a blinded assessor. A standardized set of directions is utilized, with a pre-defined process for administration and measurement. But, even in more controlled, direct data collection environments, what is being measured and what that actually illustrates, is not straight forward. Representation is not always linear. Even in randomized, tightly controlled, double blind studies bias and flaws are present. This does not inherently make the data useless. Leaps of logic need to be recognized.

If data is sloppy enough it is beyond useless. It’s harmful.

Why? Because, unreliable, variable data that is not truly measuring or representing the phenomena one assumes will ultimately lead to inaccurate conclusions. Regardless if the data is positive, negative, or neutral it is misleading.

How? Because, the data itself can not be representative of what we think it is measuring, purely by the the fact that the data itself is unreliable, overly variable, and “sloppy.” Further, if the assumption is made that a measure represents a certain construct, but it actually does not, it has no validity. Without reliability, validity is unobtainable. Without validity, reliability is misleading.

Data Quantity vs. Data Quality

So, should the focus remain on quality or quantity in data? Both. Is more data always better? Well, that depends on the quality. But, what is quality data? Quality is a relative term. Collecting, analyzing, or using data is only part of the equation. Once collected, questioning validity, reliability, representativity, and relevance is necessary. In the cases when data has already been collected and potentially presented, it’s time for some serious skeptical inquiry. Understanding what data actually represents and illustrates assists in proper critical appraisal. Proper critical appraisal allows proper interpretation. Proper interpretation is the foundation for  effective utilization. Less controlled data collection environments do not necessarily produce unusable data, and in fact can be quite useful in the realm of health services and care delivery models. Yet, the conclusions drawn on effects, mechanisms, and efficacy need to be tempered. Focus on understanding exactly what a data set can and can not illustrate given the data collection environment and design and metrics.

Unreliable and invalid data in, wrong conclusions out. Always. Any accurate representation will be by chance alone. But, in these instances, the probability of attaining an accurate representation will often be less than chance. Limits are always present, and can not be avoided, but understanding the limits of the data assists in drawing conclusions that are the least wrong. While the data itself is important, what is done with the data, and why, is almost more important. And, these principles apply whether you are assessing your clinics “outcomes” or tracking disease outbreaks with big data. Focus on improving the quality and accuracy of data collection on the front end. Train those measuring, collecting, and entering data. Improve analysis and inquiry on the back end. In addition to asking “where’s the data?” we should be asking “where did that data come from?” and, “what does it actually illustrate?”

Be skeptical. Garbage in = garbage out.

#DPTSTUDENT CHAT TOPIC FOR WEDNESDAY, MAY 14, 2014: PAYING FOR A DPT DEGREE

As the next class of DPT students enter schools around the country, they are likely facing the highest tuition costs yet, while possible changes to forgiveness programs are on the horizon. Is the DPT degree still worth it? We certainly think so, but financial responsibility is still a huge concern. What can students do to minimize the cost of their DPT degree well before they graduate? What loan repayment options are out there? Will PSLF still be an option? Are there still clinics offering loan repayment assistance or is competition for jobs making these benefits more scarce? We will pose these questions (and more!) on Wednesday, May 14th at 9 PM EST. Join in the discussion!