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The clinician: endangered or extinct

Discussion in 'Teaching and Learning' started by Atlas, Oct 4, 2007.

  1. Atlas

    Atlas Well-Known Member


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    The bonefide full-time clinician. In a teaching environment, it is virtually extinct.

    If you find one, capture it; maintain it, and hopefully one day, we can find another of the opposite sex.


    Why have they become less relevant today? Since when did assessing and treating patients proficiently; and treating non-textbook presentations in a non-textbook way become an nth-order issue? Since when has the clincian-student relationship been deemed less important than say...the cochrane-student relationship?


    Fortunately for most of you, I am in the minority and I have been wrong before. But I think that the compentency and proficiency and clinical thought processes of (younger) musculo-skeletal clinicians now, is probably at its lowest ebb. I have no doubt that your modern physiotherapy or podiatry graduate can recite a plethora of relevant research articles. I have no doubt that most of them can pick up one flaw in each article. But in a clinical situation, too many are struggling. Despite advancement and more readily accessible diagnostic imaging; despite more intense and longer (in some instances) courses, today's graduates are more confused, and definitely not more competent than those of yester-year.




    So if I am correct, or even half correct, what are possible contributing factors?

    1. University's love affair with EBP. I can't understand its total infatuation. Even Sackett himself proposed that one eye be kept on the clinical picture. More research will further aspects of a profession; but at what clinical cost? Is it necessary for its existence; for its funding; for its standing in the world's top 100 (universities); for its reputation? Why the absolute 100 km/hour pursuit, when your brakes aren't great?


    EBP has a place, but its in its infancy. How can we possibly expect "the evidence" to provide appropriate answers until quality research has been performed on most clinical presentations, in most environments, in various subjects, with various nuances, with certain secondary/tertiary concurrent issues? We are 50-100 years away at least.



    2. A faculty's invariable preference to employ/reward/promote academics over clinicians. The balance is now out-of-kilter. A clinician without letters after his/her name is virtually an endangered species in today's musculo-skeletal clnical environment.

    When a student asks a lecturer or tutorer a clinical question, I think it is a bit rich for the 'answer' to be "what does the evidence say" time and time again. Universities owe the taxpayer/public, the profession and their students more than that.



    The hierarchy of knowledge academically does not reflect clinical knowledge
    In 1999/2000, I spent $15,000 on a masters degree in Physiotherapy. It didn't make me a much better clinician.

    If Betty around the corner contacted 2 podiatry practices (Melbourne, Victoria) tomorrow, and was offered an appointment with a new graduate in each of them. But practice 'b' sells the fact that their new graduate is an honours student. Betty will go for practice 'b', as most people would. The reality however is the less preferred graduate in practice 'a' has had more clinical coal-face hands-on patient contact hours during their university education.

    Fact is, a sports trainer has taught me more about strapping than 2 undergraduate and 1 masters musculo-skeletal university courses have. But this type of 'old school - pre-EBP' education is an anachronism, and the antithesis of what your modern musculoskeletal university student will confront.



    In my learning experience, nothing taught me more than being with an experienced clinician, and watching first hand, how he/she grappled with the specific presentation before him/her. Via clinical reasoning and trial'n'error, the processes became clear; and more importantly, were more easy to reproduce in a number of contexts. Contexts that the literature wont cover for decades to come.

    The late Simon Wilson was one such physiotherapy tutorer. Podiatry student/colleagues tell me their is also one fellow at LaTrobe that also fits the bill.



    The love affair must become a like affair. The clincian needs to be cloned, and allow to re-enter the university domain. Otherwise, the clinical competence of musculo-skeletal therapists will remain sub-par for decades to come.


    Ron
     
  2. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Ron

    I find it difficult to disagree with any of what you have written. I consider myself a full-time clinician.

    Unfortunately in the UK and Australia, it is the university-based academics and PhD holders who are considered the 'peak' of our profession. Naturally, these are the people who have seen the least number of patients throughout their career, and had pressure on them to actually 'fix' a condition.

    I feel you would have a different mindset if you worked as a podiatrist in the US - where the real 'high-flyers' of the profession work in busy practices/hospitals, seeing stacks of patients, and where the penetration of EBM has made little impression upon the broader profession.

    The per capita output rate of podiatry researchers in the US is very low compared to UK and Australia. My impression is that the focus of podiatrists in the US is to focus very much on developing clinical skills, with a reasonable nod to the literature. In parts of the world where the broader profession effectively has almost no scope of practice beyond physical medicine and minor cutaneous procedures - we turn to 'reading' about it, rather than 'doing it'.

    Just look at the number of posts by Admin and the team reporting recent research in foot and ankle - my gut feel is that the average Commonwealth podiatrist could actually never do the vast majority of what that research tells us anyway...

    I agree the focus needs to switch back to broadening our clinical scope, rather that trotting out esoteric research. However, David Armstrong and Craig Payne are amongst the only researchers out there I regularly see giving useful outcomes-based clinical research for us to bother paying attention to.

    LL
     
  3. Admin2

    Admin2 Administrator Staff Member

  4. Felicity Prentice

    Felicity Prentice Active Member

    Ron,

    I agree with you. As long as the academic zeitgeist embraces the dissociation of theory and practice, I believe students will be disadvantaged.

    What I can not understand is the term 'evidence' in EBM/EBP. While the results of RCTs are, no doubt, valid, accurate and such - they are reductionist in nature. The phenomenon of the human function and experience does not lend itself to reductionism. Therefore the results do not always reflect the evidence that is seen in the full and complex interaction of clinician and patient.

    There is scant EBM applicable to Podiatry (even if you trawl through the Cochrane Catacombs), so if we waited to get directives before we made a move, ours would be a motionless profession. We need to increase our research output to build up the evidence, this is without dispute. However, I am not confident that exposing students to unfiltered quantities of half-prepared research is of great benefit to them.

    They should be given the skills of critical analysis to interpret and use the literature, and introduced to the methodologies of the research - but most of all they should be exposed to passionate, well informed and enthusiastic teachers who act as professional clinical role models. Only a small number of undergraduates will go on to becomes researchers (and most have already self selected). The vast majority will enter the profession as clinicians, and while their learning has just begun, they should be optimistic, realistic and ready to learn. These last three characteristics seem to be under-developed.
     
    Last edited: Oct 5, 2007
  5. Josh Burns

    Josh Burns Active Member

    Hi All,

    As a clinical researcher trying to improve the effectiveness and profile of podiatry through collaborative research investigating new treatments for common foot complaints, I see the debate on evidence-based medicine as an important one to clarify.

    Evidence-based practice is simply using the best available evidence to improve patient care. As Sackett states "Evidence-based medicine is not restricted to randomised trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions.....if no randomised trial has been carried out for our patient’s predicament, we follow the trail to the next best external evidence and work from there" and goes on to conclude "Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough". (Sackett, D.L. et al. (1996) Evidence based medicine: what it is and what it isn't. BMJ 312 (7023), 13 January, 71-72).

    Kind regards
    Joshua Burns
     
  6. pscotne

    pscotne Active Member

    :hammer:

    Unfortunately?........Naturally ??!!

    :bash:
     
    Last edited by a moderator: Oct 9, 2007
  7. krome

    krome Active Member

    I would like to take this opportunity to give a fair reflection on podiatric research and its momentum over the last decade. When I qualified over 25 years ago there was virtually no research pertaining to podiatry. We were told what to learn and used textbooks that were written a decade before. Only with the introduction in the mid 1980s of a part-time postgraduate degree in podiatry time degree in podiatry did people became aware that research is the back-bone to the progression of our profession. Since, the part-time course the introduction of full-time podiatry degrees, postgraduate qualifications that include masters and ultimately PhDs has the profession gained momentum.

    As Josh alluded to in the previous email not all clinicians will become researchers but those who have the inclination to do research should not be criticised. We are but a few who are trying to enhance the profile of the profession so that clinicians can benefit. It is very difficult to undertake podiatric research due mostly to financial constraints but one thing that saddens me is the criticism of clinicians to podiatric researchers. However, the debate is an interesting one and one possible way to overcome the difficulties is to hold a forum.
     

  8. Colleagues:

    Good to see Keith come out of the woodwork for this discussion.;)

    Being a clinician that has done only a few research papers and projects, I still feel that I am very research-oriented since I have read, written, lectured and judged proposed research for grant funds on foot and lower extremity research for over two decades. I have a great deal of respect for those researchers that sacrifice hours upon hours of their lives to do quality research, for very little monetary compensation. I commend those podiatric researchers who are doing good foot and lower extremity research, including those like Keith Rome, Josh Burns, Jim Woodburn, Craig Payne, Anthony Redmond, Hylton Menz, Karl Landorf, Chris Nester, Angela Evans, David Armstrong, Simon Spooner, Jeff Christensen (sorry if I left someone out!!) and numerous others. We should, as a profession, be seeking these people to lecture at our seminars on their latest research findings since we already have plenty of anecdotal stories from clinician's as to their opinions of how the foot functions and what therapies work best in treating podiatric complaints. What we need more of is good, solid scientific research that helps us direct our treatment toward better therapeutic results for our patients.

    However, from under my clinician's hat, I see many failings in some of the research that has been done in the past. I am especially sensitive as to how research on certain therapeutic modalities is being used by the governmental authorities and insurance carriers to deny treatments to our ailing patients, even though considerable clinical experience shows that these same treatments may be effective for a large number of patients. In other words, when the research statistics are not showing a strong significant effect, the treatments may be denied as being a covered services, even though many patients may benefit from the therapies, especially when performed by a skilled clinician.

    One point of Ron's that I do agree with is that clinicians need to be teaching podiatry students and podiatrists to increase their clinical skills. A researcher that sees few patients can only offer the podiatry student a limited amount of information regarding the finer details about how to best treat patients. However, even worse for the student is the clinician that does not pay attention to the latest research, does not instill the importance of staying abreast of the latest research to his/her students and is still teaching students old, outdated information.

    In conclusion, being a clinician-researcher or researcher-clinician, as the case may be, I will continue to stride along the top of the wall between the researcher's camp and clinician's camp in the hopes that the wall between them will soon vanish......no longer obstructing the researcher and clinician from understanding and having mutual respect for each other.
     
    Last edited: Oct 10, 2007
  9. rajna

    rajna Member

    I agree with you both - this is a real hobby horse of mine and I can rave for hours on this area... I think I can talk on this area as I have done my PhD and work in both research and clinical settings as a podiatrist. I am allied with a research focussed clinical centre within a hospital and find that it is absolutely fantastic - the clinicians are from various backgrounds and they all undertake to incorporate clinically relevant research into their practice. Clinical research is also undertaken by the centre - with evidence presented in a weekly forum so that information is disseminated to the team, and broken down into its clinical usefulness. In an ideal world, this is the way clinical practice should be normally!

    Now, onto my whining:

    1. I think it is a sign of the times that people expect to pick up all sorts of information about the skills of their profession very quickly - and the new rage to do this is by reading a book/journal article. There is little emphasis in the undergraduate courses that it takes a lot of time and effort to actually understand how the research fits into clinical practice - and you do need to keep up to date with the research and to include it in clinical practice - but to understand the context in which to use it - that takes experience. I know that a few years back, the average working lifespan of a podiatrist was 8 years before they moved on to other jobs (Melbourne, Australia) - in my view, that's when they've just started getting good!

    I have had pods tell me that they refuse to work in a hospital environment as they feel they will not get the respect they feel they deserve as a clinician from clinicians of other fields - and how long have they been working as a pod? On average: 2 years...... I am sorry, but in my view that is a baby. Let alone the final year students that come through and start the day thinking that you can't teach them anything, then leave demoralised, recognising that they have a lot to learn after I've finished with them - it really gets on my nerves !!

    2. I think that looking at the evidence is essential - we need to ensure that all clinicians use clinical guidelines (when available) and understand what has been found effective and use it in the clinical setting. This is not being done and I suggest this needs to be pushed. The next step is filling in the gaps in evidence - you can't do that if you don't have clinical experience to recognise what these gaps are - and as you've pointed out, there are MANY gaps.

    3. I think we need more academics that work within the clinical system hand-in-hand. I can't understand how you can possibly know what research is required if you don't work 'at the coalface'. I find in reading a lot of the research articles that there is little understanding about what a clinician is actually doing in practice. How to tackle this? In the too hard basket!! It takes too much time than i have now...

    I am glad that other people are as stroppy about this as I am.

    Rajna
     
  10. One Foot In The Grave

    One Foot In The Grave Active Member

    Fully agree.

    Whilst we've had at least one fabulous student for 3rd year placement each year, we've had some that just leave you gritting your teeth and hoping to God that they don't do something disastrous to your high risk client!

    These are 3rd year students...why don't they know how to hold a scalpel, file a nail, find a pulse with a Doppler or measure an ABI??? Clinicians (who actually want to be clinicians) at uni are incredibly valuable!

    This was my experience of you as a Clinician at uni Felicity - there was always a queue to get you to check our work.


    Whoops! I'm a few years overdue!:D
     
  11. Atlas

    Atlas Well-Known Member

    Statistical Significance Versus Clinical Importance: Trials on Exercise Therapy for Chronic Low Back Pain as Example
    [Literature Review]
    van Tulder, Maurits PhD*†§; Malmivaara, Antti MD, PhD‡; Hayden, Jill DC§; Koes, Bart PhD[//]



    Very interesting article.

    Well worth the read.
     
  12. Cameron

    Cameron Well-Known Member

    netizens

    Conditions do apply and there are distinct differences from country to country. The common denominator is however universities cannot & will no longer fund on-the-job apprenticeships. The concept of the training foot hospital (sadly) has gone forever and National Incentives such as the NHS student placement have forced podiatry education centres to accept outpost learning experiences as part of planned curriculum. This is positive where and when this works well, but there are always potential for bad learning. Lack of competent supervision would certainly challenge such the system.

    Universities can only aim to hit base line competencies in their undergraduate programs. Developing common professional competencies has become a more focused activity within the profession (nationally and internationally) and these findings are likely to have a major impact on the present curriculum.

    The Profession needs to acknowledge and accept mandatory life long learning is essential and adopt a CPD which marries clinical and intellectual development. An 'earn a learn approach' would reduce the burden of expense in the earlier years of a career where money might be tight. This model does however challenge the idea that podiatry graduates are all things to all employers.

    In bigger disciplines new graduates experience a phased integration into the work situation which is not obvious in podiatry. There is some level of control such as pay scales commensurate with experience but these are not universal nor do they guarantee a novice practitioner undertakes an industry approved induction training which most other graduates would receive.

    I would suggest the death of the clinical (educator) is the end of an era and lamentable as that is, the brave new world will see a new order where CPD will become more clincially focused.

    toeslayer
     
  13. pgcarter

    pgcarter Well-Known Member

    As far as the research vs clinical practice debate goes and how little research appears to happen within clinical practices......I'd be interested to know how many GP'S or dentists or physio's are doing and publishing research from within their private practices......not much I would expect. It is also about funding streams...podiatry is a young and small profession and in Aus has no large businesses, even the biggest practices are probably not turning over more than 3 million or so.....compare this to the size of revenue streams in pharmcology.....or the size of budgets in large footwear companies...Nike etc.

    I think we need to be careful not to flog ourselves to death trying to be all things to all people. Yes aim high etc.....but be realistic.....if your practice turns over $300, 000 and you put say 2% to education and research thats $6,000 and by the time you pay association subs and a couple of conference attendances.....if you live in the country yout turnover is more likely $100-200K.....not much research happens on these kind of budgets......and we should not be bluffed into thinking it should.......if the Uni's can't do it how can small and quite small businesses be expected to fund it?

    Having been one of those endangered species trying to be a useful and experienced clinical teacher......without a PhD......my kids got sick of the taste of peanuts.

    Accountants and education.......a nasty combination that we have all been bluffed into accepting.
    regards Phill Carter
     
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