S P E C I A L
C O M M U N I C A T I O N
Perspectives on Pediatric Physical Therapy Education Ellen F. Spake, PT, PhD Department of Physical Therapy, Rockhurst University, Kansas City, Missouri.
Purpose: The Section on Pediatrics convened an Education Summit in July 2012 to examine, discuss, and respond to documented inconsistencies and challenges in teaching pediatric physical therapy content in entry-level professional education programs. This lecture was designed to provide attendees with the history of pediatric physical therapy education, stemming from the author’s early involvement with the Section on Pediatrics and as a long-standing academician. Summary of Key Points: The limited literature on pediatric physical therapy education was reviewed and used to highlight the continued variability across programs. The challenge was presented to build upon attendees’ scholarship of teaching and learning. Statement of Conclusions: These remarks were designed to help understand the growth and development in pediatric physical therapy education over the past 40 years and to encourage others to use what has been learned to build a stronger foundation for the future. (Pediatr Phys Ther 2014;26:2–6) Key words: curriculum, educational measurement/methods, educational status, humans, pediatrics/education, physical therapy specialty/education, professional competence, program evaluation, teaching/methods, United States It is truly a pleasure to have been asked to participate in this historic event for the Section on Pediatrics. I have been a long-standing member since 1974, which you history buffs will know was just a year after the inception of the Section. I have served in various capacities over that time: as a state representative, program chair, secretary, delegate, and president. When I was invited to provide this commentary, I was asked to describe some of the history and vision of pediatric physical therapy education set forth in the 1990s and to provide some insights into how the Scholarship of Teaching and Learning (SoTL) might provide a foundation for the work upon which we are embarking. There is an often-repeated saying that goes something like, “You can’t know where you are going if you don’t know where you have been.” The importance of looking back on the lessons of our past as a foundation for our future cannot be underestimated. To that end, I invite you to go with me on a journey “back to the future.”
0898-5669/110/261-0002 Pediatric Physical Therapy C 2014 Wolters Kluwer Health | Lippincott Williams & Copyright Wilkins and Section on Pediatrics of the American Physical Therapy Association
Correspondence: Ellen F. Spake PT, PhD, Rockhurst University, 5200 Rockhurst Rd, Kansas City, MO 64110 ([email protected]). The author declares no conflicts of interest. DOI: 10.1097/PEP.0000000000000002
2 Spake
HISTORICAL PERSPECTIVE In 1994, I wrote an article, published in Pediatric Physical Therapy, titled “Reflections and Visions: The State of Pediatric Curricula.”1 I went back to that article, hoping for both inspiration and validation of that age-old phrase, “You’ve come a long way, baby!” While I found some inspiration, I don’t know that I found the validation that I was searching for. Let’s see what you think . . . . In 1974, there were 59 accredited entry-level physical therapist (PT) programs and 28 physical therapist assistant (PTA) programs.1 Most entry-level PT programs conferred either a certificate or a bachelor’s degree. Only 5 entry-level PT programs offered a master’s degree. Data about program length were not kept until 1984, when the mean length of an entry-level program was 80 weeks and the average length of clinical education was 20 weeks. No data were available about the length of PTA programs. Fast forward a bit to 1993. At that time, there were 134 entrylevel PT programs and 132 PTA programs. Sixty-four of the entry-level programs were at the master’s degree. The mean length of PT programs was 92 weeks with 26 weeks of clinical education; the mean length of PTA programs was 49 weeks of didactic education and 20 weeks of clinical education. During that span of time, the amount of time allotted to pediatric curricula did not universally increase, despite the increase in the length of programs.1 Currently, there are 211 entry-level PT programs and 293 PTA programs.2 Ninety percent of the current PT programs are at the doctor of physical therapy (DPT) level. The mean Pediatric Physical Therapy
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
length of PT programs is 122 weeks of which 36 weeks are full-time clinical education. The mean length of PTA programs is 92 weeks of didactic instruction and 15 weeks of clinical education. Because there are so few data available about pediatric curricula in PTA programs, outside of some limited data on PTA clinical education collected by Gandy3 in 1993, most of my remarks will address PT pediatric curricula. However, I would suggest that either as part of this Summit or in a different venue, we should not lose sight of the importance of being as systematic and intentional about PTA pediatric education as we are becoming about PT education. In June 2012, the House of Delegates considered 2 motions relative to the degree qualifications for the PTA. While no decisions about advancing the PTA degree to a baccalaureate level have yet been made, when I look in MY crystal ball, I believe that this is a strong possibility for the future. Thus, we should also be poised to influence pediatric curricula both now and in the future of PTA programs. As we look at the history of curricula for PT programs, only anecdotal evidence is available relative to specific pediatric curriculum content from the early to mid-1970s and before.1 At that time, although a few programs seem to have had specific courses related to both child development and (what was then called) pediatric assessment and treatment, the majority of programs seem to have included a relatively sparse amount of information relevant to pediatrics. Much of that information was found primarily as a unit in a larger course. Pathology or dysfunction related to pediatrics was primarily taught by physician residents, rather than by PTs, as part of a medical conditions or pathology course. Few clinical experiences were available and generally these were not integrated within the curriculum, but rather found at the end. Not all students with an interest in pediatrics were given an opportunity to pursue a clinical experience. Fast forward a bit to 1993, when Cherry and Knutson4 documented the state of pediatric curricula. Those data indicated that pediatric content continued to be taught primarily as a unit within a broader course, rather than as a stand-alone course. More hours were still devoted to child development over content on pediatric disorders or management of pediatric conditions, and the number of hours spent was highly variable. The collection of data on the state of pediatric curricula in 1993 provided the impetus for development of guidelines for pediatric content in educational programs. In 2001, the Guidelines for Pediatric Content in Professional Education5 were published. These were subsequently revised and updated in 2009 and the document titled Pediatric Curriculum Content in Professional Physical Therapist Education: A Cross-reference for Content, Behavioral Objectives, and Professional Sources6 now provides the most comprehensive resource available for pediatric educators. While we are very proud of this work—and it should be recognized that only 4 other specialty sections, Neurology, Women’s Health, Geriatrics, and Clinical Electrophysiology and Wound Management, have developed similar documents—we still have much work to do. Pediatric Physical Therapy
Part of what faces us over our 2 days together are the questions of how much is “just right,” how much is “too much,” is “more” always better, and what are the best curricular and pedagogical strategies to accomplish what we want to do? While our current curricular document is very helpful, anecdotal information suggests that some pediatric educators express frustration about being able to “fit” all of the recommended content into the time they have available within the curriculum. In 2008, in a very forward thinking move, the Section on Pediatrics created a task force to describe the current content and structure of pediatric curricula. Schreiber and colleagues7 described this work in an important article published in Pediatric Physical Therapy just this past year. In their survey, they examined a number of variables including perceived adequacy of the curriculum, stand-alone pediatric courses, requirements for a pediatric clinical experience, and hours devoted to pediatric content (lecture, laboratory, contact hours with children, problem-based learning opportunities with children, etc). Seventy percent of programs reported including at least 1 stand-alone pediatric course; likewise, 70% reported that pediatric content within the curriculum was adequate. Eighty-three percent of respondents reported that they used curricular content recommendations published by the Section. In contrast to Cherry and Knutson’s4 findings, 66% of the individuals teaching pediatric content held a full-time faculty appointment. Of particular note, however, is that 38% indicated that they planned to retire in the next 10 years and 59% within the next 15 years. This is critically important information and suggests that the Section must be systematic and intentional in endeavors to ensure that there will be well-prepared faculty to replace those who will be retiring. A look at the evolution of clinical education may also give us some moments for reflection. In 1994, I reported that clinical education had not appeared to have changed markedly in the 20 years from 1974 to 1994.1 At that time, although most programs appeared to have had pediatric clinical sites available, few programs required a pediatric clinical experience for all students and most programs only allowed the pediatric experience to “count” as a specialty clinical experience. In her 1993 study, Gandy3 noted that according to the 1992 national APTA clinical education database, a total of 5572 nonduplicate clinical education sites were affiliated with PT and PTA programs. Of those sites, only 516 (9.3%) were categorized as “pediatric.” Although the overall number of clinical sites in general had increased between 1984 and 1992, no data were available regarding changes in the number of pediatric sites across that same time period. During the 1991-1992 academic year, 26% of PT students had requested a pediatric clinical experience. Thirteen percent, only one-half, of those students could be accommodated. The data were even more alarming in PTA programs, with 23% of the students requesting a pediatric experience and only 3% able to be placed. While Schreiber and colleagues7 found that 70% of their survey respondents felt that the number of pediatric Perspectives on Pediatric PT Education
3
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
clinical sites was adequate to meet the needs of their program, only 10 programs, or 7% of the sample, required a mandatory pediatric clinical education experience. In fact, some students were found to be graduating with either very few pediatric laboratory hours or little contact with children. The range was from 3 to 148 hours of either laboratory or hands-on experience (excluding clinical education). Given that not all students complete a pediatric clinical, these numbers should give us pause for concern. Thus, an important consideration in pediatric professional education is how to create opportunities for students to practice their pediatric clinical skills. Cherry and Knutson4 also suggested that pediatric clinical instructors had some concerns about the level of preparation of the students, before coming to them for clinical placement. Specifically, concerns were raised about adequate examination, intervention, and decision-making skills. While clearly this could be related, at least in part, to the amount of time spent on these curricular areas, anecdotal accounts from some Directors of Clinical Education/Academic Coordinators of Clinical Education today paint a similar picture. In fact, some of the information we were asked to review before coming to the Pediatric Education Summit suggests the same. I would like to suggest that it is possible that we are not yet in a position to answer all the questions about pediatric curriculum and instruction because many of these questions have not yet been asked. The literature addressing curriculum and instructional strategies in pediatric PT education is extremely sparse. As part of the challenges that we face, I would like to add yet 1 more-–to challenge each and every one of us to use our imagination to explore the breadth and depth of teaching and learning opportunities that can help us reach the outcome goals that we will articulate as part of this summit. This will involve a systematic and intentional exploration of curricular, teaching, and learning strategies that will best position us for not only now, but also the future. SCHOLARSHIP OF TEACHING AND LEARNING Surely, pediatric PT educators consider themselves to be scholarly teachers. Shulman8 suggests that scholarly teaching is that which is well grounded in the sources and resources appropriate to the field, reflects a thoughtful selection and integration of ideas and examples, and demonstrates well-designed strategies of course-design, development, transmission, interaction, and assessment. Furthermore, scholarly teachers are familiar with the literature on teaching and learning, including teaching and learning in their own discipline, apply this information in their classrooms, assess what is happening in their classrooms, and continue to make changes throughout their career. But to guide us, is it enough to just be a scholarly teacher, or should we be asking questions specific to the SoTL as it relates to pediatric PT education? What is SoTL and how is this different from scholarly teaching? Huber and Hutchings9 advocate that we must begin to view the 4 Spake
classroom as a site for inquiry and further suggest that we must begin asking and answering questions about students’ learning in ways that can improve our own classrooms and also advance the larger profession of teaching. Work toward these goals involves significant shifts in thought and practice. Shulman8 posits that for faculty in most settings, teaching is a private act, limited only to the interaction between teacher and students and rarely evaluated by professional peers. The result is that those who engage in innovative acts of teaching rarely build upon the work of others and nor can others build upon theirs. One of the main challenges to developing an SoTL in higher education is that in most disciplines, this process of “reconstruction” has just begun.10 A great deal more remains to be done before it is commonplace for scholars to examine their teaching practice in light of what is known or imagined possible in one’s own or other fields. Cambridge11 suggests that SoTL involves posing problems about an issue of teaching or learning, studying these problems through methods appropriate to disciplinary epistemologies, applying the results to practice, and engaging in self-reflection and peer review. As such, teachers who engage in SoTL take what is done as a scholarly teacher and make it public. Their work becomes available to colleagues in a public forum that is accessible to peer review. Work is exchanged with other members of the professional community who, in turn, build on that work. People often ask, “How do I get started?” The answer is simple. Look for what is underreported in physical therapy education. Consider in what way your findings could have relevance beyond physical therapy education. McKinney12 suggests that it is as easy as thinking about a curricular, teaching, or learning issue; a problem or question that you have about your students, a course, an assignment, or a pedagogical strategy. Any of these can provide impetus to begin. State that issue as a question and you are off and running. I suggested earlier that as we explore the vast possibilities that we have for pediatric physical therapy education, we may not be in a position to answer some of the questions that are important, simply because we have not yet asked them. A review of Pediatric Physical Therapy and the Journal of Physical Therapy Education revealed a paucity of teaching and learning articles in pediatric physical therapy curriculum and education. Take a quick journey with me through these publications, beginning with the Journal of Physical Therapy Education. I examined 8 years (2004-2011) and found 14 articles specific to the teaching of practice specific, professional, or basic science content (eg, cardiopulmonary, neurology, core values, anatomy, statistics): • A hybrid model of student-centered instruction improves PT student performance in cardiopulmonary practice patterns by enhancing performance in higher cognitive domains.13 • Development and implementation of an objective structured clinical examination (OSCE) in neuromuscular physical therapy.14 Pediatric Physical Therapy
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
• A model for teaching and assessing core values development in “doctor of physical therapy” students.15 • Graphic organizers can facilitate selection of statistical tests: part 2—correlation and regression analysis.16 • Use of deconstructed cases in physical therapy ethics education: an assessment of student learning.17 • Student outcomes in a pathophysiology course based on mode of delivery: distance versus traditional classroom learning.18 • Assessing performance in the area of cultural competence: an analysis of reflective writing.19 • The varied-integrative-progressive (VIP) model for anatomy instruction in PT education.20 • Perceived usefulness of reciprocal peer teaching among “doctor of physical therapy” students in gross anatomy laboratory.21 • A comparison of 2 teaching strategies for teaching medical screening and physical therapy referral in a PT professional degree program.22 • Making meaning of whiteness: a pedagogical approach for multicultural education.23 • Effect of computer-assisted instruction versus traditional modes of instruction on student learning of musculoskeletal tests.24 • Graphic organizers facilitate selection of statistical tests—part 1: analysis of group differences.25 • Integrating Web-enhanced instruction into a research methods course: examination of student experiences and perceived learning.26 Absolutely nothing in pediatrics! Hoping for better news, I turned to our own journal, Pediatric Physical Therapy. While we fared a bit better there, I found only 3 articles in 10 years (2002-2012): • Clinical instructor’s perception of what we should be teaching in pediatrics.27 • A description of professional pediatric physical therapy education.7 • Comparison of 2 methods for teaching therapists to score the test of infant motor performance.28 Although we must be discouraged about the lack of attention given to teaching and learning in pediatrics, perhaps it is a positive sign that 2 of these articles have been printed in the last year! It is my hope that this is the beginning of a trend and not simply an anomaly. Any one of the articles that I shared with you from the Journal of Physical Therapy Education could easily be adapted in some way to examine teaching and learning in pediatrics. In addition, I would pose a host of other “interesting” questions just begging to be studied. Many of these have been adapted from an excellent article on SoTL by Hinman and Darden29 titled, “Beyond Scholarly Teaching: Opportunities for Engaging in the Scholarship of Pediatric Physical Therapy
Teaching and Learning in Physical Therapist Education.” For example: • How much clinical education is needed to prepare a PT or PTA who is competent in pediatric physical therapy? Is there a threshold at which performance peaks? Is there a minimum amount that must be experienced? • How much laboratory or direct experience with children preclinically affects student performance on pediatric clinical internships? • To what extent do pedagogical techniques and instructional technology influence the effective delivery of pediatric curricular content? • To what extent do student learning styles, generational differences, or interest in pediatrics influence the effective delivery (or outcomes) in pediatric physical therapy? • What factors contribute to the success/failure of nontraditional teaching methods in pediatric physical therapy? • How do instructors establish the content validity of their examinations or other instruments used to measure student performance in pediatric physical therapy? • How well do student performance evaluations given during formal curriculum correlate with their performance on pediatric clinical experiences? Do some measures have better predictive validity than others? • At what point postgraduation do new pediatric PTs perceive themselves to be autonomous practitioners? Is this related in any way to the type of curricular structure in their entry-level program? CONCLUSION The seminal work for which each of you has been chosen can set the stage for pediatric education in the future and become recognized as a truly historic event for the Pediatric Section. When rare opportunities to participate in such influential and decisive events have presented themselves in the past, I’ve often been reminded of the poem by Henry Wadsworth Longfellow,30 titled “A Psalm of Life,” which I recount to you, just in part, as a reminder of the importance for how we proceed over these 2 days together. Longfellow says: Lives of great men all remind us We can make our lives sublime, And, departing, leave behind us Footprints on the sands of time; Let us, then be up and doing, With a heart for any fate; Still achieving, still pursing, Perspectives on Pediatric PT Education
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Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
Learn to labor and to wait. Lives of great men all remind us We can make our lives sublime, And, departing, leave behind us Footprints on the sands of time.
You might think that this is an odd passage to begin a Summit on the state of pediatric physical therapy education. I chose it for a number of reasons. Longfellow was a professor, a translator, and a poet, and was the first American to earn his living as a poet.30 His writing helped forge the historic identity of America. His song-like poems brought awareness of natural beauty and freshness to old and familiar traditions. The fruits of his imagination were famous during his lifetime. We have before us that same opportunity. Like Longfellow, we are collectively “professors”— teachers, whether in the classroom or in the clinic. Like Longfellow, we have the opportunity to help forge historic development—the historic development of pediatric physical therapy education. Like Longfellow, we have the opportunity to bring freshness to old and familiar traditions. And as Longfellow so eloquently did in 1838, we are being invited to use the fruits of our imagination and create something of significance that will greatly affect the lives of others. In her 1985 McMillan Lecture,31(p1694) Dr Geneva Johnson told us: “I cannot be certain what our tomorrow will be like. One thing I am certain about is that your tomorrow and mine will be what we choose to make it.” For our 2 days together at this Summit, indeed, we have the opportunity to “make our tomorrow how we choose” and to leave our footprints on the sands of time!
REFERENCES 1. Spake EF. Reflections and visions: the state of pediatric curricula. Pediatr Phys Ther. 1994;6:128-132. 2. Commission on Accreditation in Physical Therapy Education. Aggregate program data: 2011-2012 fact sheet, physical therapist education programs. http://www.capteonline.org/AggregateProgramData. Accessed June 2012. 3. Gandy JS. Gandy Survey of academic programs: exploring issues related to pediatric clinical education. Pediatr Phys Ther. 1993;5:128133. 4. Cherry DB, Knutson LM. Curriculum structure and content in pediatric physical therapy: results of a survey of entry-level physical therapy programs. Pediatr Phys Ther. 1993;5:109-116. 5. Section on Pediatrics. Guidelines for Pediatric Content in Professional Education. Alexandria, VA: Section on Pediatrics; 2001. 6. Section on Pediatrics. Pediatric curriculum content in professional physical therapist education: a cross-reference for content, behavioral objectives, and professional sources. Alexandria, VA: Section on Pediatrics; 2009. 7. Schreiber J, Goodgold S, Moerchen VA, Remec N, Aaron C, Kreger A. A description of professional pediatric physical therapy education. Pediatr Phys Ther. 2011;23:201-204. 8. Shulman LS. From Minsk to Pinsk: why a scholarship of teaching and learning? J Scholarsh Teach Learn. 2000;1:48-58. 6 Spake
9. for The Carnegie Foundation for the Advancement of TeachingHuber MT, Hutchings P. The Advancement of Learning: Building the Teaching Commons. San Francisco, CA: Jossey-Bass; 2005. 10. Huber MT, Morreale SP. Situating the scholarhip of teaching and learning. In: Huber M, Morreale SP, eds. Disciplinary Styles in the Scholarship of Teaching and Learning: Exploring Common Ground. Washington, DC: American Association for Higher Education and the Carnegie Foundation for the Advancement of Teaching; 2002:2. 11. Cambridge BL. Fostering the scholarship of teaching and learning: communities of practice. Improve Acad. 2001;19:3-16 12. McKinney K. How Do I Get Started? In Enhancing Learning Through the Scholarship of Teaching and Learning: The Challenges and Joys of Juggling. Bolton, MA: Anker Publishing; 2007:25-40. 13. Bayliss AJ, Warden SJ. A hybrid model of student-centered instruction improves physical therapist student performance in cardiopulmonary practice patterns by enhancing performance in higher cognitive domains. J Phys Ther Educ. 2011;25:14-20. 14. Gorman SL, Lazaro R, Fairchild J, Kennedy B. Development and implementation of an objective structured clinical examination (OSCE) in neuromuscular physical therapy. J Phys Ther Educ. 2010;24: 62-68. 15. Hayward LM, Blackmer B. A model for teaching and assessing core values development in doctor of physical therapy students. J Phys Ther Educ. 2010;24:16-26. 16. Protsman L, Carlson M. Graphic organizers can facilitate selection of statistical tests: part 2—correlation and regression analysis. J Phys Ther Educ. 2010;22:36-41. 17. Hughes M, Laubscher K, Black L, Jensen G. Use of deconstructed cases in physical therapy ethics education: an assessment of student learning. J Phys Ther Educ. 2009;25:22-28. 18. Maring J, Costello E, Plack MM. Student outcomes in a pathophysiology course based on mode of delivery: distance versus traditional classroom learning. J Phys Ther Educ. 2008;22:24-32. 19. Wong CK, Blissett S. Assessing performance in the area of cultural competence: an analysis of reflective writing. J Phys Ther Educ. 2007;21:40-47. 20. McKenzie AL, Gutierrez B. The varied-integrative-progressive (VIP) model for anatomy instruction in physical therapist education. J Phys Ther Educ. 2007;21:17-29. 21. Youdas JW, Krause DA, Hellyer NJ, et al. Perceived usefulness of reciprocal peer teaching among doctor of physical therapy students in the gross anatomy laboratory. J Phys Ther Educ. 2007;21:30-38. 22. Boissonnault W, Morgan B, Buelow J. A comparison of two strategies for teaching medical screening and patient referral in a physical therapist professional degree program. J Phys Ther Educ. 2006;20:28-36. 23. Gordon SP. Making meaning of whiteness: a pedagogical approach for multicultural education. J Phys Ther Educ. 2005;19:21-27. 24. Ford GS, Mazzone MM, Taylor K. Effect of computer-assisted instruction versus traditional modes of instruction on student learning of musculoskeletal special tests. J Phys Ther Educ. 2005;19:22-30. 25. Carlson M, Protsman L, Tomaka J. Graphic organizers can facilitate selection of statistical tests—part 1: analysis of group differences. J Phys Ther Educ. 2005;19:57-65. 26. Hayward LM. Integrating web-enhanced instruction into a research methods course: examination of student experiences and perceived learning. J Phys Ther Educ. 2004;18;54-65. 27. Kenyon LK, Tovin MM, Hellman M. Clinical instructor’s perspectives: what should we be teaching in pediatrics? Pediatr Phys Ther. 2012;24:183-191. 28. Liao PM, Campbell SK. Comparison of two methods for teaching therapists to score the test of infant motor performance. Pediatr Phys Ther. 2002;14:191-198. 29. Hinman MR, Darden A. Beyond scholarly teaching: opportunities for engaging in the scholarship of teaching and learning in physical therapist education. J Phys Ther Educ. 2005;19:14-22. 30. Carlson MR. The Writer’s Hour: Footprints on the Sands of Time. Main Memory Network 2005. www.hwlongfellow.org/pdf/Carlson IntroTour. Accessed June 2012. 31. Johnson GR. Great expectations: a force in growth and change. Phys Ther. 1985;65:1690-1695. Pediatric Physical Therapy
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
C O M M U N I C A T I O N
Perspectives on Pediatric Physical Therapy Education Ellen F. Spake, PT, PhD Department of Physical Therapy, Rockhurst University, Kansas City, Missouri.
Purpose: The Section on Pediatrics convened an Education Summit in July 2012 to examine, discuss, and respond to documented inconsistencies and challenges in teaching pediatric physical therapy content in entry-level professional education programs. This lecture was designed to provide attendees with the history of pediatric physical therapy education, stemming from the author’s early involvement with the Section on Pediatrics and as a long-standing academician. Summary of Key Points: The limited literature on pediatric physical therapy education was reviewed and used to highlight the continued variability across programs. The challenge was presented to build upon attendees’ scholarship of teaching and learning. Statement of Conclusions: These remarks were designed to help understand the growth and development in pediatric physical therapy education over the past 40 years and to encourage others to use what has been learned to build a stronger foundation for the future. (Pediatr Phys Ther 2014;26:2–6) Key words: curriculum, educational measurement/methods, educational status, humans, pediatrics/education, physical therapy specialty/education, professional competence, program evaluation, teaching/methods, United States It is truly a pleasure to have been asked to participate in this historic event for the Section on Pediatrics. I have been a long-standing member since 1974, which you history buffs will know was just a year after the inception of the Section. I have served in various capacities over that time: as a state representative, program chair, secretary, delegate, and president. When I was invited to provide this commentary, I was asked to describe some of the history and vision of pediatric physical therapy education set forth in the 1990s and to provide some insights into how the Scholarship of Teaching and Learning (SoTL) might provide a foundation for the work upon which we are embarking. There is an often-repeated saying that goes something like, “You can’t know where you are going if you don’t know where you have been.” The importance of looking back on the lessons of our past as a foundation for our future cannot be underestimated. To that end, I invite you to go with me on a journey “back to the future.”
0898-5669/110/261-0002 Pediatric Physical Therapy C 2014 Wolters Kluwer Health | Lippincott Williams & Copyright Wilkins and Section on Pediatrics of the American Physical Therapy Association
Correspondence: Ellen F. Spake PT, PhD, Rockhurst University, 5200 Rockhurst Rd, Kansas City, MO 64110 ([email protected]). The author declares no conflicts of interest. DOI: 10.1097/PEP.0000000000000002
2 Spake
HISTORICAL PERSPECTIVE In 1994, I wrote an article, published in Pediatric Physical Therapy, titled “Reflections and Visions: The State of Pediatric Curricula.”1 I went back to that article, hoping for both inspiration and validation of that age-old phrase, “You’ve come a long way, baby!” While I found some inspiration, I don’t know that I found the validation that I was searching for. Let’s see what you think . . . . In 1974, there were 59 accredited entry-level physical therapist (PT) programs and 28 physical therapist assistant (PTA) programs.1 Most entry-level PT programs conferred either a certificate or a bachelor’s degree. Only 5 entry-level PT programs offered a master’s degree. Data about program length were not kept until 1984, when the mean length of an entry-level program was 80 weeks and the average length of clinical education was 20 weeks. No data were available about the length of PTA programs. Fast forward a bit to 1993. At that time, there were 134 entrylevel PT programs and 132 PTA programs. Sixty-four of the entry-level programs were at the master’s degree. The mean length of PT programs was 92 weeks with 26 weeks of clinical education; the mean length of PTA programs was 49 weeks of didactic education and 20 weeks of clinical education. During that span of time, the amount of time allotted to pediatric curricula did not universally increase, despite the increase in the length of programs.1 Currently, there are 211 entry-level PT programs and 293 PTA programs.2 Ninety percent of the current PT programs are at the doctor of physical therapy (DPT) level. The mean Pediatric Physical Therapy
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
length of PT programs is 122 weeks of which 36 weeks are full-time clinical education. The mean length of PTA programs is 92 weeks of didactic instruction and 15 weeks of clinical education. Because there are so few data available about pediatric curricula in PTA programs, outside of some limited data on PTA clinical education collected by Gandy3 in 1993, most of my remarks will address PT pediatric curricula. However, I would suggest that either as part of this Summit or in a different venue, we should not lose sight of the importance of being as systematic and intentional about PTA pediatric education as we are becoming about PT education. In June 2012, the House of Delegates considered 2 motions relative to the degree qualifications for the PTA. While no decisions about advancing the PTA degree to a baccalaureate level have yet been made, when I look in MY crystal ball, I believe that this is a strong possibility for the future. Thus, we should also be poised to influence pediatric curricula both now and in the future of PTA programs. As we look at the history of curricula for PT programs, only anecdotal evidence is available relative to specific pediatric curriculum content from the early to mid-1970s and before.1 At that time, although a few programs seem to have had specific courses related to both child development and (what was then called) pediatric assessment and treatment, the majority of programs seem to have included a relatively sparse amount of information relevant to pediatrics. Much of that information was found primarily as a unit in a larger course. Pathology or dysfunction related to pediatrics was primarily taught by physician residents, rather than by PTs, as part of a medical conditions or pathology course. Few clinical experiences were available and generally these were not integrated within the curriculum, but rather found at the end. Not all students with an interest in pediatrics were given an opportunity to pursue a clinical experience. Fast forward a bit to 1993, when Cherry and Knutson4 documented the state of pediatric curricula. Those data indicated that pediatric content continued to be taught primarily as a unit within a broader course, rather than as a stand-alone course. More hours were still devoted to child development over content on pediatric disorders or management of pediatric conditions, and the number of hours spent was highly variable. The collection of data on the state of pediatric curricula in 1993 provided the impetus for development of guidelines for pediatric content in educational programs. In 2001, the Guidelines for Pediatric Content in Professional Education5 were published. These were subsequently revised and updated in 2009 and the document titled Pediatric Curriculum Content in Professional Physical Therapist Education: A Cross-reference for Content, Behavioral Objectives, and Professional Sources6 now provides the most comprehensive resource available for pediatric educators. While we are very proud of this work—and it should be recognized that only 4 other specialty sections, Neurology, Women’s Health, Geriatrics, and Clinical Electrophysiology and Wound Management, have developed similar documents—we still have much work to do. Pediatric Physical Therapy
Part of what faces us over our 2 days together are the questions of how much is “just right,” how much is “too much,” is “more” always better, and what are the best curricular and pedagogical strategies to accomplish what we want to do? While our current curricular document is very helpful, anecdotal information suggests that some pediatric educators express frustration about being able to “fit” all of the recommended content into the time they have available within the curriculum. In 2008, in a very forward thinking move, the Section on Pediatrics created a task force to describe the current content and structure of pediatric curricula. Schreiber and colleagues7 described this work in an important article published in Pediatric Physical Therapy just this past year. In their survey, they examined a number of variables including perceived adequacy of the curriculum, stand-alone pediatric courses, requirements for a pediatric clinical experience, and hours devoted to pediatric content (lecture, laboratory, contact hours with children, problem-based learning opportunities with children, etc). Seventy percent of programs reported including at least 1 stand-alone pediatric course; likewise, 70% reported that pediatric content within the curriculum was adequate. Eighty-three percent of respondents reported that they used curricular content recommendations published by the Section. In contrast to Cherry and Knutson’s4 findings, 66% of the individuals teaching pediatric content held a full-time faculty appointment. Of particular note, however, is that 38% indicated that they planned to retire in the next 10 years and 59% within the next 15 years. This is critically important information and suggests that the Section must be systematic and intentional in endeavors to ensure that there will be well-prepared faculty to replace those who will be retiring. A look at the evolution of clinical education may also give us some moments for reflection. In 1994, I reported that clinical education had not appeared to have changed markedly in the 20 years from 1974 to 1994.1 At that time, although most programs appeared to have had pediatric clinical sites available, few programs required a pediatric clinical experience for all students and most programs only allowed the pediatric experience to “count” as a specialty clinical experience. In her 1993 study, Gandy3 noted that according to the 1992 national APTA clinical education database, a total of 5572 nonduplicate clinical education sites were affiliated with PT and PTA programs. Of those sites, only 516 (9.3%) were categorized as “pediatric.” Although the overall number of clinical sites in general had increased between 1984 and 1992, no data were available regarding changes in the number of pediatric sites across that same time period. During the 1991-1992 academic year, 26% of PT students had requested a pediatric clinical experience. Thirteen percent, only one-half, of those students could be accommodated. The data were even more alarming in PTA programs, with 23% of the students requesting a pediatric experience and only 3% able to be placed. While Schreiber and colleagues7 found that 70% of their survey respondents felt that the number of pediatric Perspectives on Pediatric PT Education
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clinical sites was adequate to meet the needs of their program, only 10 programs, or 7% of the sample, required a mandatory pediatric clinical education experience. In fact, some students were found to be graduating with either very few pediatric laboratory hours or little contact with children. The range was from 3 to 148 hours of either laboratory or hands-on experience (excluding clinical education). Given that not all students complete a pediatric clinical, these numbers should give us pause for concern. Thus, an important consideration in pediatric professional education is how to create opportunities for students to practice their pediatric clinical skills. Cherry and Knutson4 also suggested that pediatric clinical instructors had some concerns about the level of preparation of the students, before coming to them for clinical placement. Specifically, concerns were raised about adequate examination, intervention, and decision-making skills. While clearly this could be related, at least in part, to the amount of time spent on these curricular areas, anecdotal accounts from some Directors of Clinical Education/Academic Coordinators of Clinical Education today paint a similar picture. In fact, some of the information we were asked to review before coming to the Pediatric Education Summit suggests the same. I would like to suggest that it is possible that we are not yet in a position to answer all the questions about pediatric curriculum and instruction because many of these questions have not yet been asked. The literature addressing curriculum and instructional strategies in pediatric PT education is extremely sparse. As part of the challenges that we face, I would like to add yet 1 more-–to challenge each and every one of us to use our imagination to explore the breadth and depth of teaching and learning opportunities that can help us reach the outcome goals that we will articulate as part of this summit. This will involve a systematic and intentional exploration of curricular, teaching, and learning strategies that will best position us for not only now, but also the future. SCHOLARSHIP OF TEACHING AND LEARNING Surely, pediatric PT educators consider themselves to be scholarly teachers. Shulman8 suggests that scholarly teaching is that which is well grounded in the sources and resources appropriate to the field, reflects a thoughtful selection and integration of ideas and examples, and demonstrates well-designed strategies of course-design, development, transmission, interaction, and assessment. Furthermore, scholarly teachers are familiar with the literature on teaching and learning, including teaching and learning in their own discipline, apply this information in their classrooms, assess what is happening in their classrooms, and continue to make changes throughout their career. But to guide us, is it enough to just be a scholarly teacher, or should we be asking questions specific to the SoTL as it relates to pediatric PT education? What is SoTL and how is this different from scholarly teaching? Huber and Hutchings9 advocate that we must begin to view the 4 Spake
classroom as a site for inquiry and further suggest that we must begin asking and answering questions about students’ learning in ways that can improve our own classrooms and also advance the larger profession of teaching. Work toward these goals involves significant shifts in thought and practice. Shulman8 posits that for faculty in most settings, teaching is a private act, limited only to the interaction between teacher and students and rarely evaluated by professional peers. The result is that those who engage in innovative acts of teaching rarely build upon the work of others and nor can others build upon theirs. One of the main challenges to developing an SoTL in higher education is that in most disciplines, this process of “reconstruction” has just begun.10 A great deal more remains to be done before it is commonplace for scholars to examine their teaching practice in light of what is known or imagined possible in one’s own or other fields. Cambridge11 suggests that SoTL involves posing problems about an issue of teaching or learning, studying these problems through methods appropriate to disciplinary epistemologies, applying the results to practice, and engaging in self-reflection and peer review. As such, teachers who engage in SoTL take what is done as a scholarly teacher and make it public. Their work becomes available to colleagues in a public forum that is accessible to peer review. Work is exchanged with other members of the professional community who, in turn, build on that work. People often ask, “How do I get started?” The answer is simple. Look for what is underreported in physical therapy education. Consider in what way your findings could have relevance beyond physical therapy education. McKinney12 suggests that it is as easy as thinking about a curricular, teaching, or learning issue; a problem or question that you have about your students, a course, an assignment, or a pedagogical strategy. Any of these can provide impetus to begin. State that issue as a question and you are off and running. I suggested earlier that as we explore the vast possibilities that we have for pediatric physical therapy education, we may not be in a position to answer some of the questions that are important, simply because we have not yet asked them. A review of Pediatric Physical Therapy and the Journal of Physical Therapy Education revealed a paucity of teaching and learning articles in pediatric physical therapy curriculum and education. Take a quick journey with me through these publications, beginning with the Journal of Physical Therapy Education. I examined 8 years (2004-2011) and found 14 articles specific to the teaching of practice specific, professional, or basic science content (eg, cardiopulmonary, neurology, core values, anatomy, statistics): • A hybrid model of student-centered instruction improves PT student performance in cardiopulmonary practice patterns by enhancing performance in higher cognitive domains.13 • Development and implementation of an objective structured clinical examination (OSCE) in neuromuscular physical therapy.14 Pediatric Physical Therapy
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• A model for teaching and assessing core values development in “doctor of physical therapy” students.15 • Graphic organizers can facilitate selection of statistical tests: part 2—correlation and regression analysis.16 • Use of deconstructed cases in physical therapy ethics education: an assessment of student learning.17 • Student outcomes in a pathophysiology course based on mode of delivery: distance versus traditional classroom learning.18 • Assessing performance in the area of cultural competence: an analysis of reflective writing.19 • The varied-integrative-progressive (VIP) model for anatomy instruction in PT education.20 • Perceived usefulness of reciprocal peer teaching among “doctor of physical therapy” students in gross anatomy laboratory.21 • A comparison of 2 teaching strategies for teaching medical screening and physical therapy referral in a PT professional degree program.22 • Making meaning of whiteness: a pedagogical approach for multicultural education.23 • Effect of computer-assisted instruction versus traditional modes of instruction on student learning of musculoskeletal tests.24 • Graphic organizers facilitate selection of statistical tests—part 1: analysis of group differences.25 • Integrating Web-enhanced instruction into a research methods course: examination of student experiences and perceived learning.26 Absolutely nothing in pediatrics! Hoping for better news, I turned to our own journal, Pediatric Physical Therapy. While we fared a bit better there, I found only 3 articles in 10 years (2002-2012): • Clinical instructor’s perception of what we should be teaching in pediatrics.27 • A description of professional pediatric physical therapy education.7 • Comparison of 2 methods for teaching therapists to score the test of infant motor performance.28 Although we must be discouraged about the lack of attention given to teaching and learning in pediatrics, perhaps it is a positive sign that 2 of these articles have been printed in the last year! It is my hope that this is the beginning of a trend and not simply an anomaly. Any one of the articles that I shared with you from the Journal of Physical Therapy Education could easily be adapted in some way to examine teaching and learning in pediatrics. In addition, I would pose a host of other “interesting” questions just begging to be studied. Many of these have been adapted from an excellent article on SoTL by Hinman and Darden29 titled, “Beyond Scholarly Teaching: Opportunities for Engaging in the Scholarship of Pediatric Physical Therapy
Teaching and Learning in Physical Therapist Education.” For example: • How much clinical education is needed to prepare a PT or PTA who is competent in pediatric physical therapy? Is there a threshold at which performance peaks? Is there a minimum amount that must be experienced? • How much laboratory or direct experience with children preclinically affects student performance on pediatric clinical internships? • To what extent do pedagogical techniques and instructional technology influence the effective delivery of pediatric curricular content? • To what extent do student learning styles, generational differences, or interest in pediatrics influence the effective delivery (or outcomes) in pediatric physical therapy? • What factors contribute to the success/failure of nontraditional teaching methods in pediatric physical therapy? • How do instructors establish the content validity of their examinations or other instruments used to measure student performance in pediatric physical therapy? • How well do student performance evaluations given during formal curriculum correlate with their performance on pediatric clinical experiences? Do some measures have better predictive validity than others? • At what point postgraduation do new pediatric PTs perceive themselves to be autonomous practitioners? Is this related in any way to the type of curricular structure in their entry-level program? CONCLUSION The seminal work for which each of you has been chosen can set the stage for pediatric education in the future and become recognized as a truly historic event for the Pediatric Section. When rare opportunities to participate in such influential and decisive events have presented themselves in the past, I’ve often been reminded of the poem by Henry Wadsworth Longfellow,30 titled “A Psalm of Life,” which I recount to you, just in part, as a reminder of the importance for how we proceed over these 2 days together. Longfellow says: Lives of great men all remind us We can make our lives sublime, And, departing, leave behind us Footprints on the sands of time; Let us, then be up and doing, With a heart for any fate; Still achieving, still pursing, Perspectives on Pediatric PT Education
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Learn to labor and to wait. Lives of great men all remind us We can make our lives sublime, And, departing, leave behind us Footprints on the sands of time.
You might think that this is an odd passage to begin a Summit on the state of pediatric physical therapy education. I chose it for a number of reasons. Longfellow was a professor, a translator, and a poet, and was the first American to earn his living as a poet.30 His writing helped forge the historic identity of America. His song-like poems brought awareness of natural beauty and freshness to old and familiar traditions. The fruits of his imagination were famous during his lifetime. We have before us that same opportunity. Like Longfellow, we are collectively “professors”— teachers, whether in the classroom or in the clinic. Like Longfellow, we have the opportunity to help forge historic development—the historic development of pediatric physical therapy education. Like Longfellow, we have the opportunity to bring freshness to old and familiar traditions. And as Longfellow so eloquently did in 1838, we are being invited to use the fruits of our imagination and create something of significance that will greatly affect the lives of others. In her 1985 McMillan Lecture,31(p1694) Dr Geneva Johnson told us: “I cannot be certain what our tomorrow will be like. One thing I am certain about is that your tomorrow and mine will be what we choose to make it.” For our 2 days together at this Summit, indeed, we have the opportunity to “make our tomorrow how we choose” and to leave our footprints on the sands of time!
REFERENCES 1. Spake EF. Reflections and visions: the state of pediatric curricula. Pediatr Phys Ther. 1994;6:128-132. 2. Commission on Accreditation in Physical Therapy Education. Aggregate program data: 2011-2012 fact sheet, physical therapist education programs. http://www.capteonline.org/AggregateProgramData. Accessed June 2012. 3. Gandy JS. Gandy Survey of academic programs: exploring issues related to pediatric clinical education. Pediatr Phys Ther. 1993;5:128133. 4. Cherry DB, Knutson LM. Curriculum structure and content in pediatric physical therapy: results of a survey of entry-level physical therapy programs. Pediatr Phys Ther. 1993;5:109-116. 5. Section on Pediatrics. Guidelines for Pediatric Content in Professional Education. Alexandria, VA: Section on Pediatrics; 2001. 6. Section on Pediatrics. Pediatric curriculum content in professional physical therapist education: a cross-reference for content, behavioral objectives, and professional sources. Alexandria, VA: Section on Pediatrics; 2009. 7. Schreiber J, Goodgold S, Moerchen VA, Remec N, Aaron C, Kreger A. A description of professional pediatric physical therapy education. Pediatr Phys Ther. 2011;23:201-204. 8. Shulman LS. From Minsk to Pinsk: why a scholarship of teaching and learning? J Scholarsh Teach Learn. 2000;1:48-58. 6 Spake
9. for The Carnegie Foundation for the Advancement of TeachingHuber MT, Hutchings P. The Advancement of Learning: Building the Teaching Commons. San Francisco, CA: Jossey-Bass; 2005. 10. Huber MT, Morreale SP. Situating the scholarhip of teaching and learning. In: Huber M, Morreale SP, eds. Disciplinary Styles in the Scholarship of Teaching and Learning: Exploring Common Ground. Washington, DC: American Association for Higher Education and the Carnegie Foundation for the Advancement of Teaching; 2002:2. 11. Cambridge BL. Fostering the scholarship of teaching and learning: communities of practice. Improve Acad. 2001;19:3-16 12. McKinney K. How Do I Get Started? In Enhancing Learning Through the Scholarship of Teaching and Learning: The Challenges and Joys of Juggling. Bolton, MA: Anker Publishing; 2007:25-40. 13. Bayliss AJ, Warden SJ. A hybrid model of student-centered instruction improves physical therapist student performance in cardiopulmonary practice patterns by enhancing performance in higher cognitive domains. J Phys Ther Educ. 2011;25:14-20. 14. Gorman SL, Lazaro R, Fairchild J, Kennedy B. Development and implementation of an objective structured clinical examination (OSCE) in neuromuscular physical therapy. J Phys Ther Educ. 2010;24: 62-68. 15. Hayward LM, Blackmer B. A model for teaching and assessing core values development in doctor of physical therapy students. J Phys Ther Educ. 2010;24:16-26. 16. Protsman L, Carlson M. Graphic organizers can facilitate selection of statistical tests: part 2—correlation and regression analysis. J Phys Ther Educ. 2010;22:36-41. 17. Hughes M, Laubscher K, Black L, Jensen G. Use of deconstructed cases in physical therapy ethics education: an assessment of student learning. J Phys Ther Educ. 2009;25:22-28. 18. Maring J, Costello E, Plack MM. Student outcomes in a pathophysiology course based on mode of delivery: distance versus traditional classroom learning. J Phys Ther Educ. 2008;22:24-32. 19. Wong CK, Blissett S. Assessing performance in the area of cultural competence: an analysis of reflective writing. J Phys Ther Educ. 2007;21:40-47. 20. McKenzie AL, Gutierrez B. The varied-integrative-progressive (VIP) model for anatomy instruction in physical therapist education. J Phys Ther Educ. 2007;21:17-29. 21. Youdas JW, Krause DA, Hellyer NJ, et al. Perceived usefulness of reciprocal peer teaching among doctor of physical therapy students in the gross anatomy laboratory. J Phys Ther Educ. 2007;21:30-38. 22. Boissonnault W, Morgan B, Buelow J. A comparison of two strategies for teaching medical screening and patient referral in a physical therapist professional degree program. J Phys Ther Educ. 2006;20:28-36. 23. Gordon SP. Making meaning of whiteness: a pedagogical approach for multicultural education. J Phys Ther Educ. 2005;19:21-27. 24. Ford GS, Mazzone MM, Taylor K. Effect of computer-assisted instruction versus traditional modes of instruction on student learning of musculoskeletal special tests. J Phys Ther Educ. 2005;19:22-30. 25. Carlson M, Protsman L, Tomaka J. Graphic organizers can facilitate selection of statistical tests—part 1: analysis of group differences. J Phys Ther Educ. 2005;19:57-65. 26. Hayward LM. Integrating web-enhanced instruction into a research methods course: examination of student experiences and perceived learning. J Phys Ther Educ. 2004;18;54-65. 27. Kenyon LK, Tovin MM, Hellman M. Clinical instructor’s perspectives: what should we be teaching in pediatrics? Pediatr Phys Ther. 2012;24:183-191. 28. Liao PM, Campbell SK. Comparison of two methods for teaching therapists to score the test of infant motor performance. Pediatr Phys Ther. 2002;14:191-198. 29. Hinman MR, Darden A. Beyond scholarly teaching: opportunities for engaging in the scholarship of teaching and learning in physical therapist education. J Phys Ther Educ. 2005;19:14-22. 30. Carlson MR. The Writer’s Hour: Footprints on the Sands of Time. Main Memory Network 2005. www.hwlongfellow.org/pdf/Carlson IntroTour. Accessed June 2012. 31. Johnson GR. Great expectations: a force in growth and change. Phys Ther. 1985;65:1690-1695. Pediatric Physical Therapy
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