Guiding the Way
Mentoring early career physical therapists in private practice
By Michael Gans, PT, DPT, OCS, FAAOMPT
Two years ago, I was having a discussion with our human resources coordinator who said that whenever she talked to doctor of physical therapy (DPT) students they always asked about mentorship within the clinic and company. She would ask them what exactly they are looking for in a mentor, and most could not put into words what they wanted or why. The physical therapy residency model has grown to 188 programs across the country, but have only graduated 2,129 clinicians since 1999.1 Some new clinicians would like to do a residency but cannot because of financial restrictions or the limited number of residency opportunities in their area. DPT students look for residencies because they want to advance their clinical knowledge and want mentoring from experienced clinicians. Our company designed a program to be similar to a residency model to attract motivated new professionals with two objectives: first, improve clinical reasoning; and the second, improve clinical outcomes for new clinicians.
Clinical reasoning is the cornerstone of physical therapy care. As health care providers, it is the way we navigate the patient examination to attain the appropriate plan for treatment. The ability to recognize patterns and develop hypotheses from the subjective examination is difficult for newer clinicians who have limited treatment experience. Integrating concepts from the classroom into patient care can sometimes be difficult, and longer clinical affiliations can give clinicians more perspective to draw from–changing their outlook.
The Hypothesis-Oriented Algorithm for Clinicians II2 (HOACII) was developed to assist students and clinicians with this essential thought process. As an organization, we utilize HOAC II as a guide to help these individuals build their clinical reasoning skills. Developing these skills and qualities does not happen overnight and the path from novice to expert clinicians is a difficult one. American novelist Mark Twain was credited with saying, “Good decisions come from experience. Experience comes from making bad decisions.” So how do we gain experience as clinicians without failing our patients in the process? Doody and McAteer studied the decision making of both novice and expert clinicians and found that novices spend significantly more time on the physical exam than experts.3 This is most likely due to the lack of pattern recognition, lack of experience, and a lack of hypothesis generation from the subjective examination. The goal of our mentorship program, as well as most residency and fellowship programs, is to help clinicians develop that clinical reasoning and pattern recognition more quickly and efficiently.
Our second objective was to improve clinical outcomes. New clinicians complete their doctoral training with the latest evidence in examination and intervention so we wanted to look to improve patient “buy-in” during the initial evaluation to improve patient retention. I ask each new clinician during our first education session, “what is the goal of your initial evaluation?” I get answers ranging from, “to find a treatment that is effective” to “determine a diagnosis” to “develop a plan of care.” Does any of that really matter if the patient never shows up for their second visit? Getting patients to invest or “buy in” to the treatment plan that you have developed with them is just as important as any of the above answers to this question. I have heard the argument that this is just practitioners trying to maximize profits and visits, but evidence exists to show that it makes a difference in patient outcomes as well. Ferreira in 2013 randomized 182 patients with chronic low back pain (LBP) to determine the effects of exercises and spinal manipulative therapy. They also assessed their therapeutic compliance with the Working Alliance Inventory, which assesses the patient’s perceived relationship with their treating therapist. When reviewing the data of the two groups based on the randomized treatment, the results were similar. However, when reviewing patients in each group by therapeutic alliance, the group with positive outcomes had a positive relationship with their therapist. When the patient and therapist have a positive relationship based on trust, mutual cooperation, and goal setting, the patients invest in their care and their outcomes subsequently improve.4
Another aspect of our program that we have examined and discussed through our inaugural 18 months is where continuing education fits into a residency model. Is it worth the money we spend? While participation in traditionally organized workshops and conferences improves knowledge and practice behaviors of the individual attendee, there is no corollary improvement in patient outcomes.5,6,7 Clinicians spend three years learning in a doctor of physical therapy (DPT) program and afterwards entry-level clinicians spend even more time learning through continuing education. Our solution is a structured continuing education program that offers both internal courses taught by our expert clinicians and courses external to our company in each of the body’s main regions (cervical/thoracic, lumbar, upper extremity, and lower extremity). Our internal education courses are taught quarterly and are presented by our own company mentors who specialize in their respective subject-area. Not only does this give new clinicians continuing education, but it also gives them a chance to see how they can rise within the company as a clinical expert/mentor.
To date, it has been difficult to measure the individual outcomes of this program over the past year compared with clinicians hired prior to the start of the program. There have been minimal changes to productivity and retention, however, while much of the data is ongoing, our “new” clinicians have reported improved satisfaction in the workplace and within their own practice. As our company moves forward, we have found growth and prosperity in this program and a surplus of applications from surrounding clinicians. While we have begun to limit the amount of applicants to take part in this model, having a “wait list” of prospective employees is a great problem to have.
Even though this model is a work in progress and would not work for every growing practice, setting, or state, I encourage company owners and private practitioners to find new and creative ways to challenge your clinicians. Improving clinical reasoning and patient “buy-in” will change your employees and, ultimately, your practice for the better.
1. American Physical Therapy Association: American Board of Physical Therapy Residency and Fellowship Education. 2005. http://www.abptrfe.org/Home.aspx Accessed October 2015
2. Rothstein JM, Echternach JL, Riddle DL. The Hypothesis- Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management. Phys Ther. 2003;83:455– 470.]
3. Doody, C and McAteer, M. Clinical reasoning of expert and novice physiotherapists in an outpatient orthopaedic setting. Physiotherapy. 2002;88, 5, 258-268.
4. Ferreira PH, Ferreira ML, Maher CG, et al. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Phys Ther. 2013;93:
5. Chipchase LS, Johnston V, Long PD. Continuing professional development: the missing link. Man Ther. 2012 Feb;17(1):89-91. doi: 10.1016/j.math.2011.09.004. Epub 2011 Oct 20.
6. Cleland JA, Fritz JM, Brennan GP, Magel J. Does continuing education improve physical therapists’ effectiveness in treating neck pain? A randomized clinical trial. Phys Ther. 2009;89:38–47
7. Overmeer T, Boersma K, Denison E, Linton SJ. Does teaching physical therapists to deliver a biopsychosocial treatment program result in better patient outcomes? A randomized controlled trial. Phys Ther. 2011;91:804–819.]
Michael Gans, PT, DPT, OCS, FAAOMPT, is the Connecticut Physical Therapy Association president, director of clinical excellence, and a physical therapist for Physical Therapy & Sports Medicine Centers in Connecticut. He can be reached at email@example.com.