SCE 5140 Science Curriculum Development
Final Project
Course Title: Clinical Decision-Making in Geriatric Physical Therapy - A Case-Based Approach
INTRODUCTION:
I recently participated in an onsite visit (for the Commission on Accreditation of Physical Therapy Education) (CAPTE) for a 5-year accreditation of a Doctor of Physical Therapy program. Site visits are usually spaced-out every 10 years, but since the program is a new program, the first site visit happened after 5 years. (CAPTE rule does not allow site visitors to reveal programs they have visited). My final project, in a way, is an unsolicited recommendation on how to address the program's challenges..
In addition to being a fairly new program, the faculty / program is being "pressured" from all directions. When the program was first accredited, they had a first-time licensure pass rate of 100%. After 5 years, they now have an average of 75%, below the 85% required by CAPTE. The University's administration is pressuring the program to increase the class size by 100%, which has to be requested through CAPTE. There is also "pressure" coming from students. Graduate surveys and student surveys indicate that students feel that (1) the program has a limited variety of clinical sites where students will undergo their internships, and (2) that students feel unprepared or minimally prepared to practice some aspects of Physical therapy (i.e. cardiovascular / pulmonary, neuromuscular and integumentary physical therapy).
To address the licensure pass rate issue, one of the proposed solutions is to shorten clinical internships to shorten the amount of time between the didactic portion of the program and when students take the licensure exam. Engaging in Reform-Based Science Instruction guided by the C-U-E Framework (Tweed 2008) is a more evidence-informed approach to the problem of substandard licensure pass rate.
The program did not have a stand-alone, comprehensive course on clinical decision-making. Just like in most programs, clinical decision-making is embedded in siloed (i.e. musculoskeletal, neurologic, cardiopulmonary, integumentary) courses, occasionally occurring throughout the course. This is what prompted me to design this course. It is designed to facilitate meaningful learning by "putting everything together" before students go to their clinical internships. It provides students the opportunity for clinical-decision making every time they engage with the course to, hopefully, solidify their familiarity and comfort level with the process. I originally designed the course for EME 6059 Blended Learning Environments. I realized that the course I designed, in a way, epitomizes reform-based science instruction (Part 4 explains how the course fits in the context of Science Curriculum Development).
I made some modifications to my original proposal to conform to the required processes for the Final Project.
PART 1
INSTITUTION: University Program of Study
NAME OF PROGRAM: Doctor of Physical Therapy
TARGET POPULATION OF LEARNERS: The target students are the cohort of students in a DPT Program who will be transitioning from the didactic portion to the clinical education portion of the program. After successful completion of this course, students will be proceeding to their clinical internship. The summative assessment used for the course will also be used by the program as a basis for making the decision if the student is ready to safely progress to clinical internships.
RATIONALE FOR SUGGESTED COURSE:
Clinical Decision-Making (CDM) requires 2 types of knowledge – content knowledge and structural knowledge. Content knowledge includes knowing the diagnosis, the etiology of a disease and the treatment for a specific disease or condition. Structural knowledge, on the other hand, is a form of a mental model that is created from knowing how the different domains of content knowledge interact with each other in a clinical problem. Content knowledge is "knowing" and structural knowledge is "processing." This course allows for a systematic acquisition of structural knowledge by novice students.
Experts (instructors) and novices (students) use different methods for CDM, with the former group exposed to more content and structural knowledge. Deductive reasoning is a top-down process where individuals predict consequences based on their ability to logically reason, arriving at a treatment plan. Inductive reasoning, on the other hand, is a process used in decision making which is described as a bottom-up process where individuals form hypotheses and theories based on the individual’s ability to recognize meaningful patterns and connections and uses these to arrive at a treatment plan. Novice practitioners use deductive reasoning, and expert practitioners use inductive reasoning. (Shin, 2019). This course, in a way, allows for students to undergo deductive reasoning individually, but then progresses on to experience inductive reasoning in the small group F2F session.
Inductive reasoning is the basis for the Hypothesis-Oriented Algorithm for Clinicians.
Having a course in CDM provides students the opportunity to "put everything together" from what they have learned so far. It provides the program an opportunity to engage the students in a comprehensive written or practical exam, to gauge their readiness for clinical internship. (CAPTE requires programs to have a mechanism to determine that their students are ready and safe to proceed to the clinical education phase of the program.)
Having been a clinician for 28 years, with 26 of those years also as a Clinical Instructor, one of the feedback comments I often hear from students is that what is taught in school is very different to how physical therapy is practiced in the clinic. I find this statement somewhat disconcerting. This course in Science Curriculum Development made me realize a possible explanation for this statement expressed by multiple students over the years. Please click on the button below for a discussion on this topic, providing additional rationale for this course. (This is a portion of PART 4 of the project - a discussion on how the course fits in the context of Science Curriculum Development).
PROGRAM GOALS: The Program will:
1. graduate students who exhibit professionalism
2. graduate students who are mindful practitioners of physical therapy
3. graduate students who are competent practitioners of physical therapy
4. graduate students who are skilled practitioners of physical therapy
Success in the suggested course leads to realization of these Program Goals.
FOUR SCIENCE-RELATED COURSES
Clinical Decision-Making in Neurologic Physical Therapy
Clinical Decision-Making in Geriatric Physical Therapy
Evidence-Based Practice in Physical Therapy
Professionalism in Physical Therapy
PART 2
COURSE: Clinical Decision-Making in Geriatric Physical Therapy - A Case-Based Approach
Course Goals
1. Use inductive reasoning when engaged in clinical decision-making to develop a physical therapy plan of care
2. Appreciate the psycho-social dimension of physical therapist patient management
3. Seek available evidence from peer-reviewed sources to guide physical therapist practice
4. Select, perform, and interpret objective test and measures to guide patient management
5. Identify and carry-out evidence-based physical therapy interventions consistent with the plan of care
Click on the button below for the raw list of physical therapy-related core ideas, cross-cutting concepts, science and engineering practices which I categorized and color coded-below. These are derived from the list in section 7D of the Commission on Accreditation of Physical Therapy Education's (CAPTE's) linked Standards and Required Elements for the Accreditation of Physical Therapist Education Programs.
science curriculum (2).pdfIn the list above, under Skilled Clinical Practice, it is further subdivided to Patient Examination (lilac) and Patient Post-Examination (purple). In the second column, under Professionalism, entries were categorized as Legal Practice (orange), Ethical Practice (yellow) and Interprofessional Practice (light brown). In the last column, entries were categorized as Evidence-Based Practice (light green), Holistic Care (blue) and Practice Management (green).
PART 3
GENERAL COURSE DESIGN: The course is a 4 credit course, with each lesson requiring 2 hours spent by the student engaging with content individually (asynchronously) and 2 hours spent face-to-face in the classroom.
ONLINE CONTENT: Content for asynchronous delivery to be engaged with individually can be instructor-developed or instructor-curated. The content will depend on the Lesson Objectives. For example, in Lesson 1, the sample online content include videos of clinical manifestations of Parkinson's Disease (PD), examination of the patient with PD, physical therapy intervention of patients with PD. Alternative content may include, for example, gait deviations seen in PD or pharmacotherapy in PD. Both of these can be reflected in the lesson objectives, how they affect intervention selected.
Online content will also include 4 journal articles from peer-reviewed publications to be used later by the students for decision-making (during the F2F session). Each student in the group is expected to write an "Annotated Bibliography" or produce an Infographic, or make a video / audio recording about the peer-reviewed article assigned to them, related to the case to be discussed during the F2F session.
F2F CONTENT: During the first F2F session, in the first hour, the course instructor explains the structure of the course and the course expectations, followed by a lecture on Inductive Reasoning / Hypothesis-Oriented Algorithm for Clinicians (HOAC). During this time, students will be asked to form groups of 4. In the second hour of the first class session, groups are provided case and are expected to submit a completed Initial Examination form by the end of the class. The instructor will post all completed forms by groups for commenting by students
By midnight of that day, the student is expected to submit an individual reflection on the F2F small group CDM session. Each student will also submit an exercise prescription (i.e. 3 suggested exercises / interventions based on the case) to be posted with the group-completed Initial Examination form.
ONLINE CONTENT: Prior to the next F2F session, students are expected to engage with online content individually and asynchronously, answering embedded formative questions related to Lesson 2. Students will also create an infographic / annotated bibliography / audio or video recording as to what they have learned from their assigned journal article also related to Lesson 2.
F2F CONTENT: During the next F2F session, in the first hour, 4 groups (selected by the instructor) will present their Lesson 1 case to the class with opportunities for question-and-answer after each presentation. Before going to the next part of the F2F class session, the instructor will provide a summary of the important points discussed on Lesson 1. In the second hour of F2F session, groups are provided the next case (i.e. Lesson 2), then sit together to complete the patient Initial Examination form to be submitted by the end of the class
The cycle of engaging with content individually and asynchronously followed by a 2-hour F2F session consisting of (1) case presentations of discussions from last week and (2) small group discussion / clinical decision making of new cases for discussion next week repeats every week.
Summary of Weekly Learning Activities:
In the image below, GREEN boxes indicate learning activities completed individually and asynchronously online, while PINK boxes indicate face-to-face activities. The ONLINE content is designed to harness or highlight students' prior knowledge. Because it is consumed by students individually and asynchronously, this gives them the opportunity to identify gaps in their knowledge, and to mitigate these gaps in preparation for the F2F session. It is used to "prime" the student for the F2F session. The FACE-TO-FACE session is designed for students to apply their harnessed prior knowledge. It is intended to create a robust community of inquiry where students discuss and make decisions as colleagues and as equals. They support each other in understanding during learning activities. Throughout the lesson, the onus for learning is on the student. The instructor is the facilitator of this learning.
diagram.pdfSOURCES:
McTighe, J., & Wiggins, G. P. (1999). Understanding by design handbook. Association for Supervision and Curriculum Development.
Wegmann, Susan and Thompson, Kelvin. SCOPE-ing Out Interactions in Blended Environments. In Picciano, A. G., Dziuban, C., & Graham, C. R. (Eds.). (2014). Blended learning: Research perspectives, volume 2. Routledge, Taylor & Francis Group.