Alliance Physical Therapy Partners: Alliance Physical Therapy Partners in Agile Virtual Physical Therapy proudly present Agile and Me, a physical therapy Leadership Podcast devised to help emerging and experienced therapy leaders learn more about various topics relevant to outpatient therapy services.
Richard Leaver: Welcome back to Agile and Me, a Physical Therapy Leadership Podcast series. Today, I’m extremely excited to welcome Ashley Butler. So, Ashley, welcome to the show.
Ashlee Butler: Thank you.
Richard Leaver: So today we’re going to talk about clinical placements and clinical education in general, perhaps a little bit for physical therapy students specifically. And, Ashley, you have a remarkable background in PT and also education. When I looked you up and typed in Ashley Butler pt, there’s actually another Ashley Butler PT in Nashville as well. So I didn’t know whether you knew that or not. There’s two of you.
Ashlee Butler: I knew there was a Nashley Butler. I didn’t know that she was also a pt, but I did know there were two of us in Nashville.
Richard Leaver: That’s funny. So for the listeners, would you be so kind as to perhaps give them a little bit of your background as to how we perhaps ended up talking today and your experience in clinical education?
Ashlee Butler: Absolutely. Happy to. I’m proud of it. I graduated from a program in rural North Georgia that was actually designed to be one of the first DPT programs in the country. So pre a lot of people getting DPTs, the program I went to was designed for that. So becoming a clinical educator was very much a part of that curricula, and I became very passionate about doing that. And my very first job out of PT school, the psych coordinator of clinical education left until my boss said, would you like to do this? Would you like to be the psych coordinator? And I was like, oh, gosh, what does that mean? And she explained it to me is basically I would be the liaison between academic programs in our specific clinic and I would be a clinical instructor. And then I would also help to onboard the students that came, whether or not they were with me as the clinical instructor or another one of our physical therapists. So I took that job. Small clinic. I think we only had like four or five academic partnerships, but I became really excited about working with the academic programs and bridging that gap between academic knowledge and clinical application. I got married in the process, and my husband’s a musician, so he moved me from North Georgia to Nashville, Tennessee, and I got a job with outpatient orthopedic company that did not have a coordinator of clinical education, although they were taking students. And I was assigned a student. And my student was subpar, to say the least. She was only in Nashville because she Wanted to come to Nashville. She didn’t want to learn manual therapy. She didn’t necessarily want to learn what I was teaching her. She just wanted to be in in Nashville, Tennessee. This checked a box and I saw a need. So I asked my boss if I could do it. And I decided that I wanted to apply what I learned from school, making things structured. And I designed a curricula for our students and grew that program as the company grew and we went from just a middle Tennessee based company to a nine state 160 clinic company. And I helped plant different parts of the company and different states and grew the student program which actually grew to a really robust new hire or new hire program and super proud of what we built. And then Covid and when Covid happened, I had to transition out of my role as a clinical educator and I took another job within the company and realized that that’s not what I wanted to do. So I started looking for more clinical education jobs and I went to work for Tennessee State University. So I was on staff at TSU in their DPT department. I worked right alongside the director of clinical education. So I actually was on the academic side of the clinical education coin, helping to place students in clinical sites. I’m also, and I still am, a clinical instructor in the pro bono clinic on campus. So I work with first year and second year students as I treat patients and I guide the students along in the treatment of patients. So I’m still actually clinical. And then I had a colleague tell me about alliance and everything that alliance was doing and that they needed a clinical coordinator. And so I found myself at alliance doing again what I’m really passionate about, which is developing relationships with academic programs and working to bridge the gap between academic knowledge and clinical competencies. That’s quite a. I’ve been doing it since 99.
Richard Leaver: 99. Since you were five years old. So congratulations.
Ashlee Butler: Exactly. Maybe seven.
Richard Leaver: Maybe seven. I think what’s interesting is really your perspective as it pertains to the responsibility to assist with education of others. I think there’s definite alignment there. When I trained as a therapist, it was really made very clear that as a professional one of the responsibilities of such is to assist in the development of future clinicians. And the education in various forms was really a responsibility of everyone within that profession to maintain and continue to grow that profession and really help those that will follow in footsteps. And I think some of that expectation or perception of being almost a requirement of being a professional has been lost or was never taught because there’s a Lot of clinicians that aren’t involved with education maybe for very good reason, but I’ve certainly embraced this concept all the way through my career that education and supporting education is really an imperative as a professional.
Ashlee Butler: Absolutely, 100%. And I mean, to me the most basic part of that is you wouldn’t be where you are and I wouldn’t be where I am unless a clinical instructor sewed into my life. And so how is our profession going to grow if we don’t continue to emphasize clinical education?
Richard Leaver: Yes. So obviously, as it pertains to clinical education, let’s dive into the weeds a little bit and really take a look at clinical education, particularly placements as part of that clinical education and clinical instructors, the role thereof, and see what perhaps we can learn from you. And for our listeners, which are primarily PT leaders within outpatient. So to kick off, tell us a little bit about kind of clinical placements generally, how are they structured for students, duration and how are they perhaps chosen? So a little bit of background.
Ashlee Butler: Right. So on the academic side, every program is different in how they design a clinical rotation. Some schools start students in the clinic within their very first year of the didactic curriculum because they want the students to have exposure and to see that what they’re learning in the classroom actually has application outside of the classroom. However, more and more programs are going towards having all of their clinical rotations toward the end of their didactic curriculum, where the students are able to assimilate all the coursework that they’ve sat through for two plus years and then apply it clinically. So it depends on the program. I will say there is a trend in academic physical therapy education to have fewer rotations but longer in duration. So instead of like when I was in school, I had like three four week rotations and then an eight week rotation and then another eight week rotation. Now it’s way more common to see 12, 12, 12 and all at the end of the didactic curriculum. So you’re giving students more opportunity to really delve into the patient population to be able to use clinical decision making, learn differentials, really progress with that student. I mean, sorry, with that patient. Take a patient from initial evaluation through to discharge, which is much easier to do with a longer affiliation versus sort of little bursts of experiences. So you’re seeing that in clinical education, the push towards longer rotations with the development of more and more hybrid PT programs. That’s especially important because one of the, I’ll say, criticisms with a hybrid program is that the students aren’t necessarily onboarded to a lot of the professional behaviors that your traditional student has because you’re not dealing with faculty in person, face to face on a day in, day out basis. It’s primarily distance learning where students come to campus in short spurts of time. So the students are actually really doing a lot better, better with longer affiliations so that they can learn those professional behaviors and what it looks like to be a physical therapist in every facet. So that’s the trend for clinical rotations. Most programs are utilizing a company called Exact for their clinical placements and Xact is a software company that is actually designed to help logarithmically assign students to clinical sites. And you have to have an affiliation with the program for the students to be able to see your clinical site. And then they take into account factors like where the student lives, where they have housing available, things of that nature. So it can be random. Random like exac decides what the placement is or the academic instructors hand placed students in different clinical sites based on students goals. Students needs, students housing. One of the challenges in clinical education is the fact that it costs a lot. Students are still paying full tuition, yet they’re needing to get to a clinical site. Sometimes pay for housing at a clinical site. I think the last research that I saw that was published was that each clinical rotation costs the student about $2,000. So it is, it’s costly for the student to actually be involved in clinics. So that’s something that they try to, they the schools, the programs try to have clinical sites that are close to student housing so they can cut down on some of those costs. But that’s basically it really depends on the program in terms of how clinical sites are chosen.
Alliance Physical Therapy Partners: At alliance, we believe that partnership means creating something greater than the sum of its partners. Our focus is finding physical therapy practices with a strong culture and thriving community and providing them with additional tools, resources and expertise to take their practice to the next level. To learn more about joining our nationwide community of outpatient physical therapy practices, visit our website@allianceptp.com it’s interesting how clinical education.
Richard Leaver: Has changed because a few years ago when I trained, I’m not saying it was a good way of training, but certainly a different way of training is. First and foremost, we had a minimum of 2000 clinical hours just within our training, which is substantially more than current students have. I think current students have just over a little over a thousand hours in total.
Ashlee Butler: If I’m correct, the capdia requirement is 32 weeks of clinical education.
Richard Leaver: Okay. And then not only was the Number of hours significantly different, but how it was structured. So in the first year we were actually placed treating as a PT student, but actually placed as essentially as a aid nursing aide. And it was a humbling experience if nothing else. But certainly that was the beginning of the clinical practice and whilst the, the actual task didn’t necessarily directly translate but certainly the interaction with patients was invaluable. And then thereafter we had multiple placements to really give us a depth, well, not necessarily depth but certainly a breadth of all the subspecialties that therapists work within. So I worked in an amputee limb fitting center, I worked in a burns unit, worked in ice intensive care, er, orthopedics, neuro, et cetera, et cetera. So it gave me a great perspective of the profession. Perhaps didn’t go into the depth and perhaps the clinical reasoning skills so much, but certainly allowed me to really have a great perspective of at least what was available as a therapist.
Ashlee Butler: Right. And there are definite pros to that. I think especially since COVID 19 and the amount of burnout from the healthcare profession, there have been fewer and fewer clinicians available to become clinical instructors. So that’s a whole nother ball of wax to talk about, especially in the inpatient setting. So inpatient sites are getting fewer and further between. And then if you want to combine that with the number of new PT programs that are opening up across the country now we have more programs competing for fewer slots. It’s easier to find an outpatient rotation than it is an inpatient rotation. But now even an inpatient rotation, the variety of what’s available to the students is so much less than what it used to be. Students that get placed in hospitals now are either, unless it’s a small rural hospital where the PT department does everything, you’re designated to your space, you’re acute care, your trauma, your burns, your neuro, that’s where you stay, you stay in your lane and then there’s very little variety involved and they don’t have the clinical instructors for it.
Richard Leaver: Yeah. So going into the weeds a little bit, what do students need to know before starting a clinical placement? So we’ll talk about perhaps the CIS in a minute. But what, what do students really should know? And I don’t think necessarily sometimes they do really know. But what is it they need to be told or advised before placement?
Ashlee Butler: Great question. First and foremost, I think you have to emphasize professionalism. It’s a non negotiable. They need to be communicated with in a timely manner in terms of what the Dress code is, you know, they need to be punctual. And what that means, punctual doesn’t mean if you, you know, start treating at eight, that you show up at eight, you know, you have to be there early, prepared, ready to go. All onboarding needs to be complete before your affiliation starts. So all of these things would be considered professional behaviors. And in my experience, I feel like that is where students are lacking the most right now. They’ve got the didactic skills, they haven’t really learned how to navigate being a professional at the same time. So professionalism is a non negotiable and I think the CIS need to be very upfront about that and make it very clear that you know, what you lack in experience, you will make up for in appearance and behavior. So you’ve got to carry yourself well. I think that’s first and foremost. Secondly, you’ve got to know your basics like the back of your hand. And depending on where you are in your curriculum and what the expectations are for that experience, you’ve got to know your didactic basics, your manual muscle tests, your goniometers, where does the stable hand go? Where does the moving hand go? Where’s the axis? What are my norms? What are the vitals that I need to be looking at? Whether it’s a blood pressure, respiratory rate, heart rate, what are are the common exercise principles that I need to remember so that I can build on or regress depending on who the patient is. I need to know the red flags, I need to know the contraindications for certain treatments and modalities. And I really need to know the basics of documentation, what goes in the subjective, what goes in the objective. Students, if they’re in their first or second year of their curriculum, they might not be great at making an assessment. That’s okay. You should at least have the subjective and objective down pat and really have an idea of what good therapeutic goals are. Of course, all students need assistance with that and it’ll differ setting to setting, but they really have to know the basics of documentation. And then lastly, I think that the student needs to come in prepared, knowing the patient population. So again, this circles back to communication with the clinical instructor so that the CI is communicating. These are the types of patients that we see, these are the diagnoses that you need to be familiar with and the student needs to prep for that. They need to know common treatment protocols for those common diagnoses. And they can talk to other students that have been to the same, you know, the same site or they can research online. What types of patients is this clinic affiliated with in communication with the CI. So know, know your patient population before you’re walking in. And if you walk in day one with those things and get ready to build on those, you’ll have a successful affil.
Richard Leaver: Yeah, that’s great. It’s interesting that, you know, the first thing you talk about is professionalism. And that was by accident really, because I, when I, we talked about a little bit before. But we cannot make assumptions. I don’t know whether this is a little sad or not, but the reality is we cannot make assumptions as it pertains to what is perceived as professional behavior. Certainly for those on the, perhaps the placements that are earlier on in their education, but you know, there’s a lot of qualified therapists that I still perhaps lack what I would say is the appropriate level of professionalism. And that might get me in trouble a little bit. But certainly with students, from what I understand, many students actually have never actually had paid employment before actually training as a therapist. So how can we expect them to adopt what we call professional behaviors when they’ve had absolutely no experience of the workplace? And I think that that’s great wisdom to pass on.
Ashlee Butler: It’s interesting. There’s been a shift in academia to the student is the customer and therefore the customer is always right. And it’s very challenging to be in the position of a teacher when the students can, you know, it, it’s, they’re the customer and they’re always right. And even if something is wrong that they’re doing, you have to negotiate and work it out and make accommodations for. And that’s what our academic system has become. It’s still creating some amazing therapists, still teaching very valuable skills, but it’s very different. It’s, it’s much less real life training and much more this is the safe place for this for the student to learn. If they have anxiety, you give them extra time, you accept excuses and can change grades because it’s just they’re not getting that training in school. And so many of them have, like you said, have never had real world employment, so they’ve never had to answer to a boss.
Richard Leaver: I don’t think I’ll go down the rabbit hole of this concept of students being customers. Geez, that’s just a little bit different. But anyway, before I get into trouble, yes, before I get into trouble, let’s talk about perhaps not so much what the students need to know before clinical placement, but what do the CIS need to prepare for. For the placement because it’s important that they prepare. So it’s successful placement, isn’t it? They can’t just wing it. So what do they need to know.
Ashlee Butler: To be the best CI, which I don’t understand why someone wouldn’t want to be the best CI? To be the best CI, you’ve got to communicate with your site coordinator. You need to know your clinic’s requirements for students, what the students have to do, you know, have an orientation scheduled out. You need to be proactive with your scheduling so that your student has adequate time to orient to the clinic, that you can spend some one on one time with your student. So being proactive in your scheduling requires some forethought. So that to me is first and foremost. And then you also need to review the academic programs requirement for that specific affiliation. Where should my student be at the end of the affiliation? What’s required of my student for this affiliation? If it’s a first year student, they’re probably not going to be doing evaluations independently. And I say that with air quotes because you they’re still treating under your license, so they’re not independent regardless of where they are in the curriculum. But if it’s a first affiliation and they haven’t completed their didactic coursework, they’re not going to be doing full evaluation. So you need to know where they are in their curriculum and what the academic program’s requirements are. And then you want to learn about your student. Students send a bunch of information like this is my learning style, this is my communication preference. And while you might not always be able to communicate with a student in their preferred style, you at least need to acknowledge it and know it so you can have conversations. So communication with your student is key. Getting to know your student, how are they going to learn best? How can I teach best? I think that makes for a successful clinical instructor.
Richard Leaver: Great. Now, I would imagine with the number of students that you’ve directly been a CI and you’ve managed in various capacities. Capacities throughout the last few years. There’s probably challenges that are quite common as it pertains to students on clinical placement. What are those common challenges for the students and what can perhaps the CI or the clinic do to address them proactively? Perhaps?
Ashlee Butler: Yeah. So the thread that I’ve seen, I’m going to go back to professionalism. That’s probably been the most common thread. When CIS are having a challenging time or a difficult time with the student, it’s less to do with their didactic knowledge and their ability to perform tests and measures, but more their behaviors and their professionalism. And the CI just doesn’t know what to do with it because they feel like the bad guy for calling the student out. So I think to, to proactively be on top of this, you’ve got to communicate clear expectations about when you want the student in the clinic and how you would like them to prepare for each day. Case conferencing every day, in my opinion is vital. Sitting down with your student before the day even begins to talk through a game plan for the day so that the student has clear set expectations and then document those times where the student does not meet those expectations. If they come in not in dress code, you can’t be afraid to say that is not dress code. I need you to go home and change. You can’t be in the clinic with your midriff showing. CIS are afraid to say that they don’t want to be the bad guy. I mean, we get into PT because we want to help people. Most of us are like type A nice people and we want to be helpful and we have a hard time having hard conversations sometimes. But these professional behaviors, sometimes it’s because there’s a lack of professionalism, but other times it’s the expectations have not been laid out clearly enough. So you can manage that proactively by laying out your expectations very clearly. Another challenge that I see is that students often struggle in applying academic knowledge in a faster paced clinical setting where they feel like they’re getting graded and that’s what they’re used to. They’re accustomed to being graded and they’re afraid they’re going to do something wrong. So they get self conscious and they get anxious and they choke up on their words and they don’t know exactly what to do. And a CI can actually really assist with that by reminding the student that this is a learning environment. They’re there to guide, they’re there to help. Have the student ask questions, ask the student, not in front of the patient necessarily. Right. Would you like to observe this the first time and then the next time they come in, I’ll let you take the lead. So just having conversations like that really reduces a lot of the stress because students do have a hard time turning off that student mentality. I’m being graded, I’m get this is I might get graded wrong or, you know, whatever the case may be. So that’s a big challenge. You want to give them an opportunity to apply their academic knowledge without feeling like they’re always being tested. And then there’s usually a challenge involved with adjusting to workflow. Again, students sit in a classroom or go to a lab and then they go home and study. And this could be the, you know, the first time that they’re actually needing to start on time and end at a certain time and be ready for the next patient. So just giving space and not expecting too much from A, your earlier students, whether it’s a first year or a second year student and then B coaching strategies on how to manage caseload just like we do with our new grads. This is. Let me give you some strategies for how to schedule and how to manage this and utilizing our extenders of care, whether that’s a PTA or a technician, students can also delegate tasks to extenders of care. So assisting the student with that to help them feel like they’re less crunched for time and then and the biggest success determinant on the student side for whether or not the affiliation was a successful affiliation was if they felt welcome in the clinic. That is the number one. Several studies back this up that if students feel like they’re actively welcomed and are a part of the team, they feel like it’s a successful affiliation. They feel they want to do more, they want to engage more. And the CI can do something as simple as have a welcome sign at the student’s desk. Welcome to Advent Physical Therapy. We’re glad to have you. Invite them to lunch to sit at lunch with you as the staff meets. Invite them to staff meetings, engage them and have them be a part of what’s going on. Ask their opinion about things like what would you do in this situation? You know, and just engage them, make them feel like they’re a part of the team. And when students feel like they’re a part of the team, they are more likely to function at their highest. And consider the affiliation successful.
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Richard Leaver: Dad can there’s so many great points, kind of going through a few of them, setting expectations I from a generation where the concept of perhaps somebody setting expectations would be perceived as micromanagement. But that’s furthest from the truth, isn’t it? With regards to other generations, they need that very clear and direct guidance because that’s what they’ve had and that’s what they’re used to. And in fact if they don’t get that, then it usually creates a lot of anxiety for them. So it’s, it’s definitely a generational piece. Not wholly, but I think there is definitely a generational component there.
Ashlee Butler: And I’ve done some classes on like the difference because when I was starting I’m a Gen Xer and I had to learn about Millennials and now having to learn about gen zers and all, all those things. And there are stereotypes for a reason, everybody doesn’t fit into one. But there are generational differences. Presently the, the thought is ambiguity breeds anxiety. And more and more students have anxiety and not feeling like they know what’s expected of them and what to do. They’ll get anxious and then they start making mistakes. So those clear expectations are a must right now. Like, I grew up in an environment where I had unsupervised playtime. I didn’t have a syllabus for classes, I didn’t have rubrics for tests, like nothing like that. The generation students now, they didn’t have free play, they had play dates. Everything was structured from who they played with to what they did in their playtime. And I’m talking as early as toddlerhood and now in the academic world they have a syllabus for every single day. They know every day what they’re going to learn. They have preloaded PowerPoint for exactly what the lecture is going to be. They get rubrics for almost for every lab practical. They know exactly what they’re going to be checked off on. And if they don’t see a rubric before a lab practical, it’s almost like panic town. They well, what am I, what am I supposed to do? It’s a patient, you treat them. But I don’t know what I’m going to be graded on. It’s a patient, you treat them. It’s pretty crazy how structured education is and how students need that bridge when they get into the clinic.
Richard Leaver: Yeah, I think the last thing I’ll say about expectation is nobody has to worry about me showing my midriff, particularly with my middle aged spread. So everyone’s safe there, I think. And then I find it reassuring but perhaps slightly amusing as well, that one of the key determinants is feeling welcome, but I can understand that. It’s really making sure that they’re given the time to support and enhance and develop the student, isn’t it? I remember as a CI that essentially the way that I tackled it or where I approached it is really whatever I was doing, wherever I was, the student was with me, either taking the lead where appropriate or being by my side. Even to the point where I worked in high security prison, I would take the student with me when I was treating high security prisoners as well. And they had a great experience, perhaps not with the actual visiting the prison, but they had a great experience from a clinical perspective because they were an integral part of the team during their clinical placement. And you know, they had the same similar kind of basic responsibilities. Obviously clinically very different, but you know, they had the same expectations as the clinicians as it pertained to timekeeping, dress code, et cetera, et cetera. And they definitely appreciated that. And I’m sure that, you know, they, many students who have good placements remember it for many years to come.
Ashlee Butler: I would have liked it.
Richard Leaver: I think that’s right. So I think clinicians and also students, but clinicians are sometimes reluctant to take students because there’s common myths, misconceptions regarding student placements and having students. What are some of those myths or misconceptions about student placements?
Ashlee Butler: Well, there are a handful of them and they reappear not just in PT education, but in nursing education, really any of the allied health fields. And there’s a lot of research behind this. So what I’m about to talk about, there’s a lot of data behind the biggest misconception is that a student will always negatively impact your productivity, that you won’t be able to be as productive with a student. And that’s been shown to be untrue over and over again in that while onboarding and orientation, yes, takes time, there is a ramp up, but well prepared students become assets to the clinical instructor and to the clinic themselves. Students can assist with documentation. They can assist with patient education where a therapist is needing to do some administrative task. They can really dive deeper into patient education and work with that patient to help with that therapeutic alliance and the buy in for treatment. They can help with treatment progressions, treatment regressions. If a patient comes into super flared up and you’re like, oh my goodness, I wasn’t expecting this today. I don’t know if I have time. If you have a student with you, your student can spend one on one time with that patient while you’re doing something else or as long as you’re supervising them. So students can assist with clinical education, students can assist with in services to educate the rest of the staff on new modalities or new techniques or new equipment. And so as long as students are adequately onboarded and oriented, they can actually, actually really help increase your productivity and become assets to the clinic. So that’s, to me, the biggest roadblock that I see is the misconception that students will negatively impact productivity. And time and time again, it shows that they don’t. Not over the long haul, like the first two weeks, yes, it’s a little slower. You have to take things a little slower. But over the long haul, no. The other thing that I hear all the time is I don’t have enough space. Our clinic is too crowded. We don’t have enough desks. We don’t have enough space to have a student. But the answer to that is actually, if you have enough space to treat a patient, then you can have a student with you. You don’t have to run to independent schedules. Your student can co treat. And as long as you’re mindful about your scheduling where a patient can go, a student can be with you while you treat them. You don’t have to have two beds to treat. Two patients at the same can be a co treat scenario. Another thing, a roadblock. A misconception that I hear is that I’m more liable, I’m putting myself or my license at risk if I have a student. And yes, your student is treating under your license, but your student comes to you from an accredited program and that program carries with it liability and malpractice insurance that the student comes with. And if you supervise correctly, then that should not be a concern at all. I like to educate and coach my clinical instructors on kind of sort of like the Maitland model of evaluations, like assess, treat, reassess. I do it with students where I discuss, treat, discuss, treat. So the student is constantly engaged in their thoughts. This is what I want to ask. This is why I want to ask it. Okay, ask away. Okay, this is what the patient said. So because this is what the patient said, this is what I want to look at. And okay, so this is what the patient looks like. So this is what I want to do. So as long as you’re having those conversations and seeing the clinical reasoning and the judgment behind the treatment that the student is providing, you don’t have to worry about liability. They’re doing the right stuff. Another common excuse that I hear for not wanting to take students is I can’t bill Medicare or federal payer if I have a student student with me. And that’s not true. Now there are requirements for supervision when it comes to federal payers and unfortunately a lot of other commercial insurances are adopting those supervision requirements. But students can absolutely participate in treatment as long as the therapist is directing. And you can bill it the same way as long as you’re directing the treatment and you’re not billing for your time elsewhere, which is even if you didn’t have a student would be the same thing. So that’s false. You can bill for the time that the student spends with the patient as long as it’s under those supervision requirements. Cis often think that there’s not a benefit to having a student in the clinic that is more facile than good. And again I’m going to go back to research. And research shows time and time again that those clinics that accept students actually have higher productivity, higher staff engagement, higher what’s the word I’m looking for. The people that work there have higher job satisfaction because they’re more engaged, they’re learning more. Students come to you with the latest and greatest knowledge. They’ve been in the research a little bit more than those of us who’ve been in the field for a long time. So they can come and talk to you about new studies and what this has found and you can learn from a student equally as much as you can teach a student. So clinics that take the most students actually have higher professional satisfaction from their clinicians and it helps you improve your teaching skills with which not only benefits your students, but it benefits your patients too and it helps you onboard new grads and new hires. And I think the biggest benefit to taking students is you have just golden recruitment opportunities. It’s like a 12 week interview. You see if the student fits the culture of the clinic, if they have the same treatment philosophies and if they do, then you bring them on board and you watch them go into a new grad and then you want to grow them into a clinic director themselves or another leadership position. So to me that so rewarding to see someone go from a student to a leadership role. And so recruiting is I think huge and it’s such a benefit for the clinic. But to me those are the biggest roadblocks that I see and the common misconceptions. One of the other reasons I hear for I can’t take this student is I’m not a 40 hour a week clinician. I’m, I’m Only part time. I’m not in the clinic 40 hours a week. Well, you can absolutely have a student. If you’re not a 40 hour a week employee, you can split that student with another clinician in your clinic. You can split that student with another clinician in a clinic that’s really close by. We’ve had very successful affiliations with students that have actually split time between clinics, not just clinical instructors. Yes, it takes a little bit of time. It takes some debriefing. What did you learn here? Show me that here. Just more communication. But it can 100% be done and be done very successfully and is. And beneficial for the student because now the student gets multiple people sewing into them instead of just one. So that’s another thing that you don’t have to be a 40 hour a week clinician to take a student. And then I think one of the. I hear it all the time. My last, My last student was terrible. Don’t give me another one. I don’t want another student. My last one was terrible. Terrible. Well, let’s talk about what went wrong. Let’s figure out how we might be able to mitigate those things prior to those happening. And the fact of the matter is, most student experiences are really good. And I always tell my CIS that say that to me, my last student was terrible. I don’t want another one. I’m like, oh, have you ever ordered something from a restaurant? It wasn’t good. Do you just stop going to restaurants because you had one bad experience? No, you don’t. You try it again. And I think the same goes with clinical education, though. I feel like as long as CIS know that they’re appreciated and they’re supported and that their company has their back, then they’ll be more likely to take students. And I’m happy in my position to coach clinicians through these common misconceptions.
Richard Leaver: Yeah. So what I’m hearing basically, and my experience has been really, there’s no excuse not to take a shot student because most of the excuses are pretty lame, to be honest. Now if you’re out on surgery or extended leave, then that’s fine. But usually the excuses can be worked through or the reasons perhaps can be worked through. The other thing is the way that placements can be structured can be different for different schools. So again, I’m not sure if this is a model that’s used in the U.S. probably not because of the reimbursement adjustment constraints. But when I was a CI many years ago, I would actually have three students up to three students assigned to myself. And at that point I became almost a full time clinical instructor and they weren’t students whilst they were assigned to me. Actually I was part of a relatively small clinic with a couple of other clinicians and we would tag it wasn’t the fact that the student had to come to me, it was really whoever was qualified therapist at that time and most convenient or who had perhaps the most experience within that perhaps condition or whatever the criteria that it was definitely treating and managing the placement as a team. And I think there was a huge benefit for the student for that because they saw different approaches, different clinical reasoning skills, et cetera, et cetera. I think the best placements not only have a clinician or CI that is engaged, but really a clinic team that is equally engaged and supportive.
Ashlee Butler: Yes, a hundred percent, absolutely. The students love, generally speaking, students love the teamwork aspect of it and the surveys that I read from students that have come through clinical clinics over the last two plus decades. The comment on how the team works together or everybody is there to help each other and the student really doesn’t even differentiate between the tech and the PTA and the CI because everybody works together as a team and it’s a great experience across the board. So the more teamwork you can bring into it, the better the experience for the student for the most part.
Richard Leaver: So for private practice owners, if they are looking to provide clinical placements, what are the schools looking for? Specifically, what do the practice owners have to be able to provide in order to be eligible to even take on student placements?
Ashlee Butler: They have to sign an affiliation agreement, which is a legal document and they have to agree to the terms of that legal document. Most clinics will take the school’s affiliation agreement and have their attorney look at it and sign it. That will include things like responsibilities. It’s the school’s responsibility to do this. It’s the clinic’s responsibility to provide education experience, a place for the student to to have get their work done. The school has to supply a certain amount of insurance and liability type of things, amongst other legalities. The clinic needs to be willing to teach. There are plenty of clinical sites out there. Unfortunately they give clin ed a bad rap that use students as texts and as free help and means to schedule a lot of patients. I think to be a good clinical partner you’ve got to be willing to teach and you’ve got to be willing to be able to block out your schedule every so often for some one on one mentoring, for some remediation. If it Comes to that the student’s not behaving or performing the way that they need to. You need to be able to meet with the student, take time out of your schedule to do so, not just shoo them away from the clinic and send them back to the school. You’ve got to be able to give some explanation as to why. So you need a desire to teach, you need the ability to schedule to do so. And then you’ve got to have a good relationship with the school. So communication with the director of clinical education or whoever they have coordinating those clinical experience for the students, I think that’s really all you need. Sign the contract, be willing to be a teacher and have a good relationship.
Richard Leaver: With the school to finish off off. If we can kind of look into the crystal ball. Where is clinical education perhaps heading? Obviously, where it’s come from and where it is currently is very different. But I’m sure that the theory of clinical education or education generally changes over time and I’m sure clinical education continues to evolve. So what are you seeing and what do you think is on the horizon down the road as it pertains to clinical education for outbreak for PT students?
Ashlee Butler: Yeah, for sure. So what I’m seeing right now is an increased use in technology and placing students using software to place students in clinical sites, which has its pros and cons. So the pro is that it’s easier for the school and it’s becoming easier for the clinical site. The con is that sometimes students get placed in sites strictly for location or strictly to check a box like I have to have outpatient, orthopedic. This place looks good to me. I’m going to request it. The algorithm puts you there, so you still have to maintain those relationships with the program. You need to know when to reach out to the school for some assistance to have those open lines of communication. So that is presently happening, the increased use of technology inside of clinical instruction. What is also presently happening is, as referred to earlier in, is that programs are shifting to longer but fewer rotations to give students ample time to dig deeper and to integrate their skills and their academic knowledge into clinical skills and to see patients progress through the plan of care. Presently, schools are having to address staff shortages. There’s staff shortages across the board, outpatient as well as inpatient and clinical. Clinical site capacity is strained in multiple settings. There’s increased productivity demand because of lowered reimbursement rates. And there’s more and more PT burnout. And then we’re still experiencing Covid aftermath because of all of that in addition to the increased number of PT programs that are out there that are graduating more students, there’s a growing use of two to one models, meaning schools are asking clinical sites to take two students at one once instead of one on one. So growing use of that model and then also being more open to splitting students between multiple clinical instructors so that they can fit more students in. There is a need, a growing need of emphasizing non clinical skills. We talked about this. Professional behaviors, cultural humility, communication and collaboration with other people. Students are fantastic at texting. They’re not so great at face to face communications. So working on those non clinical skills is having to take a lot more time in the clinical education world. The CIS are having to work with that on the horizon. What’s coming is called competency based clinical education. It’s starting in the med schools, but it’s making its way to allied health. And competency based clinical education is a shift from time based that 31 weeks of required time in the clinic to competency based students won’t pass a clinical affiliation unless they’ve mastered these skills versus oh, I finished my time. I’m going to attach a number to this rotation to give them a grade and get them out of here. So there’s a shift to competency based education and it’s coming, it’s coming for pt. And I think we’ll see some differences in making sure that students master skills versus they were here for their eight weeks and now they’re done.
Richard Leaver: Interesting. I always ask at the end of podcasts for any final words of wisdom or any other points perhaps that we haven’t covered or haven’t covered perhaps in the depth you think that they need to be. So it’s an opportunity to, to really kind of sum up perhaps and see if there’s anything that you can perhaps share with listeners that we haven’t covered already.
Ashlee Butler: I think I can’t talk about professionalism enough. It needs to be emphasized more and more and more. I think so many of the issues that CIS have with students boil down to professional behavior versus a lack of skill and setting clear expectations. I don’t want to beat a dead horse, but that’s number one, that’s key. And it can’t be emphasized enough. And then I just want to encourage practice owners and clinicians out there that they’re never going to make a change in the profession unless we train the new generation of students to be who we want our profession to be. And the only way that we can do that is by being willing to mentor them and teach them and train them and take them as students so that we can cultivate the correct behaviors, we can cultivate the correct expectations, we can turn our profession around, but we’re not going to do it by being unwilling to mentor the next generation of therapists.
Richard Leaver: Wise words from somebody so young. So Ashley, thank you so much. Thanks for your time. I’ve learned a lot and certainly it’s reassuring to hear meno of the points that you make and certainly a lot of work and dedication time effort is being done both by schools and by many clinical instructors to really try and deliver great outcomes for placement. So it’s heartening to hear. So thank you.
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