"Clinical education" versus clinical education. (Editor's Note).

When it comes to communicating about what we call "clinical education," the folks in Babel had nothing on us. We use words and terms that have different definitions or, worse yet, reflect only tacit agreement about their meaning. In fact, when we place students in settings in which they are seeing patients much the same way as full-time employed physical therapists do, it isn't always clear whether these placements are designed primarily for educational purposes or for testing.

Is the "clinical education" placement one of the final hoops in the education process, or is it a time when future physical therapists can feel free to show the gaps in their knowledge as they seek more and more information in an applied setting? If this time in the clinic is not the equivalent of an incredibly long final exam, why would we spend so much time and effort on evaluation and the development of evaluation instruments? Clinical education experiences should be a time when students develop their abilities to seek knowledge that they can use in the management of patients--in other words, for what we call evidence-based practice. For students who perceive that they are constantly being judged, however, showing vulnerability and uncertainty may not necessarily seem like the easiest path to success.

The suggestion that these clinic experiences we call "clinical education" can equally serve both purposes (learning and testing) is facile and lacks substantiation. Both educational and evaluative experiences might be taking place, but certainly one type of experience dominates, and there is a danger that we are not all agreeing on what is most important. Why don't we, as Dr Anthony Delitto of the University of Pittsburgh suggested in his Maley Lecture presented in June 2001 at PT2001 in Anaheim, simply evaluate students who are about to graduate using the same methods that we use to evaluate staff?

The very term "clinical education" introduces some confusion. Are we to assume that, within a physical therapist or physical therapist assistant education program, the rest of the curriculum is not filled with clinically relevant information? If that is the case, we are in serious trouble. Many years ago, this Journal divided articles into two major categories, "research" and "clinical." It was as though no one could envision the use of research in practice. The Journal's classification helped fortify a wall between practice and science that should never have existed.

The name that we assign to the time that students spend behaving most like therapists--"clinical education"--illustrates an ongoing problem and our continued failure to more fully integrate and understand the elements of our education process. Why are we sending students out for prolonged periods of time? What should be the general expectation of practitioners who spend time with students, and what should be the general expectation of administrators who allow such time to be allocated to this experience?

The smorgasbord of settings in which physical therapists work has grown dramatically over the past 2 decades. All physical therapists should consider whether clinical placements have changed appropriately. For that matter, they should consider what types of clinical experiences are absolutely necessary versus what types are desirable. Do we insist on certain strategies in clinical placements because they are similar to what we experienced in a health care environment that has changed dramatically since we were students?

This month, Strohschein, Hagler, and May share their perspectives on "Assessing the Need for Change in Clinical Education Practices" (pages 160-172), and there is a great deal that we can learn from their work. One sad fact, however, is that these authors show us that the literature is filled with opinions and the willingness of innovators to call every "clinical education" variant a "new model." There are few data to tell us what is the best way to get our clinicians ready for practice, let alone what manner of "clinical education" is truly efficient and effective.

People in practice might believe that the article by Strohschein et al is too distant, covering a topic best left to "educators." But I would argue that this topic is too important to be left only to those who represent a narrow community of interest. As our profession continues to evolve, we talk about greater levels of autonomy and about the professional doctorate as a means to ensure that our educational institutions universally produce physical therapists who are prepared to practice in a manner that is consistent with contemporary knowledge and need. If we do not produce clinically competent therapists at the time of graduation, those who seek to eliminate costs--and eliminate other professions--will be armed once again by our failure to act.

Just as our educational institutions should be the primary contributors to new knowledge about practice, especially clinical information, so should they also be the source of new physical therapists who push the envelope when it comes to quality of practice. Research cannot be conducted in educational institutions without resources from the schools and without partnerships between schools and people who are located primarily in clinical practice settings. The same can be said for what we now consider to be the applied element of our curriculum. Without a proper ongoing partnership between faculties in schools and people in practice, clinical education will never prepare our new graduates to the level necessary, to the level described by our Association's vision statement, and to the level that justifies the professional doctorate.

In December of last year, I argued that our profession needs greater thought and dialogue in its decision-making process. I called for locally organized discussions similar to the Lincoln-Douglas debates. I repeat that call and suggest that a major topic for debate is clinical education. These types of debates would allow more members of the profession to participate by offering new ideas. If there is a commitment to solutions, we all would benefit from the interaction. We need to transcend the voices we now hear; we need to hear the voices that have been muted or silent. We need to hear from those who are most affected by the decisions that are made and from those who have practical insights.

We avoid the discussion at our peril.

Jules M Rothstein, PT, PhD, FAPTA
Editor in Chief