Posts tagged fellowship training
Q and A with Dr. Thomas McPoil, PT, PhD, FAPTA on his Career, the Physical Therapy Profession, and the Management of the Foot and Ankle
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1.     You have experienced an illustrious and diverse career in research, education and clinical work. What is the secret to your success in all of these disciplines?

I have been very blessed to have such a great career in physical therapy – I firmly believe that the reason for any of the success that I have had is directly related to the tremendous personal and professional mentors I have had throughout my career.  On a personal note my father and mother and most importantly, my wife and my daughters, who have always been so supportive and understanding of my desire to be the best clinician, teacher, and researcher I could strive to be – even at the expense of time I could have been spending with them.  From a professional standpoint, there have been so many mentors and colleagues who have influenced my development as a clinician, teacher and researcher.  While it would be impossible to name all of these individuals, I need to recognize Harry Bergtholdt, PT, MS and Drs. Gary Hunt, Harry Knecht, Mark Cornwall, Dale Schuit, and Bill Vicenzino.  Each of these individuals as well as so many others have had a profound effect on me throughout my career. 

2.     You have witnessed many changes in the field of physical therapy. What are some good changes, what are some bad changes, and where do you see the profession going?

The accomplishments our profession has made since I started practicing physical therapy are nothing short of phenomenal!  At the time I completed my certificate in physical therapy at Children’s Hospital of Los Angeles in 1973, positions for new graduates in the Los Angeles area were extremely difficult to find.  At that time, 80% of all physical therapists worked in either hospitals or nursing homes.  In my first staff PT position, I served in a technical role as a physical therapist under the direction of a physiatrist.  Every morning I would go the PT department located in the basement of hospital and get my treatment orders from the physiatrist – the typical prescription for patients with neck and back conditions was ultrasound, followed by hot packs, and then 15 minutes of massage.  At the completion of the treatment, I did William’s Flexion Exercises with the patient on the treatment table.  I remember getting a stern lecture from the chief physical therapist when I was silly enough to attempt to do some closed-chain exercises with a patient based on my athletic training experiences in college – he told me it was not appropriate to have the patient exercise while standing.  Needless to say it was depressing and there were several times when I thought about leaving physical therapy and going back to athletic training.  I was fortunate enough to accept physical therapy position in the U.S. Public Health Service in 1976 which was a major turning point in my career.  In the Public Health Service, I was able to work with some outstanding physical therapists and was finally able to independently examine and treat a patient without physician direction.  To think that today our students now obtain an exceptional education and are granted a doctoral degree, physical therapist can practice in a variety of specialty areas in multiple practice environments, and we have achieved the ability to practice autonomously with patients having direct access to our services is remarkable.  These are definitely great changes!

Unfortunately, the physical therapy profession is still fighting for recognition in both the health care arena and society as THE primary care provider for neuromusculoskeletal conditions.  In my opinion, there is no other health care profession that has the knowledge and training to serve in this important health care role.  The other critical issues facing the profession is 1) the ongoing struggle to improve the system of payment for physical therapy services and 2) the high cost of obtaining a Doctor of Physical Therapy degree.  After teaching physical therapy students at both the undergraduate and graduate level for 36 years, I am also convinced that certain critical clinical skills including obtaining the history and appropriate decision making based on subjective and objective findings are difficult, if not impossible, to teach in the current model of academic and clinical entry-level education.  The ability to acquire these skills requires structured clinical mentorship that occurs during direct patient care that is provided with quality residency/fellowship training.  Some of the issues for entry-level students considering a physical therapy residency or fellowship is student loan debt and salaries not commensurate with advanced clinical specialization.  In addition, there are not enough residencies or fellowships positions for every entry-level graduate.  That being said, the profession needs to strongly consider reducing the length of entry-level education programs to 2 and ½ years as well as promote the path to residency or fellowship as the norm for entering the practice of physical therapy.  To do so, the profession also needs to do all that is possible to accelerate the development of residencies and fellowships.  

3.     You are world renown in research surrounding the ankle and foot. What first got you interested in specializing in that area?

As a student athletic trainer in college, I was always assigned to the cross-country and track and field teams.  As a result I had to deal with many foot and ankle injuries and I enjoyed treating these injuries that even though I did not have the necessary knowledge to adequately manage the injuries.  As I noted in question #2, my first assignment as a physical therapist in the U.S. Public Health Service (PHS) was the PHS hospital located in Staten Island, New York.  Many of the patients referred to physical therapy were diabetic and were admitted for foot plantar ulcerations that eventually lead to a lower extremity amputation.  While I enjoyed working with these patient’s as the physical therapist was responsible for fabricating the temporary protheses as well as gait training, it also was apparent that we needed to do something to help prevent the development of plantar ulcerations as a result of diabetic neuropathy.  A senior PHS physical therapist Joe Reed who had tremendous expertise in foot orthotics and footwear would visit the hospital and help us make cushioned insoles and sandals for these patients.  So Joe was the first physical therapist to get me started making orthotics.  In 1978, I accepted my second assignment at the U.S. Public Health Service Hospital located in Carville, Louisiana which was also known as the National Hansen’s Disease Center.  The lay term for Hansen’s Disease is leprosy.  Patient’s with leprosy have the same neuropathic issues as the diabetic patient even though the disease process is different.  It was also at Carville, that I was first introduced to the Podiatric Model by a podiatrist who had studied with Dr. Merton Root one of the founders of the podiatric model.  During the three years I was at Carville, I spent at least 50% of my time making foot orthoses or footwear modifications.  At the same time, I was pursuing my master’s degree in athletic training at Louisiana State University and would make foot orthoses for the intercollegiate athletes.  As a result of these experiences, when I left the U.S. Public Health Service in 1981 to join a private practice in Joliet, Illinois, I knew that I wanted to continue to specialize in the foot and ankle for the rest of my physical therapy career.

4.     There is research validating the use of custom fitted orthotics and their benefit for patient function. What is your current stance on these findings? Have your thoughts changed over the years of studying this topic?

This is very interesting and complex question.  Before discussing the “evidence” it would be best to define what is a custom fitted foot orthotic.  When I first started teaching continuing education courses on the foot and ankle in the early 1980’s, a custom foot orthosis would be defined as a device that was fabricated on a mold of the patient’s foot that was obtained using a slipper cast with the patient positioned in subtalar joint neutral position as per the podiatric model.  Unfortunately, there are two issues with this method.  First, since the typical prescription for podiatric model orthotic device is fabricated with a firm material such as polypropylene, if the polypropylene was molded to the mold of the patient’s foot obtained in subtalar joint neutral position, the orthosis would cause medial arch (navicular) pain during weight bearing.  To allow the use of firm material in the fabrication of the orthosis, the mold of the patient’s feet obtained from a neutral position plaster slipper cast are modified using “arch fill” so that the podiatric model foot orthosis is comfortable to wear.  The typical amount of arch fill reduces the height of the medial longitudinal arch by 50%.  As a result, when a patient stands on a pair of podiatric style foot orthoses, they will undergo pronation depending on the amount of arch fill selected on the prescription form.  So this leads to the question – how custom-fitted is this type of foot orthoses?  Other foot orthotic manufacturers will have the clinician use a foam box to obtain a mold of the patient’s foot rather than a plaster slipper cast.  However, in a study we did in 1989 which compared two non-weight bearing plaster slipper cast techniques to the foam box method, the foot mold obtained using the foam box was markedly different in comparison to the non-weight bearing casting methods.  Second, the examination methods and foot orthosis theory based on the podiatric model were shown to have no validity and poor reliability over 20 years ago.  The most current research on this topic published in 2017 by Jarvis et al in the Journal of Foot and Ankle Research concluded that: 1) the examination protocol advocated by the podiatric model no longer provides a suitable basis for professional practice, 2) clinicians should stop using subtalar joint neutral position as part of the clinical examination and as a means of defining foot deformities associated with the podiatric model, and 3) their results question the relevance of the podiatric model as basis for prescribing foot orthoses.  More importantly as pre-fabricated foot orthoses have developed over the past decade, many of these pre-fabricated foot orthoses can be “customized” to provide both increased contact with the plantar surface of the foot through heat molding as well as with wedging or posting.  The major disadvantage with pre-fabricated foot orthoses, in comparison a polypropylene podiatric model device, is the durability.  Since EVA foams are used to fabricate many pre-fabricated foot orthoses, they tend to “wear-out” at a faster rate than polypropylene.  To determine if durability is an issue, it is important to look at the clinical evidence for foot orthosis effectiveness.  There is evidence to support the use of custom fitted foot orthoses for individuals with rheumatoid arthritis, neuropathic diabetic ulcerations, and forefoot conditions such as metatarsalgia, hallux limitus/rigidis, and Morton’s toe.  For conditions commonly referred to physical therapy including plantar heel pain, commonly diagnosed as plantar fasciitis, excessive pronation (however that is defined!), and anterior knee pain best current evidence supports the use of foot orthoses in reducing pain and improving function for up to 12-weeks with no difference in outcomes between customized versus pre-fabricated foot orthoses.  Optimal treatment for these conditions requires a multi-modal approach with the short-term use of foot orthoses to provide pain reduction and increased functional levels.  So at this point in my career for the majority of patients I see, the use of a pre-fabricated or custom foot orthoses provides similar outcomes as long as the pre-fabricated foot orthoses selected for the patient can be modified.  So the choice – custom versus pre-fabricated – should be based on which device is most cost effective for the patient.  The important point here is that for most patients, the use of foot orthoses is only one component of the overall management program – it can never be viewed by the patient or the clinician as the “centerpiece” of the treatment plan.  

5.     You are entering into a new season of life as you retire from your position from Regis University. What are your plans going forward? What do the next 5 years look like for Dr. Tom McPoil?

I still have several professional things I am working on over the next year including some guest lectures at meetings as well as the 50th McMillan Lecture next June at the APTA NEXT Conference.  I want to get back to playing some golf and I just started playing pickleball.  I played squash for a number of years when we lived in Flagstaff, Arizona, but was never able to get back to playing since moving to Denver.  I have always enjoyed playing tennis, racquetball, and squash, so I am looking forward to learning the game of pickleball.  I also started volunteering 8 hours per week at the SAME Café in Denver as part my commitment to the Ignatian Volunteer Corp.  Of course, I want to spend more time with my wife, our two daughter’s families and our five grandchildren.  So I think I will have plenty to do to keep me busy over the next 5 years.  As I said at the start, I have had a very blessed 45-year career as a physical therapist!  I am looking forward to the next chapter in my life.   

Question and Answer with Tim Fearon, PT, DPT, FAAOMPT
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Photo Credit: phoenixmanualtherapy.com

1. What influenced your decision to start a private practice?

The primary drive behind the decision to start a private practice for me was that I had invested completely in becoming skillful at what I did, I saw no plausible rationale for pursuing a profession at an average level.  I found myself however, working in environments where the primary emphasis was on the metrics of billing.  Patient charges per man/hour were emphasized over the quality of what we held ourselves out to be delivering and which the patient thought they were receiving.  Paradoxically these places sought me out for their clinics because of the very skill set that they now wanted me to compromise on.  It became clear that they wanted the appearance of expertise, not the commitment to the reality of it but the luxury of marketing it so that they could get the patients per man hour turnstiles moving.  In short I found that not only was I burdened by the specter of being told how to deliver PT by people whom I was far more skillful than at doing so, I wasn’t capable of succumbing to such a hypocritical existence.  

2. Manual therapy plays an important role in your patient care.  What changes can our profession make in order to help further develop this intervention in practicing clinicians?

This is a dilemma.  Manual therapy is a psychomotor skill that requires good psychomotor teaching and practice from those who actually do it.  I often parallel this to playing a musical instrument.  We can learn to read and write music but until we learn to produce the physical motions in synchrony with the instrument that we are playing we cannot produce the music.  Our present educational system emphasizes immersion with those whose expertise is in teaching.  They can teach us to read the music & write the music but those who are teaching it cannot be experts in everything and hence cannot actually play the music.  Academicians & researchers have done what they can to prepare their students.  Yet we as a profession have yet to acknowledge that there is a difference between education and training. We leave school and delude ourselves with our knowledge base as being young experts when in reality we are simply now ready to really learn.

How do we change that?  

Educators and researchers are doing their job.  Some dramatically better than was the case in my early days in the profession where the research was dominated by isokinetic musings.  Clinicians should be the ones who teach the fledgling practitioner how to turn knowledge & skill into the art of treating patients.  We need to openly embrace that this profession and manual therapy in particular is an artistic application of our intellect.  Clinicians need recognize that without them there is no profession and no matter where they are in their development there is someone trailing them and someone beyond them, both of whom they should be interfacing with regularly.  

There are many ways to do this, residency & fellowship training are but 2 of them.  From these programs I have seen a disturbing emphasis on more academics with inadequate hands on training time to genuinely allow for the student to advance in their handling skills.  Environments where learning alongside a master clinician can be arranged have something to offer that is absent in the majority of the formal programs which often look to be yet another business model for selling higher levels of unconscious incompetence.

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photo credit: phoenixmanualtherapy.com

3. You have had an opportunity to mentor many fellows in training at your Phoenix clinic.  Have you observed common areas for improvement in these clinicians?

The most common deficits are intellectual freedom and manual dexterity.  Lets start with the former.

Absent confidence in their ability to guide the patient from where they are presently to where they need to get next, the fellow in training (FiT) seeks certitude.  They find certitude in supposed established knowledge, current best evidence, test item clusters, CPRs, etc. rather than in their own thinking which they then check with their command of all of the aforementioned safe grounds.  This is what I refer to as evidence driven practice as opposed to evidence informed practice.  I am not a nay-sayer on current best evidence! Genuinely I see that it finally informs third parties about what they are buying when PT is covered yet they never see what is delivered.  Additionally it drives the low and marginal practitioners up toward the middle of the bell curve for an elevated standard of care.  However the heavy handed bias that is disseminated from the current posture of the profession seeming to have an absolute need for certitude drives the other side of the bell curve populated by the intellectually analytical who are engaged in the emerging data while treating down toward the middle of the curve and suppresses the potential rise of the fledgling brilliant clinician.  

To be completely forthright, I am a clinical coal face, I have spent well over 50 hours/week treating patients for the better part of 4 decades.   What I have seen over the years is current research about that which real clinicians were talking about decades ago.   I love the fact that these things reach the printed word and affect practice patterns so much more broadly than the 1:1 real time teaching can.  The reason I raise the point is that suppressing the clear thinking, focused clinician facilitates placing a lid on our growth potential. What if Bowling & Erhardt had never freely discussed when they do or don’t see value in manipulation, or if McKenzie had decided that the current best evidence of flexion exercise is how he should continue practicing.

The other aspect of thinking that is commonly deficient is the recognition of that which needs passive movement and that which does not.  Manual therapy can be delivered with patient participation in a completely passive fashion.  It is not the solution to all problems and should always be a means to working toward establishing independent patient management.  I see an over reliance on attempting to use manual therapy as the treatment of choice because the FiT is a manual therapist.  First and foremost we should be physical therapists with an intellectual curiosity about what the nature of a patient’s problem is and how we can best assist them.  The current psyche of the profession seems to be driven by the need to do passive intervention or generic exercise that a patient could learn themselves with a little online study.  We self proclaimed ourselves to be the movement experts in our 2020 vision statement and seem to have completely abandoned the desire to design and implement genuinely therapeutic exercise preferring to relegate that to some support personnel, as if it were beneath us.

One of my mentors discouraged me from trying to make people think.  It was his position that thinkers can’t help themselves and neither can non-thinkers.  Fortunately my primary mentor was a thinker & so was I.  She instilled in me a belief that you can model the thinking and demonstrate its’ results, thereby encouraging the clinical reasoning process.   Those who are curious about how they can get the same results that they have seen modeled will naturally become curious about the setting of the stage through thinking and responding to what actually emerges.

The second item that I cited as in need of improvement is manual dexterity.  Faculty cannot be expected to teach that which they don’t do, neither can researchers.  Clinicians generally cannot teach someone to design an ideal research study either for the same reason.  What the clinicians should be expected to be able to do is teach handing skills.  The aspiring manual therapist needs to develop curious hands to match the curious mind.  The handling of a patient should be performed in much the same way that the subjective inquiring is handled, with a curiosity that naturally leads one to the next most important question to be asked manually.  The FiT needs to develop a tactile vocabulary in their hands.  They must begin to accumulate normative data in their manual assessments as to what the usual feels like, then the usual in this body type, the usual in this type of presentation or this type of injury, the quantity of range, the response to moving the structure through the range, the end feel of typical joints, abnormal joints, soft tissues, the list goes on but the point is that they need to be able to determine what is amenable to change, how that change would best be gained and how to retain it.  Again this requires hands on training and practice in clinical environments rather than more reading or listening in educational environments.  

4.  One of your strengths is clinical reasoning, how can practicing PTs best develop this part of their practice?

The most essential thing is innate curiosity.  We enter a patient encounter devoid of any idea why we are here and what we will do.  The patient should drive the initial framing of the problem with the clear statement of what seems to be their problem and what they hope to gain from working with us.  Our immediate thought process should go to how it is that we can meet their goal. In other words we should begin to plan getting them out of PT and onto independent management of their problem or the elimination of it.

In both circumstances the end should be considered first, how do we get them successfully out of care & back to the function that they desire.  If we can see the whole picture we can then set ourselves to the task of determining which components of that whole function are preventing them from being independently capable now.  If we can prioritize what they need to accomplish first in order to enable the next step in sequencing to obtain the whole, we can make better decisions about what we should do now. 

In other words if I know what I need to accomplish as a final goal it is easier to determine what do I need to know in order to determine where we are now and what the order of progression should be.  I think in terms of PT patients falling in a set of classifications.  In each phase I think about how can I drive them to the next higher level to the final level of independence.

Intervention:  This implies that the patient cannot accomplish something without our assistance and we need to determine what intervention they need which we can offer.

Rehabilitation:  The patient needs physical, psychological and intellectual assistance but they must participate for this assistance to be progressively moving toward their goal.

Management: The patient now needs intellectual assistance more than anything from us, a guide to what they need to do. This requires direction from us & discipline from them.

Prophylaxis:  The patient needs to understand what they must do and what they must avoid in order to prevent recidivism.

Independence:  The patient only needs to understand what signs or parameters would indicate need for any future interface.

5. You have often said you want to leave the profession in a better place than you found it when you started.  Where do you see yourself having the largest impact on the profession?

This is clearly through affecting as many PTs as possible and hence through teaching.  I can change lives one at a time through treating but exponentially through teaching many who then treat a greater number of patients and pass the knowledge that they have learned on to other PTs who are behind them on the learning curve.

The message that I most hope to impact the profession with is the need for genuinely therapeutic exercise.  There are some inescapable facts that go along with human existence amongst them are the influence of gravity, physiology & time on the body. 

If we persist in giving all populations of patients the same exercises because they fit in a given category, then we are no more than personal trainers with an expensive albeit unapplied education.  If we do not guide the individual who has lost the physical capacity to overcome the constant force of gravity, the effective ground reaction force and the resultant interface on the body then we turn a blind eye to elementary physics.  If we continue to ignore that all human motion was created by that individual’s self generated movement as the neurologic system stimulated it to enhance function so that the body might flourish, then we will continue to ignore the means by which all living creatures establish & sustain function.

 

 

 

 

Impact of Specialist Certification and Fellowship Training on Low Back Pain Outcomes
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Physical Therapists at Mend are both board certified in orthopedics and fellowship trained in Orthopedic Manual Physical Therapy.  Our prior post documented the superior outcomes found when patients are treated by fellowship trained Physical Therapists.  This data shows patients' pain and disability were treated more efficiently and effectively by fellowship trained PT.  A recent study shows board certification and fellowship training also have a positive impact on the management of low back pain.  

Ladeira and colleagues in the Journal of Orthopedic and Sports Physical Therapy assessed the knowledge, beliefs, and actions of over 400 practicing Physical Therapists on clinical vignettes for various patients with LBP (2017).  The authors found fellowship trained, board certified Physical Therapists demonstrated better adherence to current clinical practice guidelines in the management of patients with different causes of low back pain.  This adds to our existing knowledge on the benefits patients receive when treated by a board certified, fellowship trained Physical Therapist.