I love learning about physical therapy. I love getting other physical therapists' opinions on cases, learning how others apply current evidence to their practice, and I love problem-solving through the physical, mental, emotional, and neurological elements of patient care. If you've found yourself on this page reading this article, you must care too. My favorite way to learn is by taking live continuing education and getting to "nerd out" with people who are similarly interested and passionate. Unfortunately, there are 3 main problems with current continuing education courses that come up in literature: the quality of the courses and how much evidence is presented and applied, no significant improvement in patient outcomes over time, and that there isn't a way of knowing all the courses that are available for physical therapists. This triad of problems has contributed to what I think of as thought islands.
I have had the pleasure to practice on both coasts, and the middle of the country as my family has moved either for work, school, or to be closer to family. I have noticed a phenomenon in practice that I have started to call thought islands. A thought island is where there is a group of clinicians that think about patient care similarly. Usually they have similar educational backgrounds, both formal and continuing education. Faculty for formal education have their biases for assessment, treatment, and how they interpret the literature. I can remember many labs where our instructor said, "I know that's what the slides say but this is how I do it." Faculty may have relationships with both continuing education course providers, as well as local clinics where they currently or formally practiced. These relationships are important to the profession, but they also encourage continuing education hosts to come to areas where they know they can fill up their classes. It also makes them reluctant to host courses in new areas where they may have to spend more on marketing to get clinicians into their courses. Not every course comes to every state, and some courses are the only ones that visit relatively remote areas. Thought islands become even more pronounced as clinics dictate which courses they will reimburse their employees to attend. These courses are usually from the places that the business feels are best suited for their employees, or where the owner of the clinic embraces the theory or interventions that the course provides.
If everyone shares a similar educational background, it is easy to fall into a routine of seeing patients with a certain lens and never challenging the treatment strategy to consider other options. Peterson et al1 illustrates this by noting that when clinicians have invested significant time and money into learning a specific assessment or treatment, then it's easy to see patients solely through that way of thinking. The clinician may ignore other findings that contradict their diagnosis or just don't fit that pattern. The authors recommend an overhaul of continuing education industry with national standards and peer reviewing of courses which would ensure that ideas not supported by current evidence would start to fade away while leaving room to have some experimentation with evidence-informed treatment ideas. I don't disagree that the standard of continuing education needs to be raised, but I don't think that a governing body outside the state boards should enforce that action. Many states already require course providers to present a certain number of articles published recently, course objectives, and some sort of assessment of learning after completion of the course. If there was an optional peer review process, I think that it would benefit the hosts greatly to voluntarily submit to this, but the issue really depends on how physical therapy practice is influenced and changed.
Most physical therapists know logically that reviewing articles and reflecting on their own practice is the best way to stay on top of and apply current evidence, but Whiteley2 found that physical therapists more rely on conversations with their colleagues and continuing education to influence their practice. Physical therapists may unknowingly put themselves onto a thought islands by having the same conversations, on repeat, with their coworkers. Taking the same courses as our colleagues will continue to reinforce those same conversations and will not push physical therapy practice forward. Is this just a problem with continuing education courses? Christensen et al3 surveyed physical therapy programs around the country and found that nearly all the programs teach and assess clinical reasoning, but only 25% of the respondent programs operated with a definition of clinical reasoning. Nearly all programs assessed their students' clinical reasoning, but the researchers found there wasn't consistency in how it was taught and assessed within each teaching program and certainly not between programs.3 It seems that all the fingers are pointed at continuing education for holding the profession back. Maybe we need to further examine the foundations of our training so that new graduates have a better idea of how to find and apply valuable information for their practice. It seems to me that residency, fellowship, and private continuing education, have stepped up to fill in this clinical reasoning gap.
How do you find who is teaching the information you want to learn? The best answer is to figure out who is publishing in that area and see if they teach what they are researching to the public. The common approach is likely asking your colleagues. If you want to learn something like dry needling, you might take the same courses as your colleagues because that's what the clinic knows, but this might put us on thought island. According to PT CEUs Near Me there are at least 7 national companies that are teaching dry needling right now.4 My intention is not to get into the evidence or argue about the efficacy of specific modality or technique, but to make the point that each of these companies likely offers different perspectives to the very similar practice of using needles as a tool to improve a patient's function and symptoms. Many physical therapists may find it a large burden to research other companies and how each is different. Before we can rate or compare the quality of the course, we first need to know what is available.
There are problems with the current continuing education industry. New evidence will be published and applied in a novel way. The junk will fade away as clinicians put it to the test and researchers investigate. The applications, techniques, and ideas that work will continue to influence and change practice as long as we're conscious of thought islands. These echo chambers allow old and debunked reasoning to stay in practice and keep out new or different ideas that challenge that way of thinking. The growth in options for continuing education started for a perceived and real need for physical therapists to improve their clinical reasoning and technical skills. At the end of the day, it's up to the individual physical therapists to figure out if the information presented in these courses fits into current evidence and how it will fit into their practice.
- Peterson S, Shepherd M, Farrell J, Rhon D. the blind men, the elephant, and the continuing education course: why higher standards are needed in physical therapist professional development. J Orthop Sports Phys Ther. 2022;52(10):642-646. doi: 10.2519/jospt.2022.11377
- Whiteley R, Napier C, Van Dyk N, et al. Clinicians use courses and conversations to change practice, not journal articles: is it time for journals to peer-review courses to stay relevant? Br J Sports Med. 2021;55:651-652. doi:10.1136/ bjsports-2020-102736 W
- Christensen N, Black L, Furze J, Huhn K, Vendrely A, Wainwright S. Clinical reasoning: survey of teaching methods, integrations, and assessment in entry-level physcial therapist academic education. Phys Ther. 2017;97(2):175-186. doi:10.2522/ptj.20150320
- PT CEUs Near Me. Course Locator. PT CEUs Near Me. Accessed May 10,2023. https://www.ptceunearme.com/
The author declares that he runs ptceunearme.com.
Dr. Ben White, PT, DPT, is a residency trained Board-Certified Orthopaedic Clinical Specialist. He graduated from the MGH Institute of Health Professions in 2016 and finished orthopedic residency at the Cleveland Clinic in 2019. Prior to residency, he worked for Stanford Healthcare providing musculoskeletal care direct to employees of Cisco systems in the Bay Area. Currently, he owns Burning River Physical Therapy and Wellness in Cleveland, Ohio. He's passionate about providing quality care to patients and being a lifelong learner, in that vein he started PT CEUs Near Me to help physical therapists find live continuing education that they may have missed. His professional interests include reducing costs for musculoskeletal care, spinal manipulation, and clinical decision-making.