Becoming an expert: A Masterclass in developing clinical expertise

Use of the International IFOMPT Cervical Framework to inform clinical reasoning in postgraduate level physiotherapy students: a qualitative study using think aloud methodology

BACKGROUND

Vascular pathologies of the head and neck are rare but can present as musculoskeletal problems. The International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) Cervical Framework (Framework) aims to assist evidence-based clinical reasoning for safe assessment and management of the cervical spine considering potential for vascular pathology. Clinical reasoning is critical to physiotherapy, and developing high-level clinical reasoning is a priority for postgraduate (post-licensure) educational programs.

OBJECTIVE

To explore the influence of the Framework on clinical reasoning processes in postgraduate physiotherapy students.

METHODS

Qualitative case study design using think aloud methodology and interpretive description, informed by COnsolidated criteria for REporting Qualitative research. Participants were postgraduate musculoskeletal physiotherapy students who learned about the Framework through standardized delivery. Two cervical spine cases explored clinical reasoning processes. Coding and analysis of transcripts were guided by Elstein's diagnostic reasoning components and the Postgraduate Musculoskeletal Physiotherapy Practice model. Data were analyzed using thematic analysis (inductive and deductive) for individuals and then across participants, enabling analysis of key steps in clinical reasoning processes and use of the Framework. Trustworthiness was enhanced with multiple strategies (e.g., second researcher challenged codes).

RESULTS

For all participants (n = 8), the Framework supported clinical reasoning using primarily hypothetico-deductive processes. It informed vascular hypothesis generation in the patient history and testing the vascular hypothesis through patient history questions and selection of physical examination tests, to inform clarity and support for diagnosis and management. Most participant's clinical reasoning processes were characterized by high-level features (e.g., prioritization), however there was a continuum of proficiency. Clinical reasoning processes were informed by deep knowledge of the Framework integrated with a breadth of wider knowledge and supported by a range of personal characteristics (e.g., reflection).

CONCLUSIONS

Findings support use of the Framework as an educational resource in postgraduate physiotherapy programs to inform clinical reasoning processes for safe and effective assessment and management of cervical spine presentations considering potential for vascular pathology. Individualized approaches may be required to support students, owing to a continuum of clinical reasoning proficiency. Future research is required to explore use of the Framework to inform clinical reasoning processes in learners at different levels.

International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework

SYNOPSIS: This position statement, stemming from the International IFOMPT (International Federation of Orthopaedic Manipulative Physical Therapists) Cervical Framework, was developed based upon the best contemporary evidence and expert opinion to assist clinicians during their clinical reasoning process when considering presentations involving the head and neck. Developed through rigorous consensus methods, the International IFOMPT Cervical Framework guides assessment of the cervical spine region for potential vascular pathologies of the neck in advance of planned interventions. Within the cervical spine, events and presentations of vascular pathologies of the neck are rare but are an important consideration as part of patient examination. Vascular pathologies may be recognizable if the appropriate questions are asked during the patient history-taking process, if interpretation of elicited data enables recognition of this potential, and if the physical examination can be adapted to explore any potential vasculogenic hypothesis. J Orthop Sports Phys Ther 2023;53(1):7-22. Epub: 14 September 2022. doi:10.2519/jospt.2022.11147.

Exploration of mentor and mentee perspectives of a mentored clinical practice programme to improve patient outcomes in musculoskeletal physiotherapy

Background

A recent randomised controlled trial has demonstrated the impact on practice of an educational programme for clinicians. Mentored clinical practice in musculoskeletal physiotherapy resulted in clinically significant improvements in both physiotherapist performance and patient outcomes. The objectives of this study were to explore mentor and mentee perceptions of a mentored clinical practice programme, in order to identify key factors in the process to improve patient outcomes.

Methods

Employing a case study design of a mentoring programme that led to improved patient outcomes, mentored clinical practice was explored from multiple perspectives using a grounded theory strategy of enquiry to derive a theory of mentored clinical practice grounded in the views of the participants. Semi-structured interviews with a purposive sample of mentors and mentees were employed along with qualitative observations of mentored clinical practice. Data analysis and collection were concurrent, with analysis an iterative process deriving inductive analytical categories from the data through constant comparison.

Findings

Highly informative themes of how the complex interaction between mentor, mentee, patient and environment worked successfully were identified from the data. The mentors’ knowledge, additional perspectives, critical analysis and facilitatory style were enabling factors, as were mentees’ motivation, openness to criticism and commitment to reflect on practice. Themes around potential threats to the mentees’ development were also identified. Overloading or contradictory feedback and lack of relationship with mentees were barriers that mentors could bring; fear, defensiveness, routine working, people-pleasing and lack of experience were potential mentee barriers. A model emerges from the data demonstrating how these themes interact, providing guidance to mentors and mentees to optimise the effectiveness of mentored clinical practice.

Conclusion

This study provides a sound basis for future mentored clinical practice, producing a model from key themes from a case study where impact on clinician performance and patient outcomes are established.

The clinical management of neck pain of novice and experienced Australian osteopaths: A secondary analysis of a nationally representative sample

INTRODUCTION

Neck pain is one of the most common musculoskeletal disorders worldwide. Osteopaths are primary contact health professionals who predominantly manage musculoskeletal complaints. How Australian osteopaths manage neck pain is beginning to emerge in the literature and there may be differences based on clinical experience. This work presents a secondary data analysis of the Australian osteopathy practice-based research network and aims to examine the clinical management characteristics of experienced and novice osteopaths who often treat neck pain.

METHODOLOGY

Secondary analysis of a cross-sectional survey of osteopaths registered with the Osteopathy Research and Innovation Network (ORION), an Australian practice-based research network. Demographic, practice and treatment characteristics of osteopaths who 'often' treat neck pain. Data was split into two groups: novice practitioners (up to nine years in clinical practice), and experienced practitioners (10 years or more in clinical practice), and clinical management was compared.

RESULTS

Most (98%) of the 971 osteopaths reported that they treat neck pain often. Of those that treat neck pain often, 58% reported being male. The mean number of patient care hours per week was 28.1 ± 12.1 and the mean number of patient visits per week was 36.7 ± 18.7. There was a statistically significant difference between novice and experienced groups for discussing occupation (p < 0.01; d = 0.26) and stress (p = 0.045; d = 0.13) during their consultations, with a low to medium and low effect size, respectively.

CONCLUSION

This work demonstrates differences in the management strategies of experienced and novice Australian osteopaths that includes utilisation of a multidisciplinary approach to patient management. The results support the conclusion that there are differences in the clinical management strategies employed by experienced versus novice Australian osteopaths.

Exploring taught masters education for healthcare practitioners: a systematic review of literature

BACKGROUND

Masters-level education is a key pathway of professional development for healthcare practitioners. Whilst there is evidence that Masters-level education leads to career enhancement, it is unclear how the programme pedagogy contributes to this. The objective was to: (1) examine the programme pedagogies and context that supports learning, and (2) synthesise the outputs, outcomes and impact of Masters-level healthcare programmes.

METHODS

A systematic review was conducted according to the Cochrane Collaboration handbook and is reported in line with PRISMA. Using pre-defined key terms and eligibility criteria, two reviewers independently searched Medline, ERIC, Web of Science, ProQuest, and CINAHL Plus databases from inception to 14th November 2016, reference lists of retrieved articles and selected websites. Data were extracted independently. The Mixed Methods Appraisal Tool was used to assess methodological quality. A Weight of Evidence Framework enabled evaluation of the overall quality of evidence. Data were synthesised using thematic qualitative analysis.

RESULTS

Thirty-five studies were included. All studies were retrospective, evaluated programmes in nursing (n = 19), physiotherapy (n = 6), general and family medicine (n = 4), public health (n = 3), dentistry (n = 1), interdisciplinary (n = 1), and occupational therapy (n = 1). Most studies were rated low in methodological quality, with an overall low to moderate weight of evidence for programmes' outcomes and impact. Pedagogies that promote social participation and knowledge co-construction, reflection, learner-centred approach, relevance and authenticity influenced outcomes and impact.

CONCLUSION(S)

Notwithstanding the low to moderate weight of evidence, the review identified multiple positive outcomes of Master-level education for healthcare practitioners. Whilst the pedagogies that contributed to such positive outcomes were examined in some studies, there is a need to further explore links between programme pedagogy, outputs, outcomes and impact. A cultural approach to evaluation may capture how M-level education drives changes.