米国におけるレジデンシーおよびフェローシップ教育専門職の構築, 更なる専門領域への推進

(1)

Japanese Physical Therapy Association

NII-Electronic Library Service

JapanesePhysical Therapy Association

M5:lffza7

on'35

tsig4

lj-

132-135

fi

C2eOS")

thffdirsI

Residency

and

Fellowship

Education:

Building

the

Professional;

Advancing

the

Profession

"

Carol

_Jo

Tichenor

""

lntroduction

When

we

graduate

t'rom

physical

thcrapy

school we

look

forward

to a career of providing rehabilitation service

to

paLienls,

Wc

are young, energetic und motivated

to

providc

the

bcsL

physicat

therapy care

that

we can.

Having

oppor-tunitics

to centinue to adx,ance our clinical skills

provides

the

nioLivation to

keep

us

intercsted

in

eur

patients

and

in

our

profession.

The

purpose of

lhis

artiete

is

to

describe

res-idency

and

fellowship

education

in

the

United

States,

specil-ically,

to

outliiie lhe curriculum components and

hc)w

PhysicaL

Therapy

_<PT)

Departincmts

and academic

PT

pro-grams

cun

develop

_partnerships

to

creaze

these

prograT"s

in

the

cominunizy.

}-'Iost

irr]porlant,

this

_paper

",illalse

address

ho",

residency Eind

fellowship

educutien can

bene[it

tbe

parient,

PT

climician, medical tare

orgai]izationsl'hospi-tals.academic

1'T

programs

and the

1'T

_professien

in

Japan.

History

of

the

Deve]opment

of

Residency

and

Fellowship

Education

in

the

United

States

,'X

brief

reviesv of

how

residency and

fettowship

_programs

were

developed

iTi

the

United

ST.ates

will

demenstrate

a

long

term

proccss

of chaiige

in

education and

_practiee

that

may

Hssist

Japanese

PT

prefessionals

in

undersLanding

opportu-nities and

barriers

rhar may oucur.

Kaiser

Permanente

is

thc

]argest

non-profit

health

inaimtenance organization

in

the

Unitad

States,

In

California

in

lhe

I970's,

pliysieaL therapis[s

practiced

undcr

the

prescripTix,e

orders of physicians,

oi[er-ing

`ultrasoulld,

hot

_packs

and inassage' to

_patients.

1,Ve

rarely

questioned

er conx,ersed ",ith

_physicians.

"ie

lended

to

LreaL as `technieians'

and our raputation as a

hospila]

in

tt

'

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ee.

fi#4EfliEJff[di"Otki[

k""i-f-!t-T*>･rsr' _",

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_CgCi{1)

C/or]'espondcncc/

Carol

Jo

Ticlwnor,

PT.

N･T,X,

l'T Fcllowship in

AdrHnced

C)i'thopedic

)'Ianu[d

Therapy/

Kaisor

P[/rmnnente

N,[edjcai

C'enter,

27400

Ilcsperian

BouLevm'd

Hnywnrd,

California

e4545.USA

Key

words 1residency,

fellowship,

post-gradunte

the

community was reLatls,ely poor.

Ill

the

late

1970"s,

severaL ptiysical

theraplsts

frofn

arourid

the country "rent ovcrseas to siudy manuaL

therapy

in

Norway

and iXustrulia.

Some

came

back

to

CHLifon]ia

and

began

teaching fT]unua[ zherapy courses and

dcsigned

the

Kaiser

Permanente

Hayward

PT

Fellowship

_in

_Adx,anced

Orthopedic

ManLial

Therapy.

Kaiser

l'crmanente

elecled

to

fund

this

program

as

part

of

its

non-prolit status a"d sociaE

illission to serv{'

the

coir]inunity.

I･{any

of

lhe

graduates

of

the program stayed

to

work is,ithin tha organizatioTt and

beeame

zhe mentors

for

students and other

less

experienced

P'1'

slafE

They

also

tuught

continuing educationai courses

across

Northerm

California.

Gradually

pliysicians

began

[o recognize

the

ability of

these skitted

physicaL

thcrapists

lo solve cotnplex

_paticnl

probleLns

and ro

takc

rasporisibi]ity

for

inanaging

niuseu-loskeletul

problems

Endependently,

Over

time. physicTans

becEtme

willing to collaborate and

delegute

more

responsi-bility

to

these

skilted physical

thernpists

amd ultimately to

all

physical

therapists

in

eur

departmenLs.

They

begnn

to

trusl the clinTcal

judgrnent

aud recognize

_physical

therapists

as speciaaists

in

niusculoskeletu] cai'e.

Our

fellowship

in

man-ual

ther2py

Led

to

the

dei,etoptncnt

of

five

other residencies

and

fe]lowships

in

Caiifornia.

impacting'

over

44

clinics ancl

hospitals

and oK,er

6,6

million

Kaiser

Permanente

health

plan

nLeinbers.

Specialist

Certification

Process

in

the

United

States

[['his

section wilt address

the

spccTalist cartification process

in

Lhe

IJnited

States

and

ho-'

zhe specialisL

proccss

con-tributes

to

the

development

of residencies and

fellowships.

"/ithlm

the

American

PhysicaE

Thernpy

Association

(APTA)

thcre

is

a

board

identit'ied

as

the

iNmc/-rican

Board

of

PT

SpecialLies

_(ilBPTS)

which overseas specialisL cerLirication

i]i

seven areas/

Cardiovascuiar

und

Putmonary,

C;linicaL

(2)

Japanese Physical Therapy Association

NII-Electronic Library Service

Residency

and

Fel]owship

Education/

BuTldTng

Pediatric.

Sports

and

Wornen's

IIeatth

PT.

Each

of

the

spe-cialty areas

has

conducted an extensivc

practice

analysis or

Description

of

Speuialty

Practiee

to

determlne

foundational

knowledge

areas

_(e.g.

anaLomy,

biomechanics,

exercise

phys-iology),

ctinicaL medicaL sciences

_{Cpharmacology,}

radiology),

and

behavToral

sciences underLying

thc

specialty area.

The

practice

analysis

also

defines

the

professional

behaviors

and

rosponsibilTtTes and the extensive patient management

com-petoncies

{e.g

tests, ineasures and

intervcntTon

procedures)

Lhat an adx,anced clinician

in

that specialty zrea i･s,outd

be

expected to

demonstrate.

The

competencies

defined

in

the

practicc

analysis ot'each

specialty area

form

the

basis

for

u written exainination

in

each specialty area

Once

the

individuaL

has

_passed

the

exam-ination,

he

or she reeeives the

designa[ion

of

Orthopaedic

Clinical

Speciaiist

(C)CS},

Gcriatrit

Clinical

Speciatist

<GCS).

Neurolegical

Clin[cai

Specialist

(NCS),

etc.

In

thc

United

States

in

LO07.

there

are npproxiniately

155.000

physical

Cher-apists of "'hich :ipproxirriatcl},

6,800

are niembers ef tha

APTA.

Since

1978,

approximately

5,700

physical

therupisLs

have

successfully

passed

the

specialTsi

board

examiiiations

in

the

areas ef erthopedic, neurologicat,

_pediatric,

geriaLric,

sports amd ciinical clcetrophysiological

physical

therapy,

How

Residency

and

Fellowship

Curricula

are

Designed

The

scope of a residency curriculuni

is

defined

by

the

pr:clice

anaLysis of each speciatly area.

As

of

2007,

there

are residencies

in

orthopedic, neuro]ogie,

geriatric,

sporzs,

pediatric

and women's

health

physic/al

therapy.

The

scope of a

fellowship

curriculuin

is

dcrined

atso

by

a praclice

analy-sis

in

the subspecialty area with

fel[owships

now

crcden-tialed

in

orthopadic inanual

_physical

therapy, muvemeT]t

sci-ence,

hand

therapy

and advanced sports

training.

Fer

the

purposes

of

this

paper,

the

terms

`residenc/y'

and `t'ellowship' wiil

be

used

interchangeably.

ResideTicy

a"d i'ellowship cLLrricLila

inciude

a varicty of

learning

opporrunities that niay

inulude

didacLic

course work

(foundational

sciences) and clinical course work

(cxamination

and

intervention

in

the speciatty area), onHne chat rooms,

problem

solx,ing tic.tssions, clinic'LLrounds, and

_journat

clubs to

diseuss

critiquc current evidcnce.

4ti

curricula

include

ongoing

1/1

mentoring with advanced clinicians

i"

lhe

spe-cialty area.

Each

program

has

periodic

practjcal

examina-tions

with patients and written exaTni"ations

to

assess

com-petency

and requirements

for

publicaLions

or additionat

ctin-ical

projects,

1:1

Mentoring:

the

Key

Element

of

Residency

Education

･"

key

part of ttie residency education or

fellowship

edu-the

Prefessioiial/

.'Xdvancing

the

Profc/ssion

T3:1

caiion

is

the

opportLLnity [o

provide

patient

care under the

gitidance

oi an advanced clinician.

The

resident sccs

patients

"ithin the speciulty area at

the

hospitd

or clinic i･s,hich

is

sponsorillg the residency

progra]n.

During

rhe nientorillg

sessien, the resideiit and

the

instructor

-,ork sidc

by

side

in

solvlng patient pi'ol)lerris

together.

The

instructor

wilt

assist

the

residei]t

Lo

confirm, expand or refine examination

fTndings,

witL recommend and

demonstrate

additionai

inter-vantaons

to

help

tbe

patient

progress

more rapidly ancl scrve

'Ls

a resource

in

deterinining

-,hether additionai quasTions

nc/cd

to

be

directed

to

thc

physician

if

medica]

problems

may

be

intert'ering,

Threughout

the mentering

process,

lhc

rc/sident

is

taught

to

scliLcritiqlte

his

or

her

putient

ugamant on an ongoi"g

basis.

Mentoring

schedules vary

according

to

the

progrnm

structure

(e.g.

part-tima

versus

fulHime),

duration

of Lhe

_program,

availabiLity of

Lhe

tor

and the number of residents wtio are

being

trained.

The

mentoring may,

for

exanipLe,

be

conducted

i",o

to

five

hours

per

week on a reguLar

basis

or may

be

once evcry oL'her

week over severa] rnonlhs.

),{entoring

niay a]so occLtr

in

blocks

of

time.

e.g.

]-2

week

intervats.

Ill

parL-Lime

programs,

mentoring tends

te

b{/

conducted over a

Longar

period

of

Liine ",ith

facuLzv

ceTnacL

1-2

tiines

per

nionrh,

Length

of

Residency

and

Fellowship

Programs

and

Admission

Requirements

Physical

therapists niay attend aresldency

program

diately

after

graduation

froii]

physical

therapy schooL or afLer

gaining a

fcw

ycars of experienee.

Rasidency

programs

ing

in

length

from

one

to

three

years.

Full-time

programs

tend

to

be

one

year

iii

len.crth

and

part-lime

pregrams

lc/nd

Lo

be

three

yeurs

iii

leng:h.

Residency

programs

Tnclude

1,50()

curriculum

huitrs.

Fellowship

progi'ains

vary

in

len.orth

betweeii

6-monT.hs

lo

3 years.

Iiil[-time

programs

are

erally

6-inonths

to

one

year/

parVtiiiie

prog'rarris

tend to

be

2-:S

},ears

in

length.

In

order te attand a

fellowship,

prograins

ge'neraLly

require

1-2

ycar

of experience

prior

to

entering

the

program.

Fello",shlps

include

1,OOO

curriculum

hours.

Part-time

versus

Full-time

Models

At

the

APTiX

website on residencics and

fellowships,

there

arc "'ebsites

liszed

for

alL

prograins

which

describe

their

models

for

delivery.

hi

a

part-time

proRram,

the residcTit

might work at

his,'her

primary

ernptoyment three

days

_pcr

week and

travel

to

urieLher site

two

davs

a week

to

attcnd

course work, see

patlents

and receix,e menLoring,

CoiLrse

"'ork inav

be

on ",eekends or

in

the

evei]illg.

In

a

full-linie

niodel.

the

rcsident may move

to

the

leeation

of

the

gram

and

b

¢eomc an employee of

that

hospital

or cliuic

[or

the

duration

ol

the

program.

The

residL"t

treats

palic/nts,

(3)

Japanese Physical Therapy Association

NII-Electronic Library Service

134 mp･?uti･li',

site(s) ef

the

sponsoring

hospital(s)/clinic(s).

How

to

Build

a

Residency

or

Fellowship:

Community

and

Academic

Partnership$

Within

the

Uuited

Srates

there

are numerous models

for

how

residency and

fetlowship

pi'ograms

can

be

deN,eloped.

Two

models wilt

be

described

beluw.

In

dex,eloping

uny,

type

of resjdency

_program,

one of the

first

faciors

to consider

is

the

type.

of

program

Lhat ",ili

attract

the

most

interest

among

_physicat

therapists

in

an

area or region of the country and

the

breadth

of caseload

that

mighl

be

avui]able among'

hospita]s

in

the

area.

Figurc1

is

an example of u polential sLructure

for

a neurological

I'T

residency

program.

A

medium

to

large

hospital

specializing

ln

neuro-surgcry would

be

an

idenl

medical center

for

a

relogicai

_physTcal

therapy residency as

the

PT

inpatient

and

outpatient

departments

could offer experience

in

acute and

sub-acu[e

_physicai

therapy.

The

_program

might

be

centered

at the neurosLLrgical

hospital

with clinical courses

in

to.ff.ical

physicul

therapy

and mc/ntoring occurring

primarily

at the neitro-surgieal

hospital.

The

neurosurgical

hospTtal

might aiso elecL Lo

_partner

with arehabilitation

hospitat

and

skMcd nursing

facility

so

thai

residents are exposed te

tong

tc/rnirehabititation.

A

partnership

between

an academic

program

and

munity

hospital

can crcate an excellenL residcney

(Fig.

_2).

iXcademic

PT

faculty

members coutd

provide

eourse -,ork

in

the

foundational

scie]ices and clinical course work

in

the

specialty araa

{e.g.

_geriatrics,

orthopedic

PT).

The

acaclcmic

Fig.

1 Example

of

Neurologic

l'T

Residency

Partnership

Fig.

2 Example

of

Academic

PT

I'rogram

Partnership

with

PT

Departments

rg

35 ts

ca

4 PT

program

could

partner

with seleeted

PT

Departments

in

thc

community

to

provide

the

putient

care raquired

for

the

program.

Academic

PT

faculty

inembers and,'or seuior

physical

therapists

from

the

community

hospital

coLild

vide

the

ongoing

1/1

mentoring.

Residency

and

Fellowship

Wage

and

Benefits

Residents

ge-erally

earn approximatety

70-75%

of

the

average salury

for

regular

_physicul

therapist

and

havc

a

reduced

benefit

package such as a

heatth

plan

benef"

only.

Medical

care orgauizations may charge

tuition

to

cover

lhc

cost of

the

course worl[ proK,ided to the resident.

Like

Kaiscr

Permanente,

some medicar care orgt'mizutions will

provide

constderable

financiat

sul]port teihe

_program

as

part

of [heir

socia[ mission

to

se]'ve the communit},.

Benefits

to

Patient$,

PT

CIinicians,

Medical

Care

Organizations

and

Academic

PT

Programs

1'aLients

can expect amore consistent

lex,el

of care aL

pitals and clinics where a residency

program

has

been

eped

due

to

the

nationaL credentialing standards

that

are

requjred to

becoma

a credentialed

program.

As

graduates

finish

the

program

and continue work at

the

residenc},

gram

site or

_go

oul

to

work

ln

the

eommunity, the

quality

o[ care of

the

community will

increase.

Physical

Therapy

Clinicians:

Gruduates

of residencies aiid

feilo"'ships

report

_positive

impact

on

their

career

interest

and

fulfillment

in

the

following

areas/

1)

career

interest

and

fulfillment,

2)

ability

to

treat

complex

problems,

3}

ability

to

diagnose

problems

(e.g.

additional

problems

that

may uot

hnve

been

identified

by

the

physician).

and

4)

confidence

in

coinnmllicatieni'3).

GraduaLes

consistently report

that

Lhey

are more confident when they commumicate their

findings

to

patients,

physiciiLus

and olher

providers.

Over

tirrie

this

leads

physicians to

have

_greater

cenfidence and rcspeet

in

the ]]hysical therapist,

i'Xcademic

PT

Pro.c.rrams:

iXs a resu]t of

having

a

cy

programs

in

the

community,

PT

progrnms wiU

have

more

skilled

instructors

to

provide clinicaL practicums

for

studellts.

Students

will

be

able to see role modets of skilled clinicians

who are efficient and effective

in

treatin.u,

_patients

and

x,ated

to

continue io

_provide

excelleiit

_physieat

therapy

throughouz

their

careers,

,

The

studies

by

Donaldsoni),

Thornburg2),

and

Smith

etal.3)

taught

us some

important

tessons

about

_physical

therapy

professionals,

At

this tlme. graduates of residencies and

iowships

tend ro

have

moderate

invotvement

in

various

els of

teaching,

e.g. staff

inservicas,

mentorlng other staff,

consulting, and academic teachlng, with

limited

invelveTTient

in

research,

Tbere

are

individuals

within every

_professiom

(4)

Japanese Physical Therapy Association

NII-Electronic Library Service

Residency

and

Fellowship

Education/

Buitding

motivated

to

do

research.

Every

profession

needs avenues

to

dcx,etop

cxcetlent rcsearch

but

cvery

profession

also needs

avenues

that

allo", clinicians

to

develop

excellenL cllnical

skills.

Factors

that

Contribute

to

Building

Residency

and

Fellowship

Education

Rcsidencies

and

fellowships

develop

successfully

if

there

is

a cuLture ef

lifelong

learning

withim

the

surrounding

munity and acress

the

profcssion.

Conl.inuing

education

courses sponsored

by

physical

therapy

dapartmenrs

ior

iheir

own

PT

staffincmbcrs and othcr comtnunity

Lherapists

con-trTbLtte

strongly

to

building

intercst

and motgs,ation

for

ther-apisrs

to

attend aresidency or

fellowship.

Courses

conduct-ed once a week or once a monLh over several months

(ver-sus only on one weekend)

help

_physical

therapists

to

inte-g,rate their skMs and

knowledge

ever

time.

Development

of

continuin.[r edLtcatTon

directly

impacts

Lhe recruitmeni and retention of

_physical

therapists as

Che

hospital's

repLttation

for

excetient educatien and

parient

care

becomes

known.

University

programs

can contribute to residency

educa-tioll

by

offering course work

for

thc clinical

instructors

who

provide

ciinical training

for

their students.

This

is

an avenue

to

buitd

the expertise of the clinical comrnunity and

improve

the

clinical

tralping

of students.

Out

of

these

continuing

edu-cation courses will emerge skit:ed ctinicians who can

become

resideney aiid

fellowship

facully

members.

qonclusion

Development

of rcsidencies and

fellowships

in

Japan

requires

long

term

strategic planning

decisions

and the

abit-ity

of the

_profession

to ask

difficutt

_questions;

what

is

the

levcl

of

_praetice

that

_you

want to achieve over the next ten

years?

What

types

of

professional

relntionships

do

_you

wish

ihe

Professional:

Advancing

the

Profession

135 to

achiex,e with

physicians?

Do

you

have

avenues

in

your

post-graduate

programs

to enablc

_physicat

therapists to

attain advanced clinical skilLs?

IIew

can you

build

stronger

continuing educalioll opportunilies ",ithin commLinity

hespi-tats?

As

the

_Japanese

Physieal

Therapy

Association

moves

ferward

in

residency education, numcrous resources are

available ro

be

shared

from

the

Anieriean

Ph],sical

Tharapy

Association

to

acceterate

your

pregress,

A

small numbcr of

therapists

can

begin

the

zransformatieTi of

your

profcssion.

"/e

in

the

United

States

have

maT]y mere areas to

grow

and adx,imce our

practice

but

residency edLtcation

hns

helpcd

us

to

begin

that

transformation.

References

l)

Donaldson

)･{B/

,'Nn examk]atien c)fthe ac/crediLed orLhopuedic

physical therapy postgrnduate reside"uv. alld ortliepaedic

al

fcllowship

training'programs

in

the

Uniled

States

and

tioll of gruduat'es experience.

PhD

Disscrtation.

Nova

SotLLheastern

University.

College

of

ALIied

ITcalth.

Physical

Therapy Depart[nenT, 200Z

21/Thornburg KL. Banaitis

D,

et al:

Clinical

fellow6hip

trainiiig

in

erthopacdiic manunl physicaL therapy.

A

CIraduate

Stucly.

CiinicaL

Doctorate

Thesis.

Pauific

Universi(y,

Forest

Grove

Oregon,

2004.

3)

Smith

KL,

Tichenor

C/J,

et al:

Orthopedic

residency training/

A

surve],ofthegradunLes' perspective.

JOSPT

29(11}/

635-655,

19g9.

Other

resources:

www.apta.org."professional

dcvelopmeiitlreside"cy

&

feLLowship

This website inchLdes tlLe[redelltialillg applicaLion -･hich outlincs

tlLesf/ope of resTdency and

fellowship

curriculum rcquircmcnts,

initiuiis,

irequently

asked

_qucstions.

and reseurces

fnr

bullding

grams.

The

_prnctice

unalysis foreach speciaLLy section can

bc

purchased at the uptu website/ www.apta.org!oniine store.

Search

for

the

ABPTS Descriptioiiof ULinicaLHraclice and

Description

of

Spccialty

Practice.

The practice anaLysis

for

]nanual therapy

is

pusted om the siLe ol Lhe

AAOIIPT

at www.aaompt,org nnd

is

availnble nt i}{)