On the Need to Move Toward an Evidence-Based Athletic Training (EBAT)

Abstract

Evidence-based practice (EBP) is now a well-known paradigm for the athletic training (AT) profession. The Commission onAccreditation of Athletic Training Education accredited programs have required EBP as an explicit focus for professional education, and researchers are gradually producing insightful and relevant evidence concerning the education and implementation of clinically based EBP in educational programs. Likewise, many clinicians are attempting to incorporateEBP into their daily practice in order to guide and enhance patient care, and the Board of Certification has mandated regularEBP education in order to maintain national certification status. Although there remains much work to be completed beforeAT can claim to be a health care profession that is saturated with EBP, there is growing evidence of positive momentum toward that goal. However, the extent of EBP implementation remains limited to clinically based, patient-oriented outcomes.To date, there is little suggestion that the profession of AT has used an evidence-based approach for other related aspects of its professional practice. To that point, a multifactorial and more comprehensive model for evidence-based AT (EBAT) is presented with the intent of better situating and centering the potentiality for a larger evidence-based culture to inform and guide the AT profession’s 3 critical subcomponents of practice, regulation, and education. We attempt here to expand upon the paradigm for EBP as a precondition for an overarching, more inclusive EBAT model. To do this, we will introduce and interconnect 2 other critical aspects of professional practice: evidence-based regulation and evidence-based education.Alongside EBP, both evidence-based regulation and education are fundamentally interrelated and vital components of an effective, comprehensive, and progressive evidence-based profession of AT, or EBAT.

Full text

ATHLETIC TRAINING EDUCATION JOURNAL
COMMENTARY
QNational Athletic Trainers’ Association
www.natajournals.org
ISSN: 1947-380X
DOI: 10.4085/120281
On the Need to Move Toward an Evidence-Based Athletic Training
(EBAT)
Paul R. Geisler, EdD, ATC; Patrick O. McKeon, PhD; Jennifer M. Medina McKeon, PhD
Athletic Training Education, Ithaca College, NY
Evidence-based practice (EBP) is now a well-known paradigm for the athletic training (AT) profession. The Commission on
Accreditation of Athletic Training Education accredited programs have required EBP as an explicit focus for professional
education, and researchers are gradually producing insightful and relevant evidence concerning the education and
implementation of clinically based EBP in educational programs. Likewise, many clinicians are attempting to incorporate
EBP into their daily practice in order to guide and enhance patient care, and the Board of Certification has mandated regular
EBP education in order to maintain national certification status. Although there remains much work to be completed before
AT can claim to be a health care profession that is saturated with EBP, there is growing evidence of positive momentum
toward that goal. However, the extent of EBP implementation remains limited to clinically based, patient-oriented outcomes.
To date, there is little suggestion that the profession of AT has used an evidence-based approach for other related aspects
of its professional practice. To that point, a multifactorial and more comprehensive model for evidence-based AT (EBAT) is
presented with the intent of better situating and centering the potentiality for a larger evidence-based culture to inform and
guide the AT profession’s 3 critical subcomponents practice, regulation, and education. We attempt here to expand upon the
paradigm for EBP as a precondition for an overarching, more inclusive EBAT model. To do this, we will introduce and
interconnect 2 other critical aspects of professional practice: evidence-based regulation and evidence-based education.
Alongside EBP, both evidence-based regulation and education are fundamentally interrelated and vital components of an
effective, comprehensive, and progressive evidence-based profession of AT, or EBAT.
Key Words: Evidence-based practice, athletic training, policy, regulation, education
Dr Geisler is currently Associate Professor, Director of Athletic Training Education, School of Health Sciences and Human Performance at
Ithaca College.Please address all correspondence to Paul R. Geisler, EdD, ATC, Athletic Training Education, Ithaca College, 71G Hill
Center, 953 Danby Road, Ithaca, NY 14850. pgeisler@ithaca.edu.
Full Citation:
Geisler PR, McKeon PO, Medina McKeon JM. On the need to move toward an Evidence-Based Athletic Training (EBAT). Athl Train Educ
J. 2017;12(2):81–94.
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On the Need to Move Toward an Evidence-Based Athletic Training (EBAT)
Paul R. Geisler, EdD, ATC; Patrick O. McKeon, PhD; Jennifer M. Medina McKeon, PhD
So education often develops and changes simply on the basis
of new ideas promoted with missionary zeal, new theories with
very little evidential basis and the social and political values of
the moment. Very often, ideas which have no evidential basis
become so ingrained by constant repetition and reassertion
that the emperor’s new clothes almost seem to be real.
1(p553)
As it is currently on the precipice of what may be considered
as the most profound evolutionary step in how it educates its
future practitioners, the profession of athletic training (AT) is
at a critical juncture in its relatively young history. Most
obvious is the imminent transformation to the master’s degree
as the professional requirement for program accreditation and
ultimate certification eligibility. Connected to the degree
transition and associated curricular transformations are
several critical questions surrounding the future not only of
its professional practice, but so too about the future utility of
postprofessional residencies, clinical doctorate degrees (DAT),
and even traditional terminal degrees (PhDs and EdDs) in
AT. Further, numerous state AT associations are diligently
working to establish, strengthen, or clarify their practice acts
in order to better reflect current practice trends. In so doing,
many state associations are battling other professional
associations, governmental constraints, and public awareness
for their rightful place at the regulatory table. Nationally, our
profession is still working to secure the federal recognition it
deserves as a legitimate, nontechnician health care profession,
an initiative not yet achieved despite recent educational and
professional advancements.
Given these interconnected challenges facing the profession,
AT is now encumbered with the responsibility to make
substantial and influential decisions regarding where the
profession is going, and precisely how it plans on arriving
there. Given the substantial stakes involved and the current
evidence-based emphasis in our larger health care sphere,
policymakers, regulators, and leaders in the AT profession
have much to think about and act upon if constructive and
meaningful progress is to be achieved. Just as an evidence-
based clinician must do, the leadership in AT has a fiduciary
responsibility to weigh all proposals and strategic initiatives
being considered for implementation with a dose of guarded
skepticism. After securing relevant evidence germane to either
clinical or educational practice in AT, a thorough and critical
appraisal should be completed in order to assess the strength
and application of that evidence before decisions are made or
specific courses of action chartered.
Likewise, when appraised evidence is found to be weak or
lacking in conviction or relevance, these evidentiary gaps
should serve as impetus for the production of focused and
structured scholarly inquiry toward filling those knowledge
gaps. Given the complex and interrelated challenges involved
with professional education and practice in health care,
perhaps now is the perfect occasion for AT to heed its own
call for evidence-based practice (EBP)? Better yet, perhaps
now is the time for AT to think about becoming a more
authentic evidence-based profession by reconsidering what it
means to actually be evidence based. Given the current state
that AT now finds itself in as it transitions to a new degree
scope, shape, and structure, now is the time to listen, to look,
to speak, and mostly to think about what it should do and
how it should do it. To borrow from J¨
onsson’s analysis of
professional activities and its association with time, the AT
body would do well to embrace the discursive opportunities
that patience bestows upon the reflective and communicative
body: ‘‘Concentrated, inspired conversation is a widely
undervalued source of new knowledge, new feelings, new
impulses.’’
2(p52)
TOWARD AN EVIDENCE-BASED ATHLETIC TRAINING
OR PROFESSION
The purpose herein is to introduce a multilevel model for an
open, thoughtful, and guided endeavor for an evidence-based
AT profession—evidence-based AT (EBAT). Evidence-based
AT is a purposeful call that obliges practitioners, educators,
administrators, and regulators in AT to reconsider their
conception of EBP and to shift toward a more comprehensive
approach to our practice, education, and professional design.
We hereby challenge the AT profession to be more holistic,
more self-critical, and more interconnected by adopting an
EBAT tactic. Doing so requires for evidentiary practice to be
at the core of all that AT does, not just select domains like
clinical practice, and not at select and convenient moments in
time.
Evidence-based AT urges all AT professionals to prioritize
their ethical responsibility for securing, appraising, and
generating evidence that is germane to all functional spheres
of the profession. Conceptual guidance is perhaps necessary
for addressing the critical educational and regulatory issues
confronting the AT profession both today and in the future.
The conceptual underpinnings and sentiment for EBAT are
evident in medical educator Stewart Petersen’s contention that
‘‘the evidence base is as important in educating new doctors as
it is in assessing a new chemotherapy.’’
3(p1223)
Figure 1 illustrates our EBAT paradigm and its primary
subcomponents, each equally weighted and interrelated: EBP,
evidence-based regulation (EBR), and evidence-based educa-
tion (EBE). The tertiary level of EBAT (below EBP, EBR,
and EBE) represents further operational subcomponents for
each of the 3 primary levels, represented by familiar (EBP)
and original (EBR and EBE) Venn diagrams. Inspired and
adapted from an earlier model designed for evidence-based
health care and its regulation, the proposed parachute model
interconnects the 2 central tenets of any specialized profession
(practice and education) with a dynamic and less considered
third tenet, a fundamental keystone in the bigger model—
regulation.
4
Spector’s 2010 evidence-based regulatory model
interrelated practice, policy, and education in a symbiotic
design that underscored the systemic interdependence and
critical reliance on feed forward and feedback loops between
regulatory policies and practices that should both ideally be
informed by evidence. In our self-tailored evidence-based
model for the AT profession, we have expanded Spector’s
model in order to meet a different context and include the
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larger scope of professional activity and responsibility specific
to AT. In so doing, our model is analogous to and consistent
with Spector’s in that ‘‘all 3 realms inform each other and
provide evidence for establishing health care policies,’’ only in
this case AT policies.
4(p30)
WHAT DO WE MEAN BY EBP?
Most athletic trainers are certainly now aware of the 1992
triphasic model of Guyatt et al
5
for evidence-based medicine
(EBM) consisting of judicious parts best available evidence,
clinician expertise, and patient values, and subsequently made
famous by Sackett’s 3-circle diagram (see lower left, Figure 1).
Developed by a large EBM working group of author-
physicians mostly from Canada’s McMaster University, the
original model was an expansion upon earlier epidemiological
work published by British physician Archie Cochrane in 1972
6
with the hopes of better grounding medical decision making
by incorporating the best that medical research had to offer to
clinical care, and to subsequently teach medical residents how
to practice better by using an evidence-based perspective.
When Sackett et al
7
published their oft-cited piece in the
British Medical Journal better describing or operationalizing
what EBM was and what it was not, the debate regarding
levels or strength of evidence, the role of the clinician, and the
impact that context had in decision making was on.
Responding to early criticism that the nascent EBM paradigm
was too rigid and too empirically based because it prioritized
higher levels of evidence at the marginalization of others, and
thus, it was too dismissive of clinician expertise and other
forms of knowing regarding the clinical context and authentic
patient centeredness, Sackett et al underwent great pains to
better define what EBM was originally intended to be—a
modest guide for incorporating scientific findings into daily
practice, not a rigid, hierarchical, and autonomic decision-
making device void of human interaction.
In responding to critics, Sackett et al clarified that EBM was
intended to be a balanced, organic, and contextual integration
of all 3 components that make up the famous Venn diagram.
Further, the response from Sacket et al articulated that a
quality of judgment that can only be acquired with advancing
expertise and that a certain level of proficiency in doing so was
required for any true evidence-based practitioner. As numer-
ous others have done since,
6,8–11
Sackett et al articulated that
expert clinicians routinely use a combination of internal
(individual clinical expertise) and external evidence (from
experimental research) in the context of compassionate respect
for and incorporation of individual patient rights and
preferences. Sackett et al were also clear to express that
EBM was by no means intended to be restricted to high-
powered, Level 1 evidence at the expense or exclusion of other
levels of evidence. In fact, early amendments to EBM justly
emphasized the very human nature of EBM. According to
Sackett et al, effective and judicious EBM necessitates the
procurement and wise use of the best external evidence for the
clinical problem at hand, all in consideration of the particular
context relevant to the patient, space, and time:
External evidence can inform, but can never replace,
individual clinical expertise, and it is this expertise that
decides whether the external evidence applies to the individual
patient at all and, if so, how it should be integrated into a
clinical decision.
7(p71)
In recent years, several scholars and educators in AT have
taken up the EBM baton in order to provide structure and
guidance for its implementation for both clinical practice and
educational instruction (though, mostly for subsequent
clinical practice).
12,13
Although Sackett et al attempted to
Figure 1. Evidence-based athletic training. Adapted from Spector.
4
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better situate the sticky and limited nature of external
evidence by highlighting the role of the clinical expert and
minimizing a blind allegiance to high-level research, they may
have failed to capitalize on fully defining the flipside of external
evidence—internal evidence.
7
McKeon and McKeon
11
have
done just that for athletic trainers by elaborating further on the
critical role that clinical expertise plays in the EBM model and
by specifically positing clinician-knowledge production as
internal evidence. The idea of internal evidence is simply
this—an equal and contextually relevant component of the
clinical encounter that better situates the subjective and
experiential nature of and connection between patient-generat-
ed evidence and clinician expertise.
11
In so doing, the McKeon
and McKeon’s articulation of the organic dualism between
internal and external evidence highlights the need for and role
of advanced clinical reasoning and clinical expertise in the
generation of other forms of knowing or evidence in the duties
of clinical practice, a proposition that extends beyond the daily
clinical decisions made by athletic trainers on behalf of their
patients and into other realms of AT practice. For any medical
or health care profession, the practice comprises far more than
the day-to-day clinical services component; the complete
practice of a profession also involves aspects of regulation,
policy, and education.
EVIDENCE-BASED REGULATION: THE KEYSTONE
THAT IS POLICY
In responding to the challenges facing the nursing profession
in the early 21st century, including rising accounts of
fraudulent education and disciplinary complaints against
nurses, Spector gave notice that ‘‘boards must be aware of
innovations that are ineffective,’’ and further that ‘‘the time is
ripe to focus on [EBR].’’
4(p30)
Though there is no uniform
definition for EBR, Spector’s comprehensive review informs
us that EBR relies on ‘‘high-quality information from a
variety of sources in order to make decisions,’’ and can both
start and end with a simple question for policymakers that
also rings true with AT clinicians engaged in EBP—what
works?
4(p32)
In action, EBR requires policymakers and
regulators to secure, appraise, and incorporate relevant
evidence before, during, and after strategic planning or policy
implementation. In the vein of the EBP model of Sackett et al,
EBR is also considerate of and commensurate with varying
levels of evidence (both internal and external, across the
hierarchy of evidence), clinician (regulator) expertise, and
patient (constituencies) values.
7
In considering Spector’s EBR
and its application to AT, perhaps we should consider 1
fundamental question pertaining to change and progress:
‘‘How might regulators use evidence when making deci-
sions?’’
7(p34)
As depicted in our EBAT model (Figure 1), EBP, EBR, and
EBE are inextricably linked; all are of equal importance and
relevance, and all operate along a fluid, 2-way spectrum of
interdependent and systems-based relationships. Like all
dynamic systems, the smaller components of the larger system
are interrelated, interdependent, and integrated components
of the larger, more complex system. The behavior of any part
of the system is both dependent upon the other parts and, in
turn, directly impacts the behavior of the other component
parts. Specifically, the subcomponents of the AT profession
(practice, regulation, and education) are dynamically inter-
connected components of a larger, complex, fluid, and
dynamic system, and true to systems theory thinking must
be appreciated as an integrated whole.
15
Athletic training is
indeed a complex system, and as such, dysfunction or inferior
performance in any 1 subcomponent of the larger system will
directly impact the subcomponents of the larger system, often
in unpredictable or immeasurable manners.
Evidence-based regulation is the critical and determinate 2-
way intermediary between practice and education in AT;
changes in practice will effect education, and likewise,
deficiencies or alterations in education will invariably impact
professional practice. Connecting the 2 chaotic and fluid poles
of practice and education lies policy, or the how and why of
both doing and learning. From the perspective of practice
regulation, AT has existing and emerging policies that drive
several aspects of its clinical practice, including the many
evidence- and consensus-based policies that direct standards
of clinical care. Athletic training best practices are readily
identified and available today; the role of preparticipation
screening, the proper management of suspected cervical spine
injuries, and the proper way to manage exertional hyperther-
mia are excellent examples. The National Athletic Trainers’
Association (NATA) position and policy statements for
clinical-patient care are based on the latest extrapolation of
available evidence and expert opinion, thus (1) supporting one
of the original intents of EBP and (2) serving as welcome
information for education programs and practitioners.
Clinically, these examples are outstanding representations of
AT’s maturation as a credible, evidence-based health care
profession. These examples serve as evidentiary pillars of
professional practice and competence in AT and serve as
exceptional sources of internal (expert authors) and external
(objective data) evidence designed to guide professional
domains of practice.
Like all professional programs in health and medicine, AT has
numerous regulatory bodies and mandated policies that exert
considerable control over the professional body. For example,
the Commission on the Accreditation of Athletic Training
Education (CAATE) constructs, implements, and enforces
policies intended to guide educational practices and ensure
quality for all accredited educational programs; the NATA
has a Code of Ethics to regulate professional and student
practice; and the Board of Certification (BOC) publishes and
adheres to numerous policies and regulations which dictate
certification candidacy and the requirements for maintaining
professional certification. Lastly, 48 states currently have
specific practice acts to regulate the legal and ethical practice
of athletic trainers in those states. In some areas in EBAT, the
interconnected relationships and dynamics between practice,
regulation, and education are indeed evidence-based. For
example, extensive psychometric data is used to construct,
assess, and validate the AT credentialing exam owned by the
BOC, and role delineation studies have long been used to help
structure and dictate required educational content in accred-
ited educational programs. However, there are gaps that exist
in these connections, as well.
In returning to Spector’s rhetorical challenge (‘‘How might
regulators use evidence when making decisions?’’), we might
find potential inconsistencies in the application of an
evidence-based approach by considering how evidence has
been used in other domains or aspects of professional practice.
For example, an ongoing debate in the profession centers
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around the actual best evidence buttressing the master’s
degree requirement for AT.
16
Although the point of the
current paper is not to reargue the 2013 decision by the
NATA’s Strategic Alliance, a brief commentary is warranted
in order to better connect those events and actions to the
concept of EBR. In particular, many AT professionals have
questioned the objectivity, strength, or contextual relevance of
much of the evidence presented to support the degree change
proposal. For example, many educators took exception to the
reporting of the differences in BOC examination pass
discrepancies (‘‘. . . current professional masters programs
are more likely to meet the passing rate standard and obtain
high total scores than undergraduate programs’’
16(p7)
) be-
tween the low number of entry-level master’s degree programs
and the much higher number of entry-level undergraduate
degree programs. Although the external evidence (national
data from the BOC) may support a slight advantage in first-
time BOC pass rates, the internal evidence from dozens of
undergraduate programs with first-time pass rates close to or
equaling 100%would suggest that the issue is contextually
dependent and not as objective or revealing as the degree
paper indicates. On a more nuanced level, the frequency with
which the degree white paper used hopeful, hypothetical, and
possible verbs and adverbs to describe the potential benefits of
the degree change was quite remarkable, given the relatively
low level of objective evidence used to support the arguments
contained within. As the master’s degree is now a reality and
the details for the transition emerge, the AT profession might
do well to follow Harden’s ‘‘Best Evidence Medical Educa-
tion’’ (BEME) guide:
Best evidence medical education occurs when decisions
relating to teaching are taken with due weight accorded to
all valid relevant information. . . the approach described also
has immediate relevance to the planner or educational
administrator, and provides them with a powerful tool to
move forward the [BEME] agenda.
1(p561)
What does current evidence say about best practices in health
care education curriculum design, clinical education and
supervision, the development of competency and expertise,
or professional education outcomes? Is there strong evidence
to suggest that requiring all professional knowledge to be
taught at the graduate level will be superior to current
mechanisms, whereby early exposure and progressive learning
are hallmarks of professional education? Of what value is the
surplus of internal data from high-performing undergraduate
programs demonstrating excellent outcomes and professional
success? Wherever possible, relevant, and contextually appli-
cable, internal and external evidence should be secured,
assessed, and consulted and done so in the same vein in
which the profession operates on clinical levels. If relevant
evidence on these complex and critical issues is unavailable, or
if the evidence available (from other fields) is not malleable to
the AT profession, open conversations with stakeholders and
directed research should be initiated toward before broad-
based or sweeping policies are implemented.
LOCAL AND GLOBAL REGULATION: BIG-P AND
LITTLE-P POLICIES
Satterfield et al highlighted multiple levels of a transdisciplin-
ary EBP in stating that EBP ‘‘seeks to increase the
effectiveness and efficiency of policy,’’
8(p385)
and in so doing
entails both big-P policies and small-P policies. This includes
formal laws, rules, and regulations (big P) and organizational
guidelines, and social norms guiding behavior (small P).
Within EBR (for AT), we can play with small and capital
letters according to the precedent of Satterfield et al and the
description of Harden et al
1
of BEME. Within EBR (for AT),
we can apply the precedent of Satterfield et al and the
description of Harden et al of BEME to AT. The big P
represents the numerous policies, procedures, and rules
induced by larger entities such as state regulatory boards,
the NATA, the BOC, and the CAATE. Meanwhile, the little P
represents smaller, personal, and more local regulations and
policies, typically enforced at institutional, programmatic, and
personal levels in which athletic trainers practice their craft as
clinicians, administrators, and educators. This fundamental
differentiation for the many big-P and small-P policy
influences are together apt representations of the various
external and internal factors that influence the many
interrelated duties of our professional work, especially at the
educational level.
8
As the CAATE now owns and distributes both the required
content (knowledge, skills, competencies, etc) and the
directives (standards and guidelines) for all accredited
institutions, it has clear and definitive regulatory control over
the policies that govern and guide the educational apparatus.
Given its critical and central position in the EBAT spectrum
and utility in ensuring educational quality, the CAATE can be
considered as a primary big-P regulator of both practice and
education in AT. Given that CAATE accredited programs
must soon develop essentially brand new undergraduate
(preprofessional) and/or graduate (professional) degree cur-
ricula (for those transitioning to a 3:2 institutional model) in
order to be compliant with the new standards, there are likely
many more questions that need to be addressed than there are
answers in existence. The following matters represent just a
few of the significant policy-related and education-based items
that fundamentally require a critically informed appraisal and
an informed academic conversation:
1. Pedagogical and curricular design issues—what curricu-
lar design is more effective for AT education (a 2:3, 3:2,
or 4:1 sequence)? Is there evidence to support the
proposed 3:2 curricula as superior to other models?
How might the required design impact teaching and
learning or program outcomes? How might the proposed
design impact individual programs’ autonomy or stretch
available resources? How will imposed designs affect past
successes and accomplishments, supported by local or
internal evidence?
2. Specific learning outcomes—toward what ends should
AT design its curriculum; what are the precise learning
and professional goals that should be targeted for a
master’s degree in AT? How do the master’s AT degree
outcomes differ from current bachelor’s degree outcomes
and measures?
3. Athletic training’s professional scope of practice and
body of knowledge—should we or can we expand what
we actually do as professionals? If expanded via the new
master’s degree content requirements, what are the
implications for professionals in practice, as well as the
many AT educators charged with delivering the new
material?
4. What are the pros and cons of competency-based
education (CBE)? Is CBE the best way to produce
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professional expertise in AT; are there other models and
modes? What does the evidence say about CBE,
especially in AT? Given that current curriculum propos-
als are centered on content and not necessarily profes-
sional expertise, how are programs intended to design
their program assessment?
5. Is there a role for entrustable professional activities and
milestones in graduate AT education? They are used in
graduate medical education to promote competence and
autonomy; do they have potential utility in AT educa-
tion?
6. What are the benefits and challenges of clinical supervi-
sory polices? Is direct supervision the most effective way
to develop future clinicians, or do other practices exist
that better promote competence?
7. As clinical reasoning is a required cognitive skill set for
health care practitioners (as part of a larger skill set of
medical cognition), what are the evidence-based ways to
develop advanced medically based thinking in AT?
8. How does AT education best develop clinical expertise in
its future clinicians? What are the characteristics of
expertise in health care providers, and how might this
evidence inform what AT education does to promote
clinical experts?
Policy (big P and small P) and regulation is a 2-way street,
which must be informed by and informative to both education
and practice. Therefore, big-P policy cannot exist in a
vacuum, lest issues, such as those described above, arise and
challenge the stability of the system it operates within. Many
of these issues have already been studied by medical educators
in respect to their respective domains and led to findings that
have influenced or dictated educational policy and practice in
the making of physicians. In 1999, both the British Medical
Journal and Medical Teacher made just such a call, publishing
2 editorials that called for evidence-based medical education
and publishing its first (of 43) BEME guide,
1,3,17
Given the
obvious connections between many aspects of medical and AT
practice (diagnostic and therapeutic reasoning, compassion,
reflection, professional behaviors, clinical care, clinical com-
petencies, expertise, etc), there are assuredly some contextu-
ally relevant evidence-based initiatives that AT can borrow or
adapt from medicine.
EVIDENCE-BASED EDUCATION
Depicted in the lower right-hand corner of the EBAT graphic
(Figure 1), the EBE component was informed by multiple
sources, including the guide of Harden et al
1
for BEME, a
speech-language pathology and audiology text on EBE,
18
and
various sources from the larger field of education.
19–23
Close
inspection of EBE (Figure 2) reveals the features specific to
AT—a Venn diagram respectful of open systems theory
(relative to education),
24
the critical and fluid interplay between
internal and external evidence,
11
and the context-specific nature
of EBE from health care and social science.
25
Evidenced-based
education is as necessary to the professional education in AT as
it is for any other educational endeavor, but it is also critical
because of the immediate relationship and interdependence to
both big-P policies and little-P policies by extension.
Because evidence production, interpretation, and application
in the educational domain are somewhat different than more
traditional scientific or clinically based evidence production, it
is shaped by greater complexity, challenges, limitations, and
uncertainty. Therefore, we cannot simply or na¨
ıvely adapt a
standard EBP model to the educational domain and expect
the same utilitarian effects.
1
Due to the multifactorial and
more subjective nature of behavior, the human subject, and
the mind, it is much more difficult to conduct randomized
controlled studies in educational contexts. Appreciated as
such, research findings from educational studies are inherently
more difficult to apply outside of the context in which they
were studied, especially when the data tend to be more
qualitative in nature.
21
In light of these inherent challenges
(subjectivity, context, etc), noted medical educator Geoff
Norman
26
has recently argued that we must be skeptical of
any grand narrative presented on behalf of medical education,
wary of claims made on behalf of authority and truth
regarding the right or proper way to educate. Accepting that
Figure 2. Evidence-based education (in athletic training; Geisler 2016).
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educational research inherently possesses greater levels of
uncertainty and subjectivity simply indicates that there are
multiple truths, countless objectivities, and numerous possi-
bilities to consider and that context, time, and space must play
greater roles in the interpretation of research findings from the
educational world. Translating this sentiment to the work of
professional health care educators, this means that scientific
work in education has to be approached differently than the
work used to generate EBM in order to use educational
evidence as part of a larger EBP. Our EBE model is designed
to respect and incorporate the more nuanced, contextual, and
fluid nature of educational research and practice. As is
presented, EBE in AT prioritizes the chaotic, systems-based,
and human-centric nature of the educational relationship
between educator and pupil both in content and architecture.
EVIDENCED-BASED EDUCATION IN HEALTH CARE
FIELDS
The BEME guide of Harden et al
1
challenged readers to
embrace educational research with the same vigor and intent as
clinical science. The approach of Harden et al with the BEME
was threefold: this publication (1) reviewed the fundamental
differences between harder, objective research in the clinical
sciences and the softer, more subjective nature of educational
research; (2) defined the concept of BEME; and (3) offered
specific guidelines for evaluating, grading, and implementing
meaningful research findings. As part of this landmark paper,
the authors introduced their own hierarchy of evidence ratings
for evaluation purposes and highlighted a unique and
multidimensional approach for grading evidence known as
the QUESTS Dimensions. Consisting of 6 levels, the QUESTS
dimensions highlight the various tensions and challenges
associated with assessing educational research findings, includ-
ing the quality, utility, extent, strength, target, and setting of
the research findings being considered for implementation.
In the BEME of Harden et al, it is intended that ‘‘the culture or
ethos is such that teachers are encouraged to question their
practice, to look for the best evidence available, to relate the
evidence to their own situation and to apply their professional
judgment.’’
1(p555)
Evidence-based education for AT is intended
to honor and inspire the ethos and spirit of the first BEME
report by intentionally allowing for greater spaces and contexts
to be at the center of scientific inquiry and application in AT.
The lower right circle of the EBE model, empirical evidence, is
analogous to the original EBP inclusion of the best external
evidence by Sackett et al,
7
and because it connects directly to
the human aspect of education, to behavior, the mind,
transformation, it is inclusive of both qualitative and quanti-
tative findings regarding teaching, learning, curriculum design,
assessment, and other complex aspects of professional educa-
tion. The lower left circle, professional wisdom, is a combina-
tion of McKeon and McKeon’s
11
notion of valuing the
production and significance of internal evidence, the suggested
ethos of Harden et al,
1
and the original EBM working group’s
emphasis on individual clinical expertise. Collectively, the
delicate and contextually relevant interplay between profes-
sional wisdom and empirical evidence indicates that reflective,
committed, experienced, and well-informed educators have a
vital and local role in the educational processes of the system
within which they work. As Harden et al put it, ‘‘relevant
evidence, however, may not come from formal experimental or
quasi-experimental research studies but from professional
experience and professional judgment. In education, these
may be important sources of evidence.’’
1(p556)
The third and final circle labeled teacher-learner context is
intentionally placed on top of our EBE model in order to
prioritize the contextual, subjective, and idiosyncratic aspects
integral in the ever-evolving and fluid teaching-learning
relationship, including the myriad human dynamic factors
that define the educational experience.
26
The often unpredict-
able nature, background, state, and abilities of the central
players in education at any given time or space—the educators
and the students—requires a prioritization of the human
context and subjectivity.
18,20,21
Not intended to cover the
mammoth collection of theoretical, anecdotal, or evidentiary
information available on the many aspects of the educational
endeavor and experience—teaching, learning, curriculum
design, planning, evaluation, outcomes assessment, or effec-
tiveness—our EBE model is intended to represent a parallel
and contextually relevant model for AT educators to consider
as a guiding principle for framing their work as educators,
administrators, and preceptors.
EVIDENCE-BASED EDUCATION EXTENDS BEYOND
THE CLASSROOM
In an opening editorial to the BEME piece of Harden et al
1
in
Medical Teacher, Editor Ian Hart
17
made a concerted call for
EBP to also be applied to the business of educating physicians.
He recalled raising the question a year earlier at an
international meeting as to why the medical education field
had ‘‘never attempted to emulate something like the [EBM]
approach now commonly advocated in medical practi-
ce.’’
17(p453)
To that end, he proposed a 2-pronged approach to
EBE that, in his view, would improve both educational and
patient-based outcomes because of the inherent interconnec-
tions between education and policy that drive medical
education. Hart’s
17
prescription for a best evidence approach
to issues germane to medical education forces the education-
alists to (a) comprehensively and critically appraise existing
literature and to categorize the power of such evidence, and (b)
to identify gaps and flaws in the existing literature and, in so
doing, make specific calls for appropriately designed studies to
generate evidence that may be capable of supporting educa-
tional practice and policy. The BEME piece of Harden et al
reiterates Hart’s challenge for filling evidentiary gaps and takes
it one step further by admonishing those who may be resistant
to be an evidence-based educator: ‘‘lack of evidence should not
be used by teachers as an excuse for a failure to adopt an
evidence-based approach to their teaching practice.’’
17(p554)
The reality is that strong and reliable evidence in the
educational realm does exist in many areas, both from within
and beyond the AT body of knowledge. We just need to look
and, more importantly, want to look. Athletic training
educators do in fact know what works and what does not in
the AT classroom, lab, or clinic. Excellent research has
emerged from AT scholars concerning the role and measure-
ment of clinical reasoning, the efficacy of using objective
structured clinical exams to assess competence, and the
barriers that obstruct the teaching of EBP (and ways to better
teach EBP), amongst other areas of inquiry. However, there is
much more to know and seek to know, and there is much
more that is as of yet unknown as we move into the master’s
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degree era. For example, AT administrators and educators
know very little about the impact that the direct supervision
policy has had upon professional competence, the most
effective ways to teach clinical reasoning in preprofessional
students, or how the formal implementation of EBP may or
may have not impacted our professional practice (to date).
LINKING EVIDENCE-BASED EDUCATION TO
EVIDENCE-BASED ATHLETIC TRAINING WITH
EVIDENCE-BASED REGULATION
Our intent is not to provide a comprehensive review or
analysis of all empirical evidence in AT education, for there is
a plethora of valuable information now available for
interested minds. Rather, the point of EBAT is to highlight
the many areas and issues that we have little evidence for or
about and to appeal for more connections between evidence-
based work and our educational mission when we do have
evidence that will be of assistance, even if it is not from the
world of AT. Evidence-based education is a critical and
connected subcomponent of the larger concept of an EBAT
and thus is centrally related to the idea of EBR (and policy)
and, by extension, EBP. Evidence-based education explicitly
calls for our AT educationalists (derived from medical
educationalists, coined by Professor of Medical Education
Stewart Peterson
3
) to inform not only our clinical practice by
working to produce competent, entry-level clinicians, but also
our educational policy that governs how we work, what we do
that counts as work, and what we become as a profession. By
extension, EBAT calls for all policymakers (regulators) to
seek out and assess relevant evidence that may be capable of
informing or constructing future education-based policies and
regulations. As Hart expressed in his 1999 editorial (demand-
ing an evidence-based medical education system), ‘‘it has to be
better than making expensive decisions regarding new
educational initiatives based solely on intuition and a warm
fuzzy feeling that it seems like a good idea.’’
17(p453)
As of this writing, the future accreditation standards and
content for all professional master’s degree programs have
been proposed by the CAATE and are currently undergoing
assessment, criticism, and editing by the professional body. In
time, these working constructs will be fashioned into final
documents that will authoritatively regulate the processes and
procedures for all entry-level educational programs in the
profession.
27,28
Given the complex task of scripting the new
professional degree requirements and the educational content
at the same time, and given the responsibilities and challenges
associated with doing so in consideration of the profession’s
future position in the health care field, our EBAT model
brings to light the necessity for directly linking EBR to EBE
so that ‘‘good policy can be made from high quality
information.’’
4(p33)
For policymakers and regulators involved
in reshaping and redefining the educational processes and
professional knowledge and skills for athletic trainers and AT
educators alike, EBAT elucidates the fundamental and critical
relationships between EBE and EBR that parallels the same
interdependent nature found in other health care professions.
8
PROPOSED POLICY CHANGES: IS RELEVANT
EVIDENCE AVAILABLE?
The first iteration of the proposed accreditation standards for
the master’s degree in AT include among other things
propositional policies (also known as standards) for (a)
required basic science instruction in physics, chemistry, and
biology; and (b) specific interprofessional education (IPE)
across the curriculum, didactically and clinically.
28
On some
levels and for proponents of these ideas, these proposed
standards are somewhat logical, contain degrees of expert-
based insight, and even have a bit of historical precedent and
appeal from other health care education policies and practices.
To be sure, both have some level of evidentiary support and
precedence, and neither is outwardly counterintuitive for a
professional health care degree intended to develop profes-
sional health care providers. The AT master’s degree white
paper articulated the theoretical basis for the inclusion of
more basic sciences (citing a 1995 report from the Pew Health
Professions Commission as the chief source of evidence to
support the ‘‘need for more basic science education in AT
programs’’), although it did so in a somewhat hopeful and
speculative manner by stating that it ‘‘should make it easier
for students to connect new knowledge to current under-
standing, and then adapt this knowledge to specific clinical
situations,’’ and by providing a slight modicum of scholarly
support for the contention.
16(p12)
In making the argument for
IPE for graduate AT programs, the white paper declared that
‘‘professional education at the graduate level removes many
barriers to IPE,’’ and spent a majority of time and space
addressing how much easier it will be to incorporate IPE
programming at the graduate level, rather than presenting
specific and contextually relevant evidence to support the need
for and vision of IPE in graduate AT education.
16(p12)
WHAT DOES THE EVIDENCE SAY ABOUT BASIC
SCIENCE EDUCATION?
Requiring future athletic trainers to take more basic sciences
in their early education is on some level evidence based
(logical on the surface and with historical precedent), as this
has been standard practice for many of our colleagues in
medicine, physical therapy, and physician assistant education
for up to a century. In medicine, it was the year 1910 when
William Flexner borrowed from German medical education
and the system already in place at Johns Hopkins University
to scientifically reinvigorate the medical curriculum that still
exists in large part today—2 years of foundational and
isolated laboratory science, followed by clinical training.
29
As
Sibbald and Neville adeptly summarize in their commentary
on ‘‘100 years of basic science in medical education,’’ the
impetus for Flexner’s curriculum was to ‘‘gain public trust
through academic rigor,’’ and for basic science to become ‘‘an
aid to protect and preserve professional autonomy.’’
29(p136)
Duffy’s more comprehensive review of Flexner’s legacy
reflected the alarms of infamous medical educator William
Osler who was gravely concerned about further separating the
‘‘science from the patient,’’ inciting Duffy to express concern
over medicine ‘‘losing its soul at the same time its body is
clothed in a luminous garment of scientific knowledge.’’
16(p275)
Clearly, current regulators in AT are of the belief that adding
more science to the AT curriculum (precurriculum, actually)
will add more rigor, increase professional credibility, and in
turn, produce better clinicians, but will this be at the expense
of ‘‘losing our professional soul?’’
Despite the theoretical basis for the impression that more
science equals better clinicians and a more rigorous, scientif-
ically based profession, a review of a considerable and
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growing body of medical education literature on the role of
the basic sciences reveals that this curricular assumption may
not be as clear cut and logical as originally purported. From
an EBR, can AT policymakers confidently state that a
mandate for additional basic science preparation in the
preprofessional curriculum will significantly impact profes-
sional educational outcomes and the development of better
athletic trainers? An evidence-based appraisal of the available
evidence (from medicine) directly challenges those impres-
sions, and for some scholars in AT education, the answer may
indeed be surprising. Although there are indeed aspects of the
physical and life sciences embedded in much of what athletic
trainers (and physical therapists, medicine, etc) do clinically,
we were unable to find even 1 study conducted in AT that
provides evidentiary insight on the impacts of basic science
education on educational or professional outcomes in AT.
The same goes for physical therapy—despite the well-known
tradition for physical therapy education programs to require
anywhere between 24 and 30 credit hours of basic sciences in
their prerequisite curricula, we could find no evidence as to
the specific value or role of those classes in professional
knowledge, competence, or expertise.
In medical education, numerous studies have already discov-
ered that basic science education in undergraduate or
preprofessional education of physicians is a mixed bag, at
best.
30–37
In what may seem as counterintuitive to some,
incredulous to others, basic science education has been found
to impart a limited and varied impact on the clinical
knowledge and competence of physicians because of both
the nature and the nurture of its presentation and consump-
tion. In short, a large portion of the content from the basic
sciences is irrelevant to medical practice (content), rote
memorization is often the mechanism by which medical
students learn all of the basic science information which leads
to poor retention and application, and much of the irrelevant
components are generally not transferrable from one domain
to the next (nurture) due to the manner and timing with which
they are taught.
38
In fact, it has even been found that various
stakeholders in medical education disagree on what is
considered a basic science, where and how the social sciences
fit, and whether or not communication skills are in fact more
important than anatomy knowledge.
39
In other words, it takes
much more than 2 years of Flexnerian exposure to scientific
facts, figures, and rules to equate to that knowledge to clinical
understanding, patient context, or professional expertise.
Much as it was disproven by Thorndike in 1923 that a
‘‘mastery of Latin would automatically transfer to greater
learning and abilities with all languages later in life,’’ the
paradigm suggesting that more science equals better physi-
cians is being challenged by many medical educators for its
veracity and objectivity.
40(p55)
It has been repeatedly demonstrated in medical education that
the integration and transfer of basic science principles and
concepts into clinical contexts is far more important and
meaningful than the ability to recall facts, figures, and laws that
were learned in isolation years prior, out of context, and without
connectivity to clinical knowledge.
30–42
What medical educators
have found repeatedly is that they must often reteach the basic
science facts that are indeed relevant to the medical knowledge
at hand and that they must do so in much more enriched and
meaningful manners—they must connect the relevant biosci-
ences to the clinical sciences in order for it to be significant and,
thus, of practical utility.
43–46
A very recent study published by
Lisk et al
47
reveals both the meaning and applicability of such
findings for AT with their exploration of cognitive integration
of basic science with diagnostic reasoning in musculoskeletal
conditions. In this clever study, the authors found that an
intentional pedagogy that integrated the relevant musculoskel-
etal science with specific clinical conditions improved diagnostic
reasoning, as compared to a method that only taught the clinical
science components as injury schemas (diagnosis, signs,
symptoms, etc). Regarding diagnostic reasoning, this evidence
and the experience of effective educators demonstrates that
integrating relevant basic science information with the clinical
content allows students to construct causal pathways during
clinical encounters, an experience thought to enhance retention.
If medical educators are challenging the effectiveness of their
institutionally housed basic science curriculum and realizing
that the considerable devotion to and reliance upon the basic
sciences has been misappropriated due to content and delivery
issues, then what does that mean for AT education programs?
What is the return on investment for AT education programs
intent on sending students across campus to take basic science
classes in physics, biology, and chemistry where transfer and
integration are likely not occurring?
Renowned medical educator and scholar, Geoff Norman
summarized the rather extensive research on basic sciences in
medical education in stating that the transfer or encapsulation
of knowledge is more important than full-fledged exposure to
high credit loads in the sciences,
40
a position fully supported
even by those who have studied the impact that anatomy
education has upon the production of physicians.
41,48
In other
words, the rigorous science component of the 1910 Flexner
Report was, despite its logical rationality, misguided and in
time deemed ineffective for producing deep thinking and
expert physicians, and in Norman’s view, ‘‘It’s about content,
not classes’’ (written communication, 2016). Today, medical
education is working in earnest to improve upon the impact
and legacy that the science-dominated Flexner Report has had
upon the methods and content of medical education in the
Unites States for over a century.
Perhaps even more surprisingly, medical educators do not agree
over the best quantity, timing, and delivery of what many
consider to be the holy grail of physician training—the
anatomical sciences.
42
Numerous studies have challenged the
amount of anatomical science that physicians need to know,
41
how it should best be taught,
49
and how detailed it should be
taught (and assessed) in medical students.
48,50
Coming to the
conclusions that surgeons require a different mastery of
anatomy than do nonsurgeons, that even a mastery level of
anatomical recall does not last forever in even the brightest
students, or that high level recall ability equates poorly with
clinical relevance or expertise, many medical educators have
used this paradigm-jarring evidence to aggressively look for
effective ways to maximize the time and space they have in their
curriculum (only 2 years long, didactically), their institutional
resources (if cadaver dissection is not the most effective method,
is it worth the cost and time?), and naturally, to maximize their
learning outcomes by producing competent physicians.
If the available evidence from medical education is duly
accessed and well appraised, the take home message for
educators (EBE) and policymakers (EBR) in the AT
profession should be clear and helpful components for an
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evidence-guided path forward. There are component bits from
the basic sciences germane to AT knowledge and practice, and
though these knowledge fragments are indeed foundational to
some of what we do as health care clinicians, the total amount
of relevant knowledge from the basic sciences is likely much
less than many believe. Further, the fraction of physics and
chemistry knowledge that is relevant to the practice of AT is
only useful to students if that knowledge is transferrable or
encapsulated in manners that are meaningful and contextually
relevant to the knowledge at hand (in AT). As Bandeira et al
39
suggested for medical educators, AT should shift the focus
away from specific basic science disciplines and instead
consider the fundamental and foundational knowledge that
should and can be applied to the practice of AT with specific
and focused integrative approaches.
For example, it is given that the electromagnetic spectrum is
important to understanding certain aspects of therapeutic
modality application and competence, but can a physics
professor without a professional health care background or
pedagogy ensure that AT students learn the relevant knowledge
bits in a manner that means anything to the student when he/
she takes his/her therapeutic modalities course a semester or 2
later, or does the AT professor have to (re)teach the relevant
physics concepts so that they are meaningful in the context of
AT application, or transferrable once the student is enrolled in
the therapeutic modalities course? In our program, it is our
clinically experienced educator that integrates, encapsulates,
and transfers the relevant physics material with our AT
students. The same goes for anatomy—how often do AT
professors have to reteach large portions of anatomy and
physiology throughout their curricula despite their students
having already passed (typically) 8 credits of coursework in
anatomy and physiology in the preprofessional phases? In our
program, it is in the end all of our faculty who do the difficult
but necessary work of transferring and integrating anatomy
and physiology knowledge with injury and disease in clinical,
patient-centered contexts. The job of the excellent educator in
health care fields is often to do what should have or could have
been done in the original exposures to the material—to
transfer, to integrate, or to encapsulate the requisite basic
science information and skills into meaningful and contextual
AT specific knowledge and skills that will make sense and be
retained during clinical and patient exposures.
WHAT DOES THE EVIDENCE SAY ABOUT IPE?
Regarding the proposed standard for IPE in future AT
education, the conversation is a bit more complex and
multifactorial. As of this writing, the proposed requirements
for IPE and interprofessional practice (IPP) in AT education
are listed in multiple standards across the 2 interdependent
documents, in direct and indirect formats.
27,28
In the program
standards document, Standard 14 addresses the didactic
curriculum by calling for ‘‘planned IPE across the professional
program,’’ while Standard 22 focuses on the clinical compo-
nent by requiring clinical education to be ‘‘planned to include
exposure to and engagement in IPP on a planned and regular
basis.’’
28(p7)
Additionally, standards 3, 5, 13, 16, 32, and 45 of
the content document directly or effectively deal with aspects
of either IPE or IPP in their language and intent.
27
In
designing a curriculum to meet required standards, it is no
small feat to incorporate and articulate 8 different standards
constructed toward 1 goal or domain, especially when time
and space are likely to be even more compressed. The desire to
bring AT into the fold with other related health care fields can
be understood from theoretical and practice perspectives, but
perhaps there is reason for pause regarding how deep and how
fast we wade into these waters.
51
Clearly, IPE is a popular and worthwhile academic and
professional conversation in health care education and
practice today, including on some level the world of AT.
52,53
Given that the World Health Organization has called for all
health care fields to embrace IPE and promote its founda-
tional relations, IPP, or collaboration, IPE certainly has a
legitimacy that demands attention and evocative thought.
Beyond the logic presented and the precedence from related
health care fields, EBR is obliged to ask if IPE is an evidence-
supported initiative, or more directly if it is known to produce
meaningful or constructive long-term changes in students or
professionals? In other words, EBR would attempt to address
the intended or expected outcomes of proposed IPE initiatives
or practices, rather than merely relying upon what may be
hoped for because of surface potential or logic. Amongst
other things, IPE is commonly claimed to lead to improved
patient outcomes and improved professional performance and
communication,
52,53
but an effective and critical EBR-EBE
dynamic wonders aloud if those claims can be validated in the
context of real-time practice? More importantly, can any of
those claims be justified or demonstrated in an AT context or
setting? Would IPE implementation in AT hold up to a 6-
dimension QUESTS (see the Table) assessment for quality,
strength, setting, etc?
Despite the existence of a white paper calling for pronounced
IPE programming in the AT domain
52
and a plethora of calls
for IPE by various experts and credible sources, no outcome
Table. Harden’s 6 QUEST Dimensions for Evaluating Evidence in Educational Practice
1
1 Quality How good is the evidence? What counts as evidence?
2 Utility To what extent can the method be transferred and adopted without modification? Will adaptation
affect the expected results, for better or worse?
3 Extent What is the extent of the evidence? Is evidence based on single opinion/study or isolated example of
an approach? On a consensus view, systematic review or meta-analysis?
4 Strength Marginal statistical significance is more limiting and begs more caution in educational settings
5 Target What is the target? What is being measured? Evidence validity? Similar sample sizes? What was
measured—skill, knowledge, attitude, performance, behavior?
6 Setting How close does the context or setting approximate the original? How relevant is the application to the
desired setting or context? Educational phase? Cognitive maturity level of subjects? Similar
healthcare profession? Subject demographics? Sociocultural differences?
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studies demonstrating specific educational or professional
outcomes in AT can be found at this juncture. Despite its
current popularity and expert- and authority-driven message,
limited evidence currently exists concerning the efficacy and
impact of IPE in the larger health care spectrum beyond AT.
Systematic and critical reviews of IPE efforts conducted across
the health care education spectrum conveyed more weight to the
considerable limitations, challenges, and institutional drains on
IPE than to the actual, objective long-term outcomes with the
efforts to address the World Health Organization’s call for IPE
for all health care fields.
54,55
In appraising the available
literature on various IPE initiatives conducted in across health
education programs, high-level evidence reports have found
that IPE (a) is often well received by students, (b) changes short-
term perceptions of other professional students, (c) is perceived
to be of value by most participants who have experienced IPE as
part of their formal training, and (d) requires clinical and
experiential exercises in order to achieve any of the aforemen-
tioned positive outcomes.
54
Looking deeper, however, the
majority of these positive IPE outcomes are not lasting—most
outcomes were evaluated either in short-term assessments (by
design) or were found to waiver sharply over time.
56,57
An assessment of IPE evidence reveals that its integration into
formal academic programs induces numerous challenges and
pressures at programmatic and institutional levels, including
the significant increases in (a) time, (b) energy, (c) faculty
training, (d) faculty cooperation and enthusiasm, (e) admin-
istrative support, (f) money, and (g) curriculum flexibility and
space.
54,56–60
Also, IPE efforts designed around classroom
exposure or experiences were generally found to not have
significant impacts on measurable or meaningful outcomes,
such as professional behavior or communication, and more
than a few studies found that attitudes and perceptions
amongst the various professional bodies (of students) and
faculty represented actually became worse in that power
barriers and stereotypes were reinforced.
54,61,62
Given that the
intended and speculated outcomes for IPE are still unclear
and largely unsubstantiated,
60,63
that a working definition or
understanding of interprofessional competency is still being
debated by many in the field,
60
that significant human and
material resources are significant needs for an IPE curricu-
lum,
58
that clinical/experiential-based efforts are required to
achieve short-lived, but positive change,
55
and that AT
policymakers have yet to articulate an actual and definable
or measurable professional outcome for an IPE initiative,
52,53
it would appear that an evidence-informed platform for IPE is
not yet available for AT educators or policymakers to rely
upon (at least not a clear roadmap).
To be clear, IPE is not void of theoretical or practical merit or
precedence, and we wish not to diminish the need for effective
communication across the spectrum of care or for collabora-
tive care that leads to safe and effective patient outcomes.
Interprofessional practice and care is, on some level,
important for all health care providers, including athletic
trainers; therefore, our students need to know their role and
how to perform their role in interprofessional contexts and
situations. It is important to take note of AT’s particular
history, utility, and professional position when considering
what to do next as a result of future policy implementations. It
can be argued that athletic trainers have been practicing IPP
for decades by working under the supervision of physicians (in
most states) and alongside and in communication with other
physicians, physical therapists, nutritionists, psychologists,
and other health care providers in the daily process of patient
care. In so doing, AT students have been exposed and
immersed in IPE for decades as part of the existing
educational model, whereby effective cross communication
and practice is already being modeled as part of regular
clinical experiences and education. If one accepts our history
and professional context, what then is our specific role in the
future of IPE? What more or how differently do we need to
educate students concerning how to practice with other health
care professionals? Does the available evidence on IPE
support the need for 8 different standards, across both the
didactic and experiential components of our new master’s
degree programs in order to do what our profession has
historically done?
INCORPORATE OR IGNORE THE EVIDENCE?
At this critical juncture in the history of AT, the dearth of
quality and contextually relevant evidence from within the
profession combined with an apparent lack of appraisal of
related evidence from other health care fields should provide
considerable pause for concerned AT educators and admin-
istrators empowered to deliver our professional body of
knowledge in the coming years. We challenge the current
mindset and impending process, not because having AT
students take more classes in the hard sciences or having some
modicum of IPE are inherently bad ideas, or not that they are
without some to-be-determined value for AT education or
practice. Rather, we question because, beyond expert opinion,
theoretical allure, or axiomatic practice, there is not yet
sufficient or compelling evidence available to support the
viewpoints or rationale behind the some of the proposed
policies. More directly, many of the new policy proposals fall
far short of suggesting that implementation and adherence
will produce (more) evidence-informed, expert clinicians, and
any hoped-for gains in those arenas may be directly offset by
the considerable investment in time, resources, and energy
required for implementation.
In simple terms, there is not yet credible evidence in many
areas to support the considerable investment (new policies,
new structure) required for compliance, in hopes that it will
produce the desired returns for the effort (improved profes-
sionals). The cost-benefit analysis for this model is lacking
information or evidence to produce a predictable or credible
outcome. At a minimum, policymakers and regulators
sensitive to and respectful of EBAT should seek out and
assess or generate credible and relevant evidence for address-
ing serious proposals or standards being considered for
adoption. Whether we are talking about IPE, clinical
supervision, competency-based education, clinical reasoning,
reflective practice, curriculum design and structure, the
development of empathy, sociocultural competency, contrib-
utors to lifelong learning, or any other attribute attributed to
the development of clinical expertise in health care before
regulation becomes fixed, we should at least try our best to
track down and consult the evidence that is available.
TOWARD AN EVIDENCE-BASED PROFESSION: NOW IS
THE TIME FOR EVIDENCE-BASED ATHLETIC TRAINING
In 2009, Satterfield et al
8
published an enlightening piece that
reviewed the history of the genesis of EBM, discerned EBM
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from EBP, highlighted the early limitations and criticisms of
EBM, and reviewed the history of EBP in nursing, psychol-
ogy, social work, and public health. Of keen interest for AT
should be the fact that, in addition to medicine, nursing,
psychology (practice in psychology), social work (social work
practice), and public health, all had their own evidence-based
acronyms, complete with explicit professional histories,
including the various evolutionary cycles and iterations that
each EBP model has undergone over the years since EBM was
formally introduced in 1992.
5
Glaringly omitted from this
review was any mention of AT, a profession that has been a
profession since 1950, yet has no evidence-based history or
acronym to call its own. The intention for Satterfield et al was
to present a harmonized and ecological model for a
transdisciplinary EBP that is inclusive of a common language
and an enriched clinical decision and policy decision-making
structure. One particular emphasis in the model of Satterfield
et al was to reposition best evidence available by better
situating client characteristics and preferences into the organic
equation and to embrace the myriad material factors
associated with the varied availability of resources, the intent
being to recenter shared decision making in more meaningful
and contextually specific manners for a greater number of
health care professions—not just in clinical care aspects, but
so too in related aspects of policy and larger decision-making
challenges. This point is in fact evident in the 1996 retort by
Sackett et al
7
to the original 1992 model for EBP, but perhaps
not as recognizably applicable to professional education or
policy issues. We have attempted to rectify these oversights in
EBAT, as stakeholder expertise, perspective, and context have
been placed front and center of all things education, and thus
too in policy formation and regulation. It is thus our position
that EBR is critical for a body of professionals inherently
interested in, and engaged in the processes of contributing to
other aspects of professional practice.
Satterfield et al
8
were intent on presenting a discourse that
highlighted the environmental and organizational context that
surrounds health care in order to underscore the very real
point that each field and even specific settings within each
field have constraints placed upon them that will in certain
situations impact or effect how evidence can or cannot be used
to make decisions. Insightfully, their model actualizes the
many broad contextual factors that typically serve as
boundaries, but can also reveal opportunities and openings
for even the most well-intentioned evidence-based practition-
ers. What both the transdisciplinary model of Satterfield et al
and EBAT intend is a prioritization of the numerous
constraints related to economic, organizational, social,
cultural, personnel, and political agencies and exigencies that,
if not accounted for, can negatively affect or constrain
professional practice. Contrarily, if these various affects can
be accounted for and appreciated a priori, perhaps more
reasonable and strategic opportunities can be realized that will
chart a more predictable and desirable future.
Integrating the various aspects and challenges associated with
clinical practice with those that align with other practice
aspects of the profession best represents the core principles of
EBAT. Considered together, and not as separate and
unrelated components, EBAT holds the potential to deliver
and shape a more collective evidence-based profession, one
that has been reconceptualized by including aspects relative to
our regulation and education. As Figure 1 depicts, a
medicohealth care profession intent on being full-fledged
consumers and producers of EBP cannot operate independent
of policy, nor of the educational system and apparatus that
effectively and functionally drive its larger practice. If AT is to
achieve professional legitimacy in both clinical health care and
academic domains, it cannot reasonably be comfortable with
policies dictated by axiomatic principles, or by hoping that
ideas alone will prove effective as strategic lynchpins. To this
point, our opening quote is perhaps the most salient as it
cautions us all of ‘‘new ideas promoted with missionary zeal,
new theories with very little evidential basis and the social and
political values of the moment.’’
1(p553)
Evidence-based AT
intends just that; it opens up discursive spaces and provides an
academic blueprint for moving forward with rational, critical,
and multifactorial approaches to solving problems and
proposing evidence-informed directions forward for AT.
In referring to the complete system of the profession of
medicine (education, regulation, and practice), Batalden and
Conway unknowingly and simultaneously described AT’s
current juxtaposition in writing, ‘‘Every system is perfectly
designed to get the results it gets.’’
64
In other words, the
system of AT will get what it is designed to get in the future,
pending of course what it actually designs for itself (to get). If
the system of AT fails to take the opportunity to self-engineer
its collective future, it will get what it deserves, what it was
designed to get. On the other hand, if the system becomes
more proactive and more deliberate by better articulating
what it wants to get, it has the opportunity to design the
results that it prioritizes and values and that hold promise for
reaching those goals. That design (process) can either be
predicated from axiomatic principles and hopeful ideologies
and theories, or it can be engineered by strong, relevant, and
contextually sound evidence—the essence of EBP.
64
For many
in the profession, the primary take-home message from the
master’s degree transition movement was that we needed to
improve the competence of our future professionals, we
needed to produce better professionals. Toward that end, the
master’s degree was put forth at the desired and apt
mechanism to reach that target outcome. Given that collective
professional goal, what is then the best way to get there?
In connecting the mission of education with the mission of
professional practice, physician-researcher-educator Nigel
Oswald
65
underscores a very telling and insightful message
for the AT profession. In addressing his colleagues in medical
education, Oswald unknowingly addresses AT’s desire for a
more prominent seat at the health care table for greater
credibility in and amongst our health care colleagues that
challenge our legitimacy and authenticity. That is, the onus is
on us; the responsibility is on athletic trainers to prove that we
can deliver quality patient care. For many health care
professionals, this is an obvious and customary testament,
but Oswald extends the argument further by highlighting the
interdependent nature of education and practice: ‘‘When we
are able to firmly connect innovation and quality in education
with better outcomes for patients, then we shall be taken
seriously.’’
65(p470)
In 1999, Oswald felt that medical education was still a long
way from being able to objectively address this issue, to link
better physician education with better patient outcomes.
Athletic training is currently at this nexus in its professional
history; it has before it the opportunity to address this
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fundamental linkage between education and patient care with
strategic implementation of evidence-informed policies and
practices designed to enhance the competency of its future
professionals. How will AT proceed toward those goals?
REFERENCES
1. Harden RM, Grant J, Buckley G, Hart I. BEME guide no. 1:
best evidence medical education. Med Teach. 1999;21(6):553–
562.
2. J¨
onsson B. Unwinding the Clock: Ten Thoughts on Our
Relationship with Time. (Trans. Nunnally T, ed.). San Diego,
CA: Harcourt; 2001.
3. Petersen S. Time for evidence based medical education. BMJ Br
Med J. 1999;318(May):1223–1224.
4. Spector N. Evidence-based regulation: a challenge for regulators.
J Nurs Regul. 2010;1(1):30–38.
5. Guyatt GH, Cairns J, Churchill D, et al. Evidence-based
medicine: a new approach to teaching the practice of medicine.
J Am Med Assoc. 1992;268(17):2420–2425.
6. Hjorland B. Evidence-based practice: an analysis based on the
philosophy of science. J Am Soc Inf Sci Technol. 2011;62(7):
1301–1310.
7. Sackett DL, Rosenberg WM, Gray J, Haynes RB, Richardson
WS. Evidence based medicine: what it is and what it isn’t. BMJ
Br Med J. 1996;312(7023):71–72.
8. Satterfield JM, Spring B, Brownson RC, et al. Toward a
transdisciplinary model of evidence-based practice. Milbank Q.
2009;87(2):368–390.
9. Nevo I, Slonim-Nevo V. The myth of evidence-based practice:
towards evidence-informed practice. Br J Soc Work. 2011;41(6):
1176–1197.
10. Cohen AM, Stavri PZ, Hersh WR. A categorization and analysis
of the criticisms of evidence-based medicine. Int J Med Inform.
2004;73(1):35–43.
11. McKeon PO, McKeon JMM. Evidence-based practice or
practice-based evidence: what’s in a name? Int J Athl Ther
Train. 2015;20(July):1–4.
12. Denegar CR, Hertel J. Editorial: clinical education reform and
evidence-based clinical practice guidelines. J Athl Train. 2002;
37(2):127–128.
13. Steves R, Hootman JM. Evidence-based medicine: what is it and
how does it apply to athletic training? J Athl Train. 2004;39(1):
83–87.
14. Drake RE, Latimer EA, Leff HS, McHugo GJ, Burns BJ. What
is evidence? Child Adolesc Psychiatr Clin N Am. 2004;13(4):717–
728.
15. Wilson T, Holt T, Greenhalgh T. Complexity science: complexity
and clinical care. BMJ Br Med J. 2001;323(7314):685–688.
16. Richardson R, Herzog V, Merrick M, et al. Professional
education in athletic training. National Athletic Trainers’
Association Web site. http://www.nata.org/sites/default/files/
The_Professional_Degree_in_Athletic_Training.pdf. Updated
2013. Accessed December 10, 2016.
17. Hart I. Best evidence medical education (BEME). Med Teach.
1999;21(5):453–454.
18. Ginsberg SM, Friberg JC, Visconti CF. Scholarship of Teaching
and Learning in Speech-Language Pathology and Audiology. 1st
ed. San Diego, CA: Plural Publishing; 2012.
19. Biesta G. Why ‘‘what works’’ won’t work: evidence-based
practice and the democratic deficit in educational research. Educ
Theory. 2007;57(1):1–22.
20. Davies P. What is evidence-based education? Br J Educ Stud.
1999;47(2):108–121.
21. Detrich R, Keyworth R, States J. A roadmap to evidence-based
education: building an evidence-based culture. J Evid Base Pract
Sch. 2007;8(1):26–44.
22. van der Vleuten CP. Evidence-based education. Adv Physiol
Educ. 1995;14(1):1043.
23. Whitehurst G. Evidence-based education (EBE). In: Student
Achievement and School Accountability Conference. US Depart-
ment of Education Web site. https://www2.ed.gov/nclb/methods/
whatworks/eb/edlite-slide001.html. Updated 2002. Accessed
February 16, 2016.
24. Mennin S. Self-organisation, integration and curriculum in the
complex world of medical education. Med Educ. 2010;44(1):20–
30.
25. Cristancho S. Lessons on resilience: learning to manage
complexity. Perspect Med Educ. 2016;5(3):133–135.
26. Norman G. A bridge too far. Adv Heal Sci Educ. 2016;21(2):251–
256.
27. Curricular content standards. Commission on Accreditation of
Athletic Training Web site. http://caate.net/wp-content/uploads/
2016/06/2016-CAATE-Curricular-Content_VF.pdf. Updated
2016. Accessed September 16, 2016.
28. Standards for the accreditation of entry-level athletic training
education programs. Commission on Accreditation of Athletic
Training Web site. http://caate.net/wp-content/uploads/2016/04/
2016-CAATE-Standards-Accd-Professional-Athletic-Training-
Programs_VF.pdf. Updated 2016. Accessed September 16, 2016.
29. Sibbald M, Neville A. A hundred years of basic science in
medical education. Perspect Med Educ. 2016;5(3):136–137.
30. Woods NN, Neville AJ, Levinson AJ, Howey EH, Oczkowski
WJ, Norman GR. The value of basic science in clinical diagnosis.
Acad Med. 2006;81(suppl 10):S124–S127.
31. Goldszmidt M, Minda JP, Devantier SL, Skye AL, Woods NN.
Expanding the basic science debate: the role of physics
knowledge in interpreting clinical findings. Adv Heal Sci Educ.
2012;17(4):547–555.
32. Norman G. Teaching basic science to optimize transfer. Med
Teach. 2009;31(9):807–811.
33. de Bruin ABH, Schmidt HG, Rikers RMJP. The role of basic
science knowledge and clinical knowledge in diagnostic reason-
ing: a structural equation modeling approach. Acad Med. 2005;
80(8):765–773.
34. Woods NN, Brooks LR, Norman GR. The role of biomedical
knowledge in diagnosis of difficult clinical cases. Adv Heal Sci
Educ. 2007;12(4):417–426.
35. Woods NN, Brooks LR, Norman GR. It all make sense:
biomedical knowledge, causal connections and memory in the
novice diagnostician. Adv Heal Sci Educ. 2007;12(4):405–415.
36. Schauber SK, Hecht M, Nouns ZM, Dettmer S. On the role of
biomedical knowledge in the acquisition of clinical knowledge.
Med Educ. 2013;47(12):1223–1235.
37. Mylopoulos M, Woods N. Preparing medical students for future
learning using basic science instruction. Med Educ. 2014;48(7):
667–673.
38. Sivapragasam M. Basic science in integrated curricula: a medical
student experience. Perspect Med Educ. 2016;5(4):257–258.
39. Bandiera G, Boucher A, NevilleA, Kuper A, Hodges B. Integration
and timing of basic and clinical sciences education. Med Teach.
2013;35(5):381–387.
40. Norman G. The basic role of basic science. Adv Heal Sci Educ.
2012;17(4):453–456.
Athletic Training Education Journal
j
Volume 12
j
Issue 2
j
April–June 2017 93

41. Bergman E, Van Der Vleuten C, Scherpbier A. Why don’t they
know enough about anatomy? A narrative review. Med Teach.
2011;33(5):403–409.
42. Drake RL, McBride JM, Lachman N, Pawlina W. Medical
education in the anatomical sciences: the winds of change
continue to blow. Anat Sci Educ. 2009;2(6):253–259.
43. Duffy TP. The Flexner Report—100 years later. Yale J Biol Med.
2011;84(3):269–276.
44. Rikers RMJP, Schmidt HG, Moulaert V. Biomedical knowledge:
encapsulated or two worlds apart? Appl Cogn Psychol. 2005;
19(2):223–231.
45. Rikers RMJP, Loyens SMM, Schmidt HG. The role of
encapsulated knowledge in clinical case representations of
medical students and family doctors. Med Educ. 2004;38(10):
1035–1043.
46. Weatherall D. Science and medical education: is it time to revisit
Flexner? Med Educ. 2011;45(1):44–50.
47. Lisk K, Agur AMR, Woods NN. Exploring cognitive integration
of basic science and its effect on diagnostic reasoning in novices.
Perspect Med Educ. 2016;5(3):147–153.
48. Collins JP. Modern approaches to teaching and learning
anatomy. BMJ. 2008;337(7671):665–667.
49. Ghosh SK, Chakraborty S. Enhancing learning in anatomy
lectures. Educ Health (Abingdon). 2015;28(3):216–217.
50. Ghosh SK. Teaching anatomy: it’s time for a reality check. Acad
Med. 2016;91(10):1331.
51. Geisler P. Interprofessional education in athletic training
education: the next wave (to tap the brakes on). Int J Athl Ther
Train. 2015;20(November):1–4.
52. Breitbach AP, Richardson R. Interprofessional education and
practice in athletic training. Athl Train Educ J. 2015;10(2):170–182.
53. Breitbach AP. The organic and strategic growth of interprofes-
sionalism in athletic training. J Interprof Care. 2016;1820(Feb-
ruary):1–3.
54. Olson R, Bialocerkowski A. Interprofessional education in allied
health: a systematic review. Med Educ. 2014;48(3):236–246.
55. Herge EA, Hsieh C, Waddell-Terry T, Keats P. A simulated
clinical skills scenario to teach interprofessional teamwork to
health profession students. J Med Educ Curric Dev. 2015;2:27–
34.
56. Loversidge J, Demb A. Faculty perceptions of key factors in
interprofessional education. J Interprof Care. 2014;1820(Octo-
ber):1–7.
57. Hudson JN, Lethbridge A, Vella S, Caputi P. Decline in medical
students’ attitudes to interprofessional learning and patient-
centredness. Med Educ. 2016;50(5):550–559.
58. Lindqvist SM, Reeves S. Facilitators’ perceptions of delivering
interprofessional education: a qualitative study. Med Teach.
2007;29(4):403–405.
59. Sunguya BF, Hinthong W, Jimba M, Yasuoka J. Interprofes-
sional education for whom? Challenges and lessons learned from
its implementation in developed countries and their application
to developing countries: a systematic review. PLoS One. 2014;
9(5):e96724.
60. Thistlethwaite JE, Forman D, Matthews LR, Rogers GD,
Steketee C, Yassine T. Competencies and frameworks in
interprofessional education: a comparative analysis. Acad Med.
2014;89(6):869–875.
61. Bennett PN, Gum L, Lindeman I, et al. Faculty perceptions of
interprofessional education. Nurse Educ Today. 2011;31(6):571–
576.
62. Sheu L, O’Brien B, O’Sullivan PS, Kwong A, Lai CJ. Systems-
based practice learning opportunities in student-run clinics: a
qualitative analysis of student experiences. Acad Med. 2013;
88(6):831–836.
63. Haddara W, Lingard L. Are we all on the same page? A
discourse analysis of interprofessional collaboration. Acad Med.
2013;88(10):1509–1515.
64. Batalden P, Conway E. Like magic? Patient safety and quality
healthcare. http://psqh.com/psqh-blog/like-magic. Published
2015. Accessed June 15, 2016.
65. Oswald N. Research in medical education. Med Educ. 1999;33:
470.
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