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What Do We Need to Know? Continuing Ed, Certification, and Professional Self Assessment in Context

Lately I have observed increasing numbers of therapists questioning whether they need extra certifications and credentials to skillfully perform their duties. There are myriad reasons for this. Some insurance companies require specific credentials beyond being a therapist for service reimbursement—a practice whose legality I question. Others want to demonstrate competence and professional enthusiasm to their current employer by obtaining more training. Some therapists want to increase their marketability to future employers. Still others simply wish to increase their competence in a specialized skill that they want to excel in. And I think it is fair to say that whether we admit it or not, we work hard and we’d all like the increase in respect and status that we sometimes seek in formal education and credentialing.

I am not writing this essay to validate or invalidate anyone’s motives for obtaining additional credentials, but I do want to critically appraise some of the assumptions we take for granted regarding learning, education (especially continuing education and credentialing), degree and title. Before I begin, I want to clarify that I have no beef with formal education. Having ten years of didactic, classroom education has given me an appreciation for it—and a great love for it, at times. I have also come to appreciate differences between education versus learning, and education versus experience as paths to knowledge.

It is seldom noted that much learning is invisible. It’s informal, sometimes planned but sometimes spontaneous. It is not rewarded, and often goes unrecognized—even by the therapist in the act of attaining it. Some of the highest quality learning can take place in unplanned moments, in the crucible of experience. By sharpening our perceptive and metacognitive abilities, by being open as well as observant, we can capture the essence of those experiences and convert them into new learning.

Being learned and being educated often do coincide, so an important difference between them is overlooked. Ignorance and (let’s just call it what it is) stupidity can live and even thrive at the highest levels of training and education. No type or quantity of degrees is a safeguard against it. Ignorance is not a derogatory value judgment, just a point of reference for all of us. Stupidity is a negative judgment whose subjectivity does not negate its existence. Stupidity celebrates ignorance and lauds inflexibility in thought, action, or belief as strengths. It confuses self-aggrandizement and status seeking as intellectual superiority and is therefore closed off to the manifold lessons available by being open to what every person and every experience can teach us. Education is proof of effort, not proof of intelligence or insight. Therefore, it behooves us to cultivate the qualities of the learned, and not simply assign education as the benchmark by which we ascribe excellence in thought or skill.

My bias regarding additional credentialing is this: I don't think extra degrees make us more marketable or result in increased salaries except in rare cases. Also, while we may require additional learning, I’m not sure that additional credentialing is always the best path to professional competence; it’s certainly not the only one. I say this not only as someone who has attended many trainings and classes over the years, but also designed and taught them as well. While some credentials are essential (required even) for certain skill areas, there are many situations where we could learn new information on our own or from numerous sources. As OT's we are already highly trained bricoleurs who synthesize multiple therapeutic modalities and adapt them to help patients. Ask yourself, is there a specific skill or skill deficit that is holding you back from doing what you need or want to be able to do? What is the best way to excel as a therapist? From my earliest graduate school days to the present, I always evaluate every technique, method, or theory I encounter in terms of this one foundational question: Will this make me a better clinician? How so?

As is the case with so many practice realities, there are often more questions than answers when it comes to continuing education, professional competence, and what makes us “better.” How we define assessment of growth and professional development needs are as important as how define learning and education. Further complicating the matter is the fact that there are multiple agendas at play in this process: yours, your employer, your state, and insurance companies, among others. Above all, the most important question to ask relative to continuing education is what do your patients need from you as a clinician? What follows below are some questions to reflect on as you measure your personal and professional development needs, especially if you are considering obtaining a certificate or credential beyond what is needed for entry-level practice.

First off, can the skills you want to acquire only be obtained through a certificate program? For instance, you don't need to be a yoga instructor to use yoga therapeutically, but if you love yoga and want to make it a personal or professional focus, then additional formal education might make sense. But make it about you and what you want to offer, not just a present or future employer. By the same token, you don’t need to be an art therapist to use art as a modality or a music therapist to use music as part of an intervention. These other credentials add a richness and depth to their areas of study that make them highly valued, but just as we use the concept of grading with our patients, we can also apply it to ourselves and our own educational needs. Therefore, we do not need to be an expert in the modality we are using to use it therapeutically (with a few important exceptions, see below) if we recognize the limitations of our competence.

Some areas of practice do require advanced training, certification, or demonstrated skill and competence which are higher than entry-level. Does yours? This is often true of advanced medical techniques, like Physical Agent Modalities. Still, even with PAM’s the credentialing is not always clear-cut, and may not be considered the only path to attaining competence in their use. In some state I’ve been licensed in, advanced training and a special licensing addendum is required. In others, you may not even need a formal class so long as you are not operating beyond the limitations of your professional skills. Corollary to the point made above, hand therapy is a highly advanced specialty area, and yet there are many therapists who practice hand therapy without referring to themselves as “hand therapists.” In these situations, it’s important to see where state laws, insurance reimbursement regulations (if they are relevant) and your competence intersect. What is the commensurate level of expertise required to safely and effectively resolve the identified problem? While there are no simple answers here, think about the degree of severity and complexity of the patient’s problem areas, and self-asses your own training and experience relative to that. To continue with the hand therapy example, knowing my level of skill and knowledge to be entry-level, I would always refer a patient with a complex wrist fracture to a Certified Hand Therapist, but if the patient requires a minor adjustment to a wrist split they’re already wearing, I might consider making the adjustment myself.

If you are considering additional certification to increase your marketability to employers or to clients, what is the evidence that the certification will achieve those ends? What assurances do you have that the possible employers you are querying for jobs will take your extra credentials seriously? Will the credential lead to an increase in salary? How do you know? And is it worth the investment in both your time and money to put that extra bullet point on your resume? Not to dwell on the negative, but another aspect to consider is that in some scenarios, additional certifications could hurt your marketability with employers. As unfair as it is, there is nothing stopping an employer from rejecting you for being “overqualified,” whether because of fears of being unable to pay you a fair salary or other concerns. Even the concept of being “overqualified” is absurd, but that doesn’t stop employers from using it to make judgements. It happens. I would not advise deciding about your educational endeavors based on this point alone, but it is worth considering, especially if marketing your skills is one of your primary aims.

What are the credentials of the credential-er? (That was fun to say). In other words, how do you know that the body (or individual) that is conferring your training and certificate is qualified to do so? What agencies oversee them? What regulations must they follow? Are there agreed upon standards that must be adhered to, or are individual instructors free to do as they please? Do they make claims about increasing your knowledge and/or wealth that sound unrealistic or grandiose? These are important questions because, with the advent of online-only education, numerous “schools” offering a bewildering diversity of certificates and degrees have popped up.

The laws governing their quality are loose, vague, and rarely enforced, and it is often left to professional organizations to do their own policing. If information about the school or trainer is murky, contradictory, or difficult to find, those might be red flags. To put it bluntly, some schools and trainers are quasi-legal scams that take peoples’ money on false pretenses, offering little to nothing of value in return for the payment they receive—sometimes via loans, sometimes out of pocket, but always via the student’s supply of cash or credit. They prey on desperate consumers hoping to better their financial circumstances or their professional prospects, and many of them specifically target therapists. Some promise financial aid, implying the availability of grants or “free money” which either do not exist or are very insubstantial when compared to the total cost of the program. Some falsely cloak themselves with a veneer of credibility by making overtures to ancient practices or references to professional organizations that are misleading, perfunctory, and vague. I routinely receive numerous, questionable offers from companies that promise me more clients, more money, more skills, etc. Many of these operations begin their sales pitch by stating that everything the therapist has been doing up to this moment is wrong, and they offer the one and only solution. Look upon such declarations with a jaundiced eye. Another way of putting these offers in perspective is to ask what is the ratio between time and expense versus the expected benefit to you? For a single daylong continuing education seminar paid for by your employer, these considerations may be relatively minor, but if you are making a substantial investment of your time, money, and effort, they are worth pondering—and investigating.

Is the credential you seek in concordance with professional standards of occupational therapy? There are numerous pseudo-scientific “therapies” out there that deploy methods which are unsound, unscientific, and employ magical thinking. Therapies that employ techniques such as the laying on of hands, manipulating energy fields, or using metaphysics and mysticism may be appropriate in some settings, but not in an OT clinic or in the clinic of any licensed health care professional. There are literally dozens of permutations of these methods, and some are harder to spot than others because they selectively co-opt scientific lexicon and concepts. Some have claimed that therapies which rely solely on the placebo effect do no harm, and often make patients feel better. That may be true in some instances, but in our role as therapy professionals, we are required to do more than simply not harm our patients. We are required to actively help them.

“Best practices” is a malleable concept that defies universal agreement, and that is even more reason why it is imperative to have sound clinical justification for the treatments and interventions we use. Because there is often vehement disagreement—and strong feelings—attached to various methods, I will not mire this essay in a discussion of valid versus invalid therapies. However, we should all be held to high standards. In cases where an OT chooses to deploy mystically oriented treatments, the therapist has a duty to explain to the client that those treatments are not vetted, they are not occupational therapy, and clients should not be charged for those treatments the same as a skilled therapeutic service. Blurring the lines between occupational therapy and mysticism may be a choice with a personal dimension, but it is not an allowable professional one; it has the potential to harm not just patients, but our entire profession. There is already so much ignorance and misunderstanding regarding our role as it is, we risk seriously damaging our reputation and the public trust if we allow all therapies, theories, and modalities to use the name of occupational therapy equally. It is possible to be both skeptical and open-minded. While some treatments have received a paucity of research and aren’t vetted yet because they are new and cutting edge, others have been around for decades and failed the test of numerous standards, yet they still persist by dint of their popularity or excellent marketing. We make those nuanced assessments to promote innovation in the field—but even innovation must be tempered by established best practice, especially where safety is at issue, and efficacy is impossible to assess.

Now we return to that most basic of all questions: How will the credential make you a better clinician? Credentialing offers the allure of attaining skills above and beyond our basic continuing education requirements, and a means to show that we care about and take our profession seriously. But is an additional credential or degree the best way to do that? Sometimes the answer may be yes, for many of the complex reasons delineated above. Indeed, there are some skills we cannot master without sophisticated guidance and careful supervision from an expert. In these cases, the additional vetting conferred by formal testing and certification acts as an assurance of our safety to practice and fidelity to established standards.

However, what are the deficits in your knowledge and skills as they apply to your current or future patients? What can’t you offer them that you think they need, in terms of knowledge or skill? Is credentialing the only—or best—method for obtaining the knowledge your practice really requires? The answers here are personal as well as professional because we can all identify areas where we would like to improve. It is worth asking which of those perceived deficits are critical and which are peripheral. Put another way, what skills are we missing that we absolutely need versus what we’d just like to be better at?

Another set of questions to ask is who is really perceiving these deficits and why? Is an employer providing pressure to remediate poor performance? Is a patient giving feedback (positive or challenging)? Is your own internal voice telling you that you are not good enough at what you do? Are you being driven by curiosity and a thirst for learning, or by fear and anxiety about professional competence?

The latter question is an especially important one to regularly reflect upon, as we are sometimes subjected to forces which manipulate our attitudes toward ourselves and unconsciously shake our self-confidence. Advertising and social engineering are some causes of that. So is the all too common (and often reasonable) fear among occupational therapists of not being taken seriously as professionals. Life is complex, so it is seldom one motivation or another, but a combination of many things that drive our decisions.

At the end of the day we must synthesize the feedback we get from multiple sources and compare it to what we know about ourselves. We take it all in of necessity, but we draw our own conclusions about ourselves with the understanding that no one knows our full story as we do. The task is not to eliminate all other factors until our decisions are based on the “purest” of motivations. Instead, we must recognize the pull exerted on us by various forces, both rational and emotional, so we can make the best, most conscious decision about where to concentrate our professional development efforts.

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