Joachim Zuther, Lymphedema Specialist.
Safety of patients suffering with lymphedema and maintenance of the highest standards in the diagnosis, treatment and management of lymphedema must be the utmost priority for all medical institutions, educators and therapists involved in lymphedema care. Why? Because patients deserve nothing less, period!
Lymphedema patients have been misdiagnosed and mistreated for hundreds of years; however, in a more positive light, members of the lymphedema community, including patient advocates, therapists and educators have worked tirelessly over the past decades to improve diagnostic and treatment standards, while establishing meaningful and necessary guidelines for the training of lymphedema therapists in the U.S. and worldwide. As a matter of fact, the current state of training for Certified Lymphedema Therapists (CLT’s) is at the highest proficiency standard in history, whereby it is understood that live hands-on training in schools specialized in the training and certification of CLT’s remains the only effective and responsible system for developing the necessary manual skills to treat a disease as complex as lymphedema. This has been proven for nearly 30 years via live instructor assessment and the honing of skills in a classroom of peers, similar to all other rehabilitation, medical and surgical training programs.
This is why the announcement (1) by the Lymphology Association of North America (LANA®), which intends to allow the entire 135-hour certification course for CLT’s to be taught virtually, without certified instructors being physically present, including the hands-on practical lab work, is so startling and will inevitably prove to move the bar for responsible training for CLT’s to an all-time low if not challenged!
LANA® was created in 1998 to establish certification guidelines for health care professionals diagnosing and/or treating lymphedema and related conditions. Following in March of 2018, some 20 years later, LANA® was granted accreditation by the American National Standards Institute (ANSI), an elite organization, which assesses many quality standards in various industries. LANA’s accreditation was largely granted based upon the measure of quality of its’ CLT-LANA certification exam which measures the knowledge used in the treatment of lymphedema and, most importantly for the current and presently valid LANA® guidelines of a 1/3 theoretical, and 2/3 LIVE practical lesson format spanning a minimum of 135 hours of study.
It should be noted that LANA® would not have sought accreditation for its credential “CLT-LANA”, had it not been for leading training schools demanding and stewarding the accreditation process from start to completion.
The 1/3 theoretical portion is delivered either in the live classroom setting or via home study modules and has proven itself effective in either format since 2009. Home study includes either pre-recorded lessons accessed via various media formats to include online portals or non-electronic traditional formats; the 2/3 practical education requirement is delivered in the live classroom setting among student peers, and with an instructor physically present in the classroom, a format that has also proven itself to be effective and necessary in all instructional programs currently recognized by LANA®.
LANA® recently announced to all school directors that as of January 1, 2022, it will no longer require a live practical education requirement, instead supporting synchronous virtual training, without certified instructors being physically present, contrary to the worldwide acknowledged gold standard live practical skills training models. In our opinion as lymphedema certification trainers with extensive experience, such modifications will inevitably result in inferior training and preparation of CLT’s and subsequent incompetent practice. As inevitably follows, patients affected by lymphedema will pay the price and suffer when encountering the eventual ranks of virtually trained “CLT’s”, an objective many of us have worked for decades to eradicate!
LANA® defends its decision without data to support comparable practical skill and competencies are earned in these two groups of students. As justification LANA® cites that competencies must be examined/tested only in a live setting before students earn a Certificate of Completion, yet the examiners are not extensions of LANA®, but rather the same virtual instructors of a given virtual program. Furthermore, programs having chosen to train the virtual Certified Lymphedema Therapist will not be inclined to offer unbiased examinations for fear of exposing the substandard level of education they provide, which will lead to a new cohort of unqualified CLT’s entering the field.
As founders and directors of lymphedema training schools upholding the current standard, we strongly oppose the position LANA® has adopted and have made clear during focus groups with LANA and the American Cancer Society, that we do not intend to change the processes for the current courses’ delivery regardless of this less strenuous, logistically simpler and less financially demanding model championed by LANA® starting January 2022. The manual techniques used in the treatment of lymphedema are highly specialized and cannot be compared to any other techniques a therapist has learned and practiced in their earlier education and patient interaction. A live practical directive from certified instructors and feedback from student peers on tactile input is essential in building hands-on skills for lymphedema therapists.
In an effort to deflect a corrosion of training standards, the Academy of Lymphatic Studies and the Norton School of Lymphatic Therapy conducted a survey in September of 2020 of their respective CLT graduates. Sample questions of this survey included:
- The live practical instruction provided during my CDT Certification training was essential in building my hands-on skills as a CLT.
- Personalized instructor feedback in the classroom contributed significantly to my manual skills development and theoretical comprehension.
- Daily interaction with student peers in a live classroom was essential in preparing me to treat lymphedema patients
- The current recognized LANA® training program structure of 45 hours of theory curriculum and 90 hours of live practical instruction is of sufficient length, and utilizes an ideal ratio of time allocated between the two components
Possible answers to the above questions were “Completely Agree”, “Somewhat Agree”, “Unsure”, and “Disagree”.
Of the over 800 graduates, who answered and returned the survey 95% answered question 1. with “Completely Agree”, 91% answered question 2. with “Completely Agree”, 78% answered question 3. with “Completely Agree”, and 67% answered question 4. with “Completely Agree”.
These responses could not be any clearer, and to further underline their importance, came from CLT graduates, i.e. therapists who went through the strenuous process of lymphedema training and are thus familiar with the demanding workload of learning and internalizing the techniques necessary to treat lymphedema safely and effectively in the classroom setting.
Summary
COVID-19 forced society to adapt to distance learning models exposing which fields of study are responsible candidates for revising methods of course delivery away from traditional classrooms and into virtual formats. Conversely, COVID clarified programs of study that are poor candidates for virtual delivery, yet LANA has either not researched, or ignored this issue prior to adopting this revised approach. Available literature on the topic of remote learning frequently points out the weaknesses of online instruction, particularly when it comes to hands-on learning subjects, where physical movement and practice, as well as tactile feedback contribute to the achievement of the learning objectives (2, 3, 4) . While remote learning certainly has its strengths, hands-on, practical instruction is most certainly not one of these, as underlined in the literature and the authors’ extensive experience as trainers and educators in the field.
LANA’s lowering of the bar in terms of educational standards represents a disservice to the lymphedema community and is not supported by the authors of this article and other responsible training programs. In the future, patients suffering from lymphedema bear the additional burden of having to make sure that their therapist learned the hands-on treatment techniques in a live classroom setting!
Steve Norton – President, Norton School of Lymphatic Therapy
Joe Zuther – Founder, former Director Academy of Lymphatic Studies
Resources:
- https://clt-lana.org/
- University of Illinois, Springfield
- University of Wisconsin, Madison
- https://crowdmark.com/blog/swot-an-in-depth-look-at-pros-and-cons-of-distance-learning/
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