Portal de Periódicos da CAPES

Pauline Cerasoli Lecture

2011; Lippincott Williams & Wilkins; Volume: 25; Issue: 3 Linguagem: Inglês

10.1097/00001416-201107000-00004

1938-3533

James Gordon,

Sports injuries and prevention

INTRODUCTION The purpose of this lecture is to honor Pauline Cerasoli. The best way to honor her—as well as those past generations of leaders and visionaries who have brought us to this point in our profession's development—is to accept the challenge that they have handed down to us. They have passed us the baton. If we look very carefully (and use our imaginations), we can see some words printed on that baton: "Pursue excellence!" Since this word—excellence—is the subject of my lecture, perhaps we should begin by considering its definition. My dictionary defines excellence as "the state, quality or condition of excelling; surpassing others; superiority; pre-eminence."1 This makes us a bit uncomfortable, doesn't it? Excellence seems to be defined by the notion that we achieve excellence in some sort of competition with others. But the pursuit of excellence should not make us uncomfortable, if we understand that excellence is not merely a state; it is rather a process, or more properly—a continual striving to be better, to be the best that we can be. In striving to achieve excellence, it is not the surpassing of others that is important, it is the surpassing of ourselves, or, more properly, of what we have previously accomplished. Excellence should be considered as an important value, and a goal to be pursued. This is what our past generations of leaders, including Pauline Cerasoli, teach us. This is the legacy that they pass on to us. We should note that 90 years ago last month, the physical therapy profession was born in the United States. On January 15, 1921, 30 former reconstruction aides met at Keen's Chop House in New York City to form the organization that we now know as the American Physical Therapy Association (APTA).2 This was the true birth date of the profession. What went before (for example, reconstruction aides) was a gestational period. On this date, the profession developed an organization and an identity. Over the ensuing 90 years, physical therapists with vision and hard work and courage built the profession that we know today. Our past generations of leaders have brought us, at least in a metaphorical sense, to the proverbial mountaintop, where we can see the "promised land." There is no better description of that promised land than Vision 2020 (Figure 1). It envisions that by the year 2020, physical therapy will be provided by "… doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access …."3 In other words, the promised land is full direct access for consumers and full partnership in the US health care system for physical therapists.Figure 1. APTA's Vision 2020Since Vision 2020 was first written and adopted by the APTA in 2000, there has been a tendency to look at it as if it were guaranteed, but it is far from that. What will get us there, and beyond? We face critical challenges to achieve that promise and an uncertain future, given the political, economic, and social turmoil of our times. Indeed, there is significant potential for radical changes in the health care system that do not necessarily include us. Given the risks and challenges, what is it that will allow us to achieve this goal: recognition as practitioners of choice and full partnership as autonomous professionals? The principal argument that I am making in this lecture is this: The essential characteristic of a profession that would achieve such recognition is a strong academic foundation. AN EXAMPLE: ACADEMIC MEDICINE To begin making this argument, I would like us to consider the development of the medical profession in the united states. Specifically, I ask the following question: Why has the medical profession achieved clear supremacy or dominance in our health care system? I would argue that academic medicine is the foundation of that success. Medical schools are widely viewed by the public, by other health care providers, and by policy makers as capable of preparing competent practitioners and engaged in the discovery and testing of effective clinical treatments. This was not always the case. Indeed, in the early part of the twentieth century, the medical establishment faced a crisis of confidence in medical education. In 1910, the Flexner Report, an influential study commissioned by the Carnegie Foundation, examined the state of medical education and found it to be in need of major reform.4 Flexner proposed, among other things, the standardization of medical education, the rejection of non-scientific approaches, the closing of "proprietary" schools, and that medical schools should henceforth all be connected to universities. Before Flexner there were 160 MD-granting institutions. By 1920, there were only 85 MD-granting institutions. By 1935, there were only 66 medical schools operating in the USA. Between 1910 and 1935, more than half of all American medical schools merged or closed. Of the 66 surviving MD-granting institutions in 1935, 57 were part of a university.5 The Flexner Report led to major changes in medical education in the US and is widely credited with establishing the high-quality system of academic medicine that forms the foundation of medicine's place at the pinnacle of the American health care system. Moreover, it is perhaps the single best example of a profession taking control of its destiny by transforming its educational system.6 ASCENDANCY OF ACADEMIC PHYSICAL THERAPY: THE THREE-LEGGED STOOL I believe that academic physical therapy has made great strides in recent years, and it is approaching the level of maturity that is necessary for our profession to reach the goals articulated in Vision 2020. Academic physical therapy can be defined as the collective network of accredited physical therapist programs that carry out, in varying degrees, three interrelated functions: (1) educating the next generation of physical therapists and scientists, (2) discovering the causes of and treatments for disabling health conditions, and (3) advancing the practice of patient care while caring for patients. In this lecture, I want to particularly emphasize the importance of all three pillars of the academic mission: education, research, and practice. This tripartite mission is sometimes referred to as the three-legged stool. This metaphor underscores that the successful academic enterprise requires a strong foundation in all three areas. Furthermore, it is inadequate to define academic physical therapy as merely the combination of these three primary activities performed by academic faculty. We need to highlight the interrelationships among teaching, research, and practice. It is the added value or the synergy that should exist between these three roles—when they are brought effectively together—that defines academic physical therapy. Stated differently, the whole of academic physical therapy is greater than the sum of its parts. Why is academic physical therapy so important for the profession? Because academic programs now form the intellectual center of the physical therapy profession. As Emery notes, academic physical therapy is "where the profession does its thinking."6 In the early stages of the development of the physical therapy profession, large rehabilitation centers, such as the Rusk Institute in New York, the Rehabilitation Institute of Chicago, and Rancho Los Amigos Rehabilitation Hospital in California served this function. In these centers, the professions' leaders were trained and mentored, and new clinical approaches were developed and tested. However, while large rehabilitation centers still make important contributions to practice, they are no longer the center of our profession, and this is a good thing. Again, in order for the profession to be fully recognized by the health care community and the general public, it must be centered in academic institutions. This is where research is led, where educational advances are developed, and where practice is subjected to rigorous scrutiny. THE ACADEMIC ETHOS: A SEARCH FOR TRUTH A critical characteristic of the academic enterprise, at least in principle, is that it exists to serve society—not individuals, not private entities, not even professions. This is the academic ethos: Universities strive to discover truth, whatever the consequences. This fundamental principle is the single most important reason that academic institutions have earned the trust of society, and it has important implications. Academic physical therapy must ensure that (1) practice is based on science; (2) research is not self-serving; and (3) education prepares critical and reflective practitioners. This notion that academia is organized around a search for truth may appear naïve. It is certainly true that this principle is not always achieved, that universities are imperfect institutions, and individuals frequently fail in striving for objectivity in academic activities. Nevertheless, academic procedures (like peer review and merit-based promotion) have developed over time to ensure that we will eventually move toward greater understanding and more effective treatment approaches. This aspect of academic physical therapy is crucial. It is a key reason why the public views a sound academic foundation as essential for a health profession. HOW DO WE ACHIEVE EXCELLENCE? Until now, I have been implying that the goal is to achieve a reputation for excellence of the entire enterprise of academic physical therapy. But now I will argue that the path to such a reputation for collective excellence is demonstrated excellence by individual academic programs and individual faculty members. As some programs or individuals achieve excellence, other programs emulate that success—this is the positive and constructive aspect of competition. What is defined as excellence today is considered the norm tomorrow, and eventually mandated as the minimal accreditation standard. If academic physical therapy is a train, then excellence is the engine, and accreditation is the caboose! Thus, we should look to accreditation not to establish the standards of excellence, but rather to ensure that all programs are keeping up with the norms. We need to create a culture (really an infrastructure) in which all programs are striving for excellence in specific concrete ways and in which the qualities of excellence are copied and incorporated by other programs. That is our challenge, one that I hope will be the primary goal of the new Academic Council of the American Physical Therapy Association. What should be our agenda to achieve excellence? I propose four priorities for academic physical therapy: Research: Extend strong research/scholarship to all programs. Education: Develop a strategy for standardizing the curriculum. Practice: Expect all programs to be engaged in clinical practice. Infrastructure: Focus on program growth. In the rest of this lecture, I will address each of these priorities in turn. Research: All Programs Should Be Involved Should all physical therapist programs be involved in research? Some have argued against this principle. Indeed, just a few years ago, one of our McMillan lecturers advocated such a scenario.8 He proposed that some programs should reduce their requirements to produce scholarship and should donate to the Foundation for Physical Therapy instead. I couldn't disagree more. Research and scholarship define excellence in academia. Without a strong and vibrant research effort, an academic program sends a clear message to the other programs in the same institution—that our profession is nothing more than a set of manual skills and we are merely training programs. There can be no compromise on this principle. If we go down this path, we are in danger of slipping into a two-tier system: one set of programs that do research, another set of programs that just train clinicians. In fact, we have made considerable strides in extending strong research/scholarship to all programs. Here we should give some credit to the accreditation process, which has insisted that programs show evidence that all core faculty members engage in research and scholarship. But we have much more to accomplish. We need to build a national and regional infrastructure, developing partnerships and networks that will allow faculty members at smaller programs to collaborate with each other and with researchers at larger research institutions. This should be a priority for our new Academic Council. Education: Standardize Curricular Competencies It has been frequently stated that there is unwarranted variation in physical therapist practice.8 We might also wonder if this is mirrored by (or even caused by) unwarranted variation in what is taught in physical therapist professional programs. In fact, there is an appalling lack of standardization in virtually all aspects of physical therapist education, from prerequisites to program length to course requirements to amount of clinical education. Here, the accreditation process is no help. It gives us lists of objectives and competencies that need to be included but provides virtually no guidance on how to prioritize among these lists. The public has the right to expect much more standardization than we now deliver. Even if we cannot agree on standard courses, we should at least decide on a standard set of outcomes. I would argue that this is our most urgent task in physical therapist education. We need a strategy to develop a standard set of competencies. The problem: emphasis on preparing generalists. Look at the mission statement of most physical therapist professional programs. As often as not, they declare that the program prepares graduates to practice as generalist physical therapists. (A quick way to observe this is to enter "generalist in physical therapy" into a Google search box. You will get links to dozens of mission statements.) What is a generalist? I am not sure what this term means beyond "not a specialist." Is it somebody who can do everything? Is this realistic? Clearly not. After all, we do not expect medical schools to prepare graduates to do neurosurgery. The lack of a clear definition of this term prevents physical therapy educators from creating effective curricula, and it indirectly contributes to the wide variation in clinical practice. The problem is that we expect our graduates to be able to do everything. Our curricula attempt to prepare graduates equally for all types of practice. This is impossible! The concept of a generalist physical therapist may have been appropriate at one time, but it has clearly outlived its usefulness. The mission of physical therapist education needs to be redefined. The primary curricular objective in professional education should be to prepare a physical therapist who is capable of practicing in direct-access settings. Such a physical therapist requires competency in three areas: (1) making the diagnostic decisions necessary to determine whether a patient is appropriate for physical therapy intervention9; (2) providing effective evidencebased treatment of the common conditions that are found in direct-access settings; and (3) knowing how to refer to specialists when appropriate. This is the promise that we make to the public—to prepare physical therapists who are capable of practicing in direct-access environments. Are we keeping this promise? How would we know? We have not yet defined these "direct-access competencies" sufficiently to answer that question. Again, this is our most urgent task. We need competency-based curricular standards. We need to standardize the curricula of professional physical therapist educational programs. Not necessarily in the names of the courses, the sequences in which they are taught, or the pedagogical methods used to each them, but rather in terms of the terminal competencies. What do I mean by a standard curricular competency? Not procedures! I would define a standard curricular competency as the ability to treat a patient with a defined condition (or diagnosis) under a defined set of conditions, including setting, acuity/severity, age, presence of complications, or co-morbidities. What then should be the basis for inclusion of a given condition as a standard competency? Two things: (1) whether that condition is likely to be seen in direct access settings; and (2) whether there is scientific evidence that can guide the physical therapy intervention for that condition. As an example, consider a patient with stroke. Of course, treating a patient with stroke should be a competency for all graduating physical therapists, but does this mean that graduates should be able to treat a patient with stroke under all conditions? What about a patient with a severe stroke, two weeks after onset, just admitted to a tertiary center for intensive rehabilitation? I would argue that it is not realistic for a new graduate to be able to design and carry out a full rehabilitation program for such a patient. But if we instead consider a patient with chronic stroke who comes into an outpatient clinic with problems in mobility or pain or risk of falling, then yes, a new graduate should be able to effectively diagnosis and treat such a patient. This is a direct-access condition. We should focus our curricula to ensure that all graduates are capable of treating this patient. Does this mean that we do not consider subacute stroke rehabilitation in our curricula? Of course not, but we need to recognize that there different levels of curricular objectives or competencies. In our Doctor of Physical Therapy (DPT) program at the University of Southern California, we have begun the process of defining three levels of curricular objectives: Level 1: Competencies that all DPT graduates are expected to have. Level 2: Competencies required for graduates who intend to primarily practice in a particular specialty area. Level 3: Competencies that are expected of a clinical specialist or a graduate of a residency or fellowship program. What does this mean for the professional curriculum? In each area of practice (neurological, orthopedic, cardiopulmonary, integumentary, etc), we need to define the Level 1 and Level 2 objectives. Level 3 objectives can wait until specialty training, ideally in an organized residency or fellowship training program. Thus, in the area of neurological physical therapy, treating the patient with chronic stroke would be a Level 1 competency, while treating a patient with subacute stroke in a rehabilitation center might be a Level 2 or Level 3 competency depending on the severity and complications. The key difference between Level 1 and Level 2 objectives is that while we require all graduates to demonstrate competency in all Level 1 objectives, we do not necessarily expect all graduates to be competent in all Level 2 objectives. Instead, we expect those graduates who will be entering that area of practice to reach competency in the associated Level 2 objectives. Level 2 objectives might be taught using electives, or they might be taught by adding specific instruction to clinical education experiences. The development of relatively convenient and accessible distance-education tools makes this latter approach feasible, and probably preferable. In any case, as a profession we need to prioritize this process of defining the standard curricular competencies that all programs should be accomplishing. Clinical Practice: All Programs Should Have One All academic programs should have their own clinical practice. This is one of academic physical therapy's biggest weaknesses. Currently less than 25% of PT programs have any form of program-sponsored practice. An analysis in January 2011 of the Web sites of the 200 colleges and universities with accredited physical therapist education programs found evidence for 44 program-sponsored clinical practices. Some of these were fully functioning faculty-staffed clinics; others were relatively modest pro bono clinics. Why should academic programs have their own practice? There are some reasons that are obvious and some that are less obvious. Clearly a program-sponsored clinical practice enhances the professional program by providing a site for clinical education and also by augmenting the full-time academic faculty with clinicians who are actually treating patients in the clinic. There is no question that physical therapist programs need currently practicing physical therapists on their faculty and having a program-controlled practice is one way to ensure that high-quality clinician educators are available. Another obvious advantage to having a clinical practice is that it serves as a venue for clinical research. A less obvious but perhaps more important reason that all programs should have a clinical practice is that it helps to connect the entire faculty to the real world. Too often there seems to be a disconnect between academia and the real world. I often worry that our students get the subliminal message that it is possible to provide high-quality care as long as we do not have to worry about the bottom line, because after all, in our teaching, we do not have to worry about the bottom line. Academic programs should demonstrate that high-quality care can be delivered without losing money. Would this be easy? No! That is why they call it excellence—striving to accomplish the thing that is not easy. Infrastructure: Focus on Program Growth Clearly, to accomplish the first three items on my proposed agenda, we have a lot of work to do. To be successful, we will need to build a strong and robust academic infrastructure. What is the current state of our academic infrastructure? There has been rapid growth in the number of accredited physical therapist education programs in the last two decades; from 126 in 1991 to 213 today, a 70% increase.10 And, we should note, there are currently 13 developing programs not included in this total. The 213 currently accredited programs are housed in 200 institutions, which are evenly split between public and private. At last count, 206 of the 213 programs offer the DPT degree.10 There is much to be encouraged about. PhD-prepared faculty are now the rule rather than the exception in most programs. About 75% of full-time faculty hold the PhD or equivalent degree.10 Furthermore, physical therapist researchers, predominately based in academic settings, are increasingly successful in competing for federal grant funds and publishing in high-impact journals.11 And we have an emerging academic leadership as we see an increasing number of physical therapy faculty in university leadership positions at the dean and provost levels. Clearly academic physical therapy has matured. At the same time, the rapid growth of the physical therapy academic enterprise has created major challenges. The two biggest challenges we face, in my view, are the diversity of physical therapist academic programs and the large number of small programs. Because of the diversity of PT programs, many lack research and clinical infrastructures. One way to illustrate the diversity of physical therapist educational institutions is with the Carnegie classification system.12 In Figure 2, the Carnegie classifications are lumped together, so that the different subcategories of doctoral/research universities, master's universities, etc, are combined as single categories. From this graph, we can see that only slightly more than 50% of all physical therapist programs are housed in institutions likely to have significant research infrastructure. The rest are in masters' and baccalaureate institutions. Furthermore, only about one-third are in academic medical centers. An analysis in January 2011 of the Web sites of the 200 colleges and universities with accredited physical therapist education programs found evidence for 70 programs located within academic medical centers. For faculty in programs that are not in academic medical environments, it will be challenging, to say the least, to find collaborators and support for clinically oriented research and clinical practice. Many programs are too small to exert significant influence within and outside their institutions. Physical therapist education programs are, on average, quite small, especially when compared to programs in peer professions. This means that even those housed in research universities and academic medical centers have limited access to resources and little influence within their institutions.Figure 2. Lumped Carnegie Classifications of 200 Institutions Housing Physical Therapist Education ProgramsOne way to measure the size of a program is by looking at class size. For the 2009-2010 academic year, the Commission on Accreditation in Physical Therapy Education (CAPTE) data showed the average entering class size to be 42.5.10 Furthermore, the distribution of graduating class sizes in 2009 (Figure 3) shows that a significant number of programs are really quite small. Over 50% of programs had average graduating classes numbering between 20 and 40. A total of 20% had fewer than 20 graduates that year.Figure 3. Distribution of Graduating Class Sizes for All Physical Therapist Education Programs in 2009We should compare class size figures to those in our peer professions. We should consider physicians, dentists, and pharmacists as the doctoring professions that we benchmark ourselves against. Yes, these are our peer professions! If we do not compare ourselves to these professions, we are not taking ourselves seriously. Figure 4 shows data for medicine, dentistry, and pharmacy along with comparable data for physical therapy. In Figure 4A, the number of licensed practitioners in each profession is shown. There are more than 600,000 practicing physicians in the US, compared to about 185,000 physical therapists.13 Nevertheless, as shown in Figure 4B, there are only 133 medical schools,14 compared to 200 institutions housing physical therapist programs. Pharmacy and dentistry have only 115 and 92 institutions, respectively. And, when we look at average class size (Figure 4C), the disparity between professions becomes even more dramatic. Average class size in medical schools is 142, more than three times the average class size of physical therapist programs.14 Average class sizes for pharmacy (115) and dentistry (89) are also much larger than those for physical therapy.15-16Figure 4. Comparison of Medical, Pharmacy, Dental, and Physical Therapy ProfessionsIs there something wrong with this picture? Why Is Class Size Important? Actually, it is not class size per se that is important, it is the size of the faculty. Class size is just an indicator of program size—a large class size will support a large faculty. Again, CAPTE data shows that physical therapist programs have an astonishingly wide range of faculty sizes. In 2009, the mean number of full-time faculty per program was 9.7, and the range was 4 to 27. The average number of part-time core faculty per program was 1.2 with a range from zero to 16.10 Does anyone believe that a medical school with 10 faculty members would provide a high-quality education in medicine? Is the physical therapy profession so much less complex than medicine, dentistry, and pharmacy that we need only a few types of faculty? Does an average total of 10 core faculty per program in physical therapy provide an adequate range of expertise? Is this number viable, given the current trends toward specialization? Does this provide sufficient division of labor and economy of effort to allow adequate time for faculty to participate in clinical practice and scholarship? I believe that the answer to all these questions is a resounding "No." A program with a small faculty cannot provide a high-quality professional education program, and it certainly cannot support adequate research and clinical programs. A large faculty improves the education of our students because it exposes them to a greater breadth of expertise. A large faculty is necessary to support research and scholarship. A large faculty allows PT programs to have greater access to resources within their institutions. What is an adequate faculty size? More to the point, what is an optimal faculty size? It is an urgent priority for academic physical therapy to begin addressing these questions. In physical therapy, we have made something of a fetish of small class sizes, as if it were an indicator of quality! It is not, and we should stop pretending otherwise. Finally, we can be sure that in the coming years, there will be more demand to increase the size of the physical therapy workforce. This provides us with an opportunity. We can either start new programs and keep class sizes small, or we can grow our programs. I for one think we should take the latter course. CONCLUSION In this lecture, I have tried to convince you that building a strong infrastructure of academic physical therapy is essential for achieving Vision 2020. Furthermore, for academic physical therapy to be strong and healthy, it must be supported on all three legs of the stool: research, education, and practice. This is not a task for only a few elite programs. All programs must strive to accomplish this tripartite mission. The educational community must move beyond the training mission that we have traditionally been assigned. Our role goes beyond merely supplying workforce. I have outlined an ambitious set of priorities for academic physical therapy in the next decade. We must require all programs to have a strong scholarly agenda. We must standardize our curricular outcomes to ensure that all programs are preparing graduates for direct access. We must insist that all programs engage in clinical practice. And, most difficult of all, we need to strengthen our infrastructure by growing the size and strength of our existing programs, rather than by the proliferation of small, inadequate new programs. Clearly, we have our work cut out for us. How will we succeed? By taking up the challenge passed to us by Pauline Cerasoli and others in our previous generations of leaders: Pursue excellence! ACKNOWLEDGEMENTS Bhavna Shah, a second-year doctor of physical therapy student at the University of Southern California (USC), assisted me in the preparation for the lecture with skillful and invaluable research. Linda Fetters, a professor of physical therapy at USC, originated the idea of levels of curricular objectives, brought it to my attention, and played a major role in the development of my thinking in this area. A number of faculty members and students at USC played a significant role in the development of my ideas. In particular, they listened to an early version of the lecture and gave me wonderful suggestions for clarifying my ideas. Likewise, my colleagues on the various task forces and organizing committees that led to the formation of the Academic Council stimulated me to develop many of the ideas discussed here. I, and the profession as a whole, owe a special debt of gratitude to the family and friends of Pauline Cerasoli, whose support for the annual lecture has provided an indispensable forum for discussion of new and innovative approaches in physical therapy education. Finally, and most important, I should acknowledge my wife, Provi. Without her love and support, I certainly would not have had the opportunity to deliver this lecture.