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Developing Habits of the Heart: 22nd Polly Cerasoli Lecture

2019; Lippincott Williams & Wilkins; Volume: 33; Issue: 4 Linguagem: Inglês

10.1097/jte.0000000000000133

1938-3533

Terrence Nordstrom,

Primary Care and Health Outcomes

I am so blessed and honored to be in your presence today and to honor Polly Cerasoli. I want to express my deepest appreciation to her family for making this afternoon possible and honoring everything Polly meant to our profession. I also want to thank my predecessors who wove such a wonderful tapestry in tribute to Polly and to our collective efforts to improve physical therapy education. I hope I can add a beautiful new pattern to what they have woven, and that our successors do the same. I would not be standing here today without the love and support of my family, many of whom were able to join me today: my mother, Norma, and my sister, Lane, 2 of my 3 sons, Matt and Adam, and my daughter-in-law, Anita, and my grandson, Ashwin. My oldest son is a high school basketball coach, so you know why he isn't here. To my dear wife, Deirdre, I love how we take care of each other—more about her in a minute. I want to thank my colleagues at Samuel Merritt University who spearheaded my nomination and to those of you who wrote letters of support—I truly appreciate your support and confidence in me. Particular thanks go to Nicole, Elizabeth, and Gail for pushing me harder—in a good way. Thank you! As I was practicing for today with Deirdre, she kept telling me: "I want to hear 'Why is this important to you?' and 'How did you get you here?'" So, in honor of Deirdre's persistence, I will share that story. There are only 5 stops along the way. I will make it brief. Although it really starts with family, I am going to start with the physical therapy school at Stanford in 1975. There were many characteristics of that program that made it an exemplar of excellence, but one was its emphasis on leadership, teamwork, holistic care, and the importance of interpersonal communication with patients. Kay Shepherd, who gave the first Cerasoli lecture in 1998, was one of the faculty members and an early mentor. I heard the echoes of her voice as I was preparing for today. What a genuine honor to follow in Kay's footsteps, 21 years later. I had the honor of working with Peter Edgelow in our practice in Hayward, California. Peter taught me to be present with patients about careful, attuned listening, and of putting their stories at the forefront. He said, if you listen carefully, they will tell you what to do. Peter was also my best friend, and sadly, he passed away this summer. Another person instrumental in today's talk is Cindy Moore. Many of you knew Cindy. She was a physical therapy educator. In fact, her first faculty position was at Stanford when I was a second year student there. She and I were together for nearly 8 years. Cindy opened my heart to trust myself and to honor our spiritual selves as teachers and learners. She taught me to envision the best possible outcome for all concerned and to make expectations explicit. Cindy always said, "You have all the time you need." Sadly, we lost her to cancer in February 2011, but she was with me every step of the way. I have been at Samuel Merritt University for 27 years, having started as an adjunct instructor in the second year of the program. It is such a privilege to have worked with every physical therapy class that has graduated from the University. Samuel Merritt University has made a commitment to creating a diverse, inclusive health care workforce ready to serve our communities who are in greatest need. I have learned so much being surrounded by the students, faculty, and staff who are committed to our mission. Finally, it was my friends and colleagues on the Excellence and Innovation in Physical Therapist Education for the 21st Century (PTE-21) research team—Jan Gwyer, Laurie Hack, Gail Jensen, and Elizabeth Mostrom. What an absolute privilege to see the commitment to excellence in our profession and to work with this incredible group of women. This was the culminating experience that allowed me to integrate all of my previous learning about the importance of developing habits of the heart. There are 2 physical therapists who you are going to meet today, who told me their stories and allowed me to share them with you. AJ could not be here; she is part of the Research Section's Stanford Forum on Qualitative Research that is on the schedule at the same time as this lecture today. We could not get them to change their schedule. The other is Zachary, who is here. One of the hallmarks of professions is that they have a greater social purpose that is of significance to society.1 Our vision, "Transform society by optimizing movement to improve the human experience,"2 shines a light on our greater purpose and significance. Our educational programs are the nurseries where students learn to embody what it means to be a physical therapist.3 During their time in the nurseries of professional education, we have the challenge of developing the habits and dispositions of what it truly means to be a member of a profession so that we can realize our greater purpose and significance to society. Among the habits of the mind, the hands, and the heart, it is the habits of the heart that receives the least attention but has the greatest potential to help us realize our vision and be of greater service to society. Today, I will focus on the habits of the heart, what they mean and how we develop them to give them the attention they require and deserve. By the time I say "thank you" at the end of today's talk, I want us to have a shared commitment to do what it takes to prepare physical therapists who will serve the people and society to meet our profession's greater significant purpose that our vision expresses. THE 3 APPRENTICESHIPS An important conceptual framework of the Carnegie Foundation's Preparation for the Professions Program is that there are 3 apprenticeships that provide the foundation for learning the habits of being a member of a profession.1,4-10 Through the apprenticeship of the mind, students learn the knowledge base of the profession, the analytic reasoning, and the evidence that supports practice. Thus, in this apprenticeship, students develop habits of the mind in which they learn to think like a physical therapist. Through the apprenticeship of the hands, students learn to apply the evidence, clinical reasoning, and skills of the profession through situated cognition in the context of practice. Thus, in this apprenticeship, students develop habits of the hands in which they learn the skillful practice of the profession. Through the apprenticeship of the heart, students learn the moral foundation of the profession that encompasses our ethical and fiduciary responsibilities to individuals and to society. This apprenticeship is one of the professional formations in which the student remakes herself into a physical therapist through her own engagement with learning in the complexities of the profession's practice. The apprenticeship of the heart is an integrating apprenticeship that brings together cognitive and practical learning with the profession's larger purpose in society.1,4,11-13 Thus, in this apprenticeship, students develop habits of the heart in which the student embodies what it truly means to be a member of the profession, gaining a sense of moral agency and a sense of our significant purpose to the people and society we serve. There are 4 assumptions that underlie my talk. 4 ASSUMPTIONS Assumption (1): Students are not blank slates. They arrive with a story of their development, including their moral development, and why they want to be a physical therapist. Some of them bring experiences, identities, and ways of expressing themselves that differ from the status quo in our profession. How we create an inclusive environment that honors these differences during the journey of becoming will only enrich our profession, but the implication is we have a responsibility to honor each student and all of the richness they bring.14 I want to introduce you to the 2 physical therapists who have let me share their stories with you. Meet AJ. I first met AJ when she was a student. She has been in practice a few months. Here is what she told me about the start of her journey."I had no inclination of going into physical therapy at all. I studied gender and women's studies and history and a little bit of environmental studies. I actually did AmeriCorps for 2 years." AJ is not someone who knew she wanted to be a physical therapist from the time she was 16. She finished college in 2009 and joined AmeriCorps because the recession made for a tough job market. Her interest in activism and justice started at a very young age and was solidified by her undergraduate work in women's studies and gender. Then, she discovered physical therapy.I wanted to go into PT because I had been a patient and my partner … was a patient at the time that I … decided. … I was like I can kind of see this. I knew a lot of people who had experienced persistent pain. And was really interested in … learning more … and collaborating with people to manage … persistent pain. Through exposure to the field, she could see herself doing this work and she makes a connection to serving people learning and collaborating. As you will hear later, 2 agencies where she worked lead her to value collaborative, client-centered, community-based models of practice. We will leave AJ here, before she begins her physical therapy education. Meet Zachary. It turns out I also met Zachary the first time when he was a student at Combined Section Meeting (CSM). He has been in practice a few years. As a teenager, Zachary drove his mother to her physical therapy and became interested in what he saw. Then, he had an overuse shoulder injury and became a patient himself."… there is no way that just doing stretchy band exercises and stretching my shoulder is going to help my shoulder pain" … And lo and behold 4 weeks later I was as good as new. … this really made a big impact on my life. What does it take to get into this field and have this kind of impact on others? Similarly—through exposure, his mother's and his—he could see himself doing this work and serving people. We will jump ahead to Zachary's first year in practice. In what he calls "fortuitous luck," his first job was serving in a predominantly African American urban community where the residents were often living in poverty. He chose that job not because it was in an underserved community, but he thought it would be better for him as a new graduate than floating between clinics. Here is what he said about his first few months in practice.I have been well prepared through my education. This is going to be great. I was struggling to connect with my patients first of all because they were coming just from a very different cultural place than what I had grown up with and what my background was. Also, the interventions the actual skills I was taught did not seem to be making a difference. It is fascinating to me how Zachary sees his struggle connecting with patients and his skills as something he needs to figure out. It isn't the patient's problem. Assumption (2) The courses in our curriculum that address professionalism and ethics are often assumed to be where students learn these habits of the heart, and the rest of the faculty are off the hook. What I intend to illustrate today is that developing habits of the heart is the responsibility of every person in every course and every clinical experience that students encounter. Assumption (3) There is no perfect excellent program out there, as our study of excellence showed. Even the best programs and clinics among us have room to grow and improve. There are probably programs and clinics that are excelling in areas where those in our study were struggling. My hope is that, no matter where your program is in its development, you find something of meaning and value today. Assumption (4) Although not every student is going to graduate ready to invest in our broader purpose to society on the day they graduate, they better have a clear idea about what our significant purpose is. They need to be prepared to embody what it means to be a member of our profession with every patient and colleague. They also need to have the potential and desire to actively work to realize our greater purpose to society. We are creating the conditions that make their future possible, so if a plant nursery metaphor works for professional education instead of a baby nursery, it is important that we get the soil, light, nutrients, and water just right. But these are quite active plants; in fact, some are pretty vociferous plants. AJ and Zachary came to that potential at different times and in different ways. AJ said,I was a social justice activist organizer beforehand. I was hopeful and optimistic that I could find purpose and do social justice work from the location of being a health care practitioner. AJ brought a vision of connecting her value of social justice into practice as a physical therapist.Zachary: I thought pursuing an orthopedic residency would be the thing that helped me. I developed my skill set. My reasoning. All of these wonderful things we think about. And still it was not helping. I was getting some folks maybe a little more effectively treated, but mostly feeling very ineffective with this population. So, at that point, I started seeing what else is going on? What else could be done here? Zachary pursues an orthopaedic residency and still, he is not as effective as he wants to be. What does he do? He asks again, "What's going on here? What could I do differently?" He is taking full responsibility as the professional. He is not blaming the patients. He did some research and discovered health coaching and completed a certificate program. This leads me to our vision. Here are my questions about what we mean by the 3 elements of our vision: When we say, "transform society," what parts of society are we committed to transforming and how? Every corner? Does that transformation include people whose voices are often the least heard because of their gender, how much money they make, their skin color, or if they use a wheelchair? How are we creating a shared vision of how we will transform society? What about "optimizing movement?" Do we have a shared understanding of the moral dimensions of movement and what movement means to the people we serve? How do we move beyond the clinical and technical aspects of movement to integrate movement's moral dimension into practice and education? What do we mean when we use the word "body" in our teaching and learning?15-17 Finally, "to improve the human experience." The human experience in health care can be joyful, terrifying, sad, or messy. It can be warm and fuzzy or cool and prickly. Ultimately, it is about 2 people who come together, one in need and one with expertise. What will it take to fully integrate what it means to be part of the human experience into being a physical therapist? I will connect developing habits of the heart to our vision, but I am going to do it in a different order: I will start with optimizing movement, then move on to the human experience, and end with transforming society. OPTIMIZING MOVEMENT: FROM CLINICAL TO CONTEXTUAL These are the questions I have about movement. Do we have a shared understanding of the moral dimensions of movement and what movement means to the people we serve? How do we move beyond the clinical and technical aspects of movement to integrate the moral dimension of movement into our practice and education? What do we mean when we use the word "body" in our teaching and learning? Here is the American Physical Therapy Association (APTA) definition of the movement system:The movement system represents the collection of systems (cardiovascular, pulmonary, endocrine, integumentary, nervous, and musculoskeletal) that interact to move the body or its component parts.18 Figure 1 is the APTA's graphic representation of the movement system. Because movement is our unique contribution to health and health care, our collaborative efforts are essential to make the movement system central to our practice. It seems to me that the graphic representation of movement and definition are disembodied. Maybe it is implicit, but there is no entity that embodies movement nor does it reflect a greater purpose for movement. The APTA includes these 3 statements in the description of the movement system: Physical therapists provide a unique perspective on purposeful, precise, and efficient movement across the lifespan based on the synthesis of their distinctive knowledge of the movement system and expertise in mobility and locomotion. Physical therapists examine and evaluate the movement system (including diagnosis and prognosis) to provide a customized and integrated plan of care to achieve the individual's goal-directed outcomes. Physical therapists maximize an individual's ability to engage with and respond to his or her environment using movement-related interventions to optimize functional capacity and performance.18 Figure 1.: APTA Movement System Model.18 Reprinted with permission from the American Physical Therapy Association. Movement system. http://www.apta.org/MovementSystem/. Accessed December 29, 2018.These bring us a little closer to the meaning of movement, but they are mostly about physical therapy and physical therapists. Movement occurs in sociopolitical and sociocultural contexts.15-17 For example, how does our society advantage or disadvantage movement that is influenced by body size or using a wheelchair? How does being a person of color influence how and where one moves? Where and how does movement occur for the person who identifies and expresses themself through a nonbinary gender identity? How does me being a 65-year-old, 6-feet tall, white, straight man relate to where and how I move? What about the movement of the 65-year-old, homeless, Vietnam War veteran with PTSD and addiction who "frequently flies" through the emergency department, hospital, and clinic? I intentionally used that derogatory phrase. There is no argument that we must address the underlying physiological structures and functions that make movement possible. People come to us when they need our help as experts in movement so that they can participate in their life in whatever ways are possible and meaningful. Because movement is one means of participation in life, it expresses who that person is and what is important; thus, movement is value laden. When we place the person, who seeks our services at the very center of our interaction, we integrate the body with movement as object to be diagnosed in a biomechanical, physiological, and anatomical realm with the moral realm of situated, contextual, interpersonal, and intersubjective movement. Zachary said,… probably the musculoskeletal issue is impacting your life but coming to PT is the least of your worries. You are worried about moving from motel to motel. You are worried about where you are going to be sleeping next week. You are worried about getting food on the table for your kids. You are worried about violence in your neighborhood. Zachary acknowledges the problem in the movement system but, for his community, there is a moral dimension to movement that he must attend to. These considerations lead me to believe there is a place for humility and grace with a broader, more collaborative framework for understanding our role and influence on human movement in practice and in how we teach and structure learning about movement. As I think about optimizing movement, I think about the concept of signature pedagogies. Central to our work in the study of excellence in physical therapist education was discovering our profession's signature pedagogy.3 Signature pedagogies are the characteristic, fundamental forms of teaching and learning of a profession through which students acquire the "understanding, skills, and dispositions"3p.56 that we value. When you think of signature pedagogies, think of bedside teaching in medicine and the Socratic case dialogue method in law. We identified our signature pedagogy as "the human body as teacher."19-21 Signature pedagogies have 4 structures. There is a surface structure, a deep structure, and a moral structure that encompasses the beliefs, attitudes, values, and dispositions of the profession. There is also a shadow structure in which aspects of learning for the profession are hidden, omitted, or weakly present.3,21 In our study of excellence and innovation in physical therapist education, we saw brilliant, caring, and deliberate ways in which learning occurred through and with the human body as teacher, including students' bodies, the bodies of patients, the bodies of teachers and mentors, and the bodies of peers.19,21 We also discovered that the broader sociopolitical and sociocultural context of movement was weak or absent. We posited that this moral aspect of movement represents the shadow side of our signature pedagogy.19,21 We made 3 recommendations to further develop how we exploit our signature pedagogy20: (1) Acknowledge our signature pedagogy, have it become part of our discourse; (2) make that signature pedagogy explicit everywhere learning occurs; and (3) what do we mean by "body" in "the human body as teacher?" I will spend some time exploring the third recommendation. Is it the physical, mechanical, biologic body of anatomy and physiology? Is it the body as experienced by the person living in and with that body? It has to be both. The 3 apprenticeships and our signature pedagogy provide guidance on how to design learning and teaching so that graduates integrate both of these meanings of body and movement into practice. We need to be soundly grounded in the science of movement and in the moral dimensions of movement in its broader context. We need to be explicit about this in education, practice, and research. Because we are talking about educating physical therapists who are experts in movement, there is no question students need to be held to high standards of excellence and learning to develop habits of the head and of the hands. The apprenticeship of the heart asks us to contextualize learning into the world of the people seeking physical therapy everywhere and in every way that learning occurs: whether it is a classroom discussion, a laboratory practice, in a simulation scenario, or in clinical learning experiences where contextualizing movement into the person's life seems more intuitive. Not just in the courses that teach the "soft skills" of interpersonal communication and cultural aspects of care, but every course. Although I hate the phrase "soft skills," I used it intentionally so that I can ask, can we please stop using that phrase? Whether through written examinations, papers, or practical examinations, discussions, cases, and examples, our questions, feedback, and discussions need to: represent the diversity of bodies and where and how they move with respect and care; explore, question, and reinforce the intersubjectivity of movement and learning to reason through the patient's movement (or laboratory partner or simulated patient); reflect rich descriptions of the person and the meaning of movement in that person's life and the sociocultural and sociopolitical environment in which moves; stress the importance of and engage in discussions about the type of touch, the comfort of that touch, the meaning of facial expressions, of the underlying resistance to or acceptance of movement, and the privilege of touching the person and helping them move;16 make instructor and learner clinical reasoning, assumptions, judgments, and observations explicit particularly reasoning about, with, and through movement;16,22 reflect the narrative, ethical, and collaborative reasoning that are evident or absent in the encounter and connect those to the meaning of movement to that person or community of people.23-27 In these ways, developing habits of the heart becomes the integrating apprenticeship through which clinical and technical aspects of movement become grounded in movement's moral dimension to develop the habits of the heart that our profession requires. THE HUMAN EXPERIENCE: FROM DETACHMENT TO ENGAGEMENT Now, I will discuss the phrase, "to improve the human experience." Here is my question: What will it take to fully integrate what it means to be part of the human experience into being a physical therapist? In an editorial in the journal Physical Therapy, Alan Jette28 wrote about physicians as canaries in the health care coal mines who are providing advanced warning about the effects of mental and emotional exhaustion, cynicism, and loss of productivity. Confronted with the challenge of not being able to meet their purpose of meaningful work with patients, they suffer "moral injury."29 Jette called attention to the work of the National Academy of Medicine to develop systems-based approaches to create a health care environment that supports clinician well-being.30 Here is a perspective from AJ:it's hard to practice in a totally collaborative manner when we have so many time constraints. … pretty much every patient who's not there for an initial evaluation is double booked … it's hard to really be fully collaborative … it's very, very difficult … I'm trying to figure out how to maintain my ideals and what I wanted to do in physical therapy while also continuing to practice AJ who has been in practice barely 2 months aptly describes the pressures of practice and maintaining her ideals. Students frequently tell us about their encounters with clinicians who are cynical, judgmental, or operating on autopilot. They encounter physical therapists whose biases and coping mechanisms are on the surface and often have difficult experiences with patients, colleagues, and students. How these physical therapists choose to cope with a system that does not support their well-being and the well-being of patients and what students learn from them are of great concern. Clinical instructors tell us the exact same thing about students and that is also of great concern. We are on a 2-way street. Yes, we need to improve the system. We also need the courage to have the difficult conversations with our colleagues and students whose biases and assumptions are on the surface and destructive to our patients and learning communities. We can go back a century to uncover another concern about our stance toward patients and the human experience. When health professions education transitioned into universities in the early part of the 20th century, claims of professional expertise grounded in science rose to prominence over those of relationships built on community trust.12 The risk is that a scientific stance toward patients can lead to objectification and distance, often expressed as detached concern.31 Our choice about how we wield the power of decision-making, professional judgment, information, and communication reflects a moral choice. Picture, if you will, the flow of energy, information, and power between the physical therapist and patient. Is the dominant flow from practitioner toward patient? Or, is there a more equal interchange? Zachary had this to say:The themes from my education especially my clinical education. It's definitely a medical model where the clinician is in charge and the patients are to do what they are told, when they are told and how they are told. I think that's the implicit paradigm that our profession works off. Zachary relates the powerful messages he learned about the patient-therapist power dynamic as a student. If the underlying beliefs of the physical therapist about her practice are that of the expert who dispenses knowledge and directs the patient encounter, we are in the world of clinician-centered practice that can be contrasted with person-centered care shown in Table 1. Here is what AJ had to say about one of her clinical instructors who was person-centered:I had one … CI (who) was really embodying how to be a collaborative practitioner. Really took the patients story and ideas and priorities and goals first … she always goes back and says, "OK from our evaluation these are … the goals that I wrote for you based on what we talked about. … What do you think about that? Do you think that's a reasonable timeline? Does that resonate with you? Is that a goal that you want to work on?" Table 1.: Clinician-Centered Care Compared With Person-Centered Care32 ,p 39This clinical instructor made a significant impact on AJ's practice. She reinforced the importance of collaboration that AJ brought with her. AJ offered that this CI was the exception during her clinical experiences. I am not suggesting an abdication of our expertise, but rather a shared commitment to a partnership and patient-centeredness. In a collaborative, person-centered care, narrative reasoning becomes more important because we come to appreciate the person's stories about their illness, what it means to them, and how their cultural perspectives, values, and beliefs relate to their experience.33,34 When we can reach a mutual understanding of what ought to happen, we realize our responsibilities to one another and our responsibilities to express caring.33,34Here is how Zachary saw his practice change after his health coaching program. My metric started being have I listened today. Have I really heard my patients today? Did I really understand where they are coming from? And as my internal metric of success started changing my patients started getting better too. Maybe understanding what is going on with them would be a key … to be more effective. I started hearing quotes like, "You know, for a white guy you are alright." That's when I started going, OK I must be on to something here. Sometimes people bring additional challenges into the clinic or hospital that result in a larger gradient of power and steeper paths to understanding. Those challenges could be