Unflattening
2016; Lippincott Williams & Wilkins; Volume: 30; Issue: 3 Linguagem: Inglês
10.1097/00001416-201630030-00003
ISSN1938-3533
Autores Tópico(s)Child and Adolescent Health
ResumoFigureI am humbled and honored to be here before you today, my esteemed colleagues, and I thank Polly's family for helping to make this lectureship possible. It is a wonderful tradition and tribute to Polly and I hope my contribution is worthy. I doubt I would have taken the road here without parents who valued education, a husband and children who accepted my devotion to my profession, colleagues who shaped my love for our profession, and finally, my students who always inspired me to do better. I owe them many thanks. I also want to thank Leslie Portney for spearheading my nomination, those who wrote letters in support, and my colleagues who agreed to phone conversations with me as I prepared for this talk. They helped forward and deepen my thinking. In the first Cerasoli Lecture, Kay Shepard imagined that Polly would "expect us to think beyond our safe boundaries, to consider unusual ideas and to develop new ways of knowing."1(p4) In a tribute to Polly in 2011, Bette Ann Harris, a colleague of Polly's, said that Polly was a risk-taker and never afraid to move forward although change made her nervous and somewhat uncomfortable.2 Today I am going to ask you to look beyond your current safe boundaries, and possibly make you a bit uncomfortable. So, why "Unflattening?" Sometime last May I was asked for the title of my talk, with a description and objectives. That request sent a wave of panic over me, as the only thoughts I had had since being told I was the next Cerasoli lecturer were those of uncertainty, insecurity, what to wear, and similar Cinderella-related fears. Shortly after that, however, the Boston Sunday Globe had a large intriguing comic on the first page of the Ideas and Opinion section.3 The author and artist, Nick Sousanis, had recently published a new graphic novel titled Unflattening,4 based on his dissertation in comics form. If that was not intriguing enough, the text in the comic spoke deeply to me, and I knew immediately what I wanted my title to be. I emailed Dr Sousanis, asking for his permission to use the title. He responded, "It is just a word, so you could just use it anyhow, but if my use of it is significant to how you want to approach your talk all the better!" Thank you, Dr Sousanis. Dr Sousanis derived the term Unflattening from an 1884 satirical novel, titled Flatland.5 It was written as a comment on the hierarchy of Victorian culture and how people are often blind to anything outside of their comfortable plane of existence and experience. As only he can, Carl Sagan explained Flatland on one of his Cosmos TV shows, and this is a short excerpt animated by Timm Andrews (https://www.youtube.com/watch?v=-wv0vxVRGMY). Today I will play the role of the apple (called "sphere" in the original novel), a voice from the third dimension of higher education. I am sure that many of you have heard voices from this third dimension, talk of institutions being closed, presidents being fired, students protesting racial injustice, the public decrying spiraling costs, and politicians expounding. Do you tend to overlook those messages, thinking they really don't apply to physical therapy education, only to undergraduate education? I will argue that we need to pay close attention; that these messages provide clues that our continued success is not a given unless we adapt and change. Dr Sousanis defined unflattening as "a simultaneous engagement of multiple vantage points from which to engender new ways of seeing."4(p32) Today I'm going to suggest multiple vantage points for observing the complex third dimension of higher education and, I hope, engender new ways of seeing physical therapy education. I will ask you to look beyond the comfortable, congenial, 2-dimensional flatland of your offices, classrooms, and labs; to break through stasis of thought; to escape the trap of tacit assumptions; and to abandon "pattern[s] of one dimensional thought and behavior."4(p6) The third dimension of higher education comprises a complex, dynamic, and perhaps volatile sociopolitical system within which there is a variety of tensions, perspectives, and influences that must be examined and understood. Let's start to unflatten by considering the influences of governments. There were 150 new federal regulations related to higher education issued from 2008 to 2014.6 Many of these regulations have been in response to a demand for more transparency regarding the cost of higher education and to hold institutions accountable for their costs and outcomes. For example, last year the Obama administration proposed a politically unpopular plan to implement a college rating system that would have included marks for affordability, access, graduation rates, graduate earnings, job placement, loan repayment, and advanced degree seeking. Institutions with poor ratings would have lost access to billions of dollars in federal student aid. Instead, because of strong opposition, a new website was launched to provide a score card where prospective students can find information about these characteristics for the schools they are interested in,7 as well as lists that highlight institutions with the highest costs, the lowest costs, and those where costs are increasing rapidly.8 One intriguing new regulation is the gainful employment regulation requiring most for-profit institutions and nondegree and certificate programs at most other institutions to prepare students for "gainful employment in a recognized occupation" in order for their students to qualify for federal student aid.9 The regulation states that programs fail the requirements if graduates have annual loan payments greater than 12% of total annual earnings. Why should we pay attention? Well, what if score cards and gainful employment regulation were to apply to all graduate programs in the future? What if your program had to post information on its affordability relative to expected earnings? Even if such changes are not mandates for us in the future, we could speculate that once people become used to readily accessing this type of information when searching for undergraduate institutions, they would come to expect the same during selection of graduate programs. The Obama administration has also challenged institutions of higher learning to experiment with new approaches to education to improve quality and reduce costs, and it is enticing them with regulatory waivers.10 Opportunities include allowing institutions to award financial aid to high school students taking college courses for credit, or to students earning credits based on demonstrated competencies, or for credits based on learning acquired outside of traditional institutional boundaries. The President's initiative to make college more affordable strongly suggests that technology is part of the solution. In support of this assertion a fact sheet released by the White House10 cites several examples, including Arizona State University's interactive algebra lessons that led to 10% better student performance, despite half as many class meetings, and lower cost than a traditional algebra course. It also cites a hybrid statistics course developed by Carnegie Mellon University's Open Learning Initiative and used at 6 public universities. The students' learning outcomes were similar to those for students in a traditional course, while taking less time. An intriguing aspect of that innovation is that it suggests that every institution does not need to offer its own unique, self-designed courses. I cite these examples because I think they suggest types of changes we might want to consider for our programs. In my role as the apple, I can't talk about government's influence in the third dimension without addressing the role of politics. Perhaps this is the viewpoint that makes you question your sanity. Hillary Clinton's plan for higher education requires states to provide more money to public higher education and cuts interest rates on student loans.11 Donald Trump said the Department of Education was a "massive behemoth"12 that could be cut "way, way down."13 Ted Cruz promised he would eliminate the Department of Education and have individual states distribute federal student aid.14 Marco Rubio wants to implement an income-based repayment system and allow investors to cover students' tuition in exchange for a percent of the graduates' earnings.15 Bernie Sanders wants to make public universities free.15 While there are many examples of the role of politics in higher education, the University of Wisconsin provides a particularly salient one. In 2015, a draft of the governor's budget proposal cut $300 million from the University system and apparently supported removing phrases of the University mission statement denoting extending knowledge beyond its campuses, improving the human condition, and the search for truth.16 A new phrase was suggested for addition: "to meet the state's workforce needs."17 In the end the suggested language was deemed a "drafting error" and the mission was not changed. However, $250 million was cut from the University system over the course of 2 years.17 Although Governor Walker withdrew from the presidential primary race last fall, some have labeled the University issue an appeal to conservative republican donors and voters.17 This story suggests the complex and potent forces affecting higher education are part of the undeniably polarized political environment we have in this country today. More to come, I'm sure. Big cuts to public institutions have occurred in states other than Wisconsin. State governments have been cutting budgets to universities as their revenues declined during the recent recession. No matter how you look at the data (change in percent of revenue from the state, or state support based on income of residents), support for public institutions has declined over the past 2 to 3 decades.18,19 As state support has declined, institutions have charged students more, but because there is major pressure to keep tuition costs down, tuition increases have been accompanied by expansion of financial aid programs; however, financial aid packages have not entirely kept up with the actual costs.20 Now let's assume the vantage point of higher education institutions. While politics and government regulations affect institutions, there are other forces afoot in the third dimension of higher education demanding attention by institutions. As I suggested earlier, technology is one of those forces.21 It has affected universities in different ways, but it is definitely pushing change. A 2014 article in the Economist suggested that if technology affects the market for education the way it affected the market for newspapers, employment in higher education will drop and institutions will need to close.21 Another challenge for some institutions is poor business practices.22 Moody's July 2015 educational outlook report noted that small institutions are particularly challenged because of decreased student demand and limited financial flexibility.23 In a 2015 survey of institutional business officers, 26% were not confident about their institution's financial stability over the next 10 years, with a greater proportion of them being from private institutions.24 Eighty-eight percent of those surveyed said that their institution was focusing on increasing enrollments as a primary strategy for increasing revenue. Developing new programs, attracting overseas students, expanding campuses abroad, and collaborating with other institutions are additional strategies being adopted by institutions to increase revenues.24,25 Institutions are also grappling with ways to decrease costs. There are differing opinions about the reasons for spiraling costs. One reason is that higher education is an industry in which it is difficult to improve productivity and efficiency because the common feature of the educational enterprise is face-to-face classroom instruction,21 some of which occurs, by design, in small lab sections or seminars. The method relies on human interactions for which productivity and efficiency can be altered only to a degree, and that is primarily by having instructors teach more classes with larger enrollments. It takes the same amount of time, however, to grade an essay or a paper today as it did decades ago, and office hours are office hours. Other reasons for cost increases include growing proportions of administrators with high salaries, aging of the professoriate, rising costs of health insurance, and students reportedly demanding more luxuries. There are also fewer research dollars available, along with the attached indirects, and more competition for those dollars. While more grant applications have been submitted, the application to award ratio has experienced a steep decline in the last 15 years. No matter what the cause, most consumers believe that the costs are out of control. In order to control costs, institutions are considering questions such as: Does every institution need its own (name a central function) library, lawyers, financial aid, or instructional technology offices?26 Can faculties and facilities be used year-round, with classes routinely provided on a 3-term basis to utilize resources efficiently?26 Answers to these questions will, in turn, influence answers to additional questions. Will there be more expansion campuses nationally and abroad? Will we see consolidations, mergers, and closures similar to those we have seen in businesses and hospital systems? What unique strategies will institutions implement to address their financial issues? University of California Berkeley recently announced a $150 million deficit and reportedly is evaluating the possibilities of decreasing "spending on athletics, shedding staff, and admitting fewer doctoral students."27 What will these types of changes mean for faculty, students, accreditation, etc? New business models will necessarily evolve to address the financial issues faced by institutions, and no matter where you sit in the institutional structure, they will affect you. How aware are the faculty you work with of the financial issues facing your institution? More than 1 quarter of the respondents to the survey of institutional business officers mentioned previously had little confidence that faculty understood the financial challenges.24 In her Cerasoli Lecture, Sins of Professional Programs, in 2007, Beth Domholdt referred to this phenomenon as the sin of budget naïveté."28 It is quite possible that this sin now has more egregious consequences than it did then. A conflict between reducing costs and generating more revenue leads to another challenge for institutions: the pressure to build. Building has been done to attract students, perhaps the most iconic being the climbing wall.29 It is not clear, however, that new auxiliary facilities actually increase enrollments and they are financed by increased costs to students. Additionally, buildings cost money over the long term (heating, maintenance, etc), and universities already face a good deal of deferred maintenance for existing buildings. At the same time, new models of teaching and learning mean less need for bricks and mortar. Although today most 18-year-olds want a full-time on-campus experience, the current configurations of campus physical spaces may not be what are needed in the future as student demographics change and we adjust to new teaching and learning methods.25 The need for institutions to adapt also challenges faculty. Tenure systems are being examined mainly because large numbers of tenured faculty are seen to reduce the flexibility of universities to address changing interests of students and gain footholds in newly emerging fields of study.30 University budgets are also affected by increasing numbers of tenured faculty at the highest ranks and largest salaries who remain past traditional retirement age.31 This has led some to suggest that long-term contracts with periodic review and substantial merit awards might work better than tenure, allowing universities to be more nimble and responsive to societal needs.30 At the same time that tenure systems are being questioned, faculty composition has been changing, with a smaller proportion of full-time faculty over the past 4 decades.32 Reliance on part-time faculty helps universities financially as they teach more courses than the full-time faculty and cost less. However, this shift in faculty composition creates greater demands on the full-time faculty to meet the goals of the institution in terms of research and service, or advising, mentoring, and developing students.32 How many faculty do we really need and how many need to be full-time? Perhaps not as many as we believe. One proposition to address this question is to make faculty more efficient by unbundling roles.22 For example, having course designers implement the administrative and technical aspects of courses and curriculum and course tutors to answer students' questions, while saving faculty effort for developing content and engaging students in learning. New technologies, declining public funding, and new job roles in educational technology and design are making this possible.32 Let's go a bit more into the microcosm of the university and specifically examine the landscape of physical therapist education programs. Challenges at the institutional level effect physical therapy education across the country because those challenges push new program development. As I alluded to earlier, the size of the student body at an institution is critical for financial stability, notably at smaller institutions, so a primary strategy for addressing financial issues is increasing enrollments. I calculated that as of January 2016, out of the 28 physical therapist programs with applications submitted to the Commission on Accreditation of Physical Therapy Education (CAPTE), candidate status, or director hired, 82% were in private institutions, all but 1 of which enrolls fewer than 10,000 students. With fewer high school graduates in many regions of the country, particularly the northeast,33 institutions are looking at new graduate programs to improve their revenue. Adding graduate programs for health professions is seen as a good investment, because, unlike graduate degrees in business, law, and education, there is projected demand. An additional incentive for starting new physical therapist programs is provided by the fact that 54% of individuals applying through the Physical Therapist Centralized Application Service (PTCAS) in 2014 did not get accepted into any program,34 and CAPTE data show that on average across all programs, only 30% of qualified applicants are actually accepted.35 While new program development may help the finances of smaller institutions, I think we will all agree that the addition of new programs is not good news for our profession, as it stretches our limited resources in terms of qualified faculty and academic leaders, and complicates the lives of our clinical partners as they have to work with more programs and varied curricula. Given the demand and number of new programs being proposed, we might ask, are we in a physical therapy education bubble market? And, if so, when will it burst? The bubble is sustained by the assumptions that students will likely pay the ever-increasing price of professional education so that they can transform it into skills that they believe many consumers value enough to pay for. This paradigm suggests that the demand for, and rising costs of, professional education are only sustainable if society continues to demand the services, and purchasers of health care continue to pay clinicians more for them.36 How long will this state continue? Let's dig a little deeper and examine our programs' curricula. While some things have definitely changed, others have not changed very much. In a seminal article on health professions education in 2010, Frenk and colleagues described what to me sounds like a Flatland of health professions education, noting that "fragmentary, outdated, and static curricula [are] producing ill-equipped graduates."37(p8) They go on to note that "Curricular rigidities, professional silos, [and] static pedagogy" have contributed to "dysfunctional and inequitable health systems."37(p8) Does this assessment apply to physical therapy programs? Quite possibly. Most programs require "an elaborate sequence of discrete steps"4(p9) from their students. The steps start with completion of prerequisites for admissions whose efficacy has never been assessed, and often reluctance to accept credits for learning through any nontraditional modalities. Most of our curricula are time-bound and credit-bound. Most programs require full-time, onsite commitments of students. Generally, students are required to always be physically present in classrooms, although we have the technology to allow more flexibility. For the most part, all students have to learn the same way and show their learning with the same assessments. On average, DPT students are in a classroom 22 hours per week,35 "Suffocating and ossifying."4(p5) this approach has implications for learning as well as for the accessibility of our programs for those who need to work to support themselves, or have families, or can't afford to live near our campuses. The rigidity of our individual curricular structures has also created barriers to interprofessional education. Many of our programs continue to practice the sin of "pedagogical stodginess," identified by Domholdt in 2007.28 "Flatness permeates the landscape."4(p5) Perhaps ironically, the curricula across programs are entirely unstandardized and varied. Years ago Mary Jane Harris, the former director of CAPTE, used to say, "If you've seen 1 physical therapist program curriculum you've seen 1 program curriculum." It's still true. In spite of the fact that we are educating graduates to practice in the same US health care system and pass the same licensure exam, curricular emphases vary across programs, and course content may well reflect outworn traditional knowledge and skills or what faculty want to teach in their specialty areas, rather than what students and graduates actually need to know for best practice. Given the ease of access to large volumes of information on almost any topic, why are physical therapy programs places where students must go to get information "directly dispensed from sender to receivers?"4(p10) This generation and future generations of learners need to know how to discern the value of information and how to synthesize it from many sources to make decisions. The monumental changes in access to information provide educators with new possibilities for reexamining educational methods as well as the meaning of education itself.37 How many of you have curricula with siloed content, using the structured table d'hôte menu of predefined, content-ordered syllabi along with lectures with predigested information nicely bulleted in structured PowerPoint slides? Then during class students are told essentially what is on the slides, and they add a few of their own notes to the slides they have (of course) been provided ahead of the lecture (or look at Facebook, Instagram, Twitter feeds, or text messages). How many of you test students using multiple choice items, with only 1 right answer based, of course, on information in your slides? You justified this approach by their needing to practice for the licensure exam, or your needing to grade 50 students in a short period of time. Because there are lots of these types of classes and tests for lots of different courses every semester, students use the most judicious strategies for getting through each semester successfully. This approach may well encourage cynicism, but it definitely contributes to anxiety and stress more than it facilitates learning. Our graduates need to not only function in, but make contributions to, the complex, real world of health care. This requires ability to appropriately prioritize, interpret, and apply information, skills not well assessed with multiple choice tests, no matter how good you are at writing them.37 Furthermore, in the real world, graduates must make decisions in the face of limited information, ambiguity, and uncertainty.38 True learning occurs in relevant, and often messy, contexts where knowledge, skills, and behaviors have immediate value, where connections between facts are nonlinear, and where there is an opportunity to think on one's feet, adapt, and improve.39 Do our programs provide the elements of this environment to prepare students for the real world of practice? I fear we don't do enough. Professional life is most likely a continuous series of essays. Let's further unflatten by assuming a student vantage point. Changes in the labor market are affecting demand for education among nontraditional students. Innovation has wiped out some jobs, leaving people with the need to retool.21 The people who need this type of education are not people in their late teens and early twenties who want to have an on-campus experience of full-time education. As I've mentioned, that group is declining in number in many areas of the country, so educational institutions are shifting focus and resources to develop curricula and instructional methods to address the needs of new types of students. Demographics of the country are also shifting in terms of race and ethnicity. Higher education, however, does not reflect this shift at all levels. Non-Hispanic-White and Asian students are overrepresented at selective 4-year institutions, which have higher graduation rates, better student outcomes in terms of life-time earnings, and send more graduates to graduate school.40 There is evidence of a correlation between race/ethnicity and standardized test scores.41,42 In a recent study, race/ethnicity accounted for a higher proportion of variance in SAT scores than any other factor.41 In fact, graduate admissions committees' reliance on GRE scores and undergraduate institutional status has been shown to limit diversity.43 PTCAS data for 2013–2014 show that students enrolled in our programs are not reflective of the racial/ethnic diversity represented by the college undergraduate population in the US. In fact, (here is where I hope you become uncomfortable) if you're an applicant who is non-Hispanic White, you have almost 2 times the chance of being accepted than if you are non-White or Hispanic.34 The average GPAs of students accepted to physical therapist programs has been increasing,35 suggesting that admissions processes focus on numeric qualifications; apparently, the higher, the better. But what have we gained? No better graduation rates, it seems. What about fewer professional behavior or clinical education issues? What is the evidence that getting a good grade in "Biology 101" (or any other prerequisite) is actually tied to any specific learning necessary for success as a physical therapist student or physical therapist? How does a GPA of 3.5 reflect useful knowledge better than a GPA of 3.2 when there is grade inflation and often poor engagement in learning on the part of undergraduate students in all calibers of institutions? I surmise that many of you are in programs where there are hundreds of applications, presumably necessitating a preliminary screening and culling based on numbers. After that, how many of you consider where applicants have taken their prerequisites? Do you give high GPAs from community colleges lower value than high GPAs from more prestigious institutions? Do you decline to accept credits for AP courses or competency-based courses or courses taken without credit or a grade awarded? Do you think online chemistry labs are not acceptable as prerequisites? If so, I wonder how these approaches to admissions affect the diversity of our classes. I also worry when I hear faculty talk about applicants finding a "fit" in a program. I wonder exactly what "fit" means to most people—you look like most of our students, you act like most of our students, you think and learn like most of our students, or you fit nicely in our box? If any of these are true, then the value we place on diversity is not clear. Domholdt28 identified "excessive elitism in admission decisions" as a sin of professional programs 9 years ago, and it is not clear that we have improved our ways. We can't have a discussion about the student perspective in higher education without addressing the fact that student loan debt is at an all-time high. Over 3 decades, tuition and fees at public universities have increased by over 100% while median household income in the United States has increased by approximately 2%.20 This discrepancy has made it much more difficult for families to fit tuition costs into their budgets, and students need to borrow more. Consequences of this high debt load include delays in starting families, buying homes, saving for retirement, or seeking career advancement.44 This final consequence is one reason we should be concerned that we will not have sufficient numbers of PhD-prepared physical therapists to support the next generation of physical therapy education programs and research. A more pressing issue is whether students will continue to pay for our very high-priced physical therapist education programs. With public scrutiny focused on tuition for undergraduate students, there are institutional pressures to increase tuition for graduate programs. CAPTE data indicate that over the past decade mean total costs of physical therapist education programs have nearly doubled at private institutions, and increased more than 50% for in-state students at public universities.35 On top of this many students sustain substantial additional costs to travel and move to 3, 4, or 5 different places during their education to fulfill clinical education requirements. In a report from
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