"Look forward, walk tall": exploring our "what if" questions. (Thirty-Third Mary McMillan Lecture).

Introduction

When I was a young boy, I had a need to understand just who would contribute to the development of my evolving value system and to the formulation of my personality. In my own adolescent way, I came to learn that the 2 thoughts were not mutually exclusive but, rather, were intimately intertwined. Who I would become was clearly a function of the values instilled in me by others. My personality would be molded by extracting the best elements I admired among those people. In my life as a physical therapist, I have become who I am and have the honor of standing before you today because of the patience, tolerance, guidance, and inspiration provided to me by the people whose pictures you have just seen and because of my admiration for them. I dedicate this lecture to my family members and those colleagues, for without them, my ability to formulate and articulate the thoughts I wish to express today would be nonexistent.

In preparing for this moment, I share with all my predecessors to this podium the undeniable reality that the task of constructing meaningful thought is awesome. Simply reading the first 32 McMillan lectures reinforces this notion. Embedded in the creativity that characterized the ideas of many previous lecturers is a history of dedication and love that must parallel the vision Mary McMillan conjured in helping to create the American Women's Physical Therapeutic Association in 1921. Past lecturers possessed the superlatives of wisdom, sensitivity, and dignity that characterized Ms McMillan. (1) In fact, when one reads these past lectures, a strong case can be made for the evolution of thought into prospective action governing such topics as professionalism, education, research, and clinical unity to such an extent as to predict the very elements that have become the foundation for Vision Statement 2020. (2)

The Quest for Vision

The past year has been a particularly difficult one for all of us. Our fragility and vulnerability have been exposed. For many of our youngest generations of therapists, September 11, 2001, abruptly rendered asunder an age of innocence and transformed what to some might have appeared as entitlements, undeniable rights, and anticipated privileges after several years of difficult work and, in most cases, financial hardships, into an aura of uncertainty. These feelings are seemingly in conflict with our hopes and aspirations at redefining ourselves through advanced education and emerging degree rifles that carry with them undeniable expectations from the patients and medical communities we serve. I believe we can enrich our lives and those of our patients, not through uncertainty about the unknown, but by embracing an exciting journey along a road named "destiny" illuminated by a discernable yet indescribable light we call "the future." The much-admired educator and senator, SI Hayakowa, once said, "If you see in any given situation only what everyone else can see, you can be said to be so much a representative of your culture that you are a victim of it." (3) Thus, the quest for "vision" is much more than an identification of characteristics and attributes ascribable to any body of people. The value of that vision is only as good as the validity of the processes used to achieve it.

We can all agree that, "By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as practitioners of choice to whom consumers have direct access for the diagnosis of interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function and health." (2) The more fundamental issue relates to dialogue that results in proactive procedures to secure the meaning of the vision sentence. Without question, our actions will necessitate a unity that is bolstered by a work ethic first recognizable among ourselves and second recognizable by the patients and professional communities to whom we provide services.

The unity underlying the transformation of any vision into reality, then, demands purpose of action, devoid of terms that segregate physical therapists into labels like clinicians, or educators, or researchers. Why can't we simply be physical therapists? In fact, I submit that we cannot succeed in our vision under a shroud of compartmentalization, especially if our vision statement requires that consumers and other health care professionals "recognize" us. Never in our history has there been a greater need for unification of purpose and integration of clinical, educational, and inquiry resources.

I sometimes marvel that in my 36 years since becoming a physical therapist, no one has ever asked me about my self-perception. It is simply assumed that because I spend three quarters of my time "doing research," I must be a "researcher," when, in fact, I see myself as a physical therapist clinician who simply has too many unresolved questions for which I feel the need to seek answers so that you and I manage our patients better. So, I echo the sentiments of many previous McMillan lecturers: first and foremost, we are all physical therapists. Moreover, the time has come to question the sanctity or sanity of propagating labels, whether done consciously or not.

Down the Health Care Road

The need for a united front in which our criteria for advanced educational excellence parallels the product we produce seems particularly relevant in light of dynamics of health care policy and reform. Just where we fit in the mosaic of the health care puzzle should be viewed as an opportunity requiring the maximization of identification with the minimization of role segregation. In my home state of Georgia, physical therapy leads all health care professions in growth demand during the decade interval of 1996-2006 according to that state's Health Care Workforce Technical Advisory Committee May 2001 report, called "Code Blue: Workforce in Crisis." (4)

At the same time, the ability to pay for the services we render may be compromised. Just in this year, for example, average health care benefit costs are increasing 13% to 20%. For those of us who accept out-of-pocket reimbursement from our clients beyond existing payment networks, such spending is increasing at a rate of $10 billion per year, from $162 billion in 1997 to $195 billion in 2000. (5) Many of these personal resources are earmarked for alternative forms of intervention.

Although intriguing, this reality is a potential source of concern. During a National Institutes of Health-sponsored conference for investigators with funded national centers on complementary and alternative medicine this March in Portland, Oregon, I learned that the Oregon College of Oriental Medicine will soon offer a 2-year clinical doctorate. Presuming such offerings escalate, there probably will be other doctoring groups whose claims may result in competition with our own. Furthermore, as our oldest baby boomers reach the age of 62 years in 2008 and modern medicine affords more opportunities to prolong life, not only will our geriatric population increase (and with it a potential infusion into geriatric rehabilitation) but the number of retirees will exceed the numbers entering the workforce. (6) At projected rates, if efforts are made to permit aging entitlements to keep up with inflation, those entitlements alone would consume 80% of the federal budget by mid-century. At the same time, our present generation of citizens in their teens and early twenties has been labeled "ecoboomers," those individuals who feel that entitlements are a given, partially because these young people have had limited exposure to profound economic downturns. (7)

Collectively, this smorgasbord of observations might appear discomforting to many. But these examples speak to the reality of competition to justify and secure our place in the quest for our share of the diminishing medical dollar. To some of us, the dues we pay for the American Physical Therapy Association (APTA) to conduct its business may seem unusually inflated. Perhaps even the value derived from these costs may appear obscure or incomprehensible to a new generation of therapists reared in an age of escalating costs tempered by unprecedented wealth and instant gratification, a generation demarcated by material gain while paradoxically often riddled with debt. The reality is, my friends, that as physical therapists we are relatively well paid. Our Association leaders may, at some level, devise strategies not so much for how we augment our fiscal status, but, rather, for how we secure and justify what we have. Inevitably, our progression toward more advanced education and the acquisition of data to justify treatment and to complement our caring will affect consumers and health care decision makers. The question is simple: How do we succeed? The answer is complex and requires us to embrace the challenge and optimize our choice points. Rarely does change succeed without exercising creativity, employing an open mind and fearless benevolence.

Bearing this stream of consciousness in mind, I wish to share with you some thoughts and probing "what if" questions in the hope of fulfilling an obligation to promote constructive dialogue as a fundamental vehicle for advancement and as an agent for change and growth, both personal and professional. We all ask these questions from time to time, often in a gregarious spew of hypothetical chatter and, sometimes, in moments of introspection. We may even have paid homage to special moments in our personal or professional lives that have unleashed a reverberation of multiple "what if" questions with the intent of promoting change--in ourselves, in those we love, or even in the factors contributing to how we earn our keep. To some this process can be exciting, while to others the very thought of change is associated with instability and uncertainty. Martin Luther King told us that "the ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy." (8) I suspect that the same can be said of a profession, of us, for challenge or controversy can serve as a catalyst for change.

Epiphany as an Impetus for Change

An epiphany can be more than the January 6 celebration commemorating the appearance of the Magi. Over the years, the meaning of the word "epiphany" has evolved from appearances having religious manifestations to revelations of inexplicable origin. We call these revelations "insights," or "brainstorms," or "inspirations." I believe we all experience them--some of us in our personal lives, some of us in our professional lives, and some of us in both. The issue is not the experience but the recognition of when an epiphany has occurred and how it might influence our subsequent actions; in fact, how it might change us.

The year 1979 was an extraordinary one for physical therapy. At our House of Delegates, we created the Foundation for Physical Therapy Research and with it an explicit recognition of the need to explore and validate our practice. We proclaimed that by the year 1990 the entry point into our profession would be at the postbaccalaureate level, a dramatic foreshadowing of where we see ourselves directed today. The 1979 annual meeting also marked the last year that an APTA component organized the opening ceremony, culminating in most of us clogging in the aisles. At that same meeting, we implemented an experiment, called a "poster," strategically placed under a stairwell at the Atlanta Hilton hotel, to see if there was any membership interest in this form of communication. I can clearly recall back then seeing a recent physical therapist graduate wandering aimlessly through the hotel corridors seeking means of transportation to our social outing at Stone Mountain because he had missed the departing buses; and so we gave young Ben Massey a ride.

In March 1979, APTA initiated a series of trips to the former Soviet Union so that we could learn of their culture and their physical therapy practices. I was asked to be the representative for the 6 speakers who were given the opportunity to present formal lectures. When the 150 physical therapists on this trip arrived in Moscow, we soon learned that there were to be no formal professional exchanges about treatment approaches to physical therapy, but we would be exposed to many cultural experiences within the 5 republics we were to visit. In fact, the former Soviet Union did not even have physical therapists, but, rather, nurse technicians who assisted medical doctors of rehabilitation. As if scripted from a John Le Carre novel, our Intourist guides quickly dubbed me as "leader of the American side" because, I suspect, I represented the group of speakers.

Against this background, the bizarre scene of a fading Cold War characterization unfolds. So, with a strange partnership of pride and trepidation, I share with you what became for me an epiphanic experience related to my life as a physical therapist.

The former Soviet Union was within a few years of engaging Afghanistan in mortal combat while its border republics plotted their own insurrections. For decades, Russia had exercised oppression toward minorities, many of whom sought other venues to exercise their freedom to express their religious or personal beliefs; still others were refused the opportunity to leave the country. The Word "refusenik" came to mean individuals, mostly Jews, who were denied permission to leave the Soviet Union. Their lives, always haunted by religious persecution, were made worse once authorities learned of their quest for exile. (9)

Knowing that I would be traveling to the Soviet Union, I volunteered to work for Al Tidom, an organization whose mission was to render religious and cultural aid to Russian Jews. My responsibility was to place strategic telephone calls in each of the 5 republics and, through coded numerics that I could not decipher, provide the drop points for food and prayer books. In this way, the upcoming Passover could be celebrated, because these essentials had been confiscated from most Jews as part of the Soviet refusenik program. My only preplanned human contact occurred at Prospect Marksa, a Moscow subway station near the Metropol hotel during the early morning of our third day. I had gone for a run, during which time, ironically, my room and belongings were inexplicably disrupted. I was to meet a man whose name, I learned several months later, was Ernest Axelrod. I had been informed that he would recognize me.

As the only pedestrian on the subway platform, I felt a little strange. I began to think that perhaps I had even compromised the safety and security of our entire group. The only other person on the platform was an older gentleman with a profoundly stooped posture, who was meticulously sweeping the floor and, in the process, slowly making his way toward me. Then he uttered my first name. The despair cast from his expressionless face and the trembling in his voice as he spoke very broken English truly reflected his inner pain. He explained to me that he had been a psychiatrist and now had been relegated to the role of street cleaner. He asked me about physical therapy, who we were and what we did. Then, in a gesture that seemed quite spontaneous, he led me down a steep stairway and onto the train tracks. Dr Axelrod pointed to the lights from the next subway stop that could be seen easily through the darkness of the tunnel. He then said to me, "You can never let what has happened to me happen to you or to your profession. You must look forward and walk tall!"

I was struck by the penultimate paradox. Here I was, temporarily sequestered in a Moscow subway tunnel, with the imposed designation of "leader" of the physical therapists, talking with a man who had been deprived of the opportunity to use his talents and skills to perform meaningful deeds. At the same time, I was listening to a physical therapy directive we give to our patients daily, offered by a gentleman who did not know what physical therapy is while living in a country that did not practice physical therapy. Ernest's beseeching plea has resonated with me since that day and has motivated me to optimize my contributions to the profession I love so dearly.

On Redefining Professionalism

Defining our professionalism has been the major repetitive theme of past McMillan lecturers (Tab. 1). Catherine Worthingham (10) discussed our need for a code of ethics, communication, and self-control, and Lucy Daniels introduced the notion of problem solving as an important phase of our professional identity. (11) Jane Carlin added the need for identifying a relevant body of knowledge, providing ongoing evaluation processes to ensure growth, and offering clearly stated behavioral objectives as part of our professional persona, (12) and Margaret Moore supplemented that perspective with the belief that we cannot separate our clinical and educational arenas as part of our professional identity. (13) Helen Blood talked about the importance of consumer advocacy and reinforced the need to include problem-solving abilities as an integral component of professionalism in physical therapy. (14) Ruth Purtilo more recently added that the advocacy role needed to extend to institutions as well as being patient focused. (15) Dot Pinkston offered one additional piece of sound advice when she indicated that professional maturation cannot be acquired without a sound fundamental basis for what we do. (16)

Bob Bartlett suggested that to be professionals, we must be unique in our knowledge and skills. (17) Last year, Jules Rothstein embellished this perspective when he indicated that our professional identity must be unique and essential. (18) We cannot refute the importance of all the attributes to professionalism brought forth by these distinguished contributors to our profession. However, it seems that the theme of unique and essential is perhaps most pertinent in the context of finding our place in a very Competitive health care market. Consider the writings of Everett Hughes, a sociologist who, in 1958, suggested a theme (19) that would later be amplified by Vollmer and Mills (20); specifically that professionals are individuals who provide services that are both important and esoteric. By "important" they meant that the services were very relevant to the welfare of their clients, and by "esoteric" they meant that the clients were not the best judges of either their own needs or the quality of the services they received.

Perhaps as we strive for further autonomy, we might consider contemporizing the concepts echoed by Hughes and by Vollmer and Mills. We certainly can acknowledge the important definitions from past McMillan lecturers as absolute prerequisites toward professionalism in physical therapy, and we could modify the perspectives rendered by Hughes and by Vollmer and Mills. What if, then, this modification would describe the physical therapist professional as one who renders services that are essential and esoteric? "Essential" would mean activities that are demonstrably important to the prevention or physical treatment of movement pathologies, and "esoteric" would mean that a physical therapist and only a physical therapist would be capable of evaluating the need for the service and overseeing or delivering the service during treatment (Tab. 2). Although this perspective may seem intuitively obvious to some, the reality is that we are not perceived uniformly as possessing essential and esoteric attributes and probably because we have not provided the evidence to suggest so to relevant health care decision makers.

The Professionalism/Education Interface

If, then, we are to convince our colleagues in other disciplines and in policy-making positions to acknowledge the essential and esoteric nature of our profession, what changes might we consider to reduce equivocation about the perceived value of our training and our degrees? We have always prided ourselves on our roles as clinicians, our "deep caring for people and altruistic drive." (21) Our "reason for being," as Ruth Wood (22) said, has been our caring and touching, both physical and personal, for those placed under our care. My predecessors (23-25) have spoken eloquently on our role as clinicians, calling us "humanistic practitioners," (26) while defending our full freedom of expression, including the giving and receiving of criticism. (27)

Throughout our history, this identity may have been genetically imprinted by our parents or our role models. Yet, who we are to become is truly birthed in the classroom, the place that Gary Soderberg called "the significant contributor to our practice patterns for life" (28) and what I call the womb from which we emerge having been nurtured by our academic parents, many of whom must become, if they are not already, actively practicing clinicians. With this frame of reference in mind and recognizing the responsibilities inherent in the evolution of our doctoring profession, what if the bases for the generation of educational objectives that drive our quest for knowledge are extended beyond what one must know or how one must perform to include why one must know or perform. Furthermore, what if that percept itself extended beyond the classroom and into any lecture hall or clinic in any location? Objectives would then require a purpose statement that, frankly, each of us as a student has an obligation to ask those who teach us: "Why do I need to know this information?" It seems to me that this question cannot be answered without the provision of evidence, and it would appear that successfully answering this somewhat rhetorical question is fundamental to implementing the Guide to Physical Therapist Practice (29) optimally. So, all learning objectives would be conditional, predicated upon a reasonable reason for acquiring knowledge.

The consequences of insisting on expressing objectives in this manner can be profound. I suspect the quantity of continuing education courses might be compromised, but the quality would undoubtedly be enhanced. The result might certainly be a reduction in at least the number of continuing education courses, perhaps a necessary contraction before any expansion. But this outcome would be transient, as expression of empiricism would be tempered by infusion of evidence. Would this approach not contribute to the esoteric component in our definition of professionalism?

And what about the content in our teaching? What elements about learning have we not investigated adequately? What avenues must be explored to more comprehensively keep pace with contemporary scientific and clinical pursuits? In addressing these questions, we look for constancy in our lives and in our profession. For the latter, the only constants that I can recall are the often-cited interdisciplinary platitudes about physical therapists who "have great hands" or for whom "patients would do anything." Are these praiseworthy observations simply idle chatter, or are they real? Have we ever explored these complimentary characterizations that appear to have permeated the ravages of time, including changes in reimbursement policies? Perhaps the famous Greek philosopher Heraclitus was not totally correct when he said, "There is nothing permanent except change." (30) What if we exploited the persistent belief in our great hands and inspiring attributes and actually measured the extent to which we affect patients' behaviors because of the close relationship we develop with them?

As a young physical therapist, I was told that we do not measure behavioral changes in our patients; that role is left to psychologists. The value of including behavioral science as an integral part of our learning experience has been articulated beautifully by Helen Kaiser as early as 1968 (23) and by Lucy Daniels, (11) Margaret Moore, (13) and Shirley Sahrmann. (31) Certainly, we have learned to record fear of falling or depression, but there are literally hundreds of behavioral components that we do affect, and most of them are measurable (Kutner N; personal communication; September 14, 2001). * Our colleagues who undertake qualitative research have been addressing these measures for years. One can logically ask the question: "Do our patients improve because of the physical interventions we provide, thus affecting their state of well being, or do our caring and interaction favorably affect patient behaviors, which subsequently motivates them to improve physically?" One can easily argue that we do not know the answer to that question.

Interestingly, in reviewing over 1,750 abstracts for the 1995 International Congress of the World Confederation for Physical Therapy, fewer than 30 actually addressed the behavior of patients or therapists in the provision of services, and few of those came from physical therapists in America. Even the final 72 questions emanating from our own clinical research agenda (32) do not address the impact that answering any one of those questions might have on the behavior patterns of our patients. More recently, APTA has begun to recognize the importance of examining behavioral measures as an outcome component (Goldstein M; personal communication; April 13, 2002). Thus, if we measure these behaviors and assess their relationship to physical therapy interventions, do we pave the way for evolving strategies that would lead to reimbursement as a result of our impact on them? Or, stated another way, what if we were to demonstrate that physical therapy is more than physical? To what extent would that demonstration influence what we teach our students and how we provide or reassess our practice patterns?

In her brilliantly conceived 1975 Mary McMillan address, Helen Hislop illustrated how physical therapy influences virtually every conceivable aspect of our behavior, from cell to family (Figure). (21) But science is progressing at an alarmingly fast rate, and certainly in 1975 we could not have envisioned the emerging advances in molecular science and genetics. For example, biomarkers exist for assaying endothelial cell growth factor from cerebrospinal fluid with demonstrated changes in the concentration of this substance as a function of the resolution of the penumbra encircling the site of cerebrovascular accident, (33) and blood assays are being developed for glycine and other compounds that can be administered soon after stroke with the ultimate goal of relating changes in neurotransmitter concentration over time to improvement. (34) The role of molecular imaging of cat echolamines and other entities, such as human marrow stromal cells, (35) is being studied. These discoveries and manipulations at the molecular level will bring into focus the potential to relate or refine our interventions to improve impairments. Can you imagine the vast potential for devising new interventions, modifying existing ones, or improving the outcomes in our patients through the introduction and measurement of titrated molecules or, alternatively, determining the extent to which new drugs or synthesized neurotransmitter precursors might actually impede restitution of functional movement? The impact that such advances will have on the promotion of the science and art of physical therapy awaits the eager minds and gentle hands of our future physical therapists.

[FIGURE OMITTED]

Collaborations between scientists at Georgia Tech and my institution, Emory University, seek to use LMP-1, a gene for stimulating bone cell growth, to facilitate fusion between bones or to promote trabecular bone in models of osteoporosis. (36) This form of gene therapy will soon yield the potential for interfacing genetics with physical therapy interventions. Can you imagine, for example, a study that examines whether the application of LMP-1 promotes bone growth faster in the presence of limb or trunk loading activities? What if, then, we consider advancing molecular science and genetics as part of our classroom experience? To some, this suggestion might be viewed as going far astray from our appointed task, but is it? Embracing the discoveries contained within molecules and genes affords an entirely new playing field to view impairments and how the impact of our current and as yet to be discovered interventions can be evaluated and quantified. If we are not prepared to meet the exciting interfaces between these emerging sciences and restoration of normal movement, then certainly someone else will.

Similarly, advances are being made in the study of movement control in virtual environments and the quantification of improvements using imaging techniques. Inevitably, the resolution and advancements in imaging neural or musculoskeletal structures will reveal linkages between intervention and mechanisms for restored function among a variety of diagnoses. What if, then, we also promote the study of biomedical engineering advances as part of our curriculum? What aspects of our training would need to be reduced in scope? Which aspects of our professional composition would become essential and esoteric? To what extent do these advances in science help us to define who we are and who we will become?

Association, Not Disassociation

The dynamic expansion of learning opportunities that present themselves is not restricted to the first-time learner. Whether or not one's terminal degree has the letter "D" associated with it is not the defining factor to advance our professional status. Perhaps we have reached a crossroad in our maturation where we have come to realize that a professional association cannot be disassociated. To suggest that a physical therapist cannot understand an issue because he or she is a researcher or a clinician is to plead ignorance and to promote unnecessary labels that, in turn, induce disassociation. In 1978, Margaret Moore told us that service and education are inseparable. (13) Since that time, we have come to realize that our explorations into novel interventions and mechanistic explanations of what we do and why we do them are also interwoven into the fabric of education and practice.

More than ever there is a need to dispel dichotomous notions. Clinicians are needed to educate in the classroom as well as the clinic, and educators are needed to foster clinical service, if not by traditional hands-on approaches, at least by assisting in the development of clinical databases and in the cooperative venture of analyzing those databases with clinicians who teach our students. Can there really be a better symbiosis? For those of us who have not had the good fortune to experience the interaction, can you imagine the excitement and sense of inquiry infused into our students by agreements and disagreements among clinicians or between clinician-educator pairings in the classroom?

The processes, steps, and intuitive decisions of master clinicians need to be described to those of us striving to become master clinicians in ways that embrace the student before he or she is regularly exposed to the clinic but in a manner that is amenable to documentation and analyses. Methods of documentation from which acquired information is analyzed propagates the need to revisit evidence--evidence that conceptually cannot be implicated to infer an end point, but, rather a continuum of interpretable thought, best described as "knowledge," an honest and clear depiction of who we are and who we are not as doctors of physical therapy. In a profession that advocates for doctoring to the physiotherapeutic needs of society, there are no other options. This approach is the legacy that our clinical mentors must leave to our future therapists who have not as yet left the portals of the classroom. This partnership between classroom and clinician should not and cannot absolve those of us who are non-physical therapist scientists from providing clinically relevant and valued information within the educational environment. The need for such a provision can and should promote open learning experiences between the scientist and the clinician.

These thoughts bring to a level of consciousness our constructs about how we organize some aspects of our infrastructure. Will perpetuating the congregation of educators and researchers into domains that we call "sections" promote or retard our growth as a doctoring profession? Will a need still exist for "educators" or "researchers" to meet in semi-isolation to talk about educational and researchable matters? What if there no longer were sections on education or research? Would our profession be better off by clinical groups assimilating educators so that curriculum design would now more formally capture interfaces between clinical specialists and those who oversee the educational process? Imagine how much validation of the bases for our practice could be enhanced by expending more energy in this arena! Would not clinically relevant ideas have even larger venues in which to percolate if those who explore researchable issues spent more time than they already do interfacing with other clinicians?

From a more global perspective, for us to serve as a point of entry into the health care system, for us to be seen as doctors of physical therapy, we must not only successfully attend to the problem lists with which our patients present, but also define and assist the patient to identify total health care needs beyond our skills and to address behaviors that reinforce pathological movement on the one hand and extinguish them on the other. These points of orientation, of philosophy, must serve as a common ground to what is arguably, for the present, diversity in the emergence of physical therapist doctoral programs. It seems reasonable that future dialogue would be most constructive if it targeted efforts that promote integration between the educator and the clinician, that help to dissolve dichotomy, that associate rather than disassociate. The unique and esoteric attributes of who we can become in an ever-changing health care landscape will be driven by the synthesis of our strengths and the perceived unity in our identity.

And what of the vast numbers of physical therapists who preceded the availability of training at the clinical doctorate level? The choice to make the transition is determined by age, experience, and priorities. So to partake in opportunities to formally further one's degree status is strictly a matter of choice. But know this fact: those of us who have championed the clinic in the name of physical therapy must leave as a legacy to those who follow with the label of "Doctor of Physical Therapy," the skills, knowledge, and experience that proclaim the next generation. This legacy should be left with pride, dignity, and self-respect devoid of any sense of uncertainty or inferiority. Those of us who know we are respected by our peers for the skills we possess and the services we deliver will not lose face or retreat. On the other hand, the opportunity and challenge to advance through additional education will not disappear. All who seek knowledge always have been and always will be embraced. Lastly, for all who have walked the academic corridors, any degree in physical therapy is terminal only with respect to the paper upon which it is printed. Further education, whether in the clinic or classroom, should not require a mandate, but must be self-initiated. If we have not inculcated that spirit in those we have trained and will train, then we have failed them, and, more importantly, we have failed the patients we purport to treat.

Stand Tall and Look Forward

The "what if" thoughts that have been presented are summarized in the Appendix. Many of the ideas encompassed in these notions may have sounded strange, bizarre, inconceivable, or, at the very least, discomforting. When I started this talk, I reminded us of how uncertain the unknown can be, if we so choose. But, again, not knowing what awaits us can also be exciting if we bring to bear the tools of unity, dedication, and determination, divorced from any immediate notion of entitlement but nourished by the altruism inherent in our training and nurtured in our hearts. In her book When Things Fall Apart: Heart Advice for Difficult Times, the American-born Tibetan Buddhist nun, Pema Chodron, tells a story whose theme should resonate with us, a story about how one must confront fear to overcome it:

   Once there was a young warrior. Her teacher told her that she had to do
   battle with fear. She didn't want to do that. It seemed too aggressive; it
   was scary; it seemed unfriendly. But the teacher said she had to do it and
   gave her the instructions for the battle. The day arrived. The student
   warrior stood on the one side, and fear stood on the other. The warrior was
   feeling very small, and fear was looking big and wrathful. They both had
   their weapons. The young warrior roused herself and went toward fear,
   prostrated three times, and asked, "May I have permission to go into battle
   with you?" Fear said, "Thank you for showing me so much respect that you
   ask permission." Then the young warrior said, "How can I defeat you?" Fear
   replied, "My weapons are that I talk fast, and I get very close to your
   face. Then you get completely unnerved, and you do whatever I say. If you
   don't do what I tell you, I have no power. You can listen to me, and you
   can have respect for me. You can even be convinced by me. But if you don't
   do what I say, I have no power." In that way, the student warrior learned
   how to defeat fear. (37)

To embrace the unknown, devoid of fear, for the noble intent of helping to better mankind should be the clarion that shapes our destiny. In 1921, in George Bernard Shaw's play, Back to Methuselah, the serpent tells Eve that initial perception can be deceiving and with each season the ugly serpent sheds its skin in a symbolic rebirth. For a while at least, the serpent, ensconced in its new covering, creates a different perception--a desire to see and to be seen in a different light. In that context, the snake offers the words that would be paraphrased subsequently on many occasions by Robert Kennedy, "You see things and say, `why'? But I dream things that never were and I say, `why not.'" (38) I sometimes wonder whether Mary McMillan had heard that quote when, less then 1 year after Shaw penned those words, she wrote, in her first presidential address, "The easy path in the lowland has nothing grand or new, but a toilsome ascent leads to a glorious view." (1)

Our road has been determined, and it is our duty to clear the path. The difference between our future and our destiny will be measured in our commitment. Making the decision to become identified as a doctoring profession and standing the high ground--fortressed by evidence that is derived from analyzed information and reinforced through the "art of caring," not just for our patients, but for one another, as contributors to the betterment of the human condition--will solidify our place in health care and leave no doubt as to what it means "to look forward and walk tall."

I wish to recognize some very special people. All have inspired me through their uncompromising love and commitment. To my mother, Hattie, who came to this country unable to speak English and with little awareness of the melting pot of opportunity that awaited her, I express my love and admiration for trying to do all that she felt was right for her son. By continuing to help those she calls "the older people," she finds strength to overcome infirmities and continues to infuse meaning into her life.

To my sons, Josh and Adam, whose vitality and thirst for life and knowledge never cease to refuel my energy for participating in all that life has to offer, I express my profoundest love and pride. You will never know the extent to which you validated my contribution to parenthood when you wrote on a birthday card so simply yet eloquently, "Dad, you never told us how to be, you showed us."

To my wife, Lois--my confidant, my lover, and most importantly, as John Adams so often penned to his wife, Abigail, "my dearest friend" (39) and with whom I share our anniversary on this day--I acknowledge you as the catalyst for all that I am and all that I can be.

To my in-laws, Philomena and Melvin Barnhart, who are no longer with us, I extend my profound appreciation for the faith and love you showed to me and for permitting me the honor of marrying your daughter.

When I was a young boy, I had a need to understand the meaning of death. My mother told me that the twinkle in each star was the light of a human soul that could no longer be with us. Simply pick a star and its nightly glimmer was how we would be seen by those we could not see in person. So in closing, I wish to recognize a man who came to this country stripped of his dignity and draped only in his religious identity, who lived long enough to see a little boy move from crawling to standing, but not long enough to see him reach beyond his space. Dad, perhaps on this day your star shines just a little brighter.

Appendix.

Summary of Thoughts from Exploring Our "What If" Questions

1. Professionalism--Essential and Esoteric Elements of Physical Therapy Service

2. Objectives/Educational--"Whats" and "Whys"

3. Quantify changes in patient behavior associated with our interventions

4. Determine the extent to which physical therapeutic interventions positively affect patient behavior

5. Promote learning of fundamental molecular science, genetics, imaging technology, and bioengineering concepts as an integral aspect of the classroom experience

6. Assimilate research and education sections within those of clinical specialties

Table 1.
Defining Professionalism in Physical Therapy

* Worthingham, 1965   Ethics, communication, self-control
* Daniels, 1974       Problem solving
* Carlin, 1977        Relevant knowledge, ongoing evaluation
* Moore, 1978         Clinical-educational integration
* Blood, 1979         Consumer advocacy
* Purtilo, 2000       Institutional advocacy
* Pinkston, 1986      Need to understand fundamentals
* Bartlett, 1991      Unique knowledge and skills
* Rothstein, 2001     Unique and essential identity

Table 2.

Redefining Professionalism

* Essential   "Demonstrably" important to prevention or
              physical treatment of movement
              pathologies

* Esoteric    "Uniquely" qualified to evaluate and
              oversee or deliver the service

* Web sites to describe and define quality-of-life measures: Quality of Life Assessment in Medicine (http://www.glamm.com/ql/url.htm), 800 Instruments Patient or Clinician Oriented (http://www.qlmed.org/LIST/index.html), Clinician's Computer-Assisted Guide to the Choice of Instruments for Quality of Life Assessment in Medicine (http://www.glamm.com/ql/guide.htm).

References

(1) Elson MO. First Mary McMillan Lecture: The legacy of Mary McMillan. Phys Ther. 1964;44:1067-1072.

(2) APTA Vision Statement for Physical Therapy 2020. American Physical Therapy Association House of Delegates (RC 44-00), June 2000.

(3) Peter LJ. Peter's Quotations: Ideas for Our Times. New York, NY: Quill, William Morrow; 1977:139.

(4) Mallory M. A crisis in care. Atlanta Journal Constitution. September 6, 2002.

(5) Appleby J. Health care insurance benefits to soar. USA Today. August 27, 2001.

(6) Kanell ME. Big worries loom over boomers' later years. Atlanta Journal Constitution. March 24, 2002.

(7) Ecoboomers, All Things Considered, National Public Radio, January 8, 2002.

(8) Fitzhenry RI, ed. The Harper Book of Quotations. 3rd ed. New York, NY: Harper Perennial; 1993:15.

(9) Maravillosa S. Newspeak. Laissez Faire City Times. June 28, 1999.

(10) Worthingham CA. Second Mary McMillan Lecture: Complementary functions and responsibilities in an emerging profession. Phys Ther. 1965;45:935-939.

(11) Daniels L, Ninth Mary McMillan Lecture: Tomorrow now: the master's degree in physical therapy education. Phys Ther. 1974;54: 463-473.

(12) Carlin EJ. Eleventh Mary McMillan Lecture: The revolutionary spirit. Phys Ther. 1976;56:1111-1116.

(13) Moore ML. Thirteenth Mary McMillan Lecture: Building winning teams. Phys Ther. 1978;58:1338-1345.

(14) Blood H. Fourteenth Mary McMillan Lecture: Account ability. Phys Ther. 1979;59:1388-1395.

(15) Purtilo RB. Thirty-First Mary McMillan Lecture: A time to harvest, a time to sow: ethics for a shifting landscape. Phys Ther. 2000;80: 1112-1119.

(16) Pinkston D. Twenty-First Mary McMillan Lecture. Phys Ther. 1986; 66:1739-1746.

(17) Bartlett RC. Twenty-Fifth Mary McMillan Lecture: In our hands. Phys Ther. 1991;71:833-841.

(18) Rothstein JM. Thirty-Second Mary McMillan Lecture: Journeys beyond the horizon. Phys Ther. 2001;81:1817-1829.

(19) Hughes EC. Men and Their Work. Glencoe, Ill: The Free Press; 1958:131-138.

(20) Editors' introduction and chapter 1 ("The Concept of Professionalization"). In: Vollmer HM, Mills DL, eds. Professionalization. Englewood Cliffs, NJ: Prentice-Hall Inc; 1966:1-33.

(21) Hislop HJ. Tenth Mary McMillan Lecture: The not-so-impossible dream. Phys Ther. 1975;55:1069-1080.

(22) Wood R. Twenty-Third Mary McMillan Lecture: Footprints. Phys Ther. 1989;69:975-980.

(23) Kaiser HL. Fifth Mary McMillan Lecture: Today's tomorrow. Phys Ther. 1991;71:407-411.

(24) Kendall FP. Fifteenth Mary McMillan Lecture: This I believe. Phys Ther. 1980;60:1437-1442.

(25) Magistro CM. Twenty-Second Mary McMillan Lecture. Phys Ther. 1987;67:1726-1732.

(26) Watts NT. Eighteenth Mary McMillan Lecture: The privilege of choice. Phys Ther. 1983;63:1802-1808.

(27) Michels E. Nineteenth Mary McMillan Lecture. Phys Ther. 1984;64: 1697-1704.

(28) Soderberg GL. Twenty-Seventh Mary McMillan Lecture: On passing from ignorance to knowledge. Phys Ther. 1993;73:797-808.

(29) Guide to Physical Therapist Practice. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001.

(30) Seldes G. The Great Thoughts. New York, NY: Ballantine Books (Random House); 1983:181.

(31) Sahrmann SA. Twenty-Ninth Mary McMillan Lecture: Moving precisely? Or taking the path of least resistance? Phys Ther. 1998;78: 1208-1218.

(32) Clinical Research Agenda for Physical Therapy. Phys Ther. 2000;80: 499-513.

(33) Issa R, Krupinski J, Bujny T, et al. Vascular endothelial growth factor and its receptor, KDR, in human brain tissue after ischemic stroke. Lab Invest. 1999;79:417-425.

(34) Gussev EI, Skvortsova VI, Dambinova SA, et al. Neuroprotective effects of glycine for therapy of acute ischemic stroke. Cerebrovasc Dis. 2000;10:49-60.

(35) Chopp M. Transplantation therapy in animal models of stroke. Presented at: International Stroke Symposium: Translating Principals of Brain Plasticity Into Clinical Interventions; April 28, 2002; Center on Aging, University of Kansas Medical Center, Kansas City, Kan.

(36) Sanders JM. Restoring hope to orthopedic patients. Research Horizons (Georgia Institute of Technology). 2001;19:16-18.

(37) Chodron P. When Things Fall Apart: Heart Advice for Difficult Times. Boston, Mass: Shambhala; 1997:34-35.

(38) Shaw GB. Back to Methuselah: A Metabiological Pentateuch. New York, NY: Brentano's; 1921.

(39) McCullough D. John Adams. New York, NY: Simon & Schuster; 2001.

SL Wolf, PT, PhD, FAPTA, is Professor, Department of Rehabilitation Medicine, Professor of Geriatrics, Department of Medicine, Associate Professor, Department of Cell Biology, Emory University School of Medicine, Atlanta, Ga. He is also Director, Program in Restorative Neurology, Emory University Clinic, Atlanta, Ga. Address all correspondence to Dr Wolf at Center for Rehabilitation Medicine, Emory University School of Medicine, Room 206, 1441 Clifton Rd NE, Atlanta, GA 30322 (USA) ([e-mail]).

The Thirty-Third Mary McMillan Lecture was presented at PT 2002: The Annual Conference and Exposition of the American Physical Therapy Association; June 7, 2002; Cincinnati, Ohio.

Mary McMillan Lecture Award Recipients

Mary "Mollie" McMillan (1880-1959) is remembered as one of the pioneers of our profession and as the founding president of the American Physical Therapy Association. Born in Hyde Park, Massachusetts, she grew up and was educated in England, where she decided upon a career in physical therapy. As the first physical therapy aide to be sworn into service in World War I, she supervised the training of reconstruction aides and came to be known as "The Mother of Physical Therapy" in the US Army. Mary McMillan organized one of the first courses in physical therapy in this country at Reed College in Oregon, and she established the first physical therapy training center in China at Peiping Union Medical College. Her book, Massage and Therapeutic Exercise, was the first comprehensive text on physical therapy written by an American physical therapist. During World War II, she treated prisoners of war while enduring the rigors of Japanese internment camps in Manila and Shanghai. Not only did she devote her life to furthering the profession, but she bequeathed a large part of her estate to its future, providing for the establishment of scholarship funds for students in the field of physical therapy. Mary McMillan's selfless devotion to the profession has served as the inspiration for generations of physical therapists, and the ideals and standards she envisioned at the founding of the Association are still the goals we seek today.

The Mary McMillan Lecture Award, established by the Board of Directors in 1963 to pay tribute to Mary McMillan, acknowledges and honors an APTA member who has made a distinguished contribution to the profession. The award provides an opportunity for the recipient to share his or her achievements and ideas with the membership through a special lecture at the APTA Annual Conference. Nominations for the award may be submitted by individual members and components of the Association. Recipients of the award are selected by the APTA Awards Committee, with members representing the APTA Committees on Practice, Education, and Research.

Mary McMillan Lecture Award Recipients

Mildred O Elson, PT                       1964
Catherine A Worthingham, PT, PhD, FAPTA   1965
Ruby Decker, PT                           1966
Col Emma E Vogel, PT                      1967
Helen Kaiser, PT                          1968
Margaret Rood, PT                         1969
None                                      1970
Lucy Blair, PT                            1971
Margaret Knott, PT                        1972
Lucille Daniels, PT                       1973
None                                      1974
Helen J Hislop                            1975
E Jane Carlin, PT, DSc                    1976
Mary Clyde Singleton, PT, PhD             1977
Margaret L Moore, PT, EdD                 1978
Helen Blood, PT, EdD, FAPTA               1979
Florence P Kendall, PT, FAPTA             1980
Susanne Hirt, PT, PhD                     1981
Dorothy E Voss                            1982
Nancy T Watts, PT, PhD, FAPTA             1983
Eugene Michels, PT, FAPTA                 1984
Geneva R Johnson, PT, PhD, FAPTA          1985
Dorothy Pinkston, PT, PhD, FAPTA          1986
Charles M Magistro, PT, FAPTA             1987
None                                      1988
Ruth Wood, PT, FAPTA                      1989
L Don Lehmkuhl, PT, PhD, FAPTA            1990
Robert C Bartlett, PT, FAPTA              1991
Marylou R Barnes, PT EdD, FAPTA           1992
Gary L Soderberg, PT, PhD, FAPTA          1993
None                                      1994
None                                      1995
Bella Jay May, PT, EdD, FAPTA             1996
None                                      1997
Shirley A Sahrmann, PT, PhD, FAPTA        1998
Suzann K Campbell, PT, PhD, FAPTA         1999
Ruth B Purtilo, PT, PhD, FAPTA            2000
Jules M Rothstein, PT, PhD, FAPTA         2001
Steven L Wolf, PT, PhD, FAPTA             2002

Dr Wolf thanks his colleagues and past students for providing him with the inspiration to compose this lecture. A special acknowledgment is offered to one of his past mentors, Nancy T Watts, PT, PhD, FAPTA, for insightful discussions about sociologist Everett C Hughes' perspectives on professionalism. Much appreciation is given to Andrew J Butler, PT, PhD, for helping to research concurrent studies on biomarkers that can potentially be associated with changes in impairment status and to Donald G Stein, PhD, and Stuart Hoffman, PhD, for invaluable discussions on the interface between molecular scientific advancements and physical therapeutic applications. The contributions provided by Van Hoo, MPH, in constructing the audiovisual presentation preceding this talk are very much appreciated. Dr Wolf also thanks Dr Marc Goldstein, Dr Andrew Guccione, Dr Joe Black, Dr Jody Gandy, and other staff of the American Physical Therapy Association for invaluable and frank discussions.