Camelot revisited: legacy of the physical therapy education program at Case Western Reserve University.

Camelot Revisited: Legacy of the Physical Therapy Education Program at Case Western Reserve University ... I am deeply touched by the expressions of support by former students, co-workers, and colleagues that must have been submitted to convince the selection committee to pick me for this ultimate award. ... I hope that I will in some small measure prove equal to the task before me.

First, I want to remind you of a few historical events. The American Physical Therapy Association (APTA) was founded in 1921. Mary McMillan died in 1959. The first physical therapy education program designed to provide the initial professional preparation at the graduate level was established at Western Reserve University (later named Case Western Reserve University [CWRU]) in Cleveland, Ohio, 30 years ago. The first student was enrolled in 1960 and graduated in 1962; the last class graduated in 1971. The House of Delegates voted in 1979 to set a target date of December 31, 1990, for current and future education programs to prepare persons for entry into the profession as physical therapists to be organized at the post-baccalaureate degree level. [1]

Camelot

During its brief existence, the Graduate Physical Therapy Program at CWRU has achieved a level of excellence in physical therapy education that continues even today to serve as the goal to which other programs aspire. It was the Camelot of its time. Camelot, you may recall, was the legendary capitol of King Arthur's kingdom about AD 450 to 650. [2] It was the place in which King Arthur developed the philosophy of the Round Table, around which the Knights who accepted King Arthur's philosophy assembled. King Arthur was dismayed at the waste of human potential that was rampant throughout his realm. Young men wandered about picking fights to demonstrate their superior strength and skill in individual combat. Many of the encounters ended in death for the loser. One day, Arthur came to the realization that it might be possible to channel these violent energies into a path that addressed some of the needs of society: coming to the aid of the unfortunate, righting the wrongs perpetrated by scoundrels, protecting the interests of the weak. He set down a code of conduct and invited a few outstanding knights in his kingdom to begin living by the code. The seven cardinal virtues of the knights of the Round Table were: Courage, Purity, Humility, Honesty, Diligence, Charity, and Fidelity. Because the table was circular, no one of the knights seated there could take precedence over another. The concept became appealing, and, as the fame of their good deeds spread, knights from throughout Europe came to England seeking to join that elite group.

The legendary city of Camelot came into prominence once more on the night of December 3, 1960, with the New York opening of the Allen J Lerner-Frederick Loewe musical comedy "Camelot," adapted from TH White's novel The Once and Future King.[3]

Meanwhile, in Cleveland, Ohio, a newly assembled faculty was busily engaged in polishing a curriculum for the preparation of students to become lhysical therapists who would "make a difference" in the field of physical therapy.

At this point, I need to depart from our story to tell you how I came to choose the theme and title for my lecture. During the opening reception of the Combined Sections Meeting in Honolulu, Hawaii, in February 1989, I encountered my old friend, Sam Feitelberg, Director of the Physical Therapy Education Program at the University of Vermont, who approached me muttering, "Case Western Reserve, Case Western Reserve--that's all I hear these days, about how they used to do things at Case Western Reserve! You know, I don't think it ever existed! You know, I don't think it ever existed! That's it! It was an imaginary place--a figment of people's imagination--like Camelot! Oh, here's Don--show me a brick--the program never existed!"

Well, Sam, thank you for suggesting the theme for my lecture. I decided to honor the faculty and the graduates of a program that came very close to perfection. It was Camelot! Mary McMillan would have been very pleased to see what it produced. (By the way, after the lecture, Sam was presented with a commemorative brick of the building that housed the program.)

Case Western Reserve

University Graduate Physical

Therapy Program Faculty

The Graduate Physical Theraphy Program at CWRU was conceived about 1955 through conversations between Catherine Worthingham, Louise Suchomel, and John Millis, president of the university. Dr. Millis, after reviewing an early draft of the proposal fo a new, improved baccalaureate-degree program, expressed the opinion that the knowledge, skills and capabilities expected of the graduates of the proposed physical therapy program could best be developed through graduate education. Other programs that prepared students for entry into health professions were in operation in the graduate school. Dr Millis maintained that any new program established at his university should be equal to the high standards of the other divisions of the graduate school. In February 1958, the curriculum plan was approved by the Graduate Council and faculty recruitment was begun. Louise secured the services of Geneva ("Geanie") Johnson in 1959; in December 1959, Louise made a trip to Iowa City (Iowa) to discuss the program with me. I had completed my doctoral degree in physiology 4 months earlier and was one of the few persons in the country with the combination of backgrounds in physical therapy and physiology. I agreed to vist the program to discuss possibilities with university officials and other potential faculty members. Upon arrival, I encountered what we came to know as "interview weather." Over the years, the weather often cooperated with us when we were courting potential candidates for important positions in our program.

Dorothy "Dot" Pinkston (another of the persons being recruited) and I accepted the positions offered and arrived in the summer of 1960 to prepare the course outlines we would begin using in the fall. Poor health had forced the early retirement of Louise in February, and Geneva had stepped into the role as program director. Agnes Conner, an experienced physical therapist, and Marian Russell, a kinesiology teacher in the Department of Physical Education, were added to the faculty. the first student, Elaine Bradford, was admitted in September 1960. She was the only student receiving the undivided attention of five full-time academic faculty members and several part-time clinical faculty members for 2 years. We had great difficulty recruiting students because of negative attitudes being expressed to potential students about our experimental program by other physical therapists around the country and because of the fact that the program was not yet accredited. In September 1961, the program was evaluated by an accreditation team representing the APTA and the Council on Medical Education of the American Medical Association, with official notice of accreditation being provided in April 1962 in time to cover the first graduate. Norman Taslitz, a physical therapist with a doctoral degree in anatomy, replaced Marian Russell in 1962.

Physical Facilities

The program was housed in the basement of Euclid Hall during the first 4-1/2 years of its existence and filled the building's three rooms to overflowing. When a class was in session, other faculty members working in their 4- X 5-ft cubicle offices had to go out the side door, through the snow drifts, and in the back door to reach the common restroom. In February 1965, the program moved to Ickes House (later named the Physical Therapy Building) and occupied the basement and the first two floors, eventually taking over the third floor from the Psychology Department as well.

Curriculum

The curriculum was divided into three phases, which covered two academic years and one summer (Appendix 1). Phase I, the first two semesters, was essentially a study of the normal structure and functions of the body (Fig. 1), basic principles in the administration of physical therapy procedures, and development of "beginning" skill in applying physical therapy procedures. Phase II included studies of abnormal structures and functions of the body and application of physical theraphy principles and procedures to abnormal contitions.

Phase III included submission of a thesis and courses in administration and supervision, curriculum development, and principles of teaching, as welas transition to full clinical participation. Although the major portion of clinical education occurred during Phase III, the student began acquiring clinical experience during the first semester of Phase I and continued to gain increasing breadth and depth of clinical experience throughout all phases.

First Year of Employment

Each graduate of the program agreed to accept employment for 1 year in a hospital department approved by the faculty. The faculty believed that the first year of full-time clinical practice was an essential component of the educational experience for students in the program. This first year of employment was especially important to provide new graduates with adequate supervision as well as the opportunity to increase the knowledge and skills acquired as a student. In return, the new graduates shared their knowledge and skills (particularly regarding clinical investigation) in a setting that was selected to encourage the growth and development of the recent graduate.

Reflections

In reflecting on the policies we set, the activities in which we engaged, and the lessons we learned at CWRU, the following stand out:

1. We devoted considerable time and effort at the beginning to drafting a statement of philosophy for the program that we could each support (Appendix 2)

2. We established traditions right away:

* A shoulder patch and pin were designed, which students wore in the clinic (Fig. 2).

* The CWRU Mary McMillan Lecture was established in 1962, with Catherine Worthingham delivering the first address (Appendix 3). The first APTA Mary McMillan Lecture was presented by Mildred Elson at the APTA Annual Conference in Denver, Colo, in July 1964.

* An alumni association was formed. The traditions that evolved made the group very cohesive and helped to promote respect for the importance of the efforts undertaken.

3. We involved local clinicians in planning the curriculum, evaluating students, and revising learning experiences. Early members of the Professional Advisory Committee were Loretta Boger, Sara Schoppenhorst, Helen Schroeder, Beth Fowles, Lucy Jones, and Jessica Hopkins. In later years, Leon Anderson, Director of the Physical Therapy Department at University Hospitals in Cleveland, Ohio, provided valuable assistance and advice, as did many others. Helen Meida, a clinician with extensive experience in the community, replaced Agnes Conner as Coordinator of Clinical Education.

4. We exposed the students to the clinic early in the first semester to whet their appetite for learning more anatomy and physiology.

5. We sequenced the development of knowledge and skill in identifying problems and the process for solving them. Introduction to scientific inquiry began the first semester and culminated in the completed thesis during the second year.

6. We involved local scientists in developing opportunities for thesis research. A thesis committee, consisting of a physical therapy faculty member, a clinician, and a scientist, was assigned to each student. The interactions promoted by that arrangement strengthened collegial relationships and opened many doors to exciting opportunities for collaboration.

7. We provided structured opportunities to develop skill and poise in delivering effective oral presentations, including seminars to report on progress in developing the thesis, to defend the thesis, and to report on the results of research at the next APTA Annual Conference.

8. Emphasis was placed on the development of skill in locating, assessing, and drawing inferences from information rather than memorizing a mass of facts.

9. We took full advantage of opportunities to have visiting experts in the field (eg, Signe Brunnstrom (*1)) provide classes, seminars, or workshops, even if the topic was out of sequence, so that students could meet and discuss issues sith these experts. Such opportunities increased because of the establishment of the Continuing Education Program as a component of the Graduate Physical Therapy Program in 1963. This program was headed by Mary Eleanor Brown and offered many valuable learning opportunities to physical therapists throughout the country. Especially valuable was a series of "refresher courses" designed to assist the return of former clinicians to the work force.

10. We reported on significant activities going on within district, state, and national components of the Association. Students saw the faculty being intimately involved in issues affecting the profession.

11. The philosophy of the program was dynamic and aimed at preparing graduates for the future. This goal was achieved to a remarkable degree.

We also made mistakes. For example, in the early years, each faculty member required students to prepare a term paper, which was due at the end of each semester. With five classes, students had to prepare five term papers. By the time they were graded and returned, the topics were forgotten. A student rebellion forced the faculty to reconsider the purposes to be accomplished by the assignments and the best way of achieving them. Thereafter, the student was guided in selecting one topic to be researched, and a faculty advisor was assigned to whom the paper was submitted in stages during the year. This process provided opportunities for critique and revision. The product often served as the basis for the thesis, because the topic selected always dealt with the application of science to a health problem treated by physical therapists.

Follow-up Survey of

Graduates

In 1983, Geanie Johnson, Elizabeth "Betsy" Littell, and I conducted a follow-up survey of the 54 surviving graduates (Appendix 4) of the CWRU Craduate Physical Therapy Program. [6] The data returned from 50 (93%) of the graduates yielded information that reveals their career development in considerable detail, as well as the relationship of career development to the objectives of the education program. Descriptive statistics revealed that 70% of the graduates were still actively practicing physical therapy (46% full-time, 24% part-time), 8% were full-time graduate students, 8% were employed outside of physical therapy, and 14% were not currently employed (homemakers). A majority of those employed in physical therapy anticipated remaining in the field because of interest (72%), job satisfaction (66%), or adequate financial remuneration (56%). Twelve percent had earned a doctoral degree, and 44% were associated with academic programs in some capacity. During the 14.5 years (average for all graduates) since completing the program, each graduate had participated in an average of 15 continuing education courses, made six presentations, and published one or two articles. An update of selected portions of the survey in March 1990 revealed that 80% of the 54 surviving graduates were working in the field of physical therapy, 9% were not currently working, 2% were in another field, and 8% were retired or could not be located. The results provide substantial evidence to support the conclusion that the program prepared graduates with long-term dedication to physical therapy as clinicians, teachers, and leaders. In addition, it is significant to note that three of the faculty of that program have been honored by being named Mary McMillan Lecturers: Geneva Johnson, Dot Pinkston, and me.

Demise of the Program

You may ask, "If that was such a great program, why is it no longer in existence?" The answer is that it fell victim to the Vietnam War. From the outset, the program was heavily subsidized by grants. Student tuition covered only a fraction of the costs of the program. In 1968, the heavy costs of the Vietnam War caused major reductions in federal funding of research and education in universities throughout the nation. Budgets of funded programs were slashed in half with little or no warning. Grant funding of the physical therapy program was not reduced. However, other programs within the university suffered severe cuts, which forced layoffs of staff. The university could not pay many of its bills. A task force was commissioned by the president of CWRU to study the potential financial exposure facing the university in the event that further cuts in federal funding were made. Recommendations of the task force included orderly phasing out of the Graduate Physical Therapy Program. We fought that decision, but lost. Thus, students admitted in the fall of 1969 and graduating in 1971 comprised the last class.

Lessons Learned from the

Past 30 Years of Academic

and Clinical Involvement

The science of physical therapy draws heavily on the knowledge developed in the biological, physical, and behavioral sciences. The art of physical therapy draws on knowledge from the humanities. As one of the important health care professions, physical therapy has a uniqueness that lies largely in the application of knowledge, rather than in the creation of new knowledge. For physical therapy to continue to provide high-quality and effective health care services, physical therapists must initiate and participate in the research needed to substantiate current and future practices in the field. Because physical therapists must respond to the enormous demands for patient care and meet the demands for education, as well as those for research, we must seek ways to make maximum use of our limited number. In all settings in which physical therapists are employed, research should be emphasized as a necessary part of continuing activity. Some of the research needed can be completed in concert with investigators in other professions. But a substantial part of the clinical research essential to our field is the responsibility of the physical therapist.

Clinician as Researcher

The clinician has the opportunity and the potential to be a researcher. A researcher is an observer, an evaluator, a recorder of facts, an analyzer, and a synthesizer. The clinician also functions in all of those roles while caring for patients. The researcher asks, "Why did that response occur? What is the effect of the response? Will the effect last? How long?" The clinician raises those same questions daily in managing patient care and records answers to those questions. Although a clinician may keep accurate and detailed records, the information is often recorded in such a way that comparison with information recorded by others in the same or similar settings is difficult, if not impossible. The importance of systematic, accurate, and comparable recording of what we do and the results of our interventions cannot be over-emphasized.

Standardized Documentation

The physical therapy staff in clinical settings should work toward the establishment of a system of documentation that will enable us to use our records with confidence for two different, but equally important, kinds of clinical research. The first is descriptive research (ie, research that will describe what we are doing with a patient at a given time and what happens to the patient as a result). The second type of research is "experiemental" and is designed to answer the question of why a specific response occurs. Both require the formulation of a researchable question and analysis of the recorded results of clinical evaluations performed on patients by physical therapists.

Posing Answerable Questions

Good research is the process of posing an important, answerable question and then systematically collecting data to provide a convincing answer to the question. In many of the physical therapy manuscripts I have reviewed for possible publication, the purpose of the study was unclear, either because no research question had been stated clearly or because the question (stated or implied) was virtually impossible to answer. An answerable question is one in which the answer consists of evidence in the form of data. The data are gathered by making observations or measurements. The success of the research project can be rated in terms of how convincing the evidence appears when judged by the users of the information. Thus, I urge all who contemplate embarking on a clinical research project to state the research question; check to be certain that the question is answerable; identify the data that will be needed to provide a convincing answer; and select a method of measurement that will yield valid, accurate, and reproducible data. The prospective researchers also should consider the importance of the question. In these days of limited resources, the answer to the question should be of interest to others. Important (ie, useful) information serves as the basis for deciding who, when, how, and how much to treat and for setting priorities regarding the allocation of resources, both human and financial.

Using Common Sense in

Reporting Results

Previously, I pointed out the implications of insufficient rounding of the numbers used to convey the results of a study. [7] Much of science is built on a foundation of numerical data that describe characteristics and interrelationships of objects or substances. Such numbers, of course, do not arise spontaneously; they are produced when an observer adopts some type of measuring system, applies the measuring device to the subject, and then interprets the actual entity observed. As the end product of these activities, a number will be only as good as the way the observer makes the system ready to work and the way the results are obtained and presented. If these aspects of the measuring system are managed scientifically, the number will be accurate and significant; if not, the number may be worthless, no matter how many digits it contains. Authors who report the results of a study should pay particular attention that they do not report numbers that contain more significant figures than warranted by the methods used to obtain individual measurements. A common misapplication of the rule of rounding numbers occurs when the author is reportig the results of range-of-motion (ROM) measurements. For example, the mean value of a column of individual measurements may be computed to four significant figures and rounded to three. Thus, an investigator who uses a goniometer to measure ROM with an accuracy of [+ or -] 2 degrees and then reports the mean value of a series of measurements as 36.472 degrees is communicating to the reader a implied precision that is unjustified. In reporting results of measurements, the values should be rounded to the last digit of questionable accuracy. In the example stated, the result reported in the text of the manuscript should be rounded to the nearest whole number--36 degrees.

Becoming Skilled "Consumers"

of Results Being Reported

Students and clinicians with whom I have worked have exhibited varying degrees of healthy skepticism when reading or hearing about the results of an investigation. Some have accepted as indisputable truth whatever appeared in print or was uttered by a teacher. Others wanted to know the facts upon which the statements were based. Given appropriate learning experiences, all of them could strengthen their ability to identify the question and to assess the adequacy of the methods and of the data supporting the conclusion(s) drawn by the investigator. We need to ensure that everyone entering the practice of physical therapy has acquired basic skills in assessing the merits of written and verbal reports.

What of the Future?

I stand before you today as proof that the future for ourselves and for our profession can be what we choose to make it. . . . I have selected, from the options available to me, opportunities to undertake challenges in a supportive environment. The people with whom I have chosen to work over the years have striven for excellence, and they expected t of me. The students admitted to the CWRU Graduate Physical Therapy Program were to brighter than those admitted to other programs. However, once admitted, the faculty expected each student to succeed. We were there to help the students when they needed us. We set high standards, made good opportunities available, and made the students feel special. They rose to the occasion.

I fully support the concept of developing "centers of excellence," whether funded specifically for that purpose or not. The amount and quality of productivity from a critical mass of capable professionals who complement one another far surpass the productivity of the same individuals working in isolation. I cringe when I hear of an institution operating a program (educational or clinical) with a single staff member. I question the judgment of the staff member who accpets such a position.

I also deplore the actions of the administrator of an institution housing multiple programs who takes steps to ensure that every program in the institution is equal. That philosophy ensures that all programs will reach the same level of mediocrity. Instead, I support the concept of ensuring equal opportunity and then nurturing potentially exemplary programs to achieve excellence.

Camelot was created at CWRU because a small group of people (Fig. 3) hammered out a set of reachable goals that were accepted by all. They promoted an atmosphere that encouraged open airing of disagreement to reach a consensus. They developed unbounded respect for the contributions made by each individual. They expected each faculty member and his or her students to perform exceptional work. The environment stimulated all to strive for excellence. Most of them succeeded.

I challenge you to go forth and create your own Camelot to make a better world.

(*1) Wh en reading the excellent biography of Signe authored by Jay Schleichkorn, [5] I learned that Signe was invited to present the APTA Mary McMillan Lecture in 1967 (when she was 69 years old) and again in 1971. For reasons not recorded i her diary, she chose to decline both invitations. She was very deserving of the honor, and I want to express my great admiration for the quality and quantity of her contributions to the body of knowledge in physical therapy.

References

[1] Report of the House of Delegates Session: June 11-14, 1979, Atlanta, Ga. Phys Ther. 1979; 59:1396-1400.

[2] Barber R, ed. The Arthurian Legends: An Illustrated Anthology. Totowa, NJ: Littlefield Adams & Co; 1979:6.

[3] White TH. The Once and Future King. New York, Y: Putnam Publishing Group; 1958.

[4] Elson MO. First Mary McMillan Lecture: the legacy of Mary McMillan. Phys Ther. 1964:44:1067-1072.

[5] Schleichkorn J. Signe Brunnstrom: Physical Therapy Pioneer, aster Clinician and Humanitarian. Thorofare, NJ: Slack Inc; 1990.

[6] Johnson GR, Littell EH, Lehmkuhl LD. Follow-up study of physical therapists completing a post-baccalaureate degree between 1962-1971. Phys Ther. 1987;67:790. Abstract.

[7] Lehmkuhl LD. Practical implications of the decimal point (writing tips). Phys Ther. 1984;64:549.

LD Lehmkuhl, PhD, FAPTA, is Director, Brain Injury Research, The Institute for Rehabilitation and Research, 1333 Moursund Ave, Houston, TX 77030 (USA).

The Twenty-Fourth Mary McMillan Lecture was presented at the Sixty-Fifth Annual Conference of the American Physical Therapy Association, Anaheim, Calif, June 24-28, 1990.