Preparation for the twenty-first century: the educational challenge.

Preparation for the Twnety-First Century: The Educational Challenge In my previous Presidential Addresses, I focused primarily on organizational and practice issues. There is another essential element of our profession that seldom receives major support, seldom is recognized for its accomplishments over the years, and seldom receives the attention it deserves from this Association. Because I strongly believe that our professional education programs represent a generic source of critical importance to the future of physical therapy, education will be the focus of my Address this year.

Individually and collectively, we, as physical therapists, have a tendency to be somewhat schizophrenic in our behaviors and perspectives regarding our education programs and our academic colleagues, particularly those involved in entry-level education. We are frequently vocal in our criticisms, negative in the ways in which we are inclined to promulgate the "town and gown" dichotomy, and condescending when some of us make references to shibboleths such as "those who cannot do, teach," and some of us ridicule educational terminology in a manner that suggests that the failure to converse in language common to academicians is somehow a badge of honor. That latter behavior also assumes that our documentation and communication as clinicians are free of jargon--an assumption that would be recognized as being clearly subject to question by any honest clinician in this audience.

Full-time clinicians frequently express to me their impatience with the slowness with which change occurs in our academic settings. This impatience tends to imply that the educational arm of our profession is a weight on the tail of progress. Unfortunately, it also shows a lack of understanding of academic systems and political decision making within those systems. The degree of negativism I hear has led me to suspect that some of us have forgotten that our education programs and our academic colleagues provide the very foundation of our profession and its future. As the ultimate testimony, I would question whether any physical therapist in this audience would be here without having graduated from an accredited professional education program.

Interestingly, most of the negativism I hear is expected within our professional community, whereas in external groups and communities we extol the virtues of our rigorous education programs, we take great pridt in the quality and fairness of our accreditation process, and we readily acknowlegde the respect our education programs enjoy in their higher education environments.

I feel the need to remind this audience that our professional education programs, both preprofessional and postprofessional, have had and continue to hold an awesome influence on our professional through the many generations of students they prepare for professional practice. I believe they will have an even greater role to play in the future, and their opportunities for contributing to and influencing the profession in multiple ways have not yet been fully realized.

I submit that it is time to seek treatment for our apparently schizophrenic behavior in regard to our professional education and rid ourselves of this contradictory non-sense. As we prepare for the twenty-first century, we must initiate the types of self-criticism that can be targeted to achieving and maintaining excellence in our education programs. I can state with confidence that our educational settings have a strong commitment to providing the education necessary to prepare present and future generations of physical therapists and physical therapist assistants. I consider it constructive to begin that process by identifying 11 major educational goals that require a willingness to reexamine systematically certain practices and assumptions to determine their contemporary validity and utility.

Goals for the Twenty-First

Century

I. The first goal I propose is reexamination of our accreditation process. Historical data indicate that the public trust vested in the American Physical Therapy Association via recognition as an independent accrediting body has been fulfilled with honor and integrity for more than a decade. During that time, there have been hundreds of program reviews and site visits and only two appeals.

Our accreditation process has become increasingly refined and sophisticated to the extent tht we might now consider the merit of developing a rating system of our accredited education programs that would be published and made available to prospective applicants, their parents, external agencies or organizations, and the public at large. A blue-ribbon panel of distinguished academicians and clinicians could establish the explicit criteria used to determine that ratings, and a similar group could be convened on a periodic basis (eg, once every five years) to determine the ratings. The criteria might include, but not be limited to, elements such as faculty credentials and proportion of faculty havin obtained the doctoral degree; the volume and frequency of faculty publications in refereed researcg journals; the volume of additional scholarly productivity (ie, publication of texts and instructional manuals, presentations at local and national conferences); the existence, or lack thereof, of some type of faculty practice plan; and the nature and extent of library and clinical education resources.

We may not yet be sufficiently courageous or self-confident to embark upon a rating system, but if we truly intend to be fully accountable to the public trust vested in us, the availability of such a rating system would be a positive and dramatic step forward. At the very least, in the educational marketplace, a periodic rating would clearly show where each of our education programs stands in relation to the criteria established and could assist in embracing potential students to make informed decisions as they plan for their physical therapy professional education.

II. The second goal is reexamination of our admissions processes. The traditional emphasis on prior academic achievement has served us well . . . or has it? Without a doubt, prior academic achievement constitutes an important criterion for admissions decisions. Our education programs are rigorous, and educational institutions need the assurance that students who are admitted are capable of completing the professional sequence of study successfully. However, physical therapy education program applicant pools are still large quantitatively, and most of our programs still have to reject highly qualified applicants because of limited enrollments and the competitiveness of the admissions process. In some programs, applicants with prior academic achievement records below 3.3, or even 3.5, on a 4.0 grading scale have little probability of being admitted. I have often contemplated what our profession and the health care marketplace may have lost in many of the applicants we have had to reject.

Academic achievement, albeit an important consideration, does not necessarily equate with problem-solving skills, independent thinking, clinical reasoning, or the accuracy of judgment required of the professional physical therapist in the contemporary health care marketplace. I acknowledge that many of our entry-level programs use additional measures, such as personal interviews, in their attempts to identify certain characteristics of applicants with the greatest potential for professionalism. However, those measures are seldom weighted heavily in admissions considerations, and even less frequently have been subjected to tests of validity and reliability.

Regardless of the processing expertise of the chef and the oven, the excellence of an apple pir rests in its ingredients. Developing effective, fully professionalized physical therapists is to me far more important than an apple pie, but the principle of ingredients still applies. I think it is time we reviewed the studies initiated by Dr Dorothy Pinkston and her associates at Case Western Reserve University in their attempts to identify the variables and characteristics of effective physical therapists. As we increase that data bank, the information must be fed into the admissions selection process. In other words, our profession needs to direct greater attention to the horses selected for its educational stables rather than attempting to remedy their problems after they leave the barn.

III. The third goal is reexamination of the educational environment and the nature of the relationships between faculty and students. Existing relationships sometimes appear to present a self-defeating contradiction in that we purport to prepare independent thinkers, problem solvers, and self-actuating professionals while simultaneously expecting students to be obidient to their faculty authority figures. Unfortunately, we cannot have it both ways. We must be willing to acknowledge this apparent contradiction when it exists and find additional ways to nurture the development of self-responsibility and accountability in students as active participants in their learning processes. Otherwise, we risk socializing students into subservient behavioral responses that may carry over into their clinical practice relationships with perceived authority figures such as physicians and administrators.

IV. Fourth, we must subject the process and content of our professional education curricula to much greater and far more frequent scrutiny than has been occasioned to date. I believe it was management consultant and author Peter Drucker who once observed that when an area of knowledge or skills become obsolete, it somehow manifests as a required course in professional curricula. I do not believe that adage necessarily applies to physical therapy education, but the risk of obsolescence is ever present, particularly at a time when change is occurring so rapidly in health care and in physical therapy roles, functions, and decision-making autonomy.

Feedback from academicians indicates that it is far easier to add new content to a curriculum design than to delete anything. That phenomenon has several very logical rationalizations, not the least of which is the notion that not all of a program's clinical education facilities may have the resources for, or access to, contemporary technology. However, if we accept that notion, we indirectly, with no conscious intent, perpetuate obsolescence. I personally reject that notion and suggest that our education programs consider the potential positive effects on our service recipients, our service delivery settings, and our profession's public image that might or could result from a conscious decision not to attempt to prepare students for all possible contingencies (ie, if those contingencies require preparation for therapeutic interventions that we know to be obsolete).

We also need to examine the comparative weighting of the content of various curricula in relation to the epidemiologic incidence and prevalence of the problems and conditions new graduates will most likely encounter in practice. I believe that conditions with the highest incidence and prevalence amenable to our diagnostic and therapeutic interventions should enjoy priority consideration in depth of coverage in entry-level professional education. In no way am I suggesting that other conditions are to be ignored. However, we should strive to achieve a better fit between content area emphasis and potential frequency of encounters in practice than we have experienced to date.

In regard to process, we need to reexamine our instructional strategies and formats. Sole reliance on the lecture and laboratory model that has long been our basic curriculum design will have minimal relevance as we make the continuing transition to entry-level professional education leading to a graduate degree. Association survey data indicate that nearly one third of our currently enrolled baccalaureate program students are mature learners in the process of career transition. This profile is even more evident in our 29 years of experience with entry-level master's degree students and in our long historical experience with certificate program enrollees.

There is a growing and informative literature on adult education and the needs of mature learners. I have been somewhat puzzled as to why we have not cited the research of William G Perry Jr as we present justification for postbaccalaureate degree professional education. Perry's initial study (1) and subsequent replication (2) tend to support the premise that professional education can best be conducted at the postbaccalaureate level. It is high time that we tune in to the literature of higher education and incorporate that information as we design physical therapy curricula. As a starting point, and in addition to Perry's initial study, we might benefit from revisiting some of the reports of the Carnegie Commission on Higher Education, particularly the one entitled Toward a Learning Society: Alternative Channels to Life, Work, and Service. (3)

As a final comment on process and content, I strongly believe that we must acknowledge the link between our entry-level education programs and direct-access modes of practice. Granted, many of us functioned in direct-access modes of one type or another years before the practice legislation occurred in some 23 states. However, the very existence of that legislation, which is rapidly spreading to other states, strongly suggests that it is now time to "come out of the closet," acknowledge the realities, and recognize that our entry-level programs can play a critical role in improving the preparation of graduates for direct-access modes of practice. We can anchor that linkage by ensuring that our curricula provide graduates with a strong and thorough foundation in systematic, organized client-assessment practices that result in differential physical therapy diagnoses. Medical diagnoses are a valuable and important part of our practices, but they do not necessarily equate with physical therapy diagnoses as a basis for planning treatment programs.

I believe that it will be to our benefit to acknowledge that linkage of direct access and educational preparation. That belief does not assume that current or past graduates of physical therapy education programs are less than prepared to function in a direct-access mode. On the contrary, it assumes that we desire to achieve an even greater degree of excellence and accountability in that mode of practice than has been available previously.

V. As a fifth goal, our education programs must question the extent to which they are (or are not) committed to facilitating the socialization of values targeted to active involvement in our professional association. Such involvement is clearly part and parcel of professionalism and professional education, yet our APTA membership data suggests that we should be doing much more than we are to increase the transitions from student to active membership.

In November 1987, the participants of the National Student Conclave, hosted by students at the University of Vermont, expressed a strong interest and desire to learn more about the Association and to have more involvement at district and chapter levels, and were even then discussing the means of organizing a national student association. Some students present at that conclave stated that they had strong education program and chapter support for committment to the Association and the profession; other students had far less positive experiences to share. A major source of confusion to those students was the fact that some had both academic and clinical role models who were not members of APTA.

Students not only are our colleagues, but they represent the future of this profession. I believe it is time for this professional association to make a strong value commitment to the prospective physical therapists and physical therapist assistants enrolled in our education programs. We can do so by recognizing that we must expand activity-level options at the district, component, and education program settings that can provide students with opportunities to identify with, and make conversion to, active or affiliate membership status in the APTA.

VI. As a sixth goal, our education programs must examine the extent to which they prepare their graduates to be reflective practitioners. In 1988, at the annual conference of the American Occupational Therapy Association, I had the pleasure of hearing Dr Donald A Schon discuss the research project he and his associates were conducting at the Massachusetts Institute of Technology with the AOTA and occupational therapy practitioners. I was intrigued with his concept of reflective pratitioners and the notion of reflection-in-action, which occurs in encounters between professionals and their clients.

As I understand Dr Schon's concept, he is referring to the mental concentration and considerations experienced by professional practitioners in each client encounter, even though those considerations may not be communicated. Dr Schon states that "much reflection-in-action hinges on the experience of surprise." (4) I immediately saw the applicability and importance of that concept to the practice of physical therapy. Each new client encounter presents a problem to be identified, a mystery needing to be solved, and variables that tend to be characterized by uniquenesses, uncertainty, and even unknowns. Dr Schon proposes that such interactions are experimental and constitute a form of research that, although differing from the traditional notion of research, is extremely valuable to any profession. Reflection on what we are, who we are, what we do, and why we do it is essential to the full professionalization of physical therapy. The process of developing that capability and awareness could best originate in initial professional education, and I think it would behoove us to find the means to foster that process.

That reflection process may also go hand-in-hand with the ways in which we teach students qualitative and quantitative documentation. As do other professions, we value objectivity and quantitative documentation processes. However, in so doing, we need to devalue the qualitative considerations and the themes of responding to, and learning from, unique encounters that pose equally rich research and learning opportunities.

VII. As the seventh goal, I propose that our academic programs might wish to reexamine how, and the extent to which, they use full-time clinicians as didactic faculty resources in their curricula. In recent years, there has been an increased use of full-time clinicians as part-time faculty members (ie, to teach a course, a module, or a unit within a course or to provide a clinical correlation experience in conjunction with an academic course). I commend this trend, but there are a few aspects that may warrant attention.

During the past several years, I have received an increasing amount of feedback from full-time clinicians that evidences their strong motivation to be involved in teh academic component but that raises several unresolved problems or issues regarding the nature of that involvement. Apparently some clinicians receive insufficient prior contact as to their availability to teach. Others ahve indicated tat they receive little or no information as to the philosophy or objectives of the education program or as to where their teaching contributions fits in with concomitant learning experiences. Most frequently, however, I hear concerns about the financial arrangements which, according to some clinicians, seldom accommodate for preparation time or for the costs of audiovisual resources or duplication of handout materials . . . most of which are seldom subsidized by the clinician's practice setting.

If we truly value that clinician contribution to out academic programs, we need to identify tangible means to evidence that value commitment. I am told that full-time clinicians who teach in academic programs do most of their instructional preparation on their own time (ie, because of the productivity requirements in their practice settings). I have confidence that academicians can respond to that issue as they face some similar institutional problems.

VII. Eighth, I believe that we must, as a professional association, acknowledge the necessity of providing increased opportunities for physical therapist assistant development. As I have traveled around this country, my impression is that physical therapist assistants are as oriented to personal career development and mobility as are physical therapists. To date, our Association appears not to have recognized or been responsive to this need.

Our education programs can play a critical role assisting the profession in understanding how we most appropriately and safely use the skills of the physical therapist assistant. There is a prevailing notion within our profession that the physical therapist assistant will replace the physical therapist in "hands-on" patient care and that the physical therapist will be relegated to initial evaluation and paperwork. From my perspective, that is absolute nonsense.

The physical therapist assistant can enable the physical therapist to allocate priority to those clients with conditions requiring the level of professional judgment and therapeutic intervention for which we have been educationally prepared. I would personally hope that all physical therapists would be sufficiently knowledgeable about delegation and about the role of the physical therapist assistant to recognize their responsibility and accountability for effective supervision of the physical therapist assistant. I strongly suspect some unwarranted paranoia.

If there are those among our professional community who can point to studies that clearly show that the use of physical therapist assistants, rather than physical therapists, jeopardizes the quality of the service provided for a given problem or condition, then I shall be the first to argue against the delegation of responsibility to physical therapist assistants in such a situation. Currently, I know of no such studies.

IX. As a ninth goal, I would hope that our education programs will consider the magnitude of their potential contributions to relieving physical therapist shortages. These contributions do not rest solely in the development of additional programs or in expanded enrollments in existing programs.

I envision our existing academic programs taking a strong lead in establishing consortia with their clinical education settings to provide career renewal and reentry opportunities for those physical therapists who have not been engaged in practice for many years, but who wish to find ways to resume their professional careers. We do have some education programs that offer various models of refresher programs, and that is appreciated. However, I strongly believe, based on personal experience, that career renewal is best initiated in clinical settings that provide effective preceptorships and consortia between education programs and their clinical counterparts.

Also, if we truly intend to be responsive to the societal need for increased numbers of physical therapy practitioners, our education programs might consider some innovative efforts to provide career-change pathways for those in other professional disciplines. I do not know who first coined the term "fast-tracking," nor do I care because I find that term totally inappropriate for the career-change pathways to which I refer. I foresee no "quick fixes" to physical therapy professional education routes, but surely we can improve our capabilities for developing proficiency and equivalency challenges that could facilitate the educational process. There are many highly educated individuals in professions in which supply far exceeds demand or in which there is limited diversity and career mobility. It has been estimated that persons in our society now experience three or four career changes during their lifetime. I believe we can find effective ways to take advantage of that potential without compromising the integrity of our entry-level professional education process.

X. As a 10th goal, we must reexamine how we recruit and retain faculty for our academic programs. On the surface, it appears appropriate to recruit faculty for entry-level programs on the basis of their clinical expertise and skills. Those are important qualifications, but we frequently fail to recognize that the professional academic role, as compared with our professional service role, requires far more than clinical expertise.

Higher education views the professional academic role as a triad of missions consisting of research, education, and service. That suggests to me that physical therapists desiring an academic career must acknowledge several realities, as follows:

1. In the contemporary milieu of higher education, it is close to impossible for an individual recruited to a faculty role to complete a doctoral degree and qualify for promotion and tenure simultaneously in the three-year period usually allowed.

2. Because higher education is in a constricting rather than an expanding mode, there will be an increasing expectation that physical therapy academicians and other faculty members generate up to one third of their annual salaries through obtainment of "soft" funding such as grants and contracts or through income generated for their departments in faculty practice plans.

3. Contemporary academic life styles are far more demanding and stressful than they were even a decade ago, and I seriously doubt that any faculty member can ever hope to enjoy remuneration comparable to the income potential of his or her colleagues in clinical practice.

Therefore, I would suggest that anyone contemplating an academic career start preparing now. Design a plan to complete a postprofessional master's degree, if you have not already done so, and then complete your doctoral degree. You will do yourself, your profession, and the higher education institution in which you may eventually locate a productive service if you also begin tuning in to the higher education literature to expand your understanding of the academic subculture and traditions.

XI. I have saved until last what I see as perhaps our most important educational goal for the next century. With Dr Geneva Johnson, one of our former Mary McMillan Lecturers, and with many other colleagues, I share a goal of the establishment of a freestanding physical therapy campus. It would contain not only a school of physical therapy attending to preprofessional and postprofessional graduate education, but also a clinical practice center, a center for physical therapy research, a center for technological development, a center for professional development and career renewal, a day-care center, a residential community for the well and ill elderly, and a variety of other services. The campus would bring together the very best of our board-certified clinical specialists, academicians, and researchers to advance the state of knowledge and technology in physical therapy as an environment for preparing subsequent generations of our professional practitioners, educators, and researchers. Dr Johnson has entertained this dream since her initiation of the first entry-level professional education program leading to the master's degree at Case Western Reserve University in 1960. The two of us frequently discuss the dream and add dimensions to it.

I believe it is time to stop dreaming and to make the notion of a physical therapy campus a tangible reality as a goal of this Association and our profession. As soon as our financial status permits, I would like to see our Association make a value commitment to that campus experimentation by providing seed finding on a matching grant basis. Such a commitment would provide our profession with an unfettered opportunity to demonstrate our fullest potential, and it should occur as soon as possible.

Summary

In this Presidential Address, I have presented 11 goals for our education programs that are essential to preparation for the twenty-first century. I strongly value the profession of physical therapy and the services we provide to this society. Most of all, I value our education programs and our academicians, without whose efforts none of us would be gathered here today.

Early in this Address, I indicated my belief that our education programs have an awesome influence on this profession. But the goals proposed for the twenty-first century pose a challenge to all physical therapists. I make this challenge to academicians, clinical practitioners, educational institutions, and the APTA at all levels. It is imperative that we all join together to identify ways to support, strengthen, and improve our modes of professional education for the twenty-first century. We must do so in pursuit of the educational excellence that has been our consistent endeavor and hallmark for more than 68 years.

References

[1] Perry WG Jr: Forms of Intellectual and Ethical Development in the College Years: A Scheme. New York, NY, Holt, Rinehart & Winston Inc, 1968

[2] Parker CA (ed): Encouraging Development in College Students. St Paul, MN, University of Minnesota Press, 1978

[3] The Carnegie Commission on Higher Education: Toward a Learning Society: Alternative Channels to Life, Work, and Service. New York NY, McGraw-Hill Book Co, 1973

[4] Schon DA: The Reflective Practitioner: How Professionals Think in Action. New York, NY, Basic Books Inc, Publishers, 1983, p 56

JS Mathews, MPH, PT, President of the American Physical Therapy Association, resides at 258 Atlantic Rd, Gloucester, MA 01930.

This article is based on the Presidential Address presented at the Sixty-Fourth Annual Conference of the American Physical Therapy Association, Nashville, TN, June 11-15, 1989.