Today's tomorrow.

Editor's introduction

Next month, Robert Bartlett will present the Twenty-Fifth Mary McMillan Lecture in Boston, Mass, at the American Physical Therapy Association's (APTA's) Sixty-Sixth Annual Conference. The journal, as is its custom, will publish the text of his lecture in the November issue following the 1991 Annual Conference. The 1968 Mary McMillan Lecture by Helen Kaiser, however, was a notable exception to that custom. The text of the Fifth Mary McMillan Lecture was misplaced when the APTA moved its headquarters from New York to Washington, DC. The text was recently recovered when old records were being placed in the Association's archives.

We are printing the 1968 McMillan Lecture in this issue of the journal for two reasons. First, we wish to have Ms Kaiser's speech available to future generations of physical therapy practitioners. Second, her talk still has remarkable relevance and offers a fascinating historical perspective on our profession. Although the speech was given nearly 23 years ago, the text of the speech provides considerable insight into contemporary issues. I urge a careful reading of Ms Kaiser's speech, asking that special attention be paid to her points about interdisciplinary relations and to her concerns about faculty shortages and her warnings about the development of new physical therapy programs in inappropriate settings. These messages are as relevant today as they were when they were spoken in 1968. How ironic that some of the issues that troubled Helen Kaiser persist to haunt us today. Note, however, that when Helen Kaiser gave her speech, we were in the midst of the Vietnam War and Richard Nixon was 4 months away from being elected to the presidency. Most physical therapy students today were not even born when Helen Kaiser spoke at the Palmer House in Chicago. Helen Kaiser, who died in September 1988, did not live to see widespread direct access or other recent events in physical therapy. But, after reading her words, you can have no doubt that if she were with us today she would be asking us to look carefully at ourselves and to get on with the business of moving forward. Helen Kaiser begins her speech by noting the importance of history and historical perspectives. The Journal apologizes for not publishing Helen Kaiser's speech in a more timely fashion, but also takes pride in rediscovering the words of one of our pioneers. In sharing these words with our readers, we also thank Helen Kaiser-not just for her wonderful message and her remarkable insight, but also for a lifetime of contributions to our profession.

It is said of the American Indian that, when traveling in strange territory, he frequently looked back to see from whence he had come. He thus could recognize familiar landmarks on the return journey and consequently never lost his way. The white man, on the other hand, was so eager to reach his destination that he only looked ahead, failed to notice that which was not in his direct path, and, therefore, unlike the Indian, always became lost. We know that many of our American presidents have been avid students of history. Was this because they sought to search the past in order to lend credence to the present or hopefully to find in the past a path to the future? Whatever the reason, there may be some precepts to be gleaned from these two examples that, if applied to the present dilemma of our profession, might help us to make wise decisions for the future of physical therapy. What is this dilemma to which we have referred and that, it is probably fair to state, we share with our associates in patient care? Perhaps you would not agree, but I believe the problem, stated in simplest terms, is: How can quality be preserved in the growing demand for health services? To find some solutions, it might be useful if we were to take a look at our educational programs as well as the administrative patterns of the past and present and ask, Are they adequate and are they suitable, and, if not, how should they be altered? Our past, chronologically and factually, has been well documented by several of our members. Historically, however, little has been said, or at least written, to relate the cause and effect of our actions or lack of action in a sequential manner. Perhaps if we were to ponder and examine our past with cause and effect in mind, it would enable us to respond with greater clarity to the present pressures that are catapulting us into a future for which none of us are well prepared. It is small comfort to know that we are not alone in this quandary of how to solve tomorrow's, or for that matter today's, health needs. All of the health professions appear to be equally baffled. The pity of it is that we have not seen fit to sit down together in an effort to solve our common plight, or should we say our patient's plight, for obviously it is this that should be the focus of our concern. But is it? Only occasionally does this consideration come to the surface. Instead, each profession is more likely to consider methods that fractionate the patient, duplicate effort, proliferate assistants, delegate responsibilities, or completely avoid the issue. Sometimes it appears as if each profession were striving to establish a new identity, or should we say supremacy? In the changing pattern of health care, it is as if each were trying to carve out a new role, with little regard for another's traditional competence. Magraw states in his book Ferment in Medicine that Robert Merton has called attention to this strife in these words:

Every profession is to some degree

surrounded by a zone of ambiguity.

The trouble with this zone of ambigu - ity is not that it is a no man's land but

that it seems at times to be an everyman's

land. And sometimes this leads

to undeclared war between the adjacent

occupations.1 Seldom does one hear any mention of the competence or academic preparation required to perform effectively the old or new role so possessively guarded or so zealously and enviously pursued. The tendency is rather to stake out a claim, based not so much on merit as on desire, in hopes that a declaration of intent, or squatter's rights," will convince others after sufficient repetition, elapse of time, or by sheer weight of numbers that the usurper has the right and that the original protagonist had no business there in the first place. This type of myopia is not as uncommon as one would like to see. A very substantial number of health disciplines are so afflicted. As one goes over the list of these professions, one finds little immunity-only variations in the intensity of the affliction. Each is more than likely to consider his profession the one most commonly misunderstood. In fact, sometimes it appears that all the health professions suffer from a special and similar type of paranoia. This quite naturally increases the complexity and magnitude of the problem. The very commonality of the virus would suggest that only in commonality might a remedy be found. To this speaker's knowledge, no such attempt has been made. But neither has such an admission been made. The climate today is that of a cold war in which the struggle is for position and power, with little regard for the victimized population and its needs, or more appropriately the patient and his needs. A more reasonable approach than the aforementioned tactics might be to hold a sort of Geneva peace conference of the health professions, with equal representation of those involved in and responsible for direct patient care, namely, physicians, nurses, physical therapists, occupational therapists, dietitians, and social workers-in other words, all those whose work is interrelated in patient care and who comprise the gray area that surrounds the "adjacent health professions," as Merton, called them. There of course are additional group polarized by common purpose and aspects of patient care. However, our focus today is on those previously mentioned. It must appear obvious that quality in patient care can only be achieved if these groups communicate and cluster appropriately as a patient moves from the community to the hospital and hopefully back to the community again. One learns of planning conferences held by physicians and administrators, with or without nurses present. Sometimes a dietitian is included, but how often does one hear of the other professions participating in patient care conferences? I am not speaking of the so-called "team approach" to individual patient care, but rather of institutional programming. Yet the inclusion of a physical therapist, an occupational therapist, and a social worker in these planning conferences frequently could change the complexion of the hospital census, the home care plan, and furniture design, as well as the patient's outlook, to say nothing of his progress. One is reminded of a sentence in Count's the Planning of Change.. "As our feet tread the earth of a new world our heads continue to dwell in the past."2

We seem reluctant to give up old patterns of operation. Are we unable or unwilling to do so? Do we feel threatened, unsure, complacent, or only possessive? Great efforts are being made in some medical centers to introduce and use new technology in patient diagnosis and treatment, but very little is heard as to how these efforts can be expected to affect the patient except to increase the numbers of patients processed" without the use of professional staff whose time is so valuable and in such short supply. Yet we know that 85% of the patients occupying today's hospital beds have an emotional component to their illness that, for the present, the computer has not yet solved nor has the proliferation of personnel alleviated. In fact, both usually compound the problem. Thus, we have great advances in technology, but we have not yet learned how to integrate them into the system. If proliferation, computerization, and government support for education in order to increase the number of health care personnel do not provide the answers to today's health problems, where does one turn? Perhaps the conference table would offer hope for a solution if we approached it determined to carve up the old dodo of yesterday's patient care concepts Webster, you will recall, defines "dodo" as a heavy, flightless, extinct bird) and together make an effort to reshape the denuded carcass into a streamlined, multipurpose creature able to respond sensibly, sensitively, and gracefully to a variety of demands. Or is this too much like saying, in today's materialistic and pragmatic world, something as hopelessly naive as perhaps virtue is its own reward"? Who knows, we shall risk it and make the suggestion. For this might well lead to new names for old professions or old names for new professions. The very least we might learn would be what is packaged under the old label! One dividend might be the joint planning of educational programs in addition to operational blueprints that are more consistent with present and future health needs than those currently undergoing isolated restructuring, or others being spawned because of the availability of federal funds.

Having taken an all-too-brief look and made unquestionably some much-too-simple explanations and deductions concerning today's health problems, let us move on to those directly related to physical therapy. Perhaps if we could put our house in order, sharpen our tools, and bring ourselves up-to-date on the anatomy of that old dodo, we could do a better job when it comes to carving up the carcass. Let us begin by taking a look at our educational preparation. This is especially timely because of the recent appearance of the physical therapy assistant. Thus, it is for several reasons imperative that we critically review the academic preparation of the professional physical therapist. It behooves us to provide undergraduate education of such quality and diversity that our students can move without delay into graduate school for additional specialization. Perhaps we would do well to follow the examples of many professions such as law, engineering, forestry, business administration, and social work, which have discovered that, for their graduates to practice effectively in today's complex world, a good liberal arts education is not only desirable, but essential. Therefore, the professional education for these professions has moved to the graduate level. Our present professional physical therapy programs can absorb no more courses, yet our graduates must have a background in the social sciences and the humanities if in the future they are to be effective practitioners of their art. Should we, therefore, not give serious consideration to moving more of our basic programs to the graduate level? Or shall we be content with the status quo and remain among the more poorly prepared of those who call themselves professional? At this juncture, someone usually raises the cry of numbers! Well, is there any guarantee that, if the intellectual fare and the rewards are sufficiently attractive, one will not have as many students capable of graduate education as one has had in baccalaureate programs? One thing is certain, having made a greater investment in his future, the graduate student is more likely to stay with his profession than is a student who has invested much less. There is a bit of our history that might be well for us to recount at this point. All of us have heard how our profession evolved from the demand for physical therapy services in World War 1, when short courses of only several months' duration were organized to meet these needs. What has been left unsaid, but should be noted, is that the young women who responded to the call for volunteers at that time were, for the most part, college graduates. In those days, a college education for women was far less common than it is today. (It was not until after World War 11 that men began to enter our ranks in any great numbers.) Thus, at the time of World War 1, a group of women entered our profession who were above average in initiative and well educated according to the standards of their day and whose inclination and tradition were to work with the less fortunate. These pioneers not only responded to the needs of World War I casualties, but continued afterward to work with the ever-increasing number of poliomyelitis victims. It is these women who should be given the credit for setting the tone of our profession. (Those of you who were fortunate enough to have known Mary McMillan and janet Merrill-our first president and secretary, respectively-will know the kind of women of whom I speak.)

With a great civilian need for physical therapists created by the ever-mounting number of patients with poliomyelitis in the twenties, nurses and physical education graduates were accepted into the Harvard University courses 441 and 442, the first formal physical therapy courses for civilians in the United States. The early efforts of our profession have been well documented by Mildred Elson in the First Mary McMillan Lecture, so there is no need to repeat them here. However, let us review some additional factors that have influenced our educational patterns, both past and present, and discover how these factors are likely to affect the future of our profession. What should we expect of our educational programs in preparation for tomorrow? Are there any clues? Undoubtedly, there is some evidence that, if correctly assessed, will help us to determine our future role among the health care professions. Shakespeare reminds us that "there is a tide in the affairs of men, which, taken at the flood, leads on to fortune, omitted, all the voyage of their life is bound in shallows and in miseries." But before we explore new educational approaches that are being suggested, are we willing to admit that, although the preparation many of us had has served us well, it may not be what is needed to cope with today's problems and certainly not tomorrow's if one were setting forth without a backlog of experience? We need to remind ourselves constantly that much of what is being taught today in the basic sciences and technology will be obsolete in 5 years. How, then, does one prepare students for tomorrow? As a result of experimentation, the majority of our schools now offer baccalaureate degrees in physical therapy. It was found that topping a physical education or nursing curriculum with a course in physical therapy was not the most desirable way to prepare for our profession. judging from the number of applicants to physical therapy programs with physical education backgrounds, however, I would say this belief is still widely held. No doubt the fringe benefits of such preparation are valuable, but, if so, why not incorporate directly into a physical therapy curriculum the particular material that is so helpful? Applications from nursing graduates have been less numerous, perhaps because of the great demand and opportunities in their profession or perhaps, as is so frequently the case, especially with women, when physics and mathematics rear their ugly heads, other fields look greener. No doubt there is subject matter from these professions that could be included with great benefit in a physical therapy curriculum. Certainly the nurse's knowledge of acute illness in the hospital environment is a valuable asset. Physical education, on the other hand, gives knowledge of normal body rhythm and movement and perhaps also experience in methods of group teaching, proper use of the voice in giving instructions, and knowledge about sports, all of which may be helpful when instructing patients or programming for them. If sufficiently helpful, these subjects could be incorporated as part of the physical therapy curriculum. Concentration in the courses of one profession is usually not the most expeditious or desirable route to another. It is recognized, of course, that there may be good reasons for going about one's education in this fashion. However, in the majority of cases, the time would be better spent in the liberal arts courses gaining intellectual stature for professional practice. Only if we provide our students with a greater understanding of the world in which we live can we hope to have our profession play a meaningful role in the future. Without this cultural dimension, the technologies will overwhelm us. in a recent study done on a Boston (Mass) medical service, it was found that 84% of the patients had not medical problems but social. The same study revealed that 95% of the patients did not carry out instructions, because they did not understand them. One hopes these were not all physical therapy instructions! The situation is not unique, but serves to emphasize the necessity for perceptive and effective communications, both verbal and written. A patient's chart in which only the degrees of increase in range of motion or muscle strength is recorded contributes little to the total management of the patient. In fact, such charting is likely to reveal more about the physical therapist and the standards of practice than about the patient. Such an approach smacks more of the technician or physical therapy assistant than it does of the professional. Yet, how does one find time in a crowded 4-year educational program to provide the necessary background required to become an effective and perceptive professional dealing understandingly with the patient's problems and communicating appropriately with professional colleagues?

Today's physician is faced with the even greater problem of managing and integrating into his patient's care the vast and overwhelming amount of information available to him from all of the sciences-biological, physical, and social. Even with the help of the computer, the volume is more than any one individual can hope to absorb, much less master. Of necessity, the physician must share a large portion of patient care with other specialists. Therefore, each professional must understand how to relate to others and be prepared to discuss intelligently his role in the spectrum of health services. Today, we know that good health is more than the absence of tissue and organ disease. Thus, the tissue- and organ-oriented specialist is forced to broaden his scope and embrace the social and behavioral scientist if he is to be successful in the management of his patient.

This depature from a former pattern of practice, one can easily understand, is not altogether to the liking of the traditionalist, and the occasional arrogance and impatience he displays are no doubt due to frustrations caused by the inability to find immediate solutions. It is this frustration, apparently, that has had so much to do with proliferation of personnel, a proliferation that has occurred possibly because the various professions engaged in patient care have failed to communicate and work together effectively in the distribution of responsibilities. We need to remind ourselves constantly that a teaching hospital may have been built or affiliated with a medical school in order to provide a laboratory for students of medicine, nursing, physical therapy, dietetics, and other disciplines. But with the introduction of the first patient, the focus must change and become patient-centered instead of student-centered. It is only if the very best care is demonstrated that the students will learn the ingredients their professions can contribute to good patient management. It is by the observed practice of their teachers that students learn to integrate their role with other disciplines. No longer can the patient's hospital stay, with an occasional outpatient visit, be regarded as having solved the patient's health problems. In the public clinics, we are becoming increasingly conscious of this. However, in the private sector, we have a long way to go, probably because in so many minds the utilization of public or community health services is associated with indigency. Undoubtedly, as we commence to learn more about the relationships between tissue and organ diseases and environmental factors, all sectors of the population will be better served. The forging of a new link between the health, social, and behavioral sciences is an exciting prospect. Now the question is, How well are we preparing physical therapy students for participation in this alliance?

As you know, the introduction into our vocabulary of the term allied health professions" is fairly recent, but not as recent as the legislation passed by Congress to support these professions. Consequently, today we hear much about plans for schools for the allied health professions. But not as much as we would like. One suspects, therefore, that possibly some strange and unnatural alliances are being made. Suddenly, colleges with no previous experience in health education are becoming interested in these professions. Others, previously limited to several disciplines, are increasing their offerings. An interesting factor to note is the proposed variety of disciplines included under the title of "allied health professions," such as x-ray technology, inhalation therapy, cytology, dental hygiene, orthoptics, and record librarian, in addition to occupational therapy, dietetics, and physical therapy. There are other degree as well as nondegree programs. Politics and money, it can safely be said, sometimes make strange bedfellows. Some of these programs clearly belong in the community and junior colleges. However, the fact that medicine and nursing are not included should give one pause. Without these professions, one is inclined to view the alliance possibly as a little more unholy than holy. Should we not ask: Allied for what purpose and to whom? it is not only of interest but of concern to note that, in approximately 80% of the programs receiving governmental support for the allied health professions, a pathologist is listed as director. Are these new schools under the aegis of the medical schools? It causes one to wonder if some of our present as well as developing schools are truly a part of the university or related to it only by some administrative pattern of convenience?

Establishing a new school of the health professions or reorganizing existing programs by no means rules out high-quality education, but, under the present circumstances, numerous questions do come to mind regarding the status of such a school within the academic structure of the university or college. What are the admission criteria? Who approves the budget for each program? How is the money allocated? Who approves the courses? Why does one find a pathologist serving as administrator in almost 80% of the programs? Is it because the largest number of applicants have a background in medical technology? What are or should be the credentials of the educational administrator, and to whom is he responsible? What are the qualifications of the faculty? (Especially in the case of physical therapy is this relevant! I understand there were, at the beginning of the current academic year, approximately 75 vacancies in the physical therapy schools.)

All these and many more questions come to mind as one views the scramble for government funds, in many instances without representation or even the knowledge of some of the disciplines involved. And if the health professions are to be allied, why are medicine and nursing not included? I pointed out previously that our practice brings us together with physicians, nurses, occupational therapists, and social workers. Yet, in many of these schools, x-ray and medical technologists, cytologists, record librarian assistants, and dietetic personnel are being gathered together with occupational therapists and physical therapists without the participation of physicians and nurses. How, then, shall we learn to work together? Why are programs being organized in this fashion? if educational programs are truly professional and we are allied in serving the patient, then a college of allied health professions including medicine and nursing is appropriate. However, until such time as this occurs and personally I am not very optimistic that it will come to pass in the very near future, but, until it does), we need to guard not only against compromises in education that will jeopardize the quality of our product, but against those self-appointed guardians of our future. You will recall the old adage "Beware of Greeks bearing gifts." Let us take heed! It has taken us 35 years to free ourselves of the offers we previously so gratuitously accepted. Having reviewed our education, past and present, and raised some questions about its future, let us turn to the administration and practice of our profession. The first physical therapists worked mainly with orthopedists. This continued to be the pattern until the mid-thirties, when the physiatrists persuaded the orthopedists that perhaps those physical therapists could not really do an accurate muscle test. When asked if they had checked to see if such were the case, the reply was, "Well, no, they had not," and thus there began in the thirties the change in the administrative patterns of physical therapy departments. True to our Army heritage, we retained the title of "Chief." Then came World War 11, which provided for physical medicine the sort of acceleration orthopedics received during World War I. About this time, the orthopedist began to rethink his abdication, for his ideas of rehabilitation did not always coincide with those of the doctor of physical medicine. The improved front-line management of casualties in World War 11 permitted many victims of spinal cord trauma to survive. The complexity of management of these cases created the idea of the team approach, and thus began the development of the departments of physical medicine and rehabilitation. Staff were recruited from the various disciplines but were responsible to the director of physical medicine and rehabilitation. The unfortunate part of this approach was that, although it may have been good for the patients with spinal cord lesions, when adapted to the patients of other specialties, the team members became restive because they needed and therefore wanted to be in direct contact with the patients' physicians. This opportunity frequently was denied them, and, to many of these professions, the expertise for rehabilitation management of patients representing many specialties did not rest in the hands of one medical specialty. The physician specialist, such as the cardiologist, pediatrician, neurologist, and allergist, preferred to be in close contact with his patients and did not wish to introduce another physician into the relationship. For the most part, he much preferred to work directly with the physical therapist and the other professionals experienced in his specialty in order to obtain the most satisfactory management of his patient's recovery. Today, there is scarcely a service that does not utilize physical therapy. Physical therapy is established as a part of every branch of medicine. Why, then, should physical therapy be under the management of any one medical specialty? A physical therapy department should be free to cooperate with an medical and surgical divisions, with direct responsibility to the hospital administrator. Are we not as closely related to the physician in patient care as are the nurse, the dietitian, or the pharmacist? Yet, has anyone ever heard of a medical director for these departments? Why, then, physical therapy? Our Code of Ethics requires that patients be accepted only on a referral basis. Let us hope that our educational programs are providing their graduates with the knowledge and ability to discuss intelligently with the referring physician the physical therapy management of the patient. Is there to be found anywhere a paragon who has all the answers to the physical therapy management of patients as related to all the surgical and medical specialties? Certainly no physical therapist is so endowed. However, one can believe that a physical therapist who combines his knowledge of physical therapy with the knowledge that the referring physician has of his patient and of his patient's disease will develop a treatment for the most satisfactory rendering of good patient care. Administrators must come to recognize that unless the physical therapist is given the authority commensurate with his responsibility, it will become increasingly difficult to attract students into this profession, or for that matter the other health professions. Without the assurance of upward mobility, job satisfaction, and participation as a full-fledged professional in planning, it is highly unlikely that able students will continue to be attracted to our profession, much less stay with it after graduation. Today, we bemoan the shortages of physicians and other health care professionals and try to fill the gaps by proliferation and use of supportive personnel, sometimes forgetting that intelligent and judicious decisions are required at every turn when dealing with a patient. The Office of Economic Opportunity insists we use additional manpower in the health programs. We agree that additional personnel are needed, but, if they are to be professional, they do not come like Minerva full-blown from the head of jupiter. It takes time and appropriate education, not just training, to create a professional-and professional he must be if responsibility is to be delegated and effective patient care rendered. Physicians must be convinced that their patients can be trusted to the care of others. It is only when the nonprofessional is given too much responsibility that the quality of care deteriorates-which appears to be one of today's problems. Could one be so bold as to suggest that a seminar on how the professions can combine to promote improved patient care might be a useful device to aid in solving some of our present problems? In professions in which judgment and intelligence are the key to good patient management and knowledge imperative for individualized or group patient care and safety, areas into which the computer cannot penetrate or the "subprofessional" discriminate, one thing is certain-we cannot hope to attract students of high caliber if they cannot exercise these qualities or be permitted to participate as full-fledged members of the health care team. Unless this comes to pass, and until it does, we cannot hope to improve the quality of care for our patients. it will require hard work, courage, imagination, perspective, and the ability to communicate knowledgeably, on the part of every physical therapy school director, physical therapy department head, and physical therapist, if we are to ensure a high quality of patient care in the community. We shall need to chart new courses and explore new ways. But this cannot be done in isolation, nor can it be done for us. We must make our plans together with other health care disciplines. Otherwise, collision, duplication, and rejection are inevitable. No culture has ever flourished in isolation. Its maximum contributions are only developed in concert with others. "Prehealth" must replace "premedical" in the education of the health professions, and community health" must be substituted for "public health" in the delivery of health services. Students in the health professions must come together with students in the humanities and social sciences in common courses. Common courses in the professional phase are relatively few, but contact in the preprofessional phase leads to better understanding and appreciation of the various roles and how they function in today's society. It is true that these are "times that try men's souls." Frustrations are the order of the day. However, if we, like the indian, will take a backward look occasionally and recall that the patient is our focus, the path before us to the new frontiers of health care can be an exciting and challenging journey. It will have its pitfalls and misleading byways, for there will be a lack of guide-posts, but, as is the case with all provident travelers, it is the preparation for the journey, the courage, and the effort that will determine the survival.

And, so, I wish you Godspeed on your journey. I would like to hop a ride! Thank you for permitting me to be your Fifth Mary McMillan Lecturer. It has been a great privilege. References

1 Merton R. Quoted by: Magraw RM. Ferment in Medicine. Philadelphia, Pa: WB Saunders Co; 1966:165.

2 Counts GS. The planning of change.