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Historically, invited lecturers have often challenged us to define excel lence in physical therapy practice, or in our academic programs. While some have addressed different char acteristics of excellence, our profession has not really come together to address 2 very important questions: what does “quality” mean in physical therapist education? And how do we measure it? Using 3 elements of Friendship, Leadership, and Mentoring, and Defining Excellence and juxtaposing these with Linda Crane and her life, a vision of excellence in physical therapy educational programs was explored in this invited lecture. The text of that lecture ensues.
Good afternoon everyone. I would first like to thank Dr. Frese, and the Awards Committee of the Cardiovascular and Pulmonary Section for selecting me for this great honor. I would also like to thank Drs. Meryl Cohen and Carol Davis (both previous Linda Crane Lecturers) for nominating me, making me the third person from the University of Miami, on the 10th anniversary of this Lecture.
I would also like to assure the cardiopulmonary physical therapists in the audience that while I teach neuroanatomy, I am really an acute care person at heart. I learned a lot from two very notable cardiopulmonary people—(1) The first person was while at Columbia Presbyterian Medical Center in New York City as a new graduate in 1970. We could work overtime on weekends doing chest physical therapy, but we all had to be trained first by the superb pulmonary physical therapist, Micah Rie; and (2) later at Hartford Hospital (in CT) in 1977, where I first met Linda Crane. Thus, I feel I have probably learned from two of the very best.
I also have something to share with this audience. We are all familiar with the bumper stickers that say “I Love NY,” or something similar, with the red heart in the middle. The University of Miami is often called simply “the U.” Well, one of my students came to class with this t-shirt (see Figure Figure1).1). Linda would have loved it!
When trying to decide what to speak about today, I tossed around many ideas. But I realized that I knew Linda most as a teacher. I found this poem that really captured so much of Linda as a teacher:
Teaching is a Lifelong Journey – Donna Bulgur1
To teach is to touch the lives of many
and to help us learn life's lessons.
But to teach well is to make a difference
in all the lives you touch.
To teach is to be a parent, nurse, friend, and confidant;
to be a supporter, a leader, and a motivator.
But to teach well is to be all of these things,
yet not lose sight of who you are.
You share a part of yourself
with all whose lives
you have touched.
To teach is to be tender,
loving, strong, and giving,
to all who rely upon you;
to encourage and praise.
But to teach well
is to believe in what
and whom you teach.
A teacher comes to master
these many jobs throughout the years.
But those who teach well
recognize that there
will always be more
to learn in life's journey,
and they never hesitate
to strive to learn it.
“Friend, Supporter, Leader, Motivator; Believe in what and whom you teach; Always more to learn.” Linda was all of these things. She was one of those inspiring teachers who always strived for excellence. I was Linda's Chair for 11 years. We've all heard of Linda's good qualities, especially in this forum. Somehow, however, this quote seemed perfect:
“Most great men and women are not perfectly rounded in their personalities, but are instead people whose one driving enthusiasm is so great it makes their faults seem insignificant.” (Charles A. Cerami)
As her Chair, I can tell you that Linda had a few faults. She was stubborn, impatient, demanding, and a perfectionist; but she was also dedicated, extremely loyal, caring, and fun-loving. She was a good friend. She was my friend. I felt that if Linda were here today, there are a few things she would expect me to say. I am going to focus on excellence; specifically, leadership and excellence in physical therapy education.
I have chosen 3 main themes: (1) educators love to use stories, so I have a little story about friendship and my history with Linda to share with you; (2) the importance of leadership (and mentoring) in our profession; and (3) excellence in physical therapist professional programs –where we are now, and where we need to be. For me, all 3 are intertwined and inseparable, as you will soon see.
In short, my goal is to enlighten and entertain, as well as to challenge you.
At the University of Miami, Linda was famous for her cardiopulmonary practical examinations and simulations. She often had other faculty participate, and be the “actors” for some of these cases. Sometimes it was random selection; sometimes she had a particular reason for putting specific faculty into one of the roles.
Well, my “perpetual” case was “a middle aged woman, PMH of hypertension, a previous myocardial infarction (MI), overweight, and–a smoker. The patient is in the hospital now for an open reduction-internal fixation (ORIF)-fracture of the R ankle; physical therapy prescription = teach her gait training, nonweight bearing (NWB), with a walker, prior to discharge tomorrow.”
Now – our students would often be annoyed, complaining “why is there an ortho case? This is a CP course??!!” Of course, as you all know, the reason was that this was serious cardiac and pulmonary work for someone not really physically fit; or to use a familiar admonition, especially with this audience – ALL patients have hearts and lungs, and are therefore CP patients! Linda had me act all of this out–coaching me when to feel dizzy, c/o shortness of breath, etc., in order to emphasize the need for doing continuous vital sign checks.
Well, except for the heart attack, I actually became that case on July 31, 2009 – and I can tell you – it wasn't fun. Lisa Sanders, MD, says it well2: It really is “like waking up in a foreign country; life, as you formerly knew it, is on hold.” Like all physical therapists, I was used to being on the other side of the rehab equation.
So, after the first surgery, I was really screwed (1 plate, 9 screws!). I came home from the hospital, NWB with a walker–in a very modern house with 3 levels (very modern, very chic, which I always loved before my accident!). I also had two bad shoulders from previous arthroscopic surgeries, so NWB with a walker was scary. And crutches? They were just plain dangerous! I became quite adept with one of those scooters they have now, which was a life-saver for me. I became the perfect example of all the bad things that happen when you are NWB for 10 weeks; I have learned a new appreciation for ankles, along with a new vocabulary (tri-malleolar fracture; “stress risers” – who knew?), and I'm still in therapy. At some point, I remembered, and thought – OMG! (texting term) I have become Linda's case! But my ultimate tribute to Linda is even better, since I finally kicked that nasty habit of mine.
During the process, I have to thank my husband, Tom (who really had the major caretaking challenge), as well as my faculty and staff (and especially Meryl Cohen, who was much nicer to me in her admonitions than Linda would have been!). I think Linda is watching and smiling, right now, and saying, “finally!”
So, Linda and I met in 1977 at Hartford Hospital. Our paths crisscrossed for a number of years, despite very different lives, but we would always catch up at national conferences. I taught at the University of Connecticut and in 1985, I moved to Miami, to the University of Miami (UM), with my husband and 3 children. Linda taught at the University of Connecticut, then moved to the University of Alabama-Birmingham, and then to the University of New England. In 1985, she became one of the first three ABPTS-certified Cardiopulmonary Clinical Specialists ever. While in Maine, she was doing some clinical site visits in Ft. Lauderdale, she called me, and came to stay at our house. I started trying to recruit her – and she joined us at the University of Miami in 1988.
The same year, Dr. Steven Rose also came to UM. I highlight these two individuals for a reason. Linda was Interim Chair at University of New England, and Steve was Chair at Washington University in St. Louis, as well as Editor of Physical Therapy. Also on the faculty at the time were Dr. Ira Fiebert, former Chair at UM, and Dr. Carol Davis, former Interim and Co-Chair at Boston University. In 1988, counting myself, there were 5 Interim or former Chairs on our faculty of 8 people. The phrase “herding cats” comes to mind. Daunting? Yes. Intimidating? Yes. But also, quite amazing. We were quite a unique and experienced group in the early days, building something special, together.
So to summarize the theme about Friendship, Linda and I knew each other for a long time. We stayed close despite distances and circumstances. We were different, but had a few things in common (Dutch and German heritage, stubborn, perfectionists, strong-willed, feisty). We went on day cruises (gambling), to holiday parties, birthday parties, and to UM football games during the “glory years.” There were the annual pool parties for the students at my house, X-Files parties, and Marquette Challenge Galas.
Finally, in October of 1998, we went to Las Vegas together. I went to do some clinical site visits, Linda came just to keep me company–and because we all knew she loved Vegas. I think we both knew it was her last trip there, and we made the most of it. We did the tourist things, we gambled, we “did the shows,” we gambled, we caught up with alumni, we had a blast. It was a very special trip together, for two friends.
“A leader takes people where they want to go. A great leader takes people where they don't necessarily want to go, but ought to be.” Rosalynn Carter
It has been nearly 25 years since I was named Interim Chair at the University of Miami, and I am still there. Back in 1985-86, times were different, when most of us only had our MS degrees, even as Chairs. And there I was – along with many here today. But we were fortunate, because we learned from people like Steve Rose, Marilyn Gossman, Mary Lou Barnes, Helen Hislop, Beverly Schmoll, Bob Bartlett, Geneva Johnson, and others.
We learned from those senior people, who mentored us. Some of them may have even “picked us up and dusted us off” when we needed it. Granted, there were only 90-something PT programs back then; but the senior people eagerly shared advice, and we novices eagerly learned.
The recent discussions regarding the new American Council of Academic Physical Therapy, or “The Council,” are important for the future of physical therapy education. Frankly, I see a little history repeating itself, with many of the objectives proposed, as well as the initial rationale for beginning the discussions, being similar to what some of us recalled, and honestly have missed, from 25 years ago. For example, when I read the proposed bylaws,3 some of the objectives of this “new entity” sounded very familiar. For example:
While there are certainly some exceptions, as a whole, we (current leaders and Chairs) have not sat with new Program Directors or Chairs and gotten to know them, or mentored them, as we were ourselves. The need for expertise, mentorship, and some friendly advice remains, and perhaps is even more acute with so many more programs. And the need for defining quality metrics to describe, compare, and enhance our programs is definitely more critical.
I am thrilled to see these objectives, and hope that the Council, while not yet a reality, becomes one, and rapidly attends to implementing them. So, here are two pearls of wisdom that I've learned from my mentors, and from trialand-error experience, for both academic and clinical faculty:
I am reminded of Supreme Court Justice Potter Stewart, when asked how he would define “pornography.” Now famous, he said “I can't define it, but I know it when I see it.” I think the same analogy can be made about excellence in physical therapy programs.
In the United States, we seem to take great delight in rankings of all kinds: Consumer Reports (cars, cookware), Fortune (richest), People (most beautiful), Associated Press (college sports teams), and U.S. News & World Report (colleges, majors, graduate and professional programs).5 The use of ratings for the sake of appearing successful is an indicator commonly used by universities, in newsletters or Web sites targeting alumni, new faculty, and new students. When favorable, they provide fodder for bragging rights; when less than favorable, people usually downplay their importance.5
There is a great story about rankings that was in the newspaper recently that is particularly germane for us today. The story goes that there is a university president who apparently kept copies of his past ratings of the other universities in the same state (where -apparently he rated his school a 5, or “the highest score,” and all others a 1 or 2). His obvious bias didn't sit well with his other presidential colleagues when, of course, those old copies somehow surfaced.
About this story, a wise university president said to me: the lesson shouldn't be “don't keep copies.” It should be: “be honest in your assessment as a peer, base your opinion on quality indicators, like the accomplishments and reputation of the faculty, the competitiveness of the students, with GPA or SAT indicators. There are objective measures of quality that can be used.”
And thus, I believe we need to look at what is being done in other professions and perhaps consider what criteria we could use to compare our programs. Because students and their parents are doing this–using whatever information they can find. U.S. News & World Report (USN&WR) is but one piece of this information, and we should make the information better and more complete.
First – I want to begin with Law School rankings, but think that first we need to look at the kinds of criteria that are used in these kinds of educational rankings. There are quality assessments done by peers. There are also input criteria (GPA, LSAT, MCAT, class ranks, etc), and output criteria (retention or graduation rates, pass rates on boards, etc.). As we see in Table Table1,1, peer rankings are weighted the highest (done the same as those in Physical Therapy, by Deans or Chairs, rated 1-5, low to high). In the case of law, also included are the opinions of lawyers who might employ the graduates, and judges who might see them before the bench. This latter ranking is done differently, in that the lawyers and judges are asked to “list the top 20 law schools,” and not to give all schools numerical ranks of 1-5. All scores are standardized about their means, scores are weighted, totaled, and rescaled so that the top school receives 100; other schools are then a % of the top score.
The law criteria are not without problems, especially with some recent changes in some of the criteria, and are the subject of many articles.
Second, we need to look at rankings for Medical Schools, as depicted in Table Table2.2. As a means of comparison, there are 126 schools of medicine (compared to 220+ for Physical Therapy). There are some differences in weightings, based upon whether the Medical School is strongly research oriented or more oriented to the preparation of primary care practitioners. The ranking categories are similar to those used for Law Schools, with the Peer assessments (rankings of 1-5, low to high) from the Deans/Senior Faculty. There are then opinions of Directors of Residency Programs (a category similar to the judges and other lawyers, where the Residency Directors are asked to “list the top 20 medical schools.”) The scores are standardized about their means, weighted, totaled, and rescaled so that the top school receives 100, and remaining schools are a % of the top score.
Medical school rankings are probably the most comparable to physical therapy, in terms of characteristics, but are also not without controversy. In fact, there are numerous articles criticizing these rankings, with some authors offering additional potential criteria they considered to be more important:
Nevertheless, all authors conclude that rankings such as USN&WR are readily available on the Internet, and are here to stay.
There has been a lot of discussion on our education list serve over the years about the ratings in USN&WR for physical therapy programs. Problems were cited about the flawed methodology, because they are merely based on peer assessment and not on anything objective. This is true; and when USN&WR agreed to add objective criteria along with the peer ratings (as they do for other professional graduate programs, such as law and medicine) we (physical therapy) realized something–we didn't really have any specific, agreed upon, or consensusbased criteria, for measures of quality in physical therapy programs.
Historically, physical therapy was first included in the rankings in 1995. At first, it was exciting to be included among all the other fields–it was recognition! But when some people took particular notice of the rankings, or some people took offense at not being included, the controversy began. Because what happened, I believe, was that some protested, and some were silent (and as I recall, the silent ones were the ones ranked in the “top tier”). Perhaps, some people felt that by being in such an enviable position (ie, ranked), it would not have been politically correct to comment at all. In the words of John Maxwell,
“The pessimist complains about the wind. The optimist expects it to change. The leader adjusts the sails.”
I believe we are perfectly capable of adjusting our own sails. One thing I have noted in physical therapy over the years is that we are a bit timid to criticize ourselves, even constructively, and certainly not publicly. If I were to try to define some categories for physical therapy, not reinventing the wheel but trying to use what could apply to PT programs, here might be a place to begin (See Table Table33):
As with Medical Schools and Law Schools, besides the numerical ranking of schools, the entire scores (for all criteria) would be shown in an open table, so that prospective students could determine what kinds of criteria mattered, or were important to them, such as research activity, faculty/student ratio, or small classes. It is also true that the highest ranked school might not rank the highest in every category. There could be other criteria, suggested by some authors, like “commitment to public service.”11 This may seem difficult to measure, although one could note the number of community service programs offered, the percentage of student participation, to gain a measure, for example. Racial and ethnic diversity of the faculty and student body could be a useful item, and important to some applicants.12 These kinds of criteria can also be used by Chairs for benchmarking.
Nonetheless, it is important to note, with respect to peer assessments something that Hendrix13 said: that professional opinions (ie, peer rankings) are vital in a ranking process because they are the opinions of experts in the field. Furthermore, since response rates < 50% are not scientifically acceptable, I believe it is our professional responsibility then, to (1) assume this mantle of responsibility; (2) to develop some meaningful criteria to use; (3) to participate in (and not boycott) these peer assessments when asked, and (4) to answer honestly.
So, what do we need? Some years ago, some of us talked about the need to establish some “benchmarks of quality” in PT education. Unfortunately, this concept vanished from our collective consciousness until recently revived in the Council's proposed Objectives.3 This is unfortunate, because benchmarks are really helpful for academic chairs. Chairs need to be able to see how they are doing compared to either their “comparable peers,” or their “aspirational peers.”
To illustrate what “comparable and aspirational peers” means, in research institutions there are rankings that really matter to top administration (like Presidents and Provosts), such as the AAU14 (Association of American Universities) ranking of institutions (essentially the top 62 institutions, public and private). The AAU is truly an “exclusive club,” by invitation only, that everyone wants to be in, essentially because they are considered “the top 62 institutions.”
Even within the AAU, there are multiple comparisons and rankings, in terms of SAT scores (25th and 75th percentile), comparisons by public or private school only, the number of faculty members in the Institute of Medicine or National Academy of Science, salary and benefits comparisons, etc. There are also rankings of NIH funding within Medical Schools by the Blue Ridge Institute for Medical Research,15 but this does not include physical therapy programs.
I believe that it is important for us to understand that there is a drive by higher administration (and sometimes Boards of Trustees), to rise higher in the rankings–any rankings–especially for those “not in the top 20,” or “not in the AAU.” And for nonresearch institutions, there are still rankings, just different kinds, like “top tier,” or “top quartile,” or the “most selective” institutions. For all of us then, no matter the kind of institution, it helps to have a barometer about which to judge our own performance–the amount of grant funding, salaries, percentage of faculty with tenure, faculty/student ratio, etc.
In summary, my point is this: We should be able to define QUALITY in our educational programs. Rankings are here to stay. They will not go away because we find them unfair, or because we can't quantify quality. We do have some criteria that are usable and comparable; and some criteria that we may question. We need to face the fact that there are differences among us, perhaps because of the type of institution, perhaps because of a specific history, and that may be OK. Some of us are better at some things than others. What matters then is that we recognize our strengths and our weaknesses, and that we celebrate our differences.
We are what we repeatedly do. Excellence, then, is not an act, but a habit.
You don't get to choose how you're going to die. Or when. But you can decide how you're going to live now.
– Joan Baez
Some elements of an educational program are intrinsic; things like caring, integrity, passion, cooperation, and can't be measured. Several of these elements have been themes in previous Linda Crane Lectures. But the products of these intrinsic qualities can be measured by the accomplishments and achievements of the faculty and the graduates of a program.
I believe that Linda would want us to take a chance, and to do something about how to measure quality in our educational programs. She was a cardiopulmonary clinical specialist, but she was, in her heart and soul, a Teacher; one who always strived for Excellence.
I like the quote by Mark Twain (see Figure Figure3).3). I think it's perfect; but I also like one that Linda had on her bulletin board by her office door: “When my ship finally came in, I was at the airport.”
In the 10 years since Linda's death, there have been explosions in medical breakthroughs, and an increased respect for physical therapy services: (1) the advances in human genomics and how they impact our clinical practice; (2) the advances in the use of stem cells for the treatment of cancer patients, especially breast cancer, and for patients with heart attacks; (3) the development of the first residency program in Cardiovascular & Pulmonary Physical Therapy; and (4) the recent humanitarian aid to the people of Haiti, and the selfless dedication shown by our faculty, alumni, and colleagues. Linda would have been thrilled and excited to be a part of all of these. She wouldn't want to miss the boat…..
Finally—to come full circle, and to paraphrase Apter & Josselson16 – “Every time we get overly busy with work and family, the first thing we do is let go of our friendships….This is a mistake, because friends are such sources of strength to each other.” I have been blessed over these many years by having many colleagues who are also great friends; by having mentors in my life like Steve Rose and Helen Hislop, who helped me to grow and mature professionally. And, I have been blessed by my students—past and present—that I cherish and from whom I continue to learn. I have always said that “I am the luckiest Chair of all,” and I mean it. And by “lucky,” I don't mean that things just happened to me without hard work, but that I feel fortunate to be surrounded by such fantastic people, who are leaders, always striving for excellence, and who are my friends.
So you see, I do think these 3 themes are intertwined and inseparable. We are a great profession. I think it is time that we define ourselves. Let's be proactive and really target programs for developing the leaders of tomorrow. And let's be proactive in identifying benchmarks to use, so that we can identify our different strengths, and improve rankings like U.S. News & World Report, or even to develop our own.
Let's focus on leadership and excellence. We owe it to our profession, and to the future leaders of our profession – our students.