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Thirty-Sixth Mary McMillan Lecture |
RL Craik, PT, PhD, FAPTA, is Professor and Chair, Department of Physical Therapy, Arcadia University, 450 S Easton Rd, Glenside, PA 19038-3295 (USA) (craik{at}arcadia.edu)
 | Introduction |
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I really need to thank more people than my allotted time permits. I want each of you who has helped me in any way, big or small, to know that I stand before you only because of your support and my discussions with you. None of what I say today has been generated solely by me ... my opinions have been developed because of all of the insights shared by so many of you. I am a composite of my family, my physical therapist colleagues, the APTA staff, and so many wonderful mentors and friends.
My parents provided sustained love, caring, and support for their children, with their profound respect for education and their belief that we were capable of doing anything if we tried. They provided me with the courage to take advantage of incredible opportunities. Thanks, Mom and Pop. My sister, Suzie, and her husband, Jeff, and my brother, Charly, and his family have been there for me on so many different occasions, including today. Thank you, for watching out for your big sister. And, Veronica, my niece, thank you for coming today. Mark, my partner for 33 years, has allowed me to flourish in my workaholic behavior, believed in me, and encouraged me over the next hurdle when my knees were quaking and I couldn't breathe. Thank you, Mark. Everyone at Arcadia University has been incredible. Arcadia University, formerly Beaver College, is a wonderful place to work. Who would have predicted that a tiny, primarily undergraduate, college would become a university and house a nationally ranked physical therapist education program? You have to be there to see how it happens. There is not a more talented and caring physical therapy faculty in the country. Thank you for putting up with all of my crazy ideas, my high anxiety, and all of my other quirks. I thank the students and alumni for all that you have done and will do for our profession. Thanks especially to Kate Mangione, who took on the McMillan Lecture Award nomination process. Members of the physical therapy community are really too many to mention, and I am so afraid that I will forget someone. I will just say thank you all so very much.
The good thing about me being here today is that I believe that each of you can contribute in significant ways to our profession, just like I have. You have to love what you are doing, be curious, believe that everyone has something to teach you, be willing to change your course when new information is presented, and have a burning passion to make things better. Because of my "upbringing," whatever I do, I always work really hard to do the best that I can...and I am never satisfied. I always look back, reflecting how I could have done it better, and I continue to look forward, knowing how much there is to do!
Compared with those who have come before me to deliver the Mary McMillan Lecture, I have not developed expertise in any one of the 3 arenas of practice, education, and research. In my 33 professional years, I have been extremely fortunate to watch the experts in all 3 arenas propose revolutionary change. I have tried to synthesize, facilitate, and help to translate the "big ideas" of others into action. So I will share with you my "Jack of all trades, master of none" view of where we are and what I believe we have to do.
I will start by describing some of the remarkable changes that have occurred in our profession during my career. This review will demonstrate that physical therapy, as a profession, has never been satisfied either.
The change in practice has been phenomenal. In the late 1970s, the health care system was becoming highly specialized, using all the new technology that was emerging, and was cost unaware.2 Acute care was the most common health care setting because medicine's focus was on curing disease and illness; as expected, the majority of physical therapists were employed in some type of hospital setting.3 It was certainly common to receive a prescription that dictated the intervention in painful detail. Intervention was our primary task, goniometry and manual muscle testing were our high-tech tools, and we used all sorts of big and bulky modalities. Many of us wore white uniforms with yellow and blue PT patches and white shoes.
Education also has changed dramatically over these 30 years (Fig. 1). In the late 1970s, there were 81 physical therapist education programs; today there are 208.4 Case Western Reserve University graduated one student in the first master's degree class in 1962; 40 years later, there were no baccalaureate physical therapist programs.5 On the other hand, the rate of conversion to the entry-level [professional] doctorate has been exponential. Under Gary Soderberg's leadership, Creighton University graduated the nation's first doctors of physical therapy in 1996. Less than 10 years later, a doctoral degree was offered by the majority of entry-level [professional] physical therapist programs.6 I know that the "train is out of the station" speech given across the country by Joe Black was an important factor in reducing resistance among many faculty and university administrators as programs grappled with another big change.
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In 1957, Jane Carlin and Mildred Elson convinced the APTA House of Delegates that research required funding, and the Physical Therapy Fund was established.5 This fledgling organization struggled for funding over the next 2 decades. In my opinion, the primary reason that physical therapists contributed only pennies to support the Fund was because they did not see a relationship between the "noble" research effort and clinical practice. In 1979, Charles Magistro and others, seeking ways to attract funding from external sources, established the Foundation for Physical Therapy. The early years of the Foundation were the time when a significant number of physical therapists became scientists and others were given grants to conduct small research projects. Jules Rothstein, Steve Wolf, Susan Herdman, Stuart Binder-Macleod, Dan Riddle, Lynn Snyder-Mackler, Mary Beth Brown, Michael Mueller, David Sinacore, and I were among those who benefited from this funding. The money helped to pay tuition bills, bought supplies such as rats and litter, and provided each of us with enough preliminary data to go beyond the Foundation to seek our own federal and other private funding. Although the Foundation was "growing up" scientists, the research portfolio used to attract more money was filled with studies on reliability, classification, and animal models for plasticity and was not appealing enough to garner substantial internal or external financial support. In other words, physical therapist scientists were being created, yet the research was still not immediately relevant to the profession.
In 1997, the Foundation for Physical Therapy once again partnered with APTA. A number of factors converged to change the research climate, resulting in the current health of the Foundation. With the introduction of the 1997 Balanced Budget Act, the health care system became acutely cost aware; physical therapists' jobs, salaries, and morale were lowered; and justification for reimbursement and evidence-based practice became synonyms. To prepare us to move forward, APTA staff and members successfully developed several important documents. The Guide to Physical Therapist Practice7 [the Guide] described to the external community what physical therapy is and does. The Normative Model for Physical Therapist Education codified minimal curricular content.8 The evidence-based medicine movement took hold,9 which led to "Hooked on Evidence"10—an online database containing 2,100 [approximately 2,300 at press time] structured extracts of research on intervention, each extract summarized and submitted by physical therapists. The Clinical Research Agenda focused attention on research questions and the need for results with an immediate effect on clinical practice.11 Foundation grant applicants have to explain why their research question is relevant to the Clinical Research Agenda. We have a cadre, although still small, of well-trained physical therapist scientists; approximately 8% of the profession holds PhDs or the equivalent, compared with less than 1% in the 1970s.3 Most importantly, the current financial health of the Foundation is based on giving by components and by individual physical therapists. The link between research and practice has finally been established. The Foundation Board is now ready to convince external funding agencies and corporations to partner with us and conduct research.
When the Foundation began in the late 1970s, most articles in Physical Therapy were descriptive, few were associated with funded research, and about 15% of authors had a research degree.12 In 2004, approximately 41% of the Physical Therapy articles were related to funded research projects, the majority of authors had research degrees, and academicians were the primary scholars [personal communication, Jan Reynolds, Managing Editor, Physical Therapy, APTA, April 2005]. Since 1979, the Foundation has awarded more than $11 million for research grants, scholarships, and fellowships; 2 clinical research centers; and 1 clinical research network. Research articles based on support from the Foundation have appeared in 103 different scientific journals. Foundation recipients have received more than $55 million in subsequent funding from 70 different funding sources [personal communication, Christine Williams, COO, Foundation for Physical Therapy, APTA, April 2005]. The National Institutes of Health (NIH) is one of those funding sources. The Foundation has been the springboard for the majority of physical therapists who have received subsequent funding from NIH. For example, more physical therapists are currently receiving training money than any other health care professional group at the National Center for Medical Rehabilitation Research (NCMRR), a component of NIH. Eleven percent of the NCMRR's research portfolio consists of grants led by physical therapists (personal communication, Ralph Nitkin and Carol Sheredos, NCMRR, National Institute of Child Health and Human Development, NIH, April 2005). In 1999, the National Institute of Neurological Disorders and Stroke (NINDS), another of several NIH institutes funding physical therapist scientists, awarded approximately $800,000, primarily in training grants. In 5 years, funding from this institute tripled and shifted to independent research. In fact, 5 of 6 physical therapists who had received training money in 1999 received their own independent research grants in 2004. Five years ago, 3 physical therapists sat on NIH's rehabilitation-related scientific review panels. Today, there are 18 physical therapists on these panels [personal communication, Daofen Chen, NINDS, NIH, May 2005]. Am I satisfied? No, of course not. We have only just begun.
How I wish to proceed now from giving accolades is still very tangled in my mind, much like a Gordian knot. The issues are central to all 3 domains of practice, education, and research. So, as I tell the students when we are studying neuroscience, bear with me, it will all come together at the end...or not. The common themes are flexibility, consumers, interdisciplinary teams, accountability, and money.
I come from a town called Midland, Pa. This small town grew up around a steel mill that employed 4,000 people. The steel mill brought workers into town from 3 states, and the money earned in the mill was spent in the 18 bars and 13 beauty parlors, the jewelry stores, and other specialty shops. Only 30% of my high school class went to college. Why go to college when there were jobs with great pay in the steel mill? Four generations were supported by the steel industry; why would it stop? Well, today, the steel mill employs only 250 people. What happened? Cheaper steel was brought in from other countries, the unions and the owners did not work for the same goals, and technology radically changed the way that steel was produced. You can imagine the impact on the town. All of the specialty shops closed, along with most of the bars and hair salons; the high school was torn down. A small proportion of the workers retained their jobs in the new high-tech steel mill because they kept up with the changes, some started repair or retail businesses using their steel mill skills, others left home in search of a new job, and some continued to collect unemployment benefits as long as possible and waited for everything to go back to what it used to be.
As you all know, health care is also in a state of change. New knowledge is available every day—look at the impact of recent studies indicating the dangers of Celebrex,* Vioxx,
and Bextra
—drugs that brought pain relief to so many; technology has radically altered diagnostic and surgical practice; robots and virtual reality are making their way into physical therapy clinics; many patients are extremely well-informed and demand use of the newest gizmo reported on the Web, whereas other patients are denied access to health care because they do not have insurance.
The current health care industry has not transformed completely; it is still retooling. Health care costs continue to escalate, there are at least 45 million uninsured,13 and physicians are dissatisfied because of threats to autonomy, ability to manage time, and patient interactions.14,15 The system offers equivocal quality to the consumer. Errors in health care facilities lead to as many as 98,000 dying each year and hundreds of thousands becoming sick or suffering as a result of health care accidents. Service delivery problems include overuse, misuse, or underuse.16 There are 10.5 million health care workers—120,000 of which are physical therapists—and each state has its own regulations about who can practice and what they can practice.2 As you would expect, many groups are addressing these issues, including our own professional organization, but I am going to talk only about the Pew Health Professions Commission2 and the Institute of Medicine (IOM).16–19
Statements or visions of improved health care systems usually contain goals of providing health care for everyone and allowing the public to freely choose among health care professionals. The President of the Association and the Board of Directors are very well informed on the issues of autonomous practice; I just want to make a point about evidence, so bear with me. Way back in 1995, the Pew Health Professions Commission suggested major reform in health care workforce regulation.2 They complained that state regulatory boards were out of step with today's health care needs and consumer expectations. The report proposed that "big" changes in state boards would decrease harm and demonstrate accountability, provide consumers with choice, and provide geographic and professional mobility to health care workers. The report recommended that competence assessment be part of the entry-to-practice requirements, to retain the ability to practice and to enhance professional mobility. Consider 2 examples. Example 1: if physical therapists demonstrate competence with health screening and referral, we can move into the role of primary care provider. Example 2: if X (you can fill in the blank with whatever group you fear the most) demonstrates competence in X (such as reducing limb volume in people with chronic lymphedema), that group should be reimbursed for the intervention. Both are examples of professional mobility. In line with the concept of professional mobility, the Pew report also suggested that regulatory boards consider eliminating exclusive scopes of practice that unnecessarily restrict other professions from providing competent, effective, and accessible care.
The IOM began to investigate the "chasm" between good-quality health care and actual health care. In agreement with the Pew Health Professions Commission task force, good-quality care included providing care to all and allowing the public to choose among providers.16 Between 1996 and 2003, medical errors were documented and shared with the public, reforms were implemented to build a safer health care system, and a vision for future health care was developed.17–19 The health care system conceived by the IOM reduces the burden of illness, injury, and disability and enhances health status, function, and satisfaction. Note that care rather than cure is the focus of this vision. The 2003 report includes the suggestion that all health care professionals are educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.18,19 Several points are noteworthy: (1) the vision is not limited to medical education, (2) not all health care professionals developed the vision, but it provides equal opportunity for all to participate, and (3) interdisciplinary team work is a central tenet of this vision.
Both the Pew and IOM groups agreed that fewer health care professional groups would result in improved quality for the health care system. Ten years ago, the Pew group suggested decreasing the number of health care professional groups by changing state regulations and considering professional competence; on the other hand, in the IOM vision for health care, professional groups would be eliminated or added based on demonstrating effectiveness and accountability and on demonstrating the ability to work with other groups in interdisciplinary teams for a better consumer-focused, not discipline-focused, health care system. Michael Weinrich, the Director of NCMRR, NIH, said what I am trying to say much better when he and Stuart commented on the future of rehabilitation professionals: "If the rehabilitation professions are diverted by turf wars in response to countervailing pressures and new developments in science, the field [of rehabilitation] will suffer."20 Instead of turf wars among practitioners, they suggested emphasis on building a sound foundation of scientific evidence for practice effectiveness and cultivating the hallmarks of professionalism, which include a core of technical expertise and a commitment to cost-effective service and value for patients.
In my opinion, we are well positioned to help implement the IOM vision for health care. Our professional literature moved very quickly to join the evidence-based practice movement introduced into US medical literature in 1992.9 We had excellent examples in our own literature in the 1990s illustrating how to apply the tools of evidence-based practice to our use of outcome measures such as the Berg Balance Test,21 the Roland-Morris Back Pain Questionnaire,22,23 and the Lower Extremity Functional Scale.24 The hypothesis-oriented algorithm (HOAC), a model of clinical decision making, was coupled with evidence-based practice tools to provide a framework for determining the effectiveness of the plan of care.25 All sorts of databases are available online to search for evidence, including Hooked on Evidence.10 Although evidence-based practice is in our literature, has become a part of our vocabulary, and is being used in some health care centers, there is still a huge gap—yes, I would say "chasm"—between the concept of using evidence and common clinical practice. I do not think that the relationship between the use of evidence and accountability is clear to us.
Why are we still arguing about collecting data on our patients and determining whether the change score is meaningful? Some of you may contend that we are not still arguing. I will share with you 2 examples that support my position. At Arcadia University, we routinely ask the students during their post–clinical education debriefing to tell us how many clinical instructors used some sort of outcome measure. Last year, there was 1 student among 49 who had a clinical instructor who did so. This year approximately 20% of the class reported usage. Some of the students explained that the tools used were not the "best" tools; others stated that an outcome was measured only during the initial examination; others stated that their clinical instructors had tried the tools but did not find them useful; and other students said that the clinic was too busy to use outcome tools. Now, you can blame Arcadia University for selecting "bad" clinical education experiences, but I really do not think that is the problem. We need to get beyond blaming individual therapists or individual practices; we need to determine why the system is failing.
I received a grant in 2002 because the National Library of Medicine26 was frustrated with the lack of utilization of its free online access to medical abstracts or articles. I had to identify 7 physical therapy sites to receive a free computer and printer, online fast Internet service, and instruction in the tools used for evidence-based practice. Initially, I assumed that the sites most in need of these services would be far-removed from academic research centers. I had no difficulty recruiting clinicians in private practice in North Pole, Alaska, and St Elizabeth Parish, Jamaica. Finding the other 5 sites was incredibly difficult. Reasons for refusal included: (1) a computer in the department would decrease productivity, (2) computers were to be used only to enter billing information, and (3) clinicians would spend their time accessing pornographic information. In the end, 3 of the 7 physical therapy sites were successful sustaining use of the computer to access literature through the 2-year period. Now, again, you can blame me and say that I did not ask the right clinical sites, but I would counter that question by asking, "Why are there 'bad' clinical sites?" Pointing blame is not what we need to do. We need to recognize that we have a system problem and address it.
I remember listening to Tony Delitto and others27–31 talking about the need to classify patients prior to the University of Pittsburgh being funded as a Clinical Research Center by the Foundation. Today, in my opinion, the reason for classification is obvious. John Childs and his colleagues, for example, published an article in 2004 that demonstrates the success of classifying patients and selecting the best intervention.32 A similar study was just published related to carpal tunnel syndrome.33 What do these studies illustrate? First, the publications indicate to contributors, particularly the Orthopedics Section, that the Foundation's investment in the University of Pittsburgh Clinical Research Center was worthwhile. Second, these studies reinforce the problem with using medical diagnosis to guide physical therapists' decision making. Third, the clinical prediction rules developed by the authors suggest that, if you perform a standard set of measures and have positive findings on a subset, then the best intervention is X. This research goes one important step farther. The results provide evidence that if you do not have the necessary positive findings and you provide the intervention, you will not see sufficient improvement. Why would physical therapists argue against these findings and resist implementing the approach? A common complaint is that busy clinicians have no time to read the literature and, therefore, are unaware of the findings. This complaint is understood, and it is up to all of us to figure out how to make information more accessible to the extremely busy clinicians.
Loss of autonomy. As Nero Wolf would say, "Pfui." This has nothing to do with autonomy; autonomy does not mean that the clinician gets to do whatever he or she wants to do. Doesn't autonomy mean that the clinician makes evidence-based decisions and offers the best intervention based on his or her demonstrated competence? Investigators will criticize the findings of Childs and his colleagues and argue about the conclusions based on the sample size, the examination tools, and so on. Wonderful! That is what is supposed to happen; let's engage in some healthy debate about research. This kind of discussion and constructive criticism should lead to improved clinical prediction rules. In the meantime, the clinicians should be using the clinical prediction rule to determine if it works. And, if it does not work, then they can go on using their preferred intervention.
I know that it takes time to get the results of research into clinical practice. Even in today's fast paced world, there is still a 5-year gap between publication of evidence and implementation in practice.34 More importantly, when guidelines are adopted into clinical practice, they are not followed. Dan Riddle and others investigated our knowledge about deep vein thrombosis and reported survey results from nearly 1,000 physical therapists in Physical Therapy.35 In 4 of 6 case scenarios, physical therapists overestimated or underestimated a lower-extremity deep vein thrombosis and would not refer the patient. But the authors did not merely provide a wake-up call with this article; they published a companion paper suggesting how physical therapists can more accurately identify patients who are at high risk and who should be immediately referred to a physician.36
We cannot afford to wait 5 years to get an effective screen for deep vein thrombosis into clinical practice, nor can we afford to have clinicians ignore it. As we strive for Medicare reimbursement for direct access to physical therapy, we need to demonstrate that our profession is aware of the gap between new knowledge and practice and is taking steps to ensure the competence of our practicing clinicians. However, we cannot push the burden of dealing with all of what is new in clinical practice onto the clinicians. They are already overwhelmed. As Alan Jette stated in his May 2005 editorial in Physical Therapy,37 we need to develop ways to disseminate the information more effectively. One incredibly rich research opportunity is to link our knowledge and skills with those skilled in medical informatics. I did not fully understand what the field of medical informatics was until I was preparing this lecture. Medical informatics is the discipline that focuses on the acquisition, storage, and use of information in health care and biomedicine. In recent literature, the electronic record incorporates pop-up menus when relevant data are entered.38 The pop-up menus are currently focused on drugs, radiology procedures, and laboratory testing, but the literature indicates their success. This makes incredible sense, but the implementation will be difficult and will require physical therapists to participate so that the pop-up menus are meaningful for us.
Other ways to help disseminate new knowledge that is vital to what clinicians do are to require continuing education that goes beyond teaching new intervention techniques, to require relicensure after some period of time, or to develop competencies that are based on the physical therapist's expertise for graduating students and practicing therapists. Last year, the APTA House of Delegates passed the following motion39:
The American Physical Therapy Association endorses the concept of continuing education as an integral component of professional development and as a condition of license renewal.
And APTA has just established a task force led by Marilyn Philips to examine issues surrounding competency. Believe me, I am not making this suggestion without recognizing the huge effort required by all of us.
It is really time to discuss Classifying all patients in meaningful ways, to Standardize our interventions, and to agree upon the best outcome Measures. Note the acronym is "CSM," so if you are still opposed to these concepts, you can think about CSM standing for "Combined Sections Meeting." The type of classification that we need seems to go beyond the diagnostic categories in the Guide.7 We have to get out of our specialty silos and embrace the CSM principles across all of our patients and clients in the clinical setting and in research. We really have to agree that it is time to classify our patients in ways that go beyond the diagnostic categories in the Guide, we have to standardize our interventions, and we have to agree upon the best outcome measures.
When we first entered the realm of clinical pathways, we did not have sufficient information. Now we have another approach to revisit this model—evidence-based practice. As I have stated before, we really need to stop fighting the need for independent thinking related to intervention. If we measure an 8 repetition maximum, that dictates how much weight should be applied to gain an increase in force-generating capacity. We do not have to be independent thinkers; we have to use good clinical diagnostic skills and evaluate the findings. Once done, the intervention should be standard. We need to stop fighting this standardization and work instead on determining the optimal dose of intervention. What is the most effective mode for exercise? Are some interventions more appropriate early after injury and others more appropriate later? How long is optimal?
The first clinical research center funded by the Foundation was at The University of Iowa in 1991; a paper appeared in Physical Therapy in 199440 and demonstrated the success of implementing an electronic record at the University of Iowa Hospitals. All patients received a similar set of measurements, the therapists were each trained to be reliable on the assessment tools, and the database generated in the acute care setting was used to examine patient outcomes. It is noteworthy that this paper appeared in our literature more than 10 years ago and that we are just beginning to grasp the full potential of the electronic record and databases. It is time to go beyond individual facilities, however, and collect data across the country if we, as a profession, are focused on accountability. Why is it necessary to complete more documentation in the clinical setting?
It is not necessary if we can convince investigators who oversee current national databases to add relevant tests and measures and a meaningful series of physical therapy intervention codes. The Outcomes and Assessment Information Set (OASIS), for example, measures outcomes in home health care.41,42 All Medicare-certified home health agencies are required to use this tool at the start of the episode of care and during specific time points during the episode of care. Home care physical therapists spend approximately 2
hours completing the form on laptops, and the data are sent to a central repository maintained by the Centers for Medicare & Medicaid Services (CMS). The OASIS is a database where the outcomes are useful but—there always seems to be a "but," which is why I am never satisfied. The OASIS does not include intervention information, only the number of visits. If therapeutic exercise is provided, we need to know the mode of the exercise, the intensity, and the number of repetitions. Then we can begin to determine, for example, whether the dose was adequate. If [we are] unsuccessful getting added to others' databases, then I guess we have to develop our own. So, who is going to fund the collection of data? I love to spend other people's money, so I will go out on a limb. Since it is most important to physical therapists, I think that APTA, not the Foundation for Physical Therapy, should develop a proposal seeking assistance from others, such as third-party payers and health care organizations. The APTA has just launched an effort to collect data from outpatient facilities, but I am urging the Association to embark on a much larger endeavor that includes as many clinicians as possible. Since the IOM emphasized the need for all health care professionals to demonstrate effectiveness and the IOM advises the federal government, support should be sought from this group as well.
Educational literature and vocabulary are such a different world for me. Just as many of you have trouble grasping the concepts in neuroscience, I have had similar difficulty grasping educational concepts and language. I was truly amazed when Rita Wong, a scholar in the field of education, described our curriculum in her summary report for the Commission on Accreditation in Physical Therapy Education (CAPTE). She provided an eloquent, succinct description compared with my countless pages of description. Educational leaders such as Beth Domholdt, Laurie Hack, Gail Jensen, and Elizabeth Mostrom really understand this field and have helped us translate it.
A next big hurdle is determining how to teach clinical decision making. From our experience with teaching students about research, we know how difficult it is to help students "get" this process; it requires them to think—or to think differently—and to integrate material from many different content areas. But many other professions have tackled this problem, the literature is vast, and we already have some experts, so we do not have to figure this out all by ourselves. And medical informatics provides technology not available to us previously, so students can practice clinical decision making using models on their computers. This type of learning is fun! We know that we have to get the novice clinician closer to the master clinician level before students leave our programs if we want to push the use of evidence-based practice skills in the clinical setting. Our students are another very important way for us to integrate these processes into clinical practice.
So, everything is all right? No, I am not satisfied. Something is still lacking in our physical therapy curricula. What makes physical therapists different from other professionals who have similar skill sets? Our essence. Our theory. I believe that we must articulate clearly the principles that underlie our practice. I was really excited when Michael Mueller and Katrina Maluf published the "Physical Stress Theory"43; in my opinion, this theory came closest to defining the principles that physical therapists use regardless of the diagnosis that physical therapists assign. At Arcadia University, we use this theory in the first weeks of our program to try to give the students a broad introduction to the scope of physical therapist practice. We, as a profession, have worked hard on defining professional values and ways to ensure that our students leave our programs with a clear understanding of what they must do to become a professional. In my opinion, we need to spend a similar amount of time and attention articulating the principles that underlie our practice.
There is little question that academia has become another frontier for big business. In many cases, university boards of trustees who agree to tuition levels at smaller institutions continue to increase tuition, because their focus is the solvency of the university. Academic institutions are also consumer-focused, so money allocated for programs and salaries is being stretched to cover scholarships to attract the best students, better fitness facilities, reasonable dining, and so on. Effective outcomes beyond graduating rates must be generated to retain accreditation. Doctoral/research-extensive universities may be able to subsidize teaching from their research income.44 Public institutions have state subsidies, but the subsidies are being squeezed because of other funding priorities. Private institutions with large endowments have some wiggle room, but many institutions are forced to continue to raise tuition rates. There is a growing public outcry about the cost of higher education, so there is additional pressure for revolutionary change in academic settings.
A strategy for universities to generate new dollars is to develop more career-specific programs, such as those in physical therapy. The dramatic rise in the number of physical therapist education programs beginning in the 1980s serves as an example. Small, primarily undergraduate, institutions examined physical therapist student applicant pools and the job market and believed that physical therapist education programs would generate revenue in excess of the cost of the program and help the institution cover other costs. Arcadia University is an example of this strategy. Today, however, many programs are failing to meet projected enrollments. Last year, for example, the projected class size for physical therapist programs was 36 students, down from 41 in 2001, and the average class was actually 32 students.6 When one program fills its class, a class in another program is not filled because we are all competing for a small number of students and the entire applicant pool has been flat for the last 3 years (Fig. 2). We are not alone; interest in other health care professions has declined as well.45 It should be obvious that one thing we have to do is determine innovative methods to attract middle-school students into health care professions and particularly into physical therapist education programs. But, although innovative recruitment strategies may guarantee future applicants, we have to address the impact of the diminished applicant pool on the viability of our current programs now.
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One way to diversify funding streams in a department is through grant funding. In an eloquent address in 1989 to the Allied Health Association, Eugene "Mike" Michels spoke about the need to enhance research and scholarship.47 Mike cited lack of research, scholarship, and external funding as the primary reasons for the closing of the University of Pennsylvania School of Allied Health. He reported that a faculty member from another department remarked that the allied health programs "were not serious intellectual disciplines." We have really come a long way in this regard. We are becoming recognized as a "serious intellectual discipline" if we use the number of grants secured and the publication record of physical therapists as gauges of progress. The number of faculty members in physical therapist education programs who hold doctoral degrees has changed dramatically from 13% (of 521 core faculty) in 1977 to 59% (of 1,811 core faculty) in 2004.3,6 The CAPTE adopted new evaluative criteria, effective January 2006, that require scholarly activity for the core faculty of physical therapist education programs.48 So how does this cadre of physical therapist scientists help us? It helps to diversify our revenue, which is one way to address decreased dollars from declining enrollment. Those of you who know me know that my interest in developing scientists is not to promote a healthy bottom line for universities, but that certainly is one of the reasons why universities are interested in this mode of scholarship; federal grants generate substantial indirect costs for the institution to build an infrastructure including better equipment to use in teaching and better information resources.
We have an incredible research capacity, but we need to make it work effectively so that it permeates all of our education programs. It is clear that working on a research agenda as a sole faculty member in the physical therapist program is not only lonely, it is also not the most effective way to make progress in the research. We need more research related to all aspects of our profession. The only way to engage in a productive research program is with money. Marilyn Moffat reviewed major discoveries in medical science last year in her McMillan address.49 It was clear to me in listening to her lecture that she was defining an opportunity; physical therapists can assist with the translation of new discoveries into clinical practice. NIH has an agenda—the "NIH roadmap."50 The focus of the roadmap is on new pathways to discovery, research teams of the future, and re-engineering the clinical research enterprise. The roadmap emphasizes the need for interdisciplinary teams to address this agenda. We need to become a part of such teams. We have to accept the fact that the molecular basis of disease is a central focus within NIH. We understand the relationships among pathophysiology, impairment, and function, and we understand care. The molecular biologists are focused on cure; they need our help in translating their discoveries.
So, why is this an opportunity for our education programs? What do we do as educational institutions with a small cadre of scientists? We build networks. If our institution does not have the infrastructure, we partner with one that does. If our programs do not have PhD programs, we partner with programs that do. I remember when Kay Shepherd came to Philadelphia and tried to develop a consortium across our city's physical therapist programs to develop a PhD program. We were not ready then to support Kay's vision; I really believe that we are ready now. The Clinical Research Network (CRN) developed by the Foundation for Physical Therapy offers a model. The CRN includes 3 different academic institutions, with the University of Southern California overseeing the administration of the research plan and housing the data management center but providing a research opportunity for faculty members at smaller institutions, such as Southwest Missouri State University. The CRN currently funded by the Foundation has minimal indirect costs, but it has salary money for faculty members to buy out teaching time while providing the program with money to hire someone to replace them and equipment to help investigators build their laboratories. We need more than one CRN; we need to use this virtual research center model and other models developed by NIH to establish research networks that include other scientists, clinical facilities, and others interested in addressing common issues. And no, I do not think that the network focus has to be on practice. The American Educational Research Association has developed an agenda for professions education research.51 We should certainly be able to work cooperatively with other investigators to secure educational research funds using physical therapy as a model of professional education.
We need to consider partnerships with industry. Manufacturers of physical therapy products and devices should be funding clinical trials to at least determine the clinical efficacy of their equipment before it comes to the marketplace. Physical therapist programs partnered with clinical facilities working in virtual research centers are perfect venues for this venture. These centers also will serve as models of physical therapist scientists. Students will not graduate from physical therapist programs believing that they have just completed their final degree; they will see the faculty members engaged in exciting research and want to play, too.
I would be remiss if I ended this talk without discussing some of the phenomenal opportunities available to us in research. Suddenly, we have "discovered" that people with chronic disease are deconditioned! There is research to support this finding for the sedentary older adult; for people with stroke, Parkinson disease, spinal cord injury, arthritis, or cerebral palsy; for people who are depressed or have cardiovascular disease; and so on. Marilyn Moffat stressed the role that physical therapists can play in addressing the issues.49 There are opportunities for physical therapists in the areas of health promotion, disease prevention, and improving outcome following injury. But what type of exercise, what intensity, and what is the dose? I would urge us to proceed systematically and to remember that we need a theoretical framework. This is the perfect opportunity for us to develop partnerships with basic scientists who are searching for ways to translate their findings into changes in clinical practice.
Of adult Americans, 64.5%, or approximately 120 million, are overweight or obese, and yet there is very little research associated with it.52 Over the last 20 years, obesity in the older adult has increased from 18% to 36%.53 At the other end of the spectrum, 1 in 5 children is overweight.54 This epidemic has an impact on health care and society. Hearts N' Parks is a program supported by the National Heart, Lung, and Blood Institute and the National Recreation and Park Association.55 This effort now has 142 programs across the country. What role are physical therapists playing in this initiative? Clinicians can become involved in these types of programs to increase public awareness of us and our expertise. At the same time, physical therapist scientists can work with basic scientists to understand the relationship between exercise and the mechanisms associated with obesity. For example, the metabolic syndrome in medicine has been characterized by abdominal obesity, hypertriglyceridemia, low high-density lipoprotein, hypertension, and hyperglycemia.56 The role that exercise plays in mediating the pathophysiology associated with the "metabolic syndrome" is becoming a research priority. We should be partnering with investigators interested in the mechanisms associated with obesity. Less than 1% of the NIH budget is currently spent on obesity research,54 and basic science investigators are seeking ways to increase the research dollars spent on this problem. We may be a link to enhance the interest in this important area.
In 2003, there were 36 million people aged 65 years or over, accounting for 12% of the population, and 6.8 million older Americans have chronic disability.53 We have already assumed an active role in health promotion for the older adult, but I think that there should be a more active role by physical therapist researchers in determining whether we can retard the rate of cognitive decline. The overall prevalence of mild cognitive impairment (ie, the transition between normal aging and dementia) is estimated at 20%.57 It is predicted that 1 in 2 baby boomers will have Alzheimer disease. Again, the concern to society is money. The cost of institutionalization or in-home care and the mental and physical burden to caregivers are enormous. Identifying interventions that preserve cognitive function or delay the onset of dementia can improve quality of individual life, reduce caregiver burden, and reduce the economic burden on society. While basic scientists search for the cure for Alzheimer disease and fight for stem cell research, the medical costs will continue to escalate. Physical therapists should be addressing the care, promoting independence for as long as possible, and partnering with basic scientists to understand the relationship between exercise and cognitive function.
Claims, however, that suggest that exercise has an effect on the brain by promoting plasticity, increasing levels of neurotrophic factors in the brain, and enhancing resistance to insults are largely unsubstantiated in people with dementia.58 Specific changes have been demonstrated in the brain for mild cognitive impairment, and these early brain changes precede a medical diagnosis by as long as 7 years.58 Coupling imaging techniques with our own tests and measures can serve as a baseline to monitor the effect of exercise over time. Our role is to determine the most effective forms of exercise, those that actually tax cognitive ability, and the adequate dose of exercise. Am I crazy? I do not think so. A recent investigation published in the Journal of Neuroscience indicates that long-term physical activity enhanced the learning ability of mice and decreased the level of plaque-forming beta-amyloid protein fragments—a hallmark characteristic of Alzheimer disease—in their brains.59
There are other really exciting examples of direct links between disease and exercise, and it is clear to me that physical therapist scientists should be assisting in the research. Here is my final example. The literature related to Parkinson disease and exercise serving as a neuroprotective agent has exploded since the first reports in 2001.60 In 2003, there was a study published in Neuroscience suggesting that exercise served as a neuroprotective agent in a rat model of Parkinson disease.61 This year, there was a report that demonstrated that treadmill training decreased the loss of dopamine but did not affect the behavioral deficits of the disease in parkinsonian rats.62 Both studies showed changes in the brain, but only one study demonstrated changes in behavior. The discussion in the second report talked about timing of exercise and the type of exercise and how they differed in the 2 studies. These investigators are contributing to our body of knowledge related to how exercise affects the pathophysiology and the effectiveness of different types of exercise. We should be collaborating with them. We know how to examine behavior, and we know that there are exercises besides treadmill training that also might have an effect on the behavioral deficits.
In case you have not guessed it, I am passionate about what our profession has to offer consumers, the health care system, universities, and the federal research enterprise. We can contribute to their vitality. There is no question that I am still a Pollyanna; I believe in happy endings, that the world is filled with good people, that our profession will survive, and that hard work will get us somewhere. But I am not naive. "Money does make the world go round." We have come so far in 30 years, but we cannot stop. I am not satisfied, because there are effective ways for us to be at the table planning a more effective health care system without defending our turf. We need to become players in interdisciplinary teams in the clinical, academic, and research arenas. We need to be accountable in these 3 arenas as well. So do not sit and wait for the return of what used to be, like some of the steel workers in Midland. Embrace new knowledge and technology to improve your expertise, and we will all be among those who survive in the next transformation of health care and academic settings. So ... do I ever wish I were better informed? Of course, because I am never satisfied.
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Dr Craik has served as a grant reviewer for the Veterans Administration, the National Science Foundation, the National Institute for Disability and Rehabilitation Research, and the NCMRR. She has served as a principal investigator or co-investigator in 18 grants and has authored several publications.
Dr Craik's impact can be seen in almost all aspects of the profession. She has demonstrated excellence in the areas of research, education, administration, and clinical practice. She has played a major role in the development of the research agenda for physical therapy and has increased the visibility of the physical therapy profession within the interdisciplinary rehabilitation community. Her success as an educator, researcher, and mentor is outstanding.
Dr Craik has been awarded APTA's Lucy Blair Service Award and was elected as a Catherine Worthingham Fellow. She has received research awards from the APTA Neurology Section and 12 invited lectureship awards, including the Silver Quill Award from the Canadian Physiotherapy Association, the Professor of the Year Award from Arcadia University, and the Distinguished Career Award from Moss Rehabilitation Hospital.
The Thirty-Sixth Mary McMillan Lecture was presented at PT 2005: The Annual Conference and Exposition of the American Physical Therapy Association; June 9, 2005; Boston, Mass.
* G.D. Searle & Co, Division of Pfizer, 235 E 42nd St, New York, NY 10017-5755. 
Merck & Co Inc, PO Box 4 WP39–206, West Point, PA 19486-0004.
Pharmacia & Upjohn, Division of Pfizer, 235 E 42nd St, New York, NY 10017-5755.
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