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Thirty-Eighth Mary McMillan Lecture |
KF Shepard, PT, PhD, FAPTA, is Professor Emeritus, Department of Physical Therapy, College of Health Professions, Temple University, Philadelphia, PA 19140 (USA)
Address all correspondence to Dr Shepard at: kshepard{at}temple.edu
 | Katherine F Shepard, PT, PhD, FAPTA |
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Her scholarly work includes more than 60 papers and book chapters and coauthorship of 3 textbooks. She has been invited to speak at state, national, and international professional meetings and has held visiting professorships in Sweden and South Africa. She was the "first" for several invited lectures, including the Polly Cerasoli Lecture at APTA's Combined Sections Meeting and the Eleanor Branch Lecture at Duke University.
Dr Shepard's list of awards and honors includes APTA's Dorothy E Baethke-Eleanor J Carlin Award for Excellence in Academic Teaching, Golden Pen Award (now the Jules M Rothstein Golden Pen Award for Scientific Writing), Dorothy Briggs Memorial Scientific Inquiry Award (3 times), and Lucy Blair Service Award. In 1989, Dr Shepard was elected as a Catherine Worthingham Fellow of APTA. She has received awards for outstanding contributions to physical therapy education from Stanford University and Temple University and the APTA Education Section's Leadership Award, and she holds an honorary doctor of science degree from the University of Indianapolis.
| Introduction |
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| Personal and Professional History |
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In 1963, the accreditation standards were set by the American Medical Association in conjunction with the American Physical Therapy Association (APTA) and stated: "Therapists should be trained in these schools to work under the direction of qualified physicians and not to practice independently."1 I attended the baccalaureate program in physical therapy at Ithaca College in Upstate New York when the final year of study was at Jacobi Hospital in the Bronx. Classes were held Monday through Saturday noon. The women in my class of 14 were often mistaken for nurses, as we wore white dresses, girdles, stockings, and sturdy, repeatedly polished white shoes. If we had an affiliation at the VA hospital, we added white stockings and a white hat to the ensemble. As my white hat was perennially limp and dripping wet from falling into the Hubbard tank, I was repeatedly counseled by my clinical instructor to "stop looking a mess." The men wore white pants and tunics and were often mistaken for physicians. We women envied them. Our clinical textbooks were limited to the Licht series, written entirely by physical medicine and rehabilitation physicians.
The month I graduated from physical therapy school, the Journal of the American Physical Therapy Association contained 4 descriptive research articles by physical therapists (Fig. 2).2–5 These articles provided us with the following information:
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We began hearing about a controversial figure traveling around the country promoting "The Kenny Method." Sister Kenny was a "bush nurse" (a public health nurse) in Australia who spent 6 months at a time working in the Outback. The title "Sister" did not refer to a religious order; the supervising nurses in Australia were called by that title.Sister Kenny had a rather unusual knowledge of muscles for a nurse because of a younger brother who was "puny." As a young girl of 14, she asked her physician to give her some information on muscles. So he gave her Gray's Anatomy, which she tackled, and she conscientiously helped her brother strengthen his muscles until he finally won a match.
At that time in the Outback, there was an epidemic among many children who presented with the same symptoms of severe spasms primarily in the back, neck, and hamstrings. Sister Kenny was not sure what it was, so she climbed a hill and got up upon a fence post to give the help signal that was a "Hooee, Hooee." In the distance, she heard tom-toms that suddenly stopped when she began shouting. She became frightened because she knew the aborigines did not like to be disturbed during their religious ceremonies. So she hurried back to her house and put her dog inside.
After awhile the dog began to growl, and she heard footsteps outside. Step-thump. Step-thump. She was relieved when she heard this step cadence. She recognized the limp as belonging to one of the aborigine chiefs who had to have his foot amputated and for whom she had arranged a prosthesis. He knocked and said, "Does white fellow Mary need something?" She said, "Yes, yes, come in. I would like one of your fastest runners to go to the nearest town where there is a railroad station and a telegraph office—10 miles away. Send this telegram and wait for a reply." The telegram was to the physician in charge. She described the symptoms and asked, "What is it? What should I do?" The physician telegraphed back, "It sounds like you have an epidemic of infantile paralysis. There is no known cure. Do the best you can and report back to us in 6 months."
Well, it was sheep country, with plenty of wool blankets. So Sister Kenny cut up wool blankets and put them in boiling water. After ringing them out tight, she put them around the body parts where there was the most spasm. After getting the hot packs, the little children, who were miserable and crying, would relax and go to sleep. And then every time she changed the packs, she would do a little passive motion and what she called "tendon stimulation"—waving a limb back and forth to get some movement. Finally, when her time in the Outback was up, she went back to the central hospital, and the physician asked, "Well, how did you do? How many deaths did you have?" And she said, "I didn’t have any." The physician asked, "Were they badly paralyzed?" And she replied, "No, most of them got all right."
And that was the beginning of the Sister Kenny Method that was brought to the United States. Sarah related how she finally got permission to go to Minneapolis to take a course from Sister Kenny:
We were about to have an APTA annual conference at Lake Geneva in Wisconsin. I sent a telegram to Catherine Worthingham, then president of APTA, and she agreed to have Sister Kenny present at this meeting. Her controversial methods were quickly embraced by many physical therapists, who were particularly intrigued with her innovative method of muscle stimulation and active assistive exercise coupled with visualization and mental practice.
The Policy and Procedures for the Mary McMillan lecture Award (BOD Y06–06–07–17) state: "The content of the lecture should be related to the contributions that the awardee has made to the profession of physical therapy."6 I remember musing, "Does that mean I don’t have to provide extensive documentation and citations for my thinking as required for publishing research?" It has always seemed somewhat paradoxical to me that, in the creative work of research, the more one can document that one's reasoning is supported by other published authors, the more reviewers seem to be reassured of one's credibility.
To my joy, the median and mean number of references used by prior McMillan Lecturers was 10. Note that I did eliminate from my calculation one outlier, a lecturer who provided 158 references because she described new developments that impacted nearly every disease entity we work with.7 Marilyn Moffat, I would never even attempt to compete with you!
The compendium of McMillan Lectures is an astounding body of work encompassing our history, rallying us to action, and foretelling our future. For example, in 1993, Gary Soderberg wrote compellingly for initiation of the entry-level [professional] Doctor of Physical Therapy curricula,8 much like Lucille Daniels in her McMillan Lecture 20 years earlier had advocated for an entry-level master's degree.9 In 1998, Shirley Sahrmann gave us specific steps to follow to ensure that our science, education, and practice as well as our professional identity would blossom and grow.10 In 2000, Ruth Purtilo challenged us to stop whimpering, do our homework, embrace, and convince members of our diverse society of the great good value they will receive for our services.11 In 2002, Steve Wolf presented us with a synopsis of the key points made by former McMillan lecturers such as Helen Hislop's brilliantly clear conceptualization of the depth and breadth of physical therapist practice.12 Wolf left us with his own challenging perspective: "The difference between our future and our destiny will be measured in our commitment."13(p1117)
Given that the big issues that illustrate and promote our professional growth have been covered superbly, I will talk with you about several subtle but pervasive issues that seem to perplex us. The title of this lecture, "Are You Waving or Drowning?" is meant to be a simile for the many ambiguous situations that face us as clinicians, academicians, researchers, administrators, and consultants. When we see someone waving from the water, we are drawn by curiosity and concern and immediately begin to reason—is this a simple solution like waving back, or a complex solution like lifesaving? The decisions we make depend on our past experience, accumulated knowledge, physical and mental abilities, and present state of mind.
There are several streams of thought in which I believe we have been clearly floundering and sometimes drowning. We could change ourselves from this floundering by the rather simple process of gaining knowledge, similar to learning to do a scissors kick under water to keep one's self upright and safe.
| Role of the Social Sciences in Physical Therapy |
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Worse, perceptions held by many physical therapy faculty and subsequently their students are that information from the social and behavioral sciences is only "common sense" and not really a science at all. Similarly, we give lip service to mind-body relationships, but our curricular content often does not reflect this concept. During the accreditation site visits I made over a period of 16 years, many faculty assured me that their students received information about the psychological and social aspects of patient care through prerequisite course work and the personal stories faculty told of their experiences in clinical practice. Yes, of course, some information can be gleaned this way; however, prerequisite course work in the social and behavioral sciences is notoriously heavy on rats, Freud, and stigmas and notoriously deficient on application to everyday life.
Then too, would one learn anatomy from the telling of stories? Where, for example, do students become acquainted with the work of neuroscientist Candace Pert, who, in her groundbreaking and delightfully readable book, Molecules of Emotion: The Science Behind Mind-Body Medicine,13 demonstrated how thoughts produce neurochemicals that orchestrate emotional and physical well-being? She stated, "Mind doesn’t dominate body, it becomes body."14 Thus, body-mind is one entity.
Kate Lorig and her colleagues, who conduct research on patients with chronic diseases, has published definitive evidence regarding how self-efficacy interventions are linked to significant improvement in health behaviors, such as exercise, and in health status, such as pain and depression.15 Do we require students to read and report on this science? Do we ever direct our students to evidence-based journals that address a wide range of healing practices, such as the Journal of Science and Healing?
Without information about the unequivocal constant interplay of body and behavior, students are left with no theoretical framework for thinking about or specific techniques to work effectively with the broad spectrum of human vagaries. As a result, patients who are quiet, respectful, and compliant and show steady progress are deemed those "wonderful to work with." Patients and families who come from different ethnic and cultural backgrounds with beliefs dissimilar to ours, those who suffer from the selective listening that accompanies trauma, those who exhibit depression that is a companion to loss, and those who give us unyielding arguments emanating from fear often are seen as "difficult" patients.
One might argue that the limitation of time in the classroom and clinic precludes us from focusing on much beyond the physical body. However, if every academic and clinical faculty member would require students to review just one piece of scientific evidence demonstrating the inextricable blending of mind and body and the resulting interplay of the social and biological sciences, I believe we would witness a groundswell of knowledge and insight that would enhance our ability to facilitate each patient's return to health. Then too, the fractured health care system and increasingly short amount of time that the traditional medical setting allows for patient care encourage us to believe "anything that is not physical is not our therapy." No wonder so many of our wise, experienced clinicians have left traditional health care settings for private practice so they can actually engage in "The Science of Healing and The Art of Caring."
| Expertise in Practice |
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Jody Tomberlin and Thea Everett, both in their 70s, are still practicing in Galveston, TX. One of their patients was a man who had been terribly burned in an oil rig fire. During the 3 months they treated him, they volunteered every Saturday and Sunday to give him Clorox whirlpool and exercise, debride his wounds, and provide him with steadfast support and encouragement. Two years later, a handsome man came back to thank them.
Elise Stettner, now in her late 60s, works on Long Island with the most difficult of patients—those with long-standing pain and dysfunction who have defied medical interventions from surgeries to psychiatry. The physicians refer their patients to Elise. She often works weekly for over 2 years teaching patients step by step how to regain control over their health and life. You will find none of what she does in textbooks or research databases. She states, "This is a very simple and very difficult process, if you don’t have the personality for long-term, very slow improvement and working with people who are very depressed and feeling hopeless." Her success rate for returning patients to happy, normal lives is 80%.
Peter Edgelow, a master orthopedic clinician from Hayward, CA, counsels, "The patient knows the answer if you just ask the right question and look and listen. Ultimately, the patient is the therapist. Empower them in the treatment process from the beginning." Kerry Besmehn and Loanne Rube, who have run a small private practice in Cupertino for nearly 30 years, assert, "Therapists bridge the gap between what the patient intuitively ‘knows’ about healing themselves and the scientific parameters limiting healing. Fear and lack of knowledge are your primary foes." Some patients with multiple trauma with whom they have worked for many years have amazing success stories, like the 73-year-old who competes in 100-mile bike events.
No floundering or drowning here. No separation of mind and body, of the social and physical sciences, or the science and art of healing and caring. The reality is that clinicians such as these probably will never conduct formal research or even write a case report and see it through the daunting task of publication. Thus, I urge those budding researchers among us to capture the tacit knowledge and wisdom of these clinicians as the basis for meaningful education and research related to the practice of physical therapy.
| The Best Research Evidence |
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Fifty years ago, Helen Hislop, then editor of our Journal, began writing editorials about physical therapy being accepted as a scientific discipline. From that time to the present, we have followed the basic sciences and medicine and embraced the traditional experimental design as the research approach to emulate. What is curious is that this method of science came to us from laboratory experiments involving seeds of grain and petri dish cultures, in which control over everything but a single variable was possible. This research echoes philosophical beliefs as far back as the 17th century that nature was ordered and could be simplified and a single objective reality could be identified.17 Epidemiologists Battista and colleagues note, "This emphasis in clinical research parallels the laboratory scientist's desire to put disturbing factors in parentheses."18 Examples of these disturbing factors for us in health care have been language, time since insult, and confounding medical issues.
We have echoed this single-minded approach to science with how we have embraced evidence-based practice. To be sure, Sackett and colleagues stated that evidence-based practice was the best research evidence coupled with clinical expertise and patient values. However, researchers, including Sackett and colleagues, have proclaimed the hierarchy listed in Figure 5 as what constitutes the best evidence.19,20
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Furthermore, randomized controlled trials can be seriously flawed yet published and cited as "evidence." A study published in the New England Journal of Medicine simply randomly assigned patients with acute nonspecific low back pain to 3 groups: 1 group received 2 days of bed rest; the second group was instructed in performing back extension and lateral bending exercises at 10 repetitions every other hour; the third group was the control group, which was advised to continue with routine activities.22 Lynn Harding, a master orthopedic physical therapy clinician, pointed out in a letter to the editor that, in conducting this research, the researchers had assumed that acute low back pain represented a single clinical entity.23 Harding cited the work of Delitto, Cibulka, and Erhard, noting that physical therapists use a classification system to determine which treatment is appropriate for which condition. He stated,
A study that randomly assigns patients with low back pain to various conservative treatment protocols will produce the same results as a study that randomly assigns patients with abdominal pain to undergo appendectomy, cholecystectomy, or exploratory laparotomy. Neither study makes any sense.23
Sometimes researchers, in their attempt to reduce the number of variables and homogenize standards of practice, seem to lose not only clinical reality but all common sense.
If we accept that there are multiple sources of useful evidence that can be used to answer clinical questions,24 we might envision a more pertinent and useful "best evidence" hierarchy. In this new hierarchy, well-done qualitative and quantitative research would provide the most assured evidence, followed closely by documentation of outcomes by expert clinicians and poorly done qualitative and quantitative research at the bottom...or perhaps out of sight (Fig. 6). Indeed, I am puzzled why anyone would even consider using results from poorly done research as evidence. Perhaps use of this egalitarian viewpoint will reduce our floundering in determining what constitutes "the best" guide to evidence.
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| Objectivity and Subjectivity |
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Do any of us really think that hypotheses can be conceived without particularistic human viewpoints? We are subjective. Of course we try to control our biases through the control of variables so that the "answer" will be unassailable. But what variables do we choose to control, or what can we control? Variables that researchers can control are usually the most obvious and most easily controlled, such as the presence of a particular type of insult or age or therapeutic intervention. What variables present in the researcher and in the subject cannot be controlled? Emotions? Perceptions? Trillions of accumulated knowledge bits? Anticipation? Likeability? Do these interfere with research results? Of course! In conducting human research involving any body part or system, we can no more separate out mind from body—or definitely subtract subjective from objective or unmistakably differentiate what is art and what is science—than we can parse out these intricately blended components in clinical practice (Fig. 7). No wonder it is almost impossible to replicate all but the simplest of research studies, like reliability of a goniometer.
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The almost sole recognition given to quantitative methods has trained students inadequately, established flawed standards of practice and research and delayed the development of essential medical knowledge. ... Good medical research requires recognizing the complementarity and interpenetration of quantitative and qualitative methods in inquiry. When qualitative methods are clearly established in our research repertoire, the advance of medical knowledge will be greatly accelerated.26
And so, I believe, it is with us.
| Combining Quantitative and Qualitative Research |
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Combining qualitative and quantitative methods in a single research study can yield a more complete and sophisticated analysis and a more valid, and often more clinically relevant, outcome.27–29 An example is the research of Margaretha Emtner and colleagues’ study of people with asthma.30 Most of the study participants had severely curtailed their physical exercise for years because of fear of triggering an acute asthmatic attack. Her intervention was a 10-week program including intensive exercise training at maximal levels and information sessions that covered a wide range of topics from pathophysiology to techniques for relaxation. At the end of the training period and at 3 years after the study, lung function numerical data remained unchanged; however, virtually all respondents reported they had increased their level of physical activity and had dramatically improved their quality of life. The preponderance of interview data gathered at the beginning of the study can be illustrated by "I was deconditioned. ... I did not dare to exercise." At the end of the study and at a 3-year follow-up, respondents’ reported "I feel no limitation in my daily life. ... I am in control of the disease. ... I don’t even think of myself as an asthmatic person." To reassure those who needed numerical data that a positive change had indeed occurred, a dramatic decrease in the number of emergency department visits was recorded following the intervention. If only quantitative data on lung function had been gathered, this study would have been cited as evidence that an intensive training intervention for people with asthma was ineffective. Not only would years of research have been discarded, but, worse, patients with severe asthma would have continued to experience needless suffering.
All methods, whether qualitative or quantitative, require researchers with ever-present vigilance who use rigorous verifiable standards (Table). In quantitative methods, reliability and validity are achieved by use of techniques such as repeating measurements and employment of criterion measures. In qualitative methods, credibility and verifiability are achieved by techniques such as triangulation, respondent validation (member checks), and audit trails.17 Lest you think that qualitative methods encompass a "soft" or spurious form of research, begin your reading with Gail Jensen's excellent article published in Physical Therapy nearly 20 years ago and titled "Qualitative Methods in Physical Therapy Research: A Form of Disciplined Inquiry."31
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Our research literature is replete with self-efficacy scales, quality-of-life-scales, impact-of-disability scales, and satisfaction scales used because they are easy to employ and the numerical results make a wide range of statistical analyses possible. These scales often show high internal consistency as well as good test-retest reliability. Validity is assumed by correlating these measures with other measures of the same ilk. As a group, respondents usually answer somewhere in the middle of a 4- or 5-point scale, and, thus, these measures demonstrate little pretest to posttest change. Finding, yet again, that scores on depression and self-efficacy scales predict scores on quality-of-life scales insufficiently informs our practice. Knowing what triggers depression and which interventions can boost self-efficacy and understanding how people define their quality of life can enhance our skill as health care providers and healers.
Here is an example of one such predetermined forced-choice psychosocial measure from an article in Physical Therapy.32 As the authors are from Hong Kong and Canada, I am hoping they will not be in the audience today to become irritated with me. A scale titled Reintegration to Normal Living Index was used to measure satisfaction with community reintegration in older adults with stroke. Respondents were presented with items such as, "In general, I am comfortable with myself when I am in the company of others" and "I feel that I can deal with life events as they happen." Think about how you would answer these questions using the required 4-point ordinal scale: "does not describe my situation," "describes my situation a little," "describes my situation a lot," or "fully describes my situation." How would you interpret "in general"? Fifty percent of the time? Eighty percent of the time? What do you think of as the "company of others"? Co-workers? Friends and strangers at a cocktail party? Convention goers? Could you give one response to indicate your ability to handle "life events"? Do you think data from this measure would accurately reflect your thoughts and feelings about satisfaction with community reintegration?
Alternatively, if we were to ask patients to tell us about their present life situation using carefully constructed qualitative research techniques, we could obtain credible and illuminating data about their satisfaction and dissatisfaction. And yes, these data can be rigorously analyzed and condensed by coding and thematic development. How much more these researchers could have learned—and how much better we would have understood the phenomenon they were interested in—if qualitative data had been collected along with the quantitative data.27–31 I urge every research group using forced-choice scales to gather data about thoughts, feelings, values, perceptions, perceived behaviors, and life to add a good qualitative researcher to their research team.
The final point I would like to make regarding research is the dismay I feel with the increasing number of PhD programs in physical therapy that encourage our next generation just graduating from professional education programs to proceed directly into PhD programs. At the end of their PhD work, these graduates come to our academic programs with reductionistic research ideas sprung from the grant-funded research labs in which they have labored. I question how these new faculty members can ask and attempt to answer meaningful clinical questions when they have never practiced physical therapy and have been intensively exposed to only one research paradigm.
Admittedly, it is difficult to embrace new ways of research and practice. We simplify our lives by declaring that a new way of thinking has no merit. This absolves us of the effort required to learn yet one more thing in an era that can easily smother us in information.
Will our educators and researchers find the courage and stamina to expand beyond their knowledge of a singular approach to research and teach themselves and their students the tenets and techniques of both quantitative and qualitative research to truly capture the impact that this profession makes on human lives?
| Closure of the Physical Therapy Program at Stanford University |
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The 1970s were also a time in our history when we, as a profession, strived to acquire the singular rights to the accreditation of our own physical therapist education programs. Moving out from under the auspices of the American Medical Association had been steadfastly opposed by some physicians, predominantly physiatrists. This year, in 2007, our independent accreditation process celebrates its 30th anniversary. So, a warm happy birthday to those upstart physical therapists who began and today perpetuate this process of ensuring unassailable quality in our education programs.
This emergence of the physical therapy profession into greater independence and assumption of health care responsibilities was not to go unnoticed and, I believe, set the stage for further trials.
In 1983, the physical therapy program at Stanford University was suddenly and without warning told by the Stanford Medical School that we were to terminate the program. The medical school dean informed us that the mission of the medical school had changed its focus from producing physicians to producing physician-researchers and that our program "was not an essential component of the academic program of the medical school." The dean subsequently appointed an all-physician ad hoc advisory committee to review materials and support his decision. At that time, the Stanford program had the largest proportion of graduates in teaching, research, and administration compared with any other program in the nation. However, during the 1970s and early 1980s, our faculty believed that devoting long hours and energy to teaching students to do research and helping them get their first publications accepted in juried journals was more important for the growth of our profession as a scientific discipline than establishing and pursuing our own grant-based research agendas.
This focus on education over research was the death knell for our program. When we met to plead our case with the president of Stanford, this arrogant bench scientist informed us that the research we produced held no meaning unless we published in the same prestigious scientific journals in which he published, such as the American Journal of Physiology. We pursued every avenue to save the program: national letter-writing campaigns, editorials, preparation of lengthy documents citing our history and accomplishments, and use of consultants and lawyers. All to no avail.
We eventually discovered that the medical school had already designated our enviable program space as the place for its new program in molecular genetic engineering. This program, which had been operational for 65 years, closed in 1985. It was a bitter loss. Stanford University had been my home for nearly 20 years, and I had earned 3 graduate degrees within its sandstone walls. Now I and the rest of the faculty and our students essentially were told we did not belong. It was many years before I could fly into the San Francisco Airport—where the flight path parallels the Stanford campus—without tears streaming down my face. The constant struggle with the medical school had already taken a severe toll on our former program director, Helen Blood, who began to lose her eyesight. She had become legally blind in 1979, just as she was awarded the 14th Mary McMillan lectureship. She wrote her lecture using information and documentation primarily from memory.33 Unable to read what she had written, I stood at a podium similar to this in Atlanta, GA, and delivered her McMillan address while she stood beside me with her hand on my shoulder. My most influential mentor, and this remarkable woman at 89 years of age is in the audience today.
As all of us with life experience know, when one phase of life ends, another phase begins, and the process of our growth and the roles we assume in our profession continue unabated. After Stanford University, I found my way to Temple University in Philadelphia, which had a physical therapist education program not directly under the aegis of a medical school. I was thrilled to be in a large-city university where diversity was the norm and all disciplines were embraced. I experienced great joy at Temple University working with Laurie Hack and the faculty to initiate a PhD program that included course work in the science of pedagogy and qualitative research. I am thrilled to have been a part of creating a small group of excellent qualitative researchers who will continue to bring this research method to help us define and provide evidence for our unique health care interventions.
In closing, I would like to express my deep gratitude to those who persevered in nominating me for this award. I would like to thank the McMillan lecturers who have gone before me, upon whose shoulders I have stood, for the paths they have opened for all of us. I want to thank physical therapists for developing multifaceted roles that help our profession grow—the educators, the researchers, those who sit on local and national boards, and especially the physical therapists and physical therapist assistants who are our foundation. To our experienced clinicians: may we never forget to watch you in practice, listen to your discourse with patients, ask you to tell us why you do what you do, marvel at your ability to heal, and document your tacit knowledge.
I also would like to thank my family, who is here today: my beloved sister, Barbara, the family matriarch, and my brother-in-law, Martin Feigenbaum, who this year was named a Physician Laureate for being one of the best doctors in America. I would also like to thank my cherished niece and nephews and their children who traveled across the country to be witness today. Thank you to Bryan, Amy, and Christopher, who have come from Florida, and to Kathy, whose husband Matthew is serving in Afghanistan and who brought from South Carolina her daughter Kasey (who also was christened Katherine Shepard), her son, Sam, and her twins, Colby and Austyn. Within my family we have public school and university educators and administrators, a public health nurse, a social worker, a nutritionist, a physical therapist, a lawyer, and a physician—no dentist yet. Finally, I would like to thank my partner of nearly 30 years, Rosalie Lopopolo, with whom all things are possible. Her brother Ron and sister-in-law Gayle are with us today from the San Joaquin Valley of California.
At the end of this day and all the other days of your life, I hope you too will learn to swim steadily on, smile, and wave at your good fortune to be in this profession.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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Introduction
Personal and Professional...
