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Thirty-Fourth Mary McMillan Lecture |
PW Duncan, PT, PhD, FAPTA, is Professor of Health Services and Administration and Physical Therapy, College of Health Professions, University of Florida, Gainesville, FL 32610-0185 (USA) (pwduncan{at}hp.ufl.edu). Dr Duncan also is Director of the Brooks Center for Rehabilitation Services at the University of Florida and is Senior Career Research Scientist for the Department of Veteran Affairs and Director of the VA Center of Excellence in Rehabilitation Outcomes Research at the Malcolm Randall VA in Gainesville
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Dr Duncan has actively participated in and contributed to physical therapist practice, physical therapist professional education, professional preparation of other health care providers, national policy development related to rehabilitation after stroke and aging, and scientific investigation. She has served several government appointments and provides leadership within several organizations. She served as co-chair of the Consensus Panel on Establishing Guidelines for Stroke Rehabilitation for the Agency for Health Care Policy, Research, and Education. She was a panel member on the National Institutes of Health's Total Hip Replacement Consensus Conference and served on the Strategic Planning Group for Stroke Research for the National Institute of Neurological Disorders and Stroke. She recently was appointed to serve on the Steering Committee of the Department of Education's National Institute on Disability and Rehabilitation Research and is currently on the Executive Leadership Council of the American Stroke Foundation and the Advisory Committee of the Canadian Stroke Network. She has served on committees and panels for the American Heart Association and was president of APTA's Neurology section.
Dr Duncan's research activities focus on geriatric rehabilitation, stroke rehabilitation, and health outcomes measurement. She developed the Functional Reach Test, used to assess balance in older adults. In the past 20 years, she has received $13 million in research awards as principal investigator or co-investigator from agencies such as the National Institutes of Health, National Institute on Aging, American Heart Association, Department of Veteran's Affairs, and National Center for Medical Rehabilitation Research and from multiple private funding sources. Dr Duncan has disseminated her research findings in more than 80 peer-reviewed articles in 20 different journals, and she has written a book and 12 book chapters.
Dr Duncan's work has influenced the care and rehabilitation of patients in the United States and worldwide. Physical therapy education programs across the country incorporate her findings and professional vision into the preparation of the next generation of physical therapists.
APTA has awarded Dr Duncan the Marian Williams Award for Research in Physical Therapy, the Catherine Worthingham Fellowship Award, and the Mary McMillan Scholarship Award. She has also received research awards from the APTA Neurology Section, Sports Physical Therapy Section, and Section on Geriatrics, as well as a service award from the Neurology Section. She is an elected fellow of the Stroke Council of the American Heart Association and has given 8 invited lectureships at universities across the United States.
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I truly appreciate this moment in time. I am on this stage as one, but I did not travel here alone. There are many factors and individuals in both my personal life and my professional life who have contributed to my journey here today. I would like to take a few moments to share some of these factors and honor those individuals.
It was quite easy to arrive here today because I grew up in a very privileged environment and I received a rich inheritance. The privileged environment was a tobacco farm in rural North Carolina. It was a place where neighbor knew neighbor from one county line to the next. Each week in the summer neighbors helped each other "barn the tobacco." A community was required to fill the old plank barn. The men worked in the fields to harvest the tobacco, the young boys drove the tobacco to the barn, the girls—my sister and I—"handed it," and the matriarchs in the community "looped it." Then everyone came to the barn and created a human chain to pass the tobacco to the hangars for curing. It was here I received an understanding of interdependence and teamwork. In our community, the elders were engaged with the youth. They taught us to play cards; they admonished us if we turned away from the game because we were losing. You could be assured that if we erred, our parents knew it before we returned home. But most importantly, the elders in this community taught us about caring, what caring really means, what it means to include the child with Down syndrome, to care for the disadvantaged and the ill, and to sit with each other as we awaited the death of a loved one.
My mother, Trannie Ellis Woods, had a huge influence on my life. What she did with her life was inspire my brother, sisters, and me to make something of ourselves. She left us with few worldly goods. But she burned into us that we did not have to be rich to make a difference, that serving others should be our defining purpose. Her legacy is best reflected in a letter she wrote to me shortly before she died, advising me how to raise my own daughters. And in this letter, she wrote, "Pam, do not raise your daughters with a silver spoon in their mouth; raise them to be a service to mankind." My inheritance—a commitment to service.
I am a physical therapist because my husband, Larry, encouraged me to follow my dreams. He saw no barriers. He accompanied me to the physical therapy admission interview at Columbia University with Dr Mary Callahan. Don't tell anyone, but he asked the intelligent questions. He asked: Is this program accredited? How many of your students pass the licensing exam? And when we left, I asked Larry, "What does it mean to be accredited?"
During physical therapy school, I practiced all of my manual skills on Larry. One night, I was practicing the head-on-body righting maneuver. You know the procedure; you flex and rotate the neck to facilitate rolling. No matter how much I tried, I could not get Larry to roll over. I became very exasperated, and I said, "I hope all my patients are not this dumb." His reply: "Did you ever consider that if your patients do not respond, it could be your skills?" What a humbling notion—if our patients are not responsive, it could be attributable to our skills.
My husband of 33 years has been the wind beneath my wings. He has been there for me when I soared, and he picked me up when I fell. And my daughters tell me that in the taxicab ride from the airport, he actually was so excited he was telling the taxicab driver about the Mary McMillan Award. The taxicab driver didn't quite understand what the Mary McMillan Award is, and Larry said, "It's the Heisman trophy for physical therapy." Never once has he asked me to quit being so crazy and come home. But rather he has always asked, "What can I do to help?"
My daughters, Meredith and Caroline, have always been engaged in my career. In fact, they have probably attended more physical therapy conventions than many of you in this room. As proud as I am at this moment, I must admit the greatest accomplishment in my life is simply being Meredith's and Caroline's mom. My daughters have humbled me and inspired me. They always kept balance in my life. Some years ago, my oldest daughter, Meredith, and I were out for a drive. It was a beautiful North Carolina spring night, and I was quite immersed in my thoughts, when Meredith said, "Mother, I think you're lost." I looked around, and sure enough I had made the wrong turn. She asked, "Mother, have you had a bad day?" I replied, "Yes, in fact, Meredith, it's been a very difficult week." She asked, "Who gives you all this work you do? Does Mr Bartlett"—that's Bob Bartlett—"give you all this work?" And I proudly replied, "I am a professional woman. I create my own work." She paused, seemed perplexed, and she said, "You know, Mother, you need to smell the roses sometime." So I asked, "Meredith, how in the world, for 11 years of age, have you acquired so much wisdom?" Her reply: "I don't know. I sure didn't inherit it."
If you think I've really accomplished a lot in my career, there are two of me. I would like to introduce to you someone who's very important in my life—my identical twin sister, Pat Longshore. I actually had laryngitis last week, and I told her she was going to have to deliver my speech. She said, "I know nothing about physical therapy." She's actually a very accomplished businesswoman and a leader of executive education at Duke University.
I must attribute much of my success in physical therapy to becoming involved in the American Physical Therapy Association (APTA). It was with the Neurology Section that I was offered the first opportunity to lead. As the chair of the Neurology Section, I created the first strategic plan. I learned from that experience that a leader without a strategic plan is just a dreamer. My research career was launched with a $10,000 award from the Foundation for Physical Therapy. To accomplish this research, I collaborated with Mary Beth Badke and Richard Di Fabio, with an inter-institutional collaboration between the University of Wisconsin and Duke University.
But the single greatest benefit of belonging to APTA is the opportunity to identify professional role models, to be mentored, and finally to be a mentor oneself. I hope each one of you participated in this morning's "Meet-a-Mentor" session.
Many of the previous Mary McMillan awardees are colleagues who have been mentors and role models to me. They are individuals for whom I have tremendous respect, admiration, and affection. I would like to take a moment to share with you examples of how they have affected my career and contributed to my journey here today.
Mary Clyde Singleton, Margaret Moore, and Suzann Campbell were my professors when I was seeking a master's degree in physical therapy at the University of North Carolina. They encouraged me to not simply be a member of APTA but to become involved. But most importantly, Margaret Moore taught me that the surest way to success is to surround yourself with people who are smarter than you are and let them shine. Suzann Campbell gave me a C- on my first paper in graduate school. Dr Campbell criticized my paper for insufficient background, lack of clarity in purpose, and poor writing skills. She did not support grade inflation. She was about building careers. She encouraged me to rewrite the paper to make it more clear and concise. This experience, I am sure, has contributed to my success in grant writing. Mary Lou Barnes taught me that if we want to do something worthwhile, we might need to stand on the edge. And if you fall off, just climb back on again. Mary Lou and I advocated on the House of Delegates floor for funding of "pre-doc" awards by APTA. There were several individuals, including a former president of this Association, willing to knock us off. And Ben Massey just reminded me backstage that when I spoke in the House of Delegates meeting, I was the only person he had to tell to be quiet. I exceeded my 3-minute limit. But Mary Lou and I persevered and came back for the second round. Thanks in part to Mary Lou's leadership and in part to her financial support, today we have adequate funding for predoctoral fellowships for research in postgraduate physical therapist education. But most importantly Mary Lou exemplified for me the elegance of a lady with a southern accent and with a sense of humility and humor. Steve Wolf first role modeled for me that sometimes the best contribution we can make to physical therapy is to move outside our own circles and represent physical therapy in a broader community of health care professionals. And I would truly feel worthy of this award today if I could have acquired just ten percent of Charles Magistro's grace. Wouldn't this be a better place? Thanks to all of you.
In preparation for this lecture, I read all of the previous Mary McMillan Lectures and Jules Rothstein's editorials. The previous Mary McMillan awardees have articulated beautifully the visions for physical therapist practice, education, and research. Over 80 years ago, in Mary McMillan's prospectus for APTA, the priorities she outlined are the same ones we have today: We need to "standardize and place physical therapy on a scientific basis" and "raise clinical standards."1(p1060) So I hate to disappoint you, but I have nothing new to say. It has all been said, and I doubt anyone will ever articulate it as elegantly or with as much erudition as did Helen Hislop in her Mary McMillan Lecture, "The Not-So-Impossible Dream."2 So I thought for a moment that my message should be short and simple—Just do it!
But of course those of you who know me, know that I would never pass up this opportunity to tell you how to do it. It is our responsibility to execute the visions. So bear with me as I make a few recommendations.
More than ever we need to execute our visions. Our health care system, including physical therapy, is in need of major changes. Let me describe for you the current state of health care. In 2001, a committee of the Institute of Medicine released a report on the quality of health care in American. They reported:
The American Health care delivery system is in need of fundamental changes. More patients, doctors, nurses, and other health care providers are concerned that the care delivered is not essentially the care that we should receive. The frustration levels of both patients and clinicians have probably never been higher. Yet the problem remains. Health care today harms too frequently and routinely fails to deliver its potential benefit. Americans should be able to count on receiving the care that meets their needs and is based on the best scientific knowledge. Between the health care we have and the care that we should have is not just a gap, but a chasm.3(p1)
The Institute of Medicine committee had previously reported on one major quality problem—poor patient safety. In To Err Is Human, the committee concluded that tens of thousands of Americans die each year from medical errors and hundreds of thousands barely escape near-fatal injury.4
Just last year my sister was medically mismanaged after surgery and ended up near death on a respirator in the intensive care unit. As physical therapists, we are rarely in the position to make such catastrophic errors. We don't have the opportunity to give the wrong medication or amputate the wrong extremity. However, physical therapists often fail to deliver the most effective programs. We do not use available evidence to design and implement the most effective interventions or services. Our practices have been plagued with too much variability and both overuse and underuse. We must improve our health care system as a whole in all of its quality dimensions for all Americans.4 At no time in the history of medicine has the growth of knowledge and technology been so profound. Advances in rehabilitation, neuroplasticity, and assistive technology hold tremendous potential for improving function and the quality of life of many individuals with disabilities. We are justifiably proud of the great strides that have been made in rehabilitation and physical therapy. However, the health care system is floundering in its ability to apply our knowledge to provide optimal care. The need for change in physical therapy has never been greater. Transforming health care, and specifically the practices of physical therapy, will not be an easy process. Yet, narrowing the quality chasm will make it possible to bring the benefits of physical therapy to many Americans with disabilities.
We have talented therapists, we have inspiring visions, but how do we execute the visions? How do we implement the needed changes in physical therapy?
My advice: the first secret to execution of our visions is that our visions must be bolstered by the 3 P's—Purpose, Passion, and Perseverance. This is best exemplified by the success of 2 of my most valued colleagues and friends, Andrea Behrman and Kathy Sullivan. Every day Andrea passionately says to me, "Pam, we are going to change the way physical therapists do locomotor training." Kathy's research has recently been featured in newspapers coast to coast. She is indeed raising the bar for stroke rehabilitation. Andrea's and Kathy's passion for excellence in research is birthed in their clinical practice. Every day they execute Helen Hislop's vision: "Science is the quest of physical therapy and humaneness is our expression."2 Specifically, evidence-based methods for locomotor training are Andrea's and Kathy's quest, but their mission is bolstered with purpose, passion, and perseverance. I would like to share with you this example. Before I show you this videotape, however, I must make a disclosure. Without Andrea's knowledge, we borrowed some tapes from her video library and secretly taped some of her conversations with her graduate students and research staff. And at times we used a candid camera. We really wanted to show you the passion of a physical therapist researcher. Now, we were HIPAA compliant. The patients signed releases for the video clips, and the featured patient conspired with us to honor her spirit as a clinician-physical therapist researcher. Join me as we watch Andrea Behrman in action. [See opposite page for transcript.]
As we execute our visions, we will have more impact if we create professional and social networks beyond physical therapy. In the book The Tipping Point: How Little Things Can Make a Big Difference,5 Malcolm Gladwell explores how social epidemics work and how visions are executed. He suggests there are 3 agents that allow us to create change and execute our visions. The first agent is the "Power of Context." If there is one single thing that has determined my effectiveness as a physical therapist and researcher, it is that I was afforded at Duke University the opportunity to build professional and social networks in the Center on Aging, the Stroke Center, and the Center for Health Policy. The power of these networks is represented by an example from Gladwell's book.5 Did you know that in April 1775 there were 2 men who left Boston Harbor to spread the word that the British were coming? Paul Revere was carrying the message west and north of Boston. Do you know the name of the second man? His name was William Dawes. Dawes was carrying the identical message as Revere. Why did Paul Revere succeed where Dawes failed? Paul Revere had developed social networks in and outside of Boston. He knew which doors to knock on when he traveled to Lexington, and when he knocked on people's doors, they listened.
Recently, APTA asked the American Heart Association (AHA) to support our efforts to prevent the reinstatement of a Medicare cap for physical therapy services and to support payment for Medicare for direct access. Prior to making a commitment, the AHA called and asked my advice. Why? Because as a physical therapist, I have developed social and professional networks in the AHA. I currently serve on the executive committee of the Stroke Council of the AHA.
I also have had a voice in establishing a strategic plan for rehabilitation and recovery research for the National Institute of Neurological Diseases and Stroke,6 because early in my career, my late colleague James Davis, a neurologist at Duke University, mentored me. Jim helped me build networks in the community of stroke neurologists.
It was during my participation in centers at Duke University and the University of Kansas that I developed the leadership skills that now afford me the opportunity as a physical therapist to lead a Department of Veteran Affairs Center of Excellence in Rehabilitation Outcomes. This center includes an interdisciplinary team of researchers, physicians, statisticians, economists, and epidemiologists. Of the 13 Health Services Centers of Excellence, only 2 are led by nonphysicians. I am proud to be a physical therapist leading one of them.
It is also imperative that we encourage our students and young therapists to develop social networks. Some years ago, I recruited Jama Pursar to participate in an interdisciplinary research program that Stephanie Studenski and I were leading at Duke University. Jama recently wrote me a note expressing her appreciation for the experience and described how it has influenced her career. She wrote:
When I came to the Duke Center on Aging, I already had excellent PT [physical therapy] credentials and rigorous training in physical therapy research. But at the Center for Aging, I was exposed to a rich and vast network of research outside the field of physical therapy. I was encouraged to work closely with statisticians, epidemiologists, nurse researchers, economists, geriatricians, psychologists, and many others, all of whom have the same goal in mind: to help older adults maintain a vigorous, healthy, and happy life. Although the work of physical therapy is central to the success of meeting this goal, it is not a goal that physical therapy can easily claim as its own, for by acting in isolation, we will necessarily fail. Because of the things I learned at the Center on Aging and what I learned about the value of interdisciplinary work, I now maintain memberships in the American Geriatrics Society, the Gerontology Association, and the American Association of Public Health, as well as APTA.
| Video Tape Transcript [Narrator] In its broadest sense, the goal of rehabilitation research is to change the face of clinical practice. Such a lofty goal can only be accomplished through a model that is interdisciplinary and collaborative, bridges basic science with clinical research, is outcome based, is readily translatable to physical therapist practice, and tangibly improves the quality of life of the individual, family, and community. This goal is bolstered with the purpose and passion of the physical therapist–scientist–researcher. A vision to enhance and progress current clinical expertise emanates from a dedicated group of researchers whose passion is rooted in their identity as physical therapists. They have known patients, participated in their struggles, and experienced the limitations and frustrations of current practice. Their passion creates a desire to improve direct patient care by expanding rehabilitation science through interaction with the models of recovery discovered and implemented by basic scientists. This "bridge research" is the catalyst by which researchers can change clinical practice and improve the functional outcomes and quality of life of those we serve. For many years, a compensatory frame of reference—assuming that the neural damage after a central nervous system lesion is permanent—has guided clinical decision making regarding expected functional outcomes for individuals with spinal cord injury and stroke. However, physical therapist–scientist–researchers such as Andrea Behrman [University of Florida] and Kathy Sullivan [University of Southern California], their colleagues, and their students are now studying a locomotor training paradigm that has emerged from animal models of neural plasticity. Recently, a 56-year-old middle school principal [Ernie] enrolled in our experimental locomotor training program 3 months after surviving an incomplete spinal cord injury. He had completed inpatient rehabilitation and outpatient physical therapy and had returned to work. His gait was slow and inefficient, and therefore his primary means of mobility was a power wheelchair. In our research protocol, he received 9 weeks of training 5 days per week, incorporating stepping on a treadmill with body weight support, overground training, and community ambulation training. [Ernie] I didn't know what to expect ... I just knew I wanted to walk again. This was more intense ... I think it's important to get people up as quickly as possible and move them as quickly as possible, whatever they can do. Repetition is so important ... I really believe that. I had a lot more input and a lot more support—that helps ... a lot of ideas ... a lot of support and encouragement. The independence at home—[the program] has allowed me to do a lot more things for myself than I was [able to do] before. It got me on my feet faster than I thought I'd be. I am pleased it has come as far as it has. I have a place where all those devices are collecting dust. All I can do is keep working at it. I can't relax any day. [Narrator] In addition, we as clinicians and researchers have more to do to be able to incorporate novel therapies into patient care, but the next steps are being taken toward changing the face of clinical practice. [Andrea Behrman] What difference would [this program] make in a life and why would I want to provide this or not? Our mission is to optimize the recovery of locomotion in individuals with central nervous system injury or disease and enhance their quality of life. We are promoting principles of neuroplasticity, practice, repetition, activity-dependent plasticity, and optimizing the intrinsic mechanisms of the nervous system to restore locomotion. But if we are going to train, then we have got to do it with focus, intensity ... so I'm saying, give me those exact same numbers that he got in outpatient care, and let me see if I can win the race. [Ernie] You all gave me my life back. [Narrator] "Changing lives" is the purpose. It is executed with the passion and perseverance of clinician scientists.
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Jama concluded by writing, "I am learning more every day that it is how far we reach that determines how much we hold. When we hold on too tightly, or when we are afraid or too undertrained to reach out, we severely restrict the range of the things that we can accomplish."
My colleagues, it is through networks that we get respect and strengthen and broaden the impact of the work we do as physical therapists.
Our ability to execute our vision is also sensitive to the conditions and circumstances of our environments. What is the context of our education and clinical practice? In addition to being interdisciplinary, are they innovative and evidence based? Recently, I was asked to visit and present a lecture to faculty and students at one of our premier DPT programs. During the visit, I met with the faculty and was overwhelmingly impressed with them, their new curriculum, and their didactic model for teaching evidence-based practice. During the reception, I met one of the second-year DPT students, and she was excited to describe for me her recent clinical affiliation. She told me that she had learned a new therapy technique that she was convinced worked but was not taught in her university program. With enthusiasm she described craniosacral therapy. I hate to disappoint the educators in this room, but the primary role models for clinical practice will not be us. We will fail miserably, regardless of how many initials we have after our name or what curriculums we have—unless we change the context of clinical practice.
Likewise, it will be clinicians, not researchers, who will ultimately determine the generalizability of our research results. As Andrea Behrman exemplified in the videotape, as researchers we will have little or no impact unless we consider the clinical context in which our research is going to be implemented.
The second agent for change that Gladwell identified in his book, The Tipping Point, is the "law of the few."5 The "law of the few" suggests that change is driven not by the majority but by the efforts of a handful of exceptional people. Maybe our new doctors of physical therapy represent the "law of the few." They are major risk takers, you know. Honestly, they do not know if the price they're paying for these DPT degrees and these transitional DPT degrees is really going to be worth it, or if they're going to be a success or failure, but they are not willing to accept the status quo. If we are going to translate research into evidence-based practice, "these new few" must not accept the status quo in clinical practice, education, or research.
The third agent for executing change that Gladwell identified is the "sticking factor."5 The sticking factor means that a message has impact. What is our message for physical therapy? What are the elements that make our message stick? Does the current APTA Vision Statement7 have a sticking factor?
The APTA Vision Statement states:
By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health.7
If you will allow me to indulge in silliness for a minute, I have created a similar mission statement for the American Medical Association:
By 2020, health care will be provided by physicians who are medical doctors, recognized by consumers and other health care professionals as practitioners of choice.
So what do you think? Does that warm your heart? Does it have any impact? In fact, I found it quite offensive. I suggest to you that our Vision Statement has no sticking factor. In truth, it sounds self-promoting and self-aggrandizing. Having a DPT degree is a process, not an outcome. Most cultural changes fail because they are not linked to an outcome. What are the outcomes of our professional degrees? Do these outcomes have social value?
Our Vision Statement should not promote us, but promote our outcomes. The APTA Vision Statement must be revised so that our message is memorable, so that it will create change and can spur us, our colleagues, and our patients to action. My recommendation for the APTA Vision Statement:
The goal of the APTA is to ensure appropriate access to physical therapy services, to promote health, and enhance the quality of life of all individuals with disability. We will accomplish this with our education programs, evidence-based clinical practice, and clinically relevant research.
In addition, dump that 2020 language. Do you think our patients really want to wait 17 years for us to achieve our goals? If I can borrow from Art Buchwald's satire from our Opening Ceremonies, he told us that he had read the new Medicare regulations for reimbursement, and a 90-year-old could get 100% reimbursement if he was an orphan and he still had a newspaper route. So I suggest to you, my colleagues, that when the 90-year-old visits our Web site and he sees 2020, he'll go, "Seventeen years? I'll be 107 years old before they get their act together!"
We will accomplish our goals if the next time we march on Washington we have 3,000 individuals—1,500 physical therapists and 1,500 patients we have successfully treated, 1,500 individuals whose quality of life we've improved, whose life we have given back to them, for whom we've prevented rehospitalization or delayed nursing home placements.
As physical therapists, our ideas, behaviors, and outcomes do have a sticking factor and can be contagious. Last year, my daughter, Caroline, wrote an award-winning poem in which she depicts the autumn of life and frailty but ends with hope. I would like to share that poem with you.
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The dark room
Begins to lighten
With morning sun
Outside, leaves of
Red, yellow, brown, hustle along moistened ground
Wind whistles thru the leafless trees
But inside, dark and cold
Like a winter's night
An old man sits aside his loving wife
Wrinkles grow deeper
Bags heavier, cheeks fainter
Under blue teary eyes
Aging worn out hands
Tremble with fear, frustration, fury
Gray slippers tap the dusty floor
A single tear falls
Moistening dry, frail hands
Of his weak wife
Patiently he waits
Aside, hoping, praying, wishing
For a miracle
In the distance
Pounding footsteps echo
Through empty hallways
In the doorway
Appears the miracle maker
"Strength will heal"
"Time will cure"
A young boy's smile brightens
On an old man's face
Hand in hand, grips grow stronger
And one life a little longer.
When I asked my daughter her inspiration for this poem, she replied, "Physical therapists, they offer hope in the autumn of life."
Our message "One Grip a Little Stronger" does have a sticking factor. The message has social value and can make a difference on the impact of physical therapy.
The greatest legacy for physical therapy occurs when our careers have inspired our children, the next generation. Let's communicate what we are really about!
My colleagues, look at the world around you. It may seem immovable—it is not. With the slightest push in just the right place, we can execute our visions. Simply ask yourself, "Have I reached as far as I can? Have I served as many individuals as I could? Have I given as much as I have received? And have I done it with purpose, passion, and perseverance?"
Thank you for this opportunity and this moment in time.
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