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In the Best Interests of the Patient

SV Paris, PT, PhD, FAPTA, is President, University of St Augustine for Health Sciences, 1 University Blvd, St Augustine, FL 32086 (USA)

Address all correspondence to: svparis{at}usa.edu

	Stanley V Paris, PT, PhD, FAPTA

 
Dr Paris has dual citizenship in the United States and New Zealand and has practiced physical therapy in the United States, Bermuda, and New Zealand. He founded the University of St Augustine, the nation's only proprietary school graduating doctorally prepared physical therapists. The University is active in Japan, Iceland, and Chile, helping to advance physical therapist practice in those nations by offering degrees and clinical certifications. Although Dr Paris may be most closely associated with his contributions in establishing manual therapy practices as an accepted essential component of physical therapist practice, he also has been a leader in physical therapist education, research, and professional service. He has lectured extensively and presented continuing education courses nationally and internationally.

As an author or co-author, Dr Paris has actively promoted the concepts of manual therapy in text chapters, professional journal articles, guest editorials, and proceedings. He also has published textbooks, a film, and a PBS television series on back pain. He currently serves as co-editor of the Journal of Manual and Manipulative Therapy.

Dr Paris was instrumental in establishing the Orthopaedic Section of APTA and the International Federation of Manipulative Therapists and has served as president of both organizations. He also was instrumental in establishing the American Academy of Orthopaedic Manual Physical Therapists. He has been a delegate to the APTA House of Delegates and has served on the APTA Board of Directors. Dr Paris was appointed to APTA's Task Force on Clinical Specialization and was an early proponent of recognizing physical therapist clinical specialists.

Dr Paris has received ATPA's Chattanooga Research Award and was elected a Catherine Worthingham Fellow of APTA. In 1992, the Orthopaedic Section established the Paris Distinguished Service Award in his honor. He is an honorary fellow of the New Zealand Society of Physiotherapy and an honorary life member of the New Zealand Manual Therapy Association. In addition, he is a member of England's Chartered Society of Physiotherapy.

	Introduction

Top Stanley V Paris, PT,... Introduction Autonomy A History of Manual... Time to Pause Our Present Status: The... Challenges in Physical Therapy Closing References

 
Mr President, Board of Directors, Mary McMillan Awardees, Catherine Worthingham Fellows, members, and guests, it is indeed an honor to be before you this day (Fig. 1). I am here in the full knowledge that there are many more who deserve this opportunity, and that is why I am so very grateful to Dr Marty Clendenin who both initiated and headed up my successful nomination.

View larger version (68K): [in this window] [in a new window]   Figure 1. APTA President Ben Massey presenting Mary McMillan Lecture Award to Dr Paris.

Given my background, it should come as no surprise that I would speak for the first portion of my address on manual and manipulative physical therapy. But then I shall focus on Vision 2020 and what I would like to add to the debate as to how best we might get there.

But first there are some traditions to take care of before delivering this address. I would like to introduce some of my guests. My oldest son, Alan Stanley Paris, is in the hospitality industry in Bermuda. Two years ago, he raced his sailboat solo around the world and, in doing so, involved the school children of Bermuda with almost daily e-mails on his experience and the sea life that surrounds them. He's a risk taker, and I am not at all sure where he got that from. For his "service to sailing," her Majesty the Queen of England, honored him at Buckingham Palace, and I was present as a proud father.

My next son, Nicholas Stanley Paris, is in the wine and spirits wholesale and retail business. Educated in America, Ecuador, and Germany, he can read and write in 6 languages and can speak several more. He is a recognized authority on wine, with a book on wine pairing soon to be published.

My youngest son is Stanley Paul Paris. He has a bachelor's degree in criminal justice and has taken a number of jobs, but most especially being an aide to the mayor of York, Pennsylvania, and being heavily involved in charitable activities and banking. He is considering a career in politics. The only problem with that is that he's a Democrat!

There is one other man in my life, and that is my father, the Stanley Paris after whom I and my 3 sons are named. Born in 1899, he is no longer with us, yet he is with me almost daily, and, of course, I would love for him to be here tonight. He was the first male physical therapist in New Zealand.

Finally, I get to introduce a very special lady known personally to many of you. She is currently a member of the Board of Directors of the Florida Physical Therapy Association and is the Chief Delegate from Florida to the American Physical Therapy Association's (APTA's) House of Delegates these past 3 years—my wife, colleague, and best friend of the past 25 years, Dr Catherine Patla.

	Autonomy

Top Stanley V Paris, PT,... Introduction Autonomy A History of Manual... Time to Pause Our Present Status: The... Challenges in Physical Therapy Closing References

 
Now, I should like to begin my presentation with a word or 2 on the subject of autonomy, for it is central to my presentation. The term "autonomy" has been the subject of much debate as we strive toward Vision 2020. Webster's Dictionary defines autonomy as "self-governing," which means, of course, the freedom to make independent decisions and to be responsible for them. Autonomy, to me, has not meant independence, but rather the status that enables collaborative relationships in research, practice, and education—the 3 pillars of a profession. Autonomy means never being a second-class citizen or ancillary employee to a physician. It means being intolerant of the term "allied health," always being an equal, and respecting all of my peers regardless of their rank. A level playing field is all I have sought, a chance to compete in the best interests of the patient.

	A History of Manual Physical Therapy in the United States

Top Stanley V Paris, PT,... Introduction Autonomy A History of Manual... Time to Pause Our Present Status: The... Challenges in Physical Therapy Closing References

 
Manual physical therapy has always appealed to me, for it's about movement. It's about joints and muscles, biomechanics, and physiology. It's hands-on—a valued-added human dimension. In a time of increasingly high-tech and low-touch, we have something rather special to offer. As a profession, we are the specialists in movement and its restoration and enhancement. We are nothing if we are not the movement scientists of today and, most especially, of tomorrow.

My introduction to manipulation was an accident that occurred while as a student at the New Zealand School of Physiotherapy, I was instructing a small group of patients with back pain in a set of exercises. In those days in New Zealand, much of therapy was conducted in classes in a gymnasium. A patient in my class was having difficulty, while lying on his back, in getting one leg across the other, so I did what seemed natural—I gave it a shove. His back "cracked," resonating for all to hear on the wooden gymnasium floor. My instructor disciplined me, no doubt on the grounds of safety concerns. Two days later, my patient did not show to the class, and my worst fears were visualized. However, a few minutes on, he swaggered in, shook my hand, and thanked me for fixing his back. I then shared this with my father, who confessed to his frustration at treating people with back problems—most recently when a good friend who he had failed to assist then went to a chiropractor and after a few visits was pain free. I asked Dad if I should be a chiropractor. He soon straightened me out on that one! But he showed me his library of Mennell and Cyriax books that he had collected, but not applied, and encouraged me to pursue my interest in the spine, which, of course, I did.

Immediately upon graduation, I was permitted to open a back pain clinic at the New Zealand School of Physiotherapy. Soon, I received a first-ever scholarship from the New Zealand Workers Compensation Board to study spinal treatments abroad in Europe and the United States for 2 years in 1960 and 1961. During that time, I met with many luminaries, but 2 stood out as the greatest influences on my practice. The first was physical therapist Freddy Kaltenborn of Norway, who was the first physical therapist to seek the science behind manipulation when he worked to develop our understanding of arthrokinematics. Manipulation to him was not about the position of a vertebra or the disk, but about restoring normal movement with the least possible force. His techniques were specific to the level involved and protective of any neighboring instabilities. He was not after an effect, but rather a long-term result. The second most influential mentor was Alan Stoddard, a doctor of medicine, a physical medicine specialist, and a doctor of osteopathy. His search was for the underlying cause—the specific diagnosis for each patient that would individualize the care that he or she received. This search impressed me greatly and has involved me for my entire career.

On my return to New Zealand, I was appointed by the Medical School of the University of Otago as faculty to the New Zealand School of Physiotherapy. I maintained a clinical practice at the hospital and entered private practice with my father. Two years later, I felt ready to conduct my first seminar. The second such seminar was attended by Robin McKenzie and Brian Mulligan, who, as you well know, later contributed greatly this field. Now, unfortunately, the Chiropractic Board of New Zealand did not like what I was doing and so brought suit against me. Neither my school nor the profession was able to provide assistance, for manipulation at that time was not an established part of our practice. The Chiropractic Board dropped their suit when I informed them that I was immigrating to the United States. My purpose in coming here was to gain a PhD degree and to go back again to New Zealand better prepared and better armed. But that never happened. America became my home, and today I am a proud citizen of this great nation.

I arrived here to a faculty position at Boston University, based no doubt on the fact that at age 28 I had published a book and several articles, including one in the New Zealand Medical Journal—all on manipulation. However, I immediately met with unexpected opposition to my interest in this field. The dean presented me with a letter that stated in no uncertain terms: "Mr Paris cannot teach, write, publish, or edit anything to do with manipulation." So much for autonomy, so much for academic freedom. I resigned almost immediately but stayed on to complete my contract.

At around the same time, I had made some contracts to teach seminars. One was to the Connecticut Chapter of APTA. My program director, upon learning of this and without my knowledge, wrote to the chapter and had them cancel the seminar, as I had not "gained medical approval to teach outside of the university." I landed in trouble again when I casually mentioned that I was treating private patients at a nursing home in the evenings. Private practice, I was informed in no uncertain terms, was the "scourge of the profession." I tell you these things because this is the way it was in 1966 in Boston and elsewhere, and, if nothing else, it shows you how far we have come, how much we have gained, and how vigorously, therefore, we must defend our present status while debating how best to get to 2020.

I had also applied for a clinical position at Massachusetts General Hospital and was initially declined because they had only employed female physical therapists. I was told there were no changing facilities for men. However, I gained an interview and showed that I did not need a changing facility, when I changed into a white coat during the interview. I got the job under Marjorie Ionta, who, after reading my book The Spinal Lesion, said, "You can do this if the doctors ask for it—but make a mistake, and you are on your own." Given my definition of joint manipulation as being the "skilled passive movement of a joint," I felt free to practice my specialty whenever a prescription arrived for exercise, for exercise is both active and passive and who would wish it performed other than skillfully? I just took care not to use high-velocity thrust techniques. I came to work at 7:00 AM, attended rounds, and volunteered in the emergency department on weekends. Soon I gained the attention I sought and spoke before Orthopaedic Grand Rounds in the historical Ether Dome. At the end of my presentation, the chief of neurosurgery, Dr William Sweet, asked, "Mr Paris, do you believe you can put a prolapsed disk back into place with a manipulation?" Without pausing to think, I replied, "Yes, sir—if you believe you can get toothpaste back into a toothpaste tube!" There was laughter and applause—I might add more so then than now! We know today that no manipulation, traction, or exercise, including lumbar extension, can reduce the disk, for once it prolapses (Fig. 2), the proteoglycans of the nucleus absorb so much water that the prolapsed material may now expand to 3 times its original enclosed size. Over time, it will dehydrate and shrink, but the nucleus cannot be replaced from whence it came.

View larger version (96K): [in this window] [in a new window]   Figure 2. Radiographs of disk rupture and prolapse.

During my PhD studies in neuroanatomy, I majored in the innervation of lumbar spine structures, trying to understand the multiple sources of pain (Fig. 3). Today, like most researchers and clinicians, I agree that virtually all spinal structures are innervated or capable of producing nociception.

View larger version (124K): [in this window] [in a new window]   Figure 3. From: Leff D. What's new for low-back pain and just plain pain. Medical World News. March 17, 1980.

I then attempted to form a section on manipulation within APTA but was informed by the president that there was no place for clinical sections, the only 2 sections at that time being the Education Section and the Private Practice Section. This was the low point for me. The American Medical Association Committee on Quackery had begun an investigation of my practice and teachings. The only medical organization that approved manipulation would not let therapists in, and our own Association did not want clinical sections. What does one do in such circumstances? I was left with no choice but to found an autonomous organization.

So, on August 25, 1968, in Boston—and, I am pleased to say, with official representation from both APTA and the Canadian Physiotherapy Association [CPA])—we founded the North American Academy of Manipulative Therapy (NAAMT) (Fig. 4), which in 6 years grew to 993 members. It dissolved when the presence of those numbers caused APTA and the CPA to see that a specialty section to meet our needs was in order; thus were formed the Orthopaedic Section and the Canadian Manual Therapy Interest Group in 1974 (Fig. 5). But forming the Orthopaedic Section did not ensure the acceptance of manipulation as part of our practice. Indeed no. A year later when APTA was offered an invitation to attend a conference on the research status of spinal manipulative therapy sponsored by the National Institute of Neurological Disease and Stroke, not only did APTA not send a representative, but they refused to pass that invitation to me and Sandy Burkhart, president and vice president, respectively, of the Orthopaedic Section. We were thus forced to sit in an annex and listen remotely to the conference proceedings. Pained indeed we were when Haldeman, speaking for chiropractic, stated, "The absence of physical therapists at this conference is a clear indication of their noninvolvement in this field." Among those who did accept invitations and were present were the likes of Dr James Cyriax of England and Dr John Mennell of the United States.

View larger version (120K): [in this window] [in a new window]   Figure 4. Formation of North American Academy of Manipulative Therapy, Boston, August 25, 1968—the forerunner of the Orthopaedic Section to be founded in 1974. (From left: Marjorie Ionta, PT, Stanley Paris, PT, and John Mennell, MD.)

View larger version (113K): [in this window] [in a new window]   Figure 5. Signing of the papers for Orthopaedic Section status, Montreal, Canada, June 1974. (Standing (left to right): Sandy Burkart, John Personius, and James Gould; seated: Ms Grover, APTA representative, and Stanley Paris.)

View larger version (109K): [in this window] [in a new window]   Figure 6. This photograph taken in Montreal, Canada, in 1974 at the successful formation of the International Federation of Orthopaedic Manipulative Therapists (IFOMT). Dr Paris was the Chair of the conference. The other 3 individuals were consultants to the process and had served in that capacity for some 6 years leading up to this event. The IFOMT later became a subsection of the World Confederation for Physical Therapy. (From left: Geoffrey Maitland, Stanley Paris, Freddy Kaltenborn, and Gregory Grieve.)

	Time to Pause

Top Stanley V Paris, PT,... Introduction Autonomy A History of Manual... Time to Pause Our Present Status: The... Challenges in Physical Therapy Closing References

 
While it might appear from my remarks thus far that manipulation was introduced to American physical therapy by such individuals as myself and Dr John Mennell, nothing could be further from the truth. In 1999 when researching in the archives of APTA's library in Washington, DC, for an article I was to write on the history of manual therapy, and again in preparing for this address today, I was amazed to find that between 1921, our founding year, and 1936, there were no fewer than 21 articles and book reviews on manipulation. The best source, I am thrilled to say, was in a review of the second edition of Massage and Therapeutic Exercise¹ by no less than our founder, Mary McMillan. In that book and in a subsequent editorial² she wrote of the 4 branches of "physiotherapy," which she identified as "manipulation of muscle and joints, therapeutic exercise, electrotherapy, and hydrotherapy." Titles of articles were quite explicit, such as "The Art of Mobilizing Joints"³ and "Manipulative Treatment of Lumbosacral Derangement."⁴ Phrases left no doubt—"adhesion ... stretched or torn by this simple manipulation"⁵ and "manipulation of the spine and sacroiliac joint."⁶ Clearly, manipulation in many of its forms was part of our practice since our founding and through to the 1930s. Why was it then, when I first visited as a graduate student in 1961 and returned as an immigrant in 1966, that not only was manipulation not part of our practice, but my employer forbade my practicing or teaching it? I can only speculate that the explosive growth of chiropractic in the 1930s, posturing itself as an alternative to medicine and majoring in manipulation, brought upon manipulation outcries of quackery and worse. Manipulation, the baby, was literally thrown out with the bath water, and therapists in dropping the word from use also dropped much of its practice. But let there be no doubt, manipulation under many guises—be it therapeutic exercise, passive movement, articulation, or mobilization—has from the beginning of our profession been a part and parcel of our practice and will continue so going forward.

	Our Present Status: The Guide to Physical Therapist Practice and Vision 2020

Top Stanley V Paris, PT,... Introduction Autonomy A History of Manual... Time to Pause Our Present Status: The... Challenges in Physical Therapy Closing References

 
Completing this brief history of manipulation brings me to the present and my wish to speak to current and future issues. But before I do, it is important that we pause to note once again the great progress this profession has made in the past 40 years and how much we owe our leadership for the completion of a number of documents, including those describing the normative models of education and those on professionalism, but especially 2 landmark documents that are positioning us now as the primary rehabilitation profession in America.

The first document is the Guide to Physical Therapist Practice⁷ (Guide) published in 1997. This document, the effort that was led by then-president Dr Marilyn Moffat, is no doubt the single most significant document in our history. For the first time, we publicly said who we were and what we did. It came on like a storm, and like a storm the beneficial effects are not always fully appreciated. It made possible the second significant document, which followed almost immediately during the presidency of Dr Jan Richardson. Here I refer to Vision 2020. I was privileged to be on the Board of Directors at that time, and I wondered then whether the profession had the courage to implement that vision. I am now convinced that we do have that courage, but I also know that there needs to be much more debate on how to get there, to get to where we are recognized as the "practitioners of choice," for if we are not seen as the practitioners of choice, most else will be for naught. The teasing out of the 6 pillars of Vision 2020 during the presidency of Ben Massey has further strengthened our resolve. It is time for us to be confident in what we know and what we can do and to display that confidence in all aspects of our professional lives.

Now, of course, my area of expertise is the musculoskeletal system, and when I look to that area today, I am aware that most physicians do not have the time, the skills, or the interest in conducting an adequate clinical examination of the musculoskeletal system—nor should they, because their place is in the diagnosis and treatment of disease, whereas our role is in the diagnosis and treatment of dysfunction. As more than one physician has said to me, "Why do I need to know how to examine the back? What difference does it make what pain medication and what anti-inflammatory I prescribe?" Well said.

I do not mean to challenge the medical profession other than to have them recognize the full scope and depth of physical therapist practice so that they will more frequently refer that 40% of their practice that is musculoskeletal to us directly rather than to the surgeon—and without delay. Unquestionably, medicine and surgery can save lives, but no profession speaks to the quality of those lives better than does physical therapy.

We are, of course, in competition with all of those who manage musculoskeletal conditions. Not just the surgeons who would choose to operate whenever they can, despite the emerging literature that supports conservative care over surgery,⁸ but also with the chiropractor, massage therapist, athletic trainer, and multiple others who refer even less frequently to us as they seek to advance their own practice and scope of licensure. Competition is American. It brings out the best in us, and this profession of ours must adopt a competitive stance at every level from education to research and, of course, in practice.

With the Guide and Vision 2020, the train is leaving the station with our leadership and most members on board, but many, I fear, are being left behind. Too many of our colleagues think like technicians and, if in practice, send out prescription pads that look like an inventory from an antique store! They are threatened by our new doctors of physical therapy and are unwilling to address them as "doctor" even when in appropriate professional situations. They are also the ones who work in salaried positions as ancillary personnel to physicians who practice referral for profit. They drag us down with their lack of professionalism, vision, and sense of autonomy. They seem to mock our growth and do little to advance health care. They work for our competitors, rather than offering the best of physical therapy, and thus are cheating patients and clients. To them, I say "the train has left the station." We are now an autonomous and doctoring profession, and all of those who through apathy or conscious decision decide not to get on board with us—who choose not to go where we will be the practitioners of choice—shall be left behind.

When I look to our colleagues in other progressive situations, however, I am encouraged. For instance, in the US military, therapists are conducting triage, ordering imaging studies, prescribing a limited number of pharmaceuticals, and deciding which patients need go to the surgeon. This cost-effective and safe method should be expanded to the nation as a whole. Let us do the research to prove its worth! In the United Kingdom, your colleagues are being sponsored by the national health care system to open clinics on Main Street so that their primary care services can become even more available—this as a recognized cost savings. This year they are to gain some 30 pharmaceuticals, and, on taking a short-term postgraduate course, they are eligible to perform soft tissue injections to muscles, ligaments, and tendons and their sheaths. In Norway, those therapists with specialty graduate certifications enjoy a higher rate of government reimbursement. We should be encouraged by these events and seek to study them as models that we might add to our own system.

When you consider the near absence of musculoskeletal education in today's medical schools, and that there is an anticipated shortfall of between 90,000 and 200,000 physicians by 2020 and that much of this shortage will be in family medicine where currently only 41% of residency slots are being filled,⁹ we have not just a real opportunity but an obligation to so elevate our skills that we may safely lead in the musculoskeletal area, both as a gatekeeper and as the practitioner of choice. There is no turning back. The rest of this presentation is structured on that premise.

	Challenges in Physical Therapy

Top Stanley V Paris, PT,... Introduction Autonomy A History of Manual... Time to Pause Our Present Status: The... Challenges in Physical Therapy Closing References

 
I choose now to briefly address 10 topics, all linked to advancing us toward 2020. I consider these as some of the key challenges that must be addressed if we are to realize our vision.

Shortage of Physical Therapists

The first of these challenges is the critical and growing shortage of physical therapists. Throughout the history of physical therapy in the United States, except for one brief period following the BBA [Balanced Budget Act] of 1997, we—as opposed to other Western nations—have been chronically short of physical therapists. This shortage has led not just to the American public being underserved, but to the formation of other professional and paraprofessional groups that, for the most part, just do not exist in other nations. I refer here to the likes of respiratory therapy, when in the 1960s we failed to provide sufficient cardiopulmonary specialists—then it was the athletic trainers in the 1970s when we were slow off the mark in sports. More recently, we have seen acupuncture spring up as a separate health care group, whereas our colleagues in Canada, Australia, New Zealand, and the United Kingdom practice this as a modality within the scope of rehabilitation, which is where it should be. We lost prenatal and postpartum care to nursing, and to date we apparently have chosen not to embrace veterinary care, unlike our colleagues elsewhere.

Each time we fail to meet the need for more therapists, not only will we see yet more groups arise, but worse still, existing groups will seek to expand their practice license to encompass our areas of practice. As a result of this proliferation of groups, our voice, strong as it may be, will weaken, and others will claim the ears of legislators. Last year in her McMillan address, Dr Rebecca Craik drew attention to the fact that physical therapy schools are failing to attract students and that the average class size is down to 33 students.¹⁰ The problem will not ease any time soon because the student numbers are just not in the pipeline. In 1999, we graduated 7,411 physical therapists. In 2005, we graduated only 5,486 physical therapists.^11(p26) This is not a pretty picture, and so I will present several challenges to help rectify this shortage.

Cost of Education

The cost of education is, I believe, a critical factor in student recruitment when students already burdened with college debt look at the salaries they will expect to earn on graduation from physical therapist professional education programs. Today, a number of alternatives such as medicine, dentistry, veterinary, athletic training, and physician's assistant all compete for our potential students. The current salaries of physical therapists do not seem to justify what some schools are charging. Of the 209 schools in 2005, 48% were private and the tuition plus fees to graduate were as high as $134,000, with an average of $67,000, average lowest quartile=$40,000.^11(pp2,10) So why are the costs of many schools so much higher than others? I am afraid that historically many physical therapy schools and others in "allied health"—a term that we should collectively ban as passé and derogatory—were created to be "cash cows" for the medical school or university. Well, autonomy states that those practices need to be reassessed. Autonomy in education states to me that most profits from physical therapist education should remain in physical therapy for the benefit of physical therapy.

Shortage of Faculty

With the advent of the Doctor of Physical Therapy (DPT) degree, most postprofessional MHSc degrees, traditionally the first step to academe for physical therapists, have faded away. How does one now become faculty? I believe that DPT program graduates, once they have attained a worthwhile board certification in a clinical area, should be considered qualified to be faculty. Physicians who have completed their residencies and fellowships can be faculty in medical schools, but we have not yet endorsed that same concept for our DPTs. Unfortunately, the Commission on Accreditation in Physical Therapy Education (CAPTE), the body that accredits professional education programs for physical therapists and education programs for physical therapist assistants, does not seem to be helping when it requires that all faculty show scholarship. Now there is nothing wrong with faculty being required to show scholarship, but CAPTE does not consider as scholarship activities such as obtaining an advanced degree, becoming board certified in a specialty area, advising graduate students on their research, submitting a thesis, or submitting a graded scholarly paper as part of doctoral work. At a time when we desperately need to culture faculty to rebuild our schools, all of these activities should be considered as scholarship, especially for junior faculty, who should focus on their professional growth rather than on some narrow definition of scholarship.

Professionalism

But there is something else we need to address in our educational environment, and that is the preparation of our students for a career as a professional. We hear a great deal today of the "clash of generations." Certainly, the youth are different from their grandparents. It is logical, of course, to recognize that they learn differently, so we must be prepared to meet those needs and to embrace the technologies with which they are so familiar. However, it should be clear from the outset that when it comes to dress, behavior, and other expectations of becoming a professional, it is they who might need to change. This is the responsibility of the educational establishment both in academe and in the clinics. And it's not just the students who might need to change. Many of us have some very nonprofessional behaviors. For instance, all too often medical colleagues have remarked to me that they would have more respect for physical therapists if occasionally they were told that the patient they had just referred for physical therapy might be better treated by a physical therapist colleague at another facility. This is what we expect of our primary care physicians, and this expectation should become a cornerstone of our clinical practice.

Focus on Outcomes

The Department of Education (DOE) is increasingly concerned that universities show little accountability for the product they educate and graduate. The DOE is working to see what outcomes schools should make readily available to the consumer—that is, potential students and their parents. These outcomes may include items such as cost of the program; graduation rates; months required after graduation to gain a job; salaries at 1-, 5- and 10-year intervals; student satisfaction; and state board pass rate. Already a number of accrediting bodies are requiring and publishing such data, and I feel it is time we did the same in our APTA pages that list our schools. By listing school outcomes, especially with regard to the variety of employment settings and the high employment rates, I am sure we could attract more students to physical therapy. But, in addition, our physical therapist schools need to get together and agree on a common set of prerequisite courses and a common application form. This is the standard in other professions such as physician's assistant. Our lack of a common application form for all schools and our confusing array of prerequisite courses make it difficult for a student to prepare to apply to our schools and, I am sure, this is hurting our enrollments.

Continuing Professional Education (CPE)

Before leaving education, I wish to speak also on CPE, an area within which I have had a long involvement. I was very disappointed when APTA dropped its CPE recognition process, and I trust that they will start it once again to help ensure items such as faculty competence and education, presence of evidence-based teaching where the evidence exists, and appropriateness of who attends the seminars. I am aware that many chapters are tempted to be liberal with their approvals because it represents to them nondues income. But there is a greater need, and that is for accountability to quality and relevancy. Other professions from medicine to social services have such a system, and we need to make a change that meets the industry standard.

Research

Last year, physical therapist faculty at our 209 schools published an incredible total of 2,374 articles!^11(p30) This is an impressive number. However, was Einstein correct when he said: "Academia places a young person under a kind of compulsion to produce impressive quantities of scientific publications—a temptation to superficiality?"¹² And, as Bradford, an academic orthopaedic surgeon, recently wrote of such papers, they "muddle up our journals and lead to excessive noise at our scientific meetings."¹³

It is my fear that much of what passes for physical therapist research today might be wasted because the bar for what is accepted as meaningful research that will be considered to form clinical guidelines has been raised beyond the talents and resources of many who publish. Clinically, the gold standard today is the multicentered randomized controlled clinical trial, which requires big funding and a sustained effort beyond the reach of many programs such as mine. Thus, we should free the schools that are not in research-focused universities from the responsibility of having to provide the research and come to recognize that research is a responsibility of the entire profession that each and every one of us should support. Be assured, evidence-based clinical practice is here to stay, and failure to provide evidence for our practice will be met with increasing denials from payers and with skepticism from consumers.

But the question is, Who should be generating this research, and where is it best to invest our precious research dollars? We cannot help but be impressed with the Foundation for Physical Therapy in recent years and its ability through its well-earned reputation to multiply those dollars received by a factor of 7. With those funds, the Foundation has been singularly successful at funding both emerging and proven investigators and has conducted studies that are making a difference, appearing as they do in journals of high regard such as the Annals of Internal Medicine and Spine. Because of this success, my university will further lessen its research demands on faculty and dramatically increase its support of the Foundation for Physical Therapy. I would ask other schools, especially those not in research-focused universities, to consider this path and for CAPTE to please take it into account when credentialing such programs.

Specialization

There is an area that, for want of a better phrase, I shall with great reluctance have to call "unfinished business." Let me begin, however, by offering sincere congratulations to all certified clinical specialists. However, I feel it necessary on occasion to caution my colleagues who are orthopaedic specialists to be careful how they speak of their status. Should they go up to an orthopaedic surgeon and say that they have just gained board certification in orthopaedics, that surgeon might well ask, "Where did you do your residency?" and we have no such requirement to do a residency. Then the orthopaedic surgeon might ask, "Well, how were you tested?" and you might have to respond "by multiple-choice questions at the Sylvan Learning Center last Saturday morning." If I were that surgeon, I would be tempted to laugh at our process, if not be offended that a physical therapist might for one moment consider that his or her specialization equated in any way with that which the physician undertook. Quite frankly, our present process has fallen far short of the industry standard for board certifications.

We need a solution. Here is a proposal that I recently made as an invited participant to the Education Strategic Plan for Vision 2020: I propose that every new physical therapist upon graduation go into a residency situation ranging from general practice to any area of specialization. Now, I am aware that we have only 37 residencies nationwide, and their growth is very slow, with little likelihood of being available to all entering therapists by 2020. On the other hand, is it not true that most employers of new graduates put together a mentoring process? Some hesitate to continue the process for more than a short period of time, lest they offend the new graduate. But what if this process were a 1-year-long expectation cultivated in our academic programs and supported by guidelines from APTA?

I therefore propose that:

1. APTA draw up a "Guidelines for Mentors of New Graduates."
   
2. Employers learn of these guidelines and sign on to them by simply registering with APTA and gain recognition as a "candidate residency," thus giving them an edge in recruitment.
   
3. Schools culture the students to look for employers who follow these guidelines.
   
4. Graduates of these "candidate residencies" after 1 year of additional clinical experience be eligible to sit for the boards.
   
5. We do our best to progress these candidate residencies to fully accredited residencies by 2020.
   

This plan, I suggest, would in no manner take away from the existing fellowship programs that would remain an option following a residency. If we are to have a process that attains the respect of the medical profession while at the same time further upgrades our clinical education and to have a process that all our members may aspire to, we must be more aligned to the industry standard, and the time is right for it now.

Identity

In moving to 2020, we must do something desperate to establish an identity for this profession. Most of us struggle to define to others what physical therapy is. The public, as I am sure you aware, knows little about us. The Guide has a 26-word definition that does not exactly resonate with the consumer. Think of the medical profession, and you think of illness, disease, and medications. Think of dentists, and you think of teeth. Think of veterinarians, and you think of animals. Think of athletic trainers, and you think of sports. Think of physical therapy, and it's ... what? Where is that association, where is that brief statement that can gain public recognition? I propose that APTA endorse a brief one-line statement that we all can associate with, such as "Physical therapy—the neuromusculoskeletal specialists" or "Physical therapy—the experts in the restoring and enhancing of physical function." I am aware that no brief definition can cover all that we do, just as a brief definition of medicine probably would not cover cosmetic surgery. But whatever we decide, it must be brief, resonating, memorable, and endorsed by this Association.

Marketing

My final challenge is marketing. I have long advocated that APTA create a Media Strike Force of selected therapists from each market area and in each specialist area and both train and equip them with continuously updated, downloadable video clips and print copy so that at a moment's notice they can swing into action at the local press, radio, and TV stations to make sure our voice is heard at each and every opportunity to do so. When a public figure such as Bill Clinton receives therapy for a knee fracture, or when movement returns to the limbs of a "Superman," or when a gassed mine worker takes his first steps following the accident, physical therapy needs to be making that information public and not waiting for a television station to interview a physician who makes only passing reference to "therapy." With the likely advent of such measures as the Health Savings Account, the consumer will have more discretion than ever before. We cannot afford to go unrecognized. The time will soon come when all we have worked for will be lost if we do not have the courage to spend our current reserves so that we can be seen as the practitioners of choice for tomorrow. It must not be said that we cannot afford such an aggressive marketing presence. That would be nonsense. This Association has borrowing power and several millions of dollars' worth of real estate in Alexandria, Virginia, that we can refinance. Older individuals and older organizations may not choose to have loans and a mortgage, but young, dynamic, and growing enterprises accept it as a matter of course. Vision 2020 is revitalizing this profession, a rebirth, if you wish, that requires renewed commitment and dedication of resources. I am convinced that such a visible campaign would do much to speak of our value, attract to our programs the students they need, gain us the legislative awareness that will grant direct payment for services, and, of course, sign up new members who can strengthen our voice and help pay off any debts. The Guide and Vision 2020 will get us to the summit, but it's marketing that will have us reach the tipping point.

	Closing

Top Stanley V Paris, PT,... Introduction Autonomy A History of Manual... Time to Pause Our Present Status: The... Challenges in Physical Therapy Closing References

 
In closing, we have come a long way in these past 40 years, and we have much to be proud of. Now, we are faced with challenges and opportunities from which we must not retreat. The nobility of Vision 2020 should inspire us all—our educators, students, graduates, and members and nonmembers of this Association. It is a vision that is in the best interests of the patient.

I have advocated today that to get there, we must hold down the cost of education, make sure our education remains clinically relevant, publish fewer but higher-impact research articles, enhance clinical practice and relevancy by completing the business of specialization by having residencies for all, and finally define a clear identity and market that identity.

I should like now to first thank the Board of Directors for my selection to honor the memory of our founder, Mary McMillan. And finally I shall quote from a recent graduation address from one of our students:

To lead, you do not have to be the smartest intellect, or the strongest body, or even the most fearless of souls: you simply have to possess the will to do what others won't.

To lead, you must reject being inoculated against vision and passion by your employer's standard operating procedures.

To lead, you must welcome the path of most resistance. Be the best therapist that you can with the resources you have and behave in such a way that others take note ... and they will.

You are more than the reach of your arms or your voice. You are the embodiment of values for all to see and experience.

Ladies and gentlemen, if the next generation follows the advice of this student, we have nothing to fear, and we can rest knowing that our profession and all we have worked and cared for is in good hands.

Thank you.

	Footnotes

 
The Thirty-Seventh Mary McMillan Lecture was presented at PT 2006: The Annual Conference and Exposition of the American Physical Therapy Association; June 22, 2006; Orlando, Fla.

	References

Top Stanley V Paris, PT,... Introduction Autonomy A History of Manual... Time to Pause Our Present Status: The... Challenges in Physical Therapy Closing References

 

1. McMillan M. Massage and Therapeutic Practice. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1925.
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3. Herman RF. The art of mobilizing joints. Phys Ther Rev. 1936;16:94–95.
4. Thornhill MC. Manipulative treatment of lumbosacral derangement: report of a series of cases treated with technic described by Dr. B. S. Troedsson. Phys Ther Rev. 1938;18:65–67.
5. Tait R. The place of manipulation and gymnastics in treatment. American Journal of Physical Therapy. December 1929:240–242.
6. Swenson LL. Study of the intervetebral disc: with special reference to rupture of the nucleus pulposus and its relation to low back pain and to sciatica. Phys Ther Rev. 1941;21:179–184.
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8. Dubourg G, Rozenberg S, Fautrel B, et al. A pilot study on the recovery from paresis after lumbar disc herniation. Spine. 2002;27:1426–1432.[CrossRef][ISI][Medline]
9. Factors Affecting the Health Workforce: Association of Academic Health Centers (AAHC) Policy Forum 2005. Washington, DC: Association of Academic Health Centers; 2005.
10. Craik RL. Thirty-Sixth Mary McMillan Lecture: Never satisfied. Phys Ther. 2005;85:1224–1237.[Free Full Text]
11. 2005 Fact Sheet—Physical Therapy Education Programs, June 2005. Alexandria, Va: American Physical Therapy Association; 2005:2, 10, 26, 30.
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