BACKGROUND AND PURPOSE
Oliver Sacks believed that “music is the profoundest non-chemical medication for our patients”1 Music has the power to heal, to create change, and “set every journey off on the right track.”2 Such journeys, including our professional journeys, have the same rhythm, flow, and patterns that characterize music.3 In my view, the voices that speak to us about purpose and change in physical therapy are a form of music that also can move us, and our profession, forward. My use of a musical analogy is aimed at illustrating the origin and impact of the voices that speak to us about our work, help us understand the urgency to make change, and guide us to organize meaningful action. In essence, we orchestrate change in physical therapy just as a conductor orchestrates a musical performance. It is through this analogy that I will address the origin and impact of the voices that speak to us about our profession and how change must proceed to meet contemporary imperatives for physical therapy. Not only will we enjoy some musical interludes, but we will have time for reflection and incubation of new ideas to catalyze change in physical therapy education.
Why Speak About Voices?
Voices calling for change in physical therapy education are heard from a myriad of sources - leaders whose insights are built on academic rigor,4–6 innovators who seek new ways to explore change,7,8 payers, and perhaps most importantly, our clients and patients whose health is influenced by what physical therapists (PTs) provide.9 In one sense, voice is simply sound. In a broader sense, however, voice receives meaning from the context of the speaker and the listener and becomes distinctive, just as one musical instrument is distinctive from another. One's voice is a musical instrument of its own! Dilemmas always arise in listening to many voices when they speak at once, in interpreting the essence of the messages received, and in trying to prioritize response(s) to the voices we hear. Clearly, there is a need to organize the sounds we hear from various voices into an orchestrated whole that provides meaning for change in physical therapy education.
Why the Musical Analogy?
Music is very much like human movement. It flows, has order (otherwise it is just noise), occurs in sequence, and has timing and energy. Creating musical compositions is much like creating human movement. A note is analogous to a muscle or muscle fiber. Many notes are like many muscles (or fibers) working synchronously to produce increasingly complex movement. A melody (instead of just a noise) occurs when many notes are organized and united to communicate a story or feeling. But, it all starts with one note.
Then, just as musical compositions arise from joining many, many notes in different patterns and unique styles, human movement results when many muscles join together in a particular pattern to enable unique movements. On a larger scale, symphonies are comprised of groups of compositions named movements, just as functional activities are comprised of complex combinations of motor skills supported by the individual components of the movement system. So, thinking about the characteristics and meaning of the music produced by voices in our work can be helpful in managing the maze of complications associated with moving our profession forward. That will be paramount if we are to meet the vision of the American Physical Therapy Association (APTA) of “Transforming society by optimizing movement to improve the human condition.”10 Let us now proceed to consider the timbre, tempo, and dynamics of change that will enable that vision!
What About Timbre, Tempo, and Dynamics?
Making change in our work has parameters that are analogous to music and to the voices that speak, sing, and shout at us. Three of these musical parameters (timbre, tempo, and dynamics) capture what I believe are relevant parameters of change in our professional lives. The idea here is to use these parameters to ignite some ideas for change in physical therapy education. Briefly, I envision the relationship of these musical parameters to parameters of change to be as follows:
- Timbre refers to the quality and style of music that distinguishes one instrument (or voice) from another. Timbre is akin to the particulars of change that will be unique to physical therapy and must be linked to the profession's vision;
- Tempo refers to the timing and speed of music, parameters that are critical for the conductor, and the musicians who collaborate to achieve just the right feeling and message from their music. Tempo is analogous to the pace of our professional work and the speed at which effective change can be achieved;
- Dynamics in music refers to the intensity and volume that communicate the emotion behind music. That emotion corresponds to the passion and power of change and requires voices to be orchestrated into a cohesive whole to create a symphony for change.
POSITION AND RATIONALE
Using these musical parameters in the context of professional education, I will advocate for making 3 major changes to lead the transformation of physical therapy. First, we must engage our professional timbre to unite ourselves by adopting the movement system as our core philosophy. This will cement our identity as experts who can deliver care designed to prevent or correct problems in human movement and the function that movement supports. Second, we need to accelerate the pace of our efforts to standardize select aspects of physical therapy to reduce variability in how we educate PTs. Doing so will be particularly important to the clinical education community, students, and employers who are demanding more consistency in outcomes across programs and whose voices are urgently calling for change. Third, we need to respond to our patients’ intense needs for better health by moving beyond our traditional boundaries of practice to maintain movement and functional independence throughout the lifespan. Using its power for change, our profession can be a force supporting new approaches for practice and new visions of education and research. I have offered a set of strategies below for each of these recommendations as a catalyst for spurring innovation in physical therapy.
The Timbre of Change
The quality of sound produced by different musical instruments and different voices in singing is quite distinctive even though those different instruments all produce the same outcome—music. Thus, the cello sounds very different from the violin, and the alto voice is very different than the bass voice, even though these voices are both produced from a low register in vocal music. Similarly, the timbre of one profession will distinguish it from other professions, even if they share a context (like health care), but only if there is consensus about identity, values, and purpose. Effective change must be focused on a common philosophy that unites its various steps. Voices calling for a common philosophy have united to develop APTA's new vision statement10,11 and are now being heard in APTA's recently appointed Movement System Task Force.12 Over time, the call to unite around a common philosophy has increased because of changes in the health care system, competition from other professions, and a myriad of internal changes in physical therapy that have made our work more complex and more variable. As a result, we risk our identity being splintered unless we openly manifest this common philosophy that underpins our work in education, practice, and research. As a philosophy, it is the movement system that unites us regardless of practice setting or specialty.11 You could say that the timbre of physical therapy is movement.
To mirror the movement-oriented timbre of the profession as a whole, the quality of physical therapy education also requires having consensus about a common philosophy that unites all phases and components of all curricula, regardless of institution. This philosophy of education must rest in the movement system for our identity to be unique from that of other health professions and for us to have an internal reference point upon which to base quality measures. Because measuring quality is expected by multiple external groups and is internally desirable, it is critical that we respond strongly to the voices calling for philosophical unity. Otherwise, physical therapy as a profession will not reach its new transformative vision.
Just as the quality of a musical composition is dependent on orchestrating the unique interaction of notes and phrases, blending our voices harmoniously when aspiring to make change can reduce internal conflict (or, in musical terms, cacophony). Such harmony obligates us to understand the cultures of our work and use communication strategies of the type(s) that were identified in the “harmonization” goals established in the 2014 Clinical Education Summit.13 The particulars of change from this viewpoint require us to adopt the movement system not only as the core philosophy of didactic and clinical education at the entry level, but also in postprofessional clinical doctorate work, residencies and fellowships that train specialists, and in continuing education that supports practice. Doing so is critical for us to be properly identified for our expertise in helping patients manage movement and function and for us to be distinctive in the eyes of the public from others who may deal with function but who are not experts in the movement system. Uniting our own voices will better assure that graduates can carry a solid identity of physical therapy forward.
Although we still need voices that bring dissonance (which feeds innovation), I believe that right now our first priority is to cement our identity as movement specialists and optimize the timbre of physical therapy. Contrary to what some might fear, having a common philosophy does not restrict our individuality and can only strengthen our profession. So, in the spirit of Randall Munroe, who used science to answer vexing questions about people and the universe,14 let us pose a “What if” scenario for optimizing the timbre of physical therapy by using the following methods:
- Adopting curriculum mission and vision statements that confirm movement as the foundation of our profession. Seeing a reference to the movement system on every program's website could be the start of the “Next Big Idea” that Jan Gwyer and Laurie Hack discussed in their recent editorial15 in the Journal of Physical Therapy Education (JOPTE).
- Encouraging students and their clinical mentors to seriously discuss whether the interventions they use match the core philosophy of the movement system. Reducing the use of interventions that don't match our role as movement experts (eg, tanning beds in clinical practices) is another step toward having a unified identity.
- Developing a standardized format for case analyses used in the classroom and the clinic that incorporates a structure for categorizing patients’ problems into movement diagnoses. This could be a precursor for achieving consensus about a naming strategy for movement-related diagnoses.
- Incorporating an expectation for learning about the movement system into criteria, used to assess student performance and for teaching about the movement system into faculty evaluation. This could prepare us to advocate that the criteria of the Commission on Accreditation of Physical Therapy Education (CAPTE) require evidence of a core commitment to the movement system in all programs.
Music uses rests to connote a pause and silence, as both are useful for reflection. Before moving to the second musical parameter, tempo, allow yourself to reflect on the timbre of physical therapy and the importance of a shared core philosophy.
The Tempo of Change
In music, the tempo of a composition is managed collaboratively by the conductor and the instrumentalists or vocalists.The speed and pattern of movement from one part of the piece to another are chosen deliberately to complete the story or feeling being communicated by the music. The challenge is to match the tempo of the composition to the goal of the music. Imagine a musical composition that got “stuck” because the musicians just preferred to stay on one note, or one that was played so slowly as to lose the listener's interest. On the opposite side of the speed spectrum, however, music that is played too rapidly (eg, prestissimo for a hymn) may cause the listener to miss the message. The same is true in determining the pace of change in physical therapy education.
The voices calling for change in the tempo of didactic education include students (“Hurry, I am in debt”), faculty (“Slow down because students aren't learning enough to perform well”), and employers who need graduates to serve the growing population of all sorts of patients who need physical therapy (“Hurry producing graduates - but make sure they can be licensed quickly”). The voices calling for change in the tempo of clinical education express even more urgency. Clinical faculty must manage an ever-increasing volume of learners from an ever-increasing number of schools that, collectively, express an ever-increasing expectation for effective teaching and learning in the clinic. The stress in the clinical education enterprise is significant and complicates decisions about whether and how to make change. The dilemma is that moving too quickly may sacrifice the voices of some stakeholders and dissipate unity; moving too slowly may cause us to miss opportunities that may not come again. Achieving well-paced change—in directions that will also enhance quality—is not a simple endeavor when there is so much pressure to keep up with changes in the academy, the health care system, and society!
In my view, the tempo (pace and pattern) of change and the timbre (quality) of change in physical therapy education are intimately linked. Many voices in the physical therapy education community are urgently calling for us to standardize our educational expectations to enhance quality and see more consistent outcomes. Others fear standardization because it appears to reduce choice in the design and delivery of curricula. However, standardizing teaching and assessment strategies and centralizing processes in clinical education could make us more efficient in delivering both didactic and clinical education, enable outcomes to be more comparable, and possibly reduce stress for everyone. Fortunately, there is existing evidence for teaching, learning, and assessment that almost immediately could be translated into use to achieve more standardized approaches. Keeping in mind that it may be difficult to balance the tempo of change, plans for both immediate change and plans for future action aimed at standardization in physical therapy education are needed. So, another “What if” scenario is the potential response to the factors affecting the tempo of physical therapy by:
- Selecting (from JOPTE) teaching and learning strategies already supported by evidence and standardize these across all curricula to increase the pace of change in teaching. Well-documented strategies include important topics such as using reflection and self-assessment for developing professionalism16 and training for cultural competence.17 Using standardized ways to achieve professionalism and cultural competence would be a major sign of collaboration among programs.
- Reducing redundancy of APTA work groups interested in addressing education priorities to avoid duplicate effort and internal competition for outcomes. One current example is that 4 separate groups appear to be addressing priorities from the Clinical Education Summit: (1) an APTA Task Force on Clinical Education, (2) Strategic Initiative Panels of the American Council of Academic Physical Therapy (ACAPT), (3) the Clinical Education Special Interest Group of the Education Section (CESIG), and (4) ACAPT's National Consortium for Clinical Education (NCCE). This is not efficient and could be corrected quickly.
- Using regionally developed assessment centers for periodic testing of student clinical performance as a replacement for the Clinical Performance Instrument (CPI) which, although reliable, is a burden at the clinical site. Assessment centers used by other professions to test progress and competence use simulations and standardized patients to test progress toward completing a course of study. Regionally-based assessment centers in physical therapy could be used to establish readiness to enter clinical education (a Summit priority)13 and be a vehicle for assessment of other outcomes. Although pilot testing of this idea could begin relatively quickly, full implementation is a long-term strategic initiative occuring at a different pace.
- Developing a national resource external to our academic institutions for clinical education administration focused on contracting, scheduling, matching, and other tasks currently performed by the director of clinical education (DCE) and the center coordinator of clinical education (CCCE). The weight of these tasks often detracts from scholarship and mentorship18 and could be centralized in the same manner as admission processes have been centralized with the Physical Therapist Centralized Application Service (PTCAS). Again, implementation of this strategy would need to be deliberate, strategic, and at a slower pace than some changes, but commitment could begin promptly.
Before moving to the third parameter of change—dynamics—we will pause for another rest to reflect on the issues associated with tempo to ensure best fit for the pace of change in physical therapy education.
The Dynamics of Change
In music, volume (eg, pianissimo versus fortissimo) is a component of music that helps to communicate its power and intensity. The dynamics of a musical composition bring strength, emotion, and life to its message. The dynamics of our work in physical therapy inherently have power and intensity, which affect the passion with which we deliver care and the direction(s) the profession grows and changes. The singular voices of innovators (who often have the loudest voices) can be very powerful, but loud voices are not always the most effective ones. Intensity derives from a variety of factors, including volume, but also including unity of purpose and the collective voice of stakeholders who care about the directions of change. I believe we are at a point in the movement of our profession where we need to be intense, not just loud. Used well, our intensity will enable us to create a powerful composition for change.
The voices for change in our profession are very intense from patients, physicians, and the general public who know that movement is important for health and life. These same individuals are beginning to look more frequently to physical therapists for help to attain, maintain, and modify movement through our expertise in the movement system. In addition to APTA's collecting the voices of patients,9 routes such as the Beryl Institute,19 the Patient Voice Institute,20 and even the United Stated Food and Drug Administration's Voice of the Patient21 have been created to listen to the perspectives of those for whom we provide care. Our patients are asking for help to avoid pain, to move under specific circumstances, to live independently, and to use movement to enhance their overall health. In my view, the patient's voice is the most important of all voices we hear—even if the patient does not speak the same technical language, or even English—because everyone needs movement for their health, and physical therapists are in a unique position to meet that need. This makes it imperative for us to use the power and intensity of change in physical therapy education to respond to the voices of patients (individual patients, groups of patients, whole societies of patients) whose welfare is our highest professional priority. Looking for ways to move beyond our traditional assumptions and boundaries of practice will be critical. So, “What if” we orchestrate the dynamics of change in physical therapy education by:
- Teaching our students to aggressively and assertively pursue missed opportunities that respond to movement intervention. These could include cancer fatigue, obesity in people with disabilities, prevention of postural pain in adolescents, and deceleration of functional decline in centenarians. Graduates’ involvement in these areas can enhance our identity as first contact practitioners for patients whose conditions could respond to prevention and/or intervention through the movement system.
- Truly embracing integrated medicine, participation in interprofessional practice,22 and the delivery of interdisciplinary care. I believe it is time for us to open supervision of our students to qualified non-PTs and seek new experiences to collaborate in delivery of interdisciplinary care. To be successful, we also must expose ourselves to the stakeholders in the business of health care whose perspectives may modify the environment for change, but certainly do not prevent innovation.
- Actively responding to the call for public health action and participation in policy development that is so desperately needed in both rural and urban areas—in this country and beyond.22 Promoting health through movement can be done in multiple ways and learning to interface with schools, government agencies, faith-based organizations, and other community organizations would prepare a new generation of leaders capable of maintaining and expanding our identity as movement experts. This approach is entirely consistent with APTA's intent to change public perception of physical therapy and increase the impact of our service to patients and clients, but will require modification of clinical education to afford students concentrated experience in these areas.
- Balancing our involvement in global health and in meeting the needs of populations in this country. The need for international service cannot be disputed,23 as is the need for service to patients in this country. The altruism of students, the value of exposure to other cultures, and the far-reaching needs of people throughout the world for health care may lead us to see international service as a solution to the stressors of clinical education. However, it is questionable whether international service-learning can replace or substitute for any significant amount of the clinical education required in our entry-level curricula. Instead, all programs should support their own clinical services with a faculty practice (pro bono or income generating) and incorporate students into those practices as a part of clinical education. International service-learning can then remain an important adjunct to the curriculum.
So many voices in the community are pleading for help—to move, to function, and to be independent in the face of increasing chronic disease and survival from catastrophic illness or injury. Physical therapists’ strength, power, and passion have always been unique attributes that contributed to successful outcomes. Stretching our boundaries in practice and education would serve both patients and students well.
A third rest is now in order for reflection and inspiration about how the dynamics of our profession can catalyze change.
All notes, phrases, and sections of a musical composition are united in the end by a coda or concluding passage. The coda allows the listener and the musician to review the composition (musically), bring the message to at least a temporary conclusion, and (possibly) set the stage for next steps of listening, feeling, or acting.
The following serves as the coda for the “Voices of PT Education: Orchestrating Timbre, Tempo, and Dynamics.” We have infinite possibilities to be creative, provocative, and innovative in physical therapy education, but are left with many unanswered questions. What role should each stakeholder take in supporting change? Who or what is the source of innovation in physical therapy? Whose voices are the most important? Where do we start to make change? The power of change relies on developing high-level communication and trust, avoiding wasteful duplication, and considering the following points as catalysts for change in physical therapy education:
It is essential to commit to movement as the foundation of physical therapy and to structure professional and postprofessional curricula around the movement system to validate the identity of the physical therapist as an expert in movement for health. The timbre of physical therapy is the movement system;
Standardization in physical therapist education (both didactic and clinical) is critical for reducing unnecessary and undesirable variability, enabling measurement of outcomes needed for public accountability and benchmarking, and making our programs more efficient. Accelerating the pace of change toward standardization in didactic and clinical education is warranted and feasible;
Expanding the boundaries of practice and education into interprofessional education and interdisciplinary models of care will require relaxing traditional assumptions about student supervision, but we better assure that our patients’ voices are heard and their needs addressed in this era of complex health profiles. The dynamics of our work explains our passion for service to patients and our power to respond to the voices calling for growth in our profession.
Just as musical compositions have a conclusion, our efforts can result in a wellorchestrated new vision of physical therapy as a powerful influence in the delivery of health care and the management of health. I hope these efforts will result in a crescendo of benefits for all who are served by our profession.
To Dennis W. Fell, PT, MD, whose love of music and confidence in the profession were beautifully expressed by “speaking” through his violin to reinforce concepts of timbre, tempo, and dynamics. His thought-provoking rendition of Ashoken Farewell24 created a spirit of community among members of the audience.
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