In 2013, the American Council of Academic Physical Therapy (ACAPT), in collaboration with the Physical Therapy Learning Institute, established the development of a Forum where stakeholders could come together in a positive and safe environment to reflect, dialogue, and cocreate new possibilities to transform physical therapy education.1 The Forum was named in honor of Dr. Geneva R. Johnson (Figure 1), a leader in physical therapy education, and research for more than 60 years.2,3 Since 2014, the Geneva R. Johnson (GRJ) Forum on Innovations in Physical Therapy Education launches the Educational Leadership Conference (ELC) held annually to promote excellence in physical therapist (PT) education. A leader external to the profession presents a provocative keynote address, followed by three short IGNITE responses applying the keynote concepts to physical therapy education from the academic, clinical, and administrative perspectives. This sets the stage for the subsequent café-style facilitated discussions using an Appreciative Inquiry approach, giving a voice to all participants.4,5 At the end of the discussions, key ideas are reported, and presentation of a synopsis serves as a call to action to create postconference momentum for change.
The forum is designed to:
- Create a safe environment for key stakeholders in physical therapy education to discuss the infinite possibilities of the future rather than focusing on past problems.
- Encourage vision, innovation, creativity, and provocative new ideas that can positively influence the future of physical therapy education.
- Challenge educators to proactively advance physical therapy education to prepare graduates to meet projected societal and professional needs rather than to merely react to external pressure.1-3
As in the past 3 years, the 2017 GRJ Forum, kickoff of the 2017 ELC in Columbus, OH, was inspirational, disruptive, and aspirational. Shafik Dharamsi, PhD, leader in medical education and global health, delivered a passionate keynote address to more than 800 participants about the pressing need to better educate health care professionals to be responsive to health inequities. The Ignite Talks were delivered by three leaders in physical therapy education, Drs. Cheryl Resnick, Samantha Zimmermann, and Sue Smith who respectively shared their insight on the role of PTs as social determinants of health from a faculty, clinical education, and administrator's perspective. Small group discussions ensued and an in-depth exploration into 19 themes related to what would a commitment to preparing graduates that are socially responsive and accountable looked like. Each discussion, facilitated by an invited group of facilitators familiar with the principles of Appreciative Inquiry to explore new possibilities for change, ended with an invitation to envision Would not it be great if …? Participants had the opportunities to discuss two topics of their choice. Afterward, the table facilitators shared with the audience three highlights of their discussions that best illustrated innovative educational changes to better prepare graduates to meet the needs of the communities they will serve.
THE FOURTH ANNUAL GRJ FORUM 2017 HIGHLIGHTS
Keynote Address: Disruptive Innovation—Health Professions Education as a Determinant of Health
The 2017 keynote speaker, Shafik Dharamsi, PhD, has dedicated his career to addressing issues of health equity and social justice through engaged scholarship and the development of an ethically and civically inspired higher education agenda. Dr. Dharamsi is dean of the College of Health Sciences and Peter De Wetter Distinguished Professor of Health Sciences at the University of Texas at El Paso. Dr. Dharamsi has extensive education, research, and community development experience in Asia, Africa, Canada, and the United States. His work has been well funded and widely published nationally and internationally, and his international humanitarian work has been recognized with multiple awards. His scholarly agenda focuses on social accountability, global health, and health professionals' education.
Dr. Dharamsi's provocative keynote addressed the critical need for physical therapy to be more attentive to social accountability, and how we and those in our profession should first and foremost devote our efforts, work, and aspirations to addressing the priority health needs of our surrounding community, particularly of those who are most vulnerable, those who live on the economic and social margins, and those who bear the highest burden of disease.6 What might health professions education as a determinant of health mean? Dharamsi believes that how we prepare the next generations of health professionals will influence health outcomes. There is a growing concern worldwide that we need to better educate health professionals to be socially responsive and accountable to society. To do so, Dharamsi unequivocally believes that we need to organize our education, research, and service in ways that meet the priority health concerns of our community. This is after all the definition of what it means to be socially accountable. His take-home message is how we prepare the next generation of health professional will influence how thoughtfully and how effectively they work to improve the quality of life of our patients and our communities. Dharamsi pointed out that focusing only on individual patient care means focusing on just a small subset of our communities as not everyone has equitable access to health care.
Dharamsi suggested that in the context of transformative education, to have truly learned is to never be able to go back to seeing the world in the same way, and once you have seen the world differently, you should never be able to go back to being in the world in the same way. It requires a perspective transformation.7 How we prepare the next generation of PTs should in fact determine health outcomes. Our profession already established the foundation articulating quite effectively and thoroughly professionalism, including social responsibility and accountability, in the American Physical Therapy Association documents. He added that furthermore, education must be student and community centric for it to be transformational. The circumstances of our community must guide what we teach and how we teach. Our research has to be responsive to what we do in the classroom to inform a more sophisticated approach to education; it must be responsive to the needs of our communities. And, we must consciously be interprofessional and intersectoral in our approach to improving health outcomes. He asked, “what good is it to treat illness only to send our patients back to the circumstances that brought them to us in the first place?” Simply encouraging patients to change their health behaviors or to avail themselves to disease prevention intervention ignores the role that systems play in health outcomes and fails to address the root causes of health inequities, the social determination of health.
Dr. Dharamsi highlighted the existing tension between a market-based health care system and social responsibility, which “is not at the forefront of the thinking in the business side of clinical practice.”8 He suggested that the privileges of autonomous practice, self-governance, and self-determination accorded to doctoring professions came with the obligation of social responsibility, the responsibility to the public. In the context of a health care system challenged by economic priorities and an inequitable distribution of resources in society, traditional health profession educational models are not adequately preparing health care professionals to meet the needs of the most vulnerable segments of society and to reduce health inequities. Dharamsi asked, “what kind of learning do students need to meet emerging challenges in an interconnected world?” In 2010, the Lancet Commission's Health Professionals for a New Century—Transforming Education to Strengthen Health Systems in an Interdependent World recommended a third generation of reforms for health profession education that should be “systems-based interventions to improve the performance of health systems by adapting core professional competencies to specific contexts, while drawing on global knowledge.”9 It is critical to evaluate not only the accessibility but also the effectiveness of health care for those in poorest health. Health starts where we live, learn, work, and play.10 Dharamsi reported that there is a worldwide movement in medical education that is starting to infiltrate the other health professions in the area of social accountability, which is leading to educational reform to meet the priority health concerns of our society. What role do PTs currently have in addressing the social determinants of health?
Dr. Dharamsi reflected on what it meant to be a doctoring profession. In Latin, doctor means teacher. He identified common themes across the professions for reasons to move in that direction, including autonomy in practice, development of the body of knowledge specific to that profession through research, and a more sophisticated development of clinical knowledge, requirement of completing of residency prior to full licensure. Specialty is another significant emergence, moving toward more specialized care, which he finds quite ironic considering that in medicine, there is now a greater emphasis on primary care. Dharamsi asked why are the health professions outside of medicine trying to be more and more like medicine? Many in the physical therapy profession have proclaimed that being a doctoring profession would allow PTs to have greater equality with other professions and to provide better care; others have articulated that everyone talking about improving patient’s access to care, bending the cost curve, and creating team-based care have not developed the evidence that moving to doctorates has really helped us achieved this. He challenged us asking, “will the title of doctor help us achieve greater equity? And if so, how are we training our emerging health professionals differently? Are our education and research mean to our own ends or is it a mean to greater equity in health care? Is physical therapy education a determination of health outcomes?” He shared a position statement from the Canadian Physiotherapy Association related to increasing the focus, in their work, teaching and practice, on primary care and addressing population health needs.
Over the past 10 years, Dr. Dharamsi has been working to develop ways to bridge the academic divide between competence and conscience. Certainly, you have heard faculty and students alike saying that “… we really need to develop proficiency in clinical skills, we need to prepare for board exam … the soft ‘stuff’ is important but we can figure that out later once we get going in our careers.” Higher education is not just about developing knowledge and skill in our students. He shared findings that commitment to caring for the medically underserved was greater when students entered medical school than when they graduated.11 Dharamsi then called our attention to implicit biases, those automatic and nonconscious responses to something, particularly a broadly stigmatized group that do not necessarily align with our declared beliefs. Students may hold negative attitudes toward patients from low socioeconomic backgrounds, with some reluctant to provide service to vulnerable populations.12 This shows that education is a determination of health outcomes. Dharamsi urged us to be transformative. Accreditation bodies are now calling for greater attention to social accountability. Universities are hubs of innovation and creativity that can help to advance the common good. He remarked that we are very good at preparing our future clinicians with the science, the technical skills. We are very good at preparing their heads and their hands. What we need and the key to transformation is preparing their heart? He has attempted to bridge this divide by nurturing a strong sense of compassion and commitment to improve the quality of life of members of our society who are most vulnerable and working to advance the common good.13 He reminded us of the importance of how compassion and empathy is taught and learned in the health professions. Being able to connect emotionally with patients makes them feel supported and understood during stressful times in their lives. Having a compassionate health care provider can positively affect a person's health.14
Dr. Dharamsi concluded his remark reaffirming the importance to shift our approach to education from that which is predominately transactional to one that is transformational and move the education of future PTs beyond a narrow focus on biomedical content into a focus on the root causes of health inequities. If we are to truly have an impact on health outcomes, we must prepare our health care workforce to intervene upstream. Physical therapy educators, clinicians, and administrators have an incredible opportunity to improve health outcomes. When it comes to health, ignorance is not bliss. We simply cannot afford to ignore how social injustices relate to health outcomes and develop curricula that address social determinant of health and the needs of the most vulnerable around us. Dharamsi left us with a curricular blueprint created to facilitate the development of socially accountable health profession programs—The REVOLUTIONS Framework—addressing the Recruitment, Environment, Vocational development, Organizing systems, Leadership, Understanding, Training of faculty, Investigation, Orientation, Nurturance, and Social responsiveness (REVOLUTIONS) required to encourage the formation of socially responsive physicians who will be master adaptive learners and work with their local and global communities in novel ways.6
First Ignite Talk—Town Shapes the Gown—the Gaps in Physical Therapist Education
Cheryl Resnik, PT, DPT, FNAP, FAPTA, is associate chair and associate professor in the Division of Biokinesiology and Physical Therapy at the University of Southern California (USC) where she serves as the director of Community Outreach and Division representative on the USC interprofessional education committee. Dr. Resnick, the current chair of the ACAPT National Interprofessional Practice, Education (IPE) consortium and liaison to the Interprofessional Education Collaborative, offered her IGNITE TALK from a faculty perspective.
Dr. Resnick defined the “town” from a national health perspective by the Healthy People 2020 goals to attain high-quality, longer lives free of preventable disease, disability, injury, and premature death, achieve health equity, eliminate disparities, and improve health for all groups, create social and physical environments that promote good for all, and promote quality of life, healthy development, and healthy behaviors across life stages.15 How does physical therapy education and practice fit in? At present, our focus has been primarily as interventionists as opposed to facilitators of these goals. She believes that we have a way to go in preparing our students to be active participants in these higher-level goals of prevention and health promotion. How do we attempt to meet these goals? According to her, we currently do this primarily through community engagement and exposing students to effective strategies to strive for cultural competence. Resnick reviewed APTA's core documents—core values, professional duties, and social responsibilities, House of Delegates' position statements, the Commission on Accreditation for Physical Therapy Education (CAPTE) standards, and the Clinical Performance Instrument—in the search for explicit statements related to the Healthy People 2020 goals. In her opinion, these documents while addressing some of the goals do not go far enough to meet the objectives of preparing graduates to be responsive to and advocate to minimize health inequities.
Dr. Resnick recognized that we have a crowded curriculum, and that for everything we add, we need to consider what can be eliminated. She suggested that the gaps related to recognizing social determinants of health, bias in the health care delivery system, epidemiological considerations as a key component of patient assessment, and the understanding of and level of skills in advocating for better health policy are subjects we must find ways to better integrate in the curriculum. Schools of medicine have a much bigger emphasis on public health in their curricula. Medical students identified experiential learning as being most effective. She proposed that as a profession, we have an opportunity to enhance our students' understanding of social determinants of health through better-organized interprofessional community engagement activities and service learning. Our programs are situated within communities. She suggested using interprofessional teams of students to evaluate the health status of these communities. We need to challenge our students about their role in community health, and performing a community health needs assessment in partnership with the community could be the key feature of this learning. We can, at a minimum, edit our current patient paper case by adding relevant community health information. Recognition that we do not deliver care in some vacuum needs to become a basic component of patient-centered care.
Dr. Resnick concluded her remark stating that service learning requires that we collaborate with the community we whom we work. For us to truly enhance our students' ability to recognize and incorporate the social determinants of health, they must empower the people they work with.16
Second Ignite Talk—Taking Ownership: Accountability Beyond Discipline Specific Treatment
Samantha Zimmerman, PT, DPT, is the rehabilitation team leader and supervisor at the Reeves Rehabilitation Center of the University Health System in San Antonio, TX, both a level 1 trauma center and county hospital. Center coordinator of Clinical of Education for 6 years, Dr. Zimmerman is passionate in her roles of provider, educator, and patients' advocate both in the clinical environment and community she serves. She strives to inspire passion in students and empower them to help their patients thinking about the now while guiding them as they plan for their future. Dr. Zimmerman offered her IGNITE TALK a clinical instructor perspective.
From her perspective, one of the big trends in the clinic is doing more with less. The subsequent increase in productivity standards is one of the biggest issues for a supervisor as it directly relates to clinicians' biggest complaint: they do not have the time to provide the quality care they want to provide. And this is true across the system—case management, medical team, nursing, rehab. Everyone is dealing with this issue. Practitioners are stressed and stretched thin, the focus shift away from the patient onto self, and it makes it easy to slip into a provider-centric mode. Clinicians typically do not realize that this is the case; they may feel that they are providing patient-centered care, but from the outside, this is not happening all the time. This trend in health care may very well contribute to health care disparities. Patients who suffer first and suffer the most are the ones who require the most resources, attention, and time. In a county hospital, these are the patients who are unfunded, often minimally educated, or those with language barriers and/or cultural differences that hinder their interactions with the staff. These are the patients who are affected the most by this trend in health care.
Dr. Zimmerman asked, “are students truly taught to own the care that they provide? Do we really equipped students to treat the whole patient and to look at all aspects of care? Are students prepared to be part of a team ready to take full responsibility for all aspects of care?”
The concept of treating the whole patients is often well understood at a cognitive level. The gap exists in translating it into action. To be able to take actions, health care professionals need to understand how to treat the whole person with what they face socially and the issues they might face at home. Active involvement in the community might be a solution. We cannot expect students to treat the whole person if they do not understand social determinants of health, the issues that their patients face, and the community that they are sending their patients back to. If they do not have an understanding or awareness, how can we expect them to treat the whole person?
Dr. Zimmerman reflected on the role and responsibility of the clinical partner to educate students to treat the whole patient. Are the clinical sites setting an example on being involved in support groups, do they provide community education or volunteer in the community, or do they perform site visits before discharging a patient in an unknown environment? Zimmerman believes that if she discharges a patient where she does not know what is available, what it is like, the issues they might face, then she is not providing quality care. As clinical instructors, we could integrate these activities into a student's experience. Students could be required to go to support groups, to volunteer, and to do certain site visits. The community experience would then be built into the clinical experience.
Dr. Zimmerman concluded her talk asking whether we could inspire social accountability this way. If we equip our students appropriately and set the expectations that community involvement and quality care go hand in hand, that you cannot have one without the other, we potentially could inspire students, clinicians, clinical instructors, and other professions to become more socially accountable and provide quality patient-centered care.
Third Ignite Talk—Transforming the Culture of Health Care: Doing Our Part
Susan Smith, PT, PhD, FNAP, is associate professor and dean Emerita of the College of Nursing and Health Professions at Drexel University in Philadelphia, PA. Dr. Smith has 45 years of clinical experience, 38 years of faculty experience, and has held a variety of administrative positions. She is an accomplished faculty, scholar, and academic leader. She has created the Interprofessional Practice, Education and Research Collaborative that involves students and faculty across the health professions.
Dr. Smith asked us to think about the community as our patient. Considering that adverse socioeconomic conditions have been correlated to poor health for over a century, as health care providers and educators, now is the time to acknowledge and accept our shared social responsibility and interdependence toward achieving the aims of improving the quality of care for patients, families, communities, and learners, improving the health of populations and reducing the per capita cost of health care. Traditional professional education has not kept up with these aims. The vision for 21st century health education reform is preparing providers competent to participate in patient- and population-based health systems as members of locally responsive and globally connected teams.
Smith stated that trends in the future of health, such as value-based payments, older population, chronic conditions, prevention, and population health, accelerate our need to invigorate health care education through transformative learning and interdependence in education. Acknowledging that health happens in home, work, and community environments requires considering not only the individual as our patient and partner but also the community as our patient and partner. Although we tend to focus on IPE and research, it is not the end game, but rather an evidenced-based means toward improving the culture of health. Evidence suggests that implementing IPE in the curriculum facilitates students' adoption of integrative practice. Interprofessional Practice, Education requires intentional learning that is experiential, context relevant, competency based, modeled, interactive, reflective, information technology empowered, life long, and team, patient, learner and population centered.
Using our shared values, we can promote curricular innovation and overcome our barriers of turf, cost, time, resources, competition, accreditation issues, outdated curricula, lack of leadership, and unprepared faculty. Collectively doing our part requires that we care, communicate, contextualize, challenge, commit, champion, collaborate, coordinate, conceive, and craft cultural change. Our focus is on who we are, what we have (not on what we don't), and where we are; it is thinking broadly, but acting locally (wherever that may be), measuring outcomes, communicating results, and transforming policy.
Small group discussions allowed the GRJ Forum participants to have a voice in the discussion and to react to the keynote address and IGNTE Talks. Using an Appreciative Inquiry approach with an intentional focus on what works well as opposed to what is wrong or needs to be fixed, Participants were encouraged to consider the best of what is and of what could be and share success stories related to a specific table topic. They were instructed to end their story by finishing the sentence “Would not it be great if …” to create positive visioning and inspire purposeful changes. Participants each had the opportunity to discuss 2 of 19 topics (Table 1).
The tangible results of the discussions are a series of statements grounded in real experiences that describe innovative and creative ideas to move physical therapy education forward to prepare graduates to be socially responsive and accountable to the needs of the community they will serve. The summary statements of the discussions were summarized and grouped under nine general themes: Profession, Accreditation and Assessment, Students' Preparation and Admissions, Didactic Curriculum, Experiential Learning and Professional Practice Education, Emerging Roles in Physical Therapy Practice, Faculty Support, and Reimbursement. A summary of the highlights from the discussions is presented in Table 2.
Dr. Dharamsi encouraged us to seek to transform ourselves, our students, and the lives they will touch, leaving us with a quote from Oscar Handlin “A troubled world can no longer afford the luxury of pursuits confined to an ivory tower;[Our work] has to prove its worth by service to the nation and the world.”17 How do we evolve to a different type of culture in physical therapy education? How do we teach ourselves to be radically different from what we have been inculturated for over a century? Our students learn a lot about words ending in “itis.” What do we as faculty do? “Coveritis.” Do we need to “takeaway and add”, this is so transactional. How do you move away from transaction to transformation? Perhaps, it has to be so disruptive in terms of its innovation that it will require something radically different. Dharamsi mentioned that participatory curricular development, including students and communities, would certainly be disruptive and innovative.
After 71 years in practice, Dr. Johnson described the culture of physical therapy practice by 3 C's: compassion, caring, and comfort offered to every body we serve. The need to prepare our graduates to be socially responsive and accountable spoke loudly to Dr. Johnson who encouraged us to be faithful to our education, the experiences we have had, and all that we have received from being a PT. As a community of educators pursuing excellence in physical therapy education, the Forum coordinators encouraged all 2017 ELC participants to mindfully consider how we can best prepare our students to become social determinants of health, demonstrating compassion, caring, and comfort toward the community they will serve. We are looking forward to share with her the impacts of the 2017 GRJ Forum at the 2018 ELC!
We are grateful to everyone who contributed to the success of the Fourth Annual GRJ Forum and looking forward to the 2018 Education Leadership Conference to learn about innovative initiatives inspired by this year’s forum discussion.
An audible version of this year's GRJ Forum can be found on the ACAPT Web site http://www.acapt.org/resources under ELC Geneva R. Johnson Forum on Innovations in Physical Therapy.
The authors thank the board members of the American Council of Academic Physical Therapy and the Physical Therapy Learning Institute, for their collaborative efforts in supporting the Forum. They thank Beth Whitehead, PT, MBA, and the Whitehead Family Foundation for their financial support to sponsor the Forum in Dr. Geneva R. Johnson's name. they also thank the table facilitators: Drs. Denise Bender, Janet Bezner, Jacki Brechter, Nathan Brown, Mary Dockter, Mike Emery, Tony English, Sarah Gilliland, Jennifer Green-Wilson, Laurie Hack, Chad Jackson, Merrill Landers, Ellen Lowe, Kay Malek, Terry Nordstrom, Corrie Odom, Mark Reinking, Alice Salzman, Anita Santasier, Doreen Stiskal-Galisewski, and Kimberly Topp, Susan Wainwright, and Thomas Werner, for their willingness to contribute, just-in-time flexibility, and invaluable assistance in the process. They specially thank Dr. Mary Blackinton, ACAPT Program Planning Committee Chair, for her support in making the GRJ Forum a success and the ELC Program Planning Committee members for offering keynote conference and programming space within the Education Leadership Conference for this year's Forum.
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Copyright2018 (C) Academy of Physical Therapy Education, APTA
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