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LECTURE

Developing Habits of the Heart

22nd Polly Cerasoli Lecture

Nordstrom, Terrence M. PT, EdD, FAPTA

Author Information
Journal of Physical Therapy Education: December 2019 - Volume 33 - Issue 4 - p 259-272
doi: 10.1097/JTE.0000000000000133

I am so blessed and honored to be in your presence today and to honor Polly Cerasoli. I want to express my deepest appreciation to her family for making this afternoon possible and honoring everything Polly meant to our profession. I also want to thank my predecessors who wove such a wonderful tapestry in tribute to Polly and to our collective efforts to improve physical therapy education. I hope I can add a beautiful new pattern to what they have woven, and that our successors do the same.

I would not be standing here today without the love and support of my family, many of whom were able to join me today: my mother, Norma, and my sister, Lane, 2 of my 3 sons, Matt and Adam, and my daughter-in-law, Anita, and my grandson, Ashwin. My oldest son is a high school basketball coach, so you know why he isn’t here. To my dear wife, Deirdre, I love how we take care of each other—more about her in a minute. I want to thank my colleagues at Samuel Merritt University who spearheaded my nomination and to those of you who wrote letters of support—I truly appreciate your support and confidence in me. Particular thanks go to Nicole, Elizabeth, and Gail for pushing me harder—in a good way. Thank you!

As I was practicing for today with Deirdre, she kept telling me: “I want to hear ‘Why is this important to you?’ and ‘How did you get you here?’” So, in honor of Deirdre's persistence, I will share that story. There are only 5 stops along the way. I will make it brief.

Although it really starts with family, I am going to start with the physical therapy school at Stanford in 1975. There were many characteristics of that program that made it an exemplar of excellence, but one was its emphasis on leadership, teamwork, holistic care, and the importance of interpersonal communication with patients. Kay Shepherd, who gave the first Cerasoli lecture in 1998, was one of the faculty members and an early mentor. I heard the echoes of her voice as I was preparing for today. What a genuine honor to follow in Kay's footsteps, 21 years later.

I had the honor of working with Peter Edgelow in our practice in Hayward, California. Peter taught me to be present with patients about careful, attuned listening, and of putting their stories at the forefront. He said, if you listen carefully, they will tell you what to do. Peter was also my best friend, and sadly, he passed away this summer.

Another person instrumental in today's talk is Cindy Moore. Many of you knew Cindy. She was a physical therapy educator. In fact, her first faculty position was at Stanford when I was a second year student there. She and I were together for nearly 8 years. Cindy opened my heart to trust myself and to honor our spiritual selves as teachers and learners. She taught me to envision the best possible outcome for all concerned and to make expectations explicit. Cindy always said, “You have all the time you need.” Sadly, we lost her to cancer in February 2011, but she was with me every step of the way.

I have been at Samuel Merritt University for 27 years, having started as an adjunct instructor in the second year of the program. It is such a privilege to have worked with every physical therapy class that has graduated from the University. Samuel Merritt University has made a commitment to creating a diverse, inclusive health care workforce ready to serve our communities who are in greatest need. I have learned so much being surrounded by the students, faculty, and staff who are committed to our mission.

Finally, it was my friends and colleagues on the Excellence and Innovation in Physical Therapist Education for the 21st Century (PTE-21) research team—Jan Gwyer, Laurie Hack, Gail Jensen, and Elizabeth Mostrom. What an absolute privilege to see the commitment to excellence in our profession and to work with this incredible group of women. This was the culminating experience that allowed me to integrate all of my previous learning about the importance of developing habits of the heart.

There are 2 physical therapists who you are going to meet today, who told me their stories and allowed me to share them with you. AJ could not be here; she is part of the Research Section's Stanford Forum on Qualitative Research that is on the schedule at the same time as this lecture today. We could not get them to change their schedule. The other is Zachary, who is here.

One of the hallmarks of professions is that they have a greater social purpose that is of significance to society.1 Our vision, “Transform society by optimizing movement to improve the human experience,”2 shines a light on our greater purpose and significance.

Our educational programs are the nurseries where students learn to embody what it means to be a physical therapist.3 During their time in the nurseries of professional education, we have the challenge of developing the habits and dispositions of what it truly means to be a member of a profession so that we can realize our greater purpose and significance to society. Among the habits of the mind, the hands, and the heart, it is the habits of the heart that receives the least attention but has the greatest potential to help us realize our vision and be of greater service to society. Today, I will focus on the habits of the heart, what they mean and how we develop them to give them the attention they require and deserve.

By the time I say “thank you” at the end of today's talk, I want us to have a shared commitment to do what it takes to prepare physical therapists who will serve the people and society to meet our profession's greater significant purpose that our vision expresses.

THE 3 APPRENTICESHIPS

An important conceptual framework of the Carnegie Foundation's Preparation for the Professions Program is that there are 3 apprenticeships that provide the foundation for learning the habits of being a member of a profession.1,4-10

Through the apprenticeship of the mind, students learn the knowledge base of the profession, the analytic reasoning, and the evidence that supports practice. Thus, in this apprenticeship, students develop habits of the mind in which they learn to think like a physical therapist.

Through the apprenticeship of the hands, students learn to apply the evidence, clinical reasoning, and skills of the profession through situated cognition in the context of practice. Thus, in this apprenticeship, students develop habits of the hands in which they learn the skillful practice of the profession.

Through the apprenticeship of the heart, students learn the moral foundation of the profession that encompasses our ethical and fiduciary responsibilities to individuals and to society. This apprenticeship is one of the professional formations in which the student remakes herself into a physical therapist through her own engagement with learning in the complexities of the profession's practice. The apprenticeship of the heart is an integrating apprenticeship that brings together cognitive and practical learning with the profession's larger purpose in society.1,4,11-13 Thus, in this apprenticeship, students develop habits of the heart in which the student embodies what it truly means to be a member of the profession, gaining a sense of moral agency and a sense of our significant purpose to the people and society we serve.

There are 4 assumptions that underlie my talk.

4 ASSUMPTIONS

Assumption (1):

Students are not blank slates. They arrive with a story of their development, including their moral development, and why they want to be a physical therapist. Some of them bring experiences, identities, and ways of expressing themselves that differ from the status quo in our profession. How we create an inclusive environment that honors these differences during the journey of becoming will only enrich our profession, but the implication is we have a responsibility to honor each student and all of the richness they bring.14

I want to introduce you to the 2 physical therapists who have let me share their stories with you.

Meet AJ. I first met AJ when she was a student. She has been in practice a few months. Here is what she told me about the start of her journey.

“I had no inclination of going into physical therapy at all. I studied gender and women's studies and history and a little bit of environmental studies. I actually did AmeriCorps for 2 years.”

AJ is not someone who knew she wanted to be a physical therapist from the time she was 16. She finished college in 2009 and joined AmeriCorps because the recession made for a tough job market. Her interest in activism and justice started at a very young age and was solidified by her undergraduate work in women's studies and gender. Then, she discovered physical therapy.

I wanted to go into PT because I had been a patient and my partner … was a patient at the time that I … decided. … I was like I can kind of see this. I knew a lot of people who had experienced persistent pain. And was really interested in … learning more … and collaborating with people to manage … persistent pain.

Through exposure to the field, she could see herself doing this work and she makes a connection to serving people learning and collaborating.

As you will hear later, 2 agencies where she worked lead her to value collaborative, client-centered, community-based models of practice. We will leave AJ here, before she begins her physical therapy education.

Meet Zachary. It turns out I also met Zachary the first time when he was a student at Combined Section Meeting (CSM). He has been in practice a few years. As a teenager, Zachary drove his mother to her physical therapy and became interested in what he saw. Then, he had an overuse shoulder injury and became a patient himself.

“… there is no way that just doing stretchy band exercises and stretching my shoulder is going to help my shoulder pain” … And lo and behold 4 weeks later I was as good as new. … this really made a big impact on my life. What does it take to get into this field and have this kind of impact on others?

Similarly—through exposure, his mother's and his—he could see himself doing this work and serving people.

We will jump ahead to Zachary's first year in practice. In what he calls “fortuitous luck,” his first job was serving in a predominantly African American urban community where the residents were often living in poverty. He chose that job not because it was in an underserved community, but he thought it would be better for him as a new graduate than floating between clinics. Here is what he said about his first few months in practice.

I have been well prepared through my education. This is going to be great. I was struggling to connect with my patients first of all because they were coming just from a very different cultural place than what I had grown up with and what my background was. Also, the interventions the actual skills I was taught did not seem to be making a difference.

It is fascinating to me how Zachary sees his struggle connecting with patients and his skills as something he needs to figure out. It isn’t the patient's problem.

Assumption (2)

The courses in our curriculum that address professionalism and ethics are often assumed to be where students learn these habits of the heart, and the rest of the faculty are off the hook. What I intend to illustrate today is that developing habits of the heart is the responsibility of every person in every course and every clinical experience that students encounter.

Assumption (3)

There is no perfect excellent program out there, as our study of excellence showed. Even the best programs and clinics among us have room to grow and improve. There are probably programs and clinics that are excelling in areas where those in our study were struggling. My hope is that, no matter where your program is in its development, you find something of meaning and value today.

Assumption (4)

Although not every student is going to graduate ready to invest in our broader purpose to society on the day they graduate, they better have a clear idea about what our significant purpose is. They need to be prepared to embody what it means to be a member of our profession with every patient and colleague. They also need to have the potential and desire to actively work to realize our greater purpose to society. We are creating the conditions that make their future possible, so if a plant nursery metaphor works for professional education instead of a baby nursery, it is important that we get the soil, light, nutrients, and water just right. But these are quite active plants; in fact, some are pretty vociferous plants.

AJ and Zachary came to that potential at different times and in different ways. AJ said,

I was a social justice activist organizer beforehand. I was hopeful and optimistic that I could find purpose and do social justice work from the location of being a health care practitioner.

AJ brought a vision of connecting her value of social justice into practice as a physical therapist.

Zachary: I thought pursuing an orthopedic residency would be the thing that helped me. I developed my skill set. My reasoning. All of these wonderful things we think about. And still it was not helping. I was getting some folks maybe a little more effectively treated, but mostly feeling very ineffective with this population. So, at that point, I started seeing what else is going on? What else could be done here?

Zachary pursues an orthopaedic residency and still, he is not as effective as he wants to be. What does he do? He asks again, “What's going on here? What could I do differently?” He is taking full responsibility as the professional. He is not blaming the patients. He did some research and discovered health coaching and completed a certificate program.

This leads me to our vision. Here are my questions about what we mean by the 3 elements of our vision:

When we say, “transform society,” what parts of society are we committed to transforming and how? Every corner? Does that transformation include people whose voices are often the least heard because of their gender, how much money they make, their skin color, or if they use a wheelchair? How are we creating a shared vision of how we will transform society?

What about “optimizing movement?” Do we have a shared understanding of the moral dimensions of movement and what movement means to the people we serve? How do we move beyond the clinical and technical aspects of movement to integrate movement's moral dimension into practice and education? What do we mean when we use the word “body” in our teaching and learning?15-17

Finally, “to improve the human experience.” The human experience in health care can be joyful, terrifying, sad, or messy. It can be warm and fuzzy or cool and prickly. Ultimately, it is about 2 people who come together, one in need and one with expertise. What will it take to fully integrate what it means to be part of the human experience into being a physical therapist?

I will connect developing habits of the heart to our vision, but I am going to do it in a different order: I will start with optimizing movement, then move on to the human experience, and end with transforming society.

OPTIMIZING MOVEMENT: FROM CLINICAL TO CONTEXTUAL

These are the questions I have about movement. Do we have a shared understanding of the moral dimensions of movement and what movement means to the people we serve? How do we move beyond the clinical and technical aspects of movement to integrate the moral dimension of movement into our practice and education? What do we mean when we use the word “body” in our teaching and learning?

Here is the American Physical Therapy Association (APTA) definition of the movement system:

The movement system represents the collection of systems (cardiovascular, pulmonary, endocrine, integumentary, nervous, and musculoskeletal) that interact to move the body or its component parts.18

Figure 1 is the APTA's graphic representation of the movement system. Because movement is our unique contribution to health and health care, our collaborative efforts are essential to make the movement system central to our practice. It seems to me that the graphic representation of movement and definition are disembodied. Maybe it is implicit, but there is no entity that embodies movement nor does it reflect a greater purpose for movement. The APTA includes these 3 statements in the description of the movement system:

  1. Physical therapists provide a unique perspective on purposeful, precise, and efficient movement across the lifespan based on the synthesis of their distinctive knowledge of the movement system and expertise in mobility and locomotion.
  2. Physical therapists examine and evaluate the movement system (including diagnosis and prognosis) to provide a customized and integrated plan of care to achieve the individual's goal-directed outcomes.
  3. Physical therapists maximize an individual's ability to engage with and respond to his or her environment using movement-related interventions to optimize functional capacity and performance.18
Figure 1
Figure 1:
APTA Movement System Model.18 Reprinted with permission from the American Physical Therapy Association. Movement system. http://www.apta.org/MovementSystem/. Accessed December 29, 2018.

These bring us a little closer to the meaning of movement, but they are mostly about physical therapy and physical therapists.

Movement occurs in sociopolitical and sociocultural contexts.15-17 For example, how does our society advantage or disadvantage movement that is influenced by body size or using a wheelchair? How does being a person of color influence how and where one moves? Where and how does movement occur for the person who identifies and expresses themself through a nonbinary gender identity? How does me being a 65-year-old, 6-feet tall, white, straight man relate to where and how I move? What about the movement of the 65-year-old, homeless, Vietnam War veteran with PTSD and addiction who “frequently flies” through the emergency department, hospital, and clinic? I intentionally used that derogatory phrase.

There is no argument that we must address the underlying physiological structures and functions that make movement possible. People come to us when they need our help as experts in movement so that they can participate in their life in whatever ways are possible and meaningful. Because movement is one means of participation in life, it expresses who that person is and what is important; thus, movement is value laden. When we place the person, who seeks our services at the very center of our interaction, we integrate the body with movement as object to be diagnosed in a biomechanical, physiological, and anatomical realm with the moral realm of situated, contextual, interpersonal, and intersubjective movement.

Zachary said,

… probably the musculoskeletal issue is impacting your life but coming to PT is the least of your worries. You are worried about moving from motel to motel. You are worried about where you are going to be sleeping next week. You are worried about getting food on the table for your kids. You are worried about violence in your neighborhood.

Zachary acknowledges the problem in the movement system but, for his community, there is a moral dimension to movement that he must attend to. These considerations lead me to believe there is a place for humility and grace with a broader, more collaborative framework for understanding our role and influence on human movement in practice and in how we teach and structure learning about movement.

As I think about optimizing movement, I think about the concept of signature pedagogies. Central to our work in the study of excellence in physical therapist education was discovering our profession's signature pedagogy.3 Signature pedagogies are the characteristic, fundamental forms of teaching and learning of a profession through which students acquire the “understanding, skills, and dispositions”3p.56 that we value. When you think of signature pedagogies, think of bedside teaching in medicine and the Socratic case dialogue method in law. We identified our signature pedagogy as “the human body as teacher.”19-21

Signature pedagogies have 4 structures. There is a surface structure, a deep structure, and a moral structure that encompasses the beliefs, attitudes, values, and dispositions of the profession. There is also a shadow structure in which aspects of learning for the profession are hidden, omitted, or weakly present.3,21

In our study of excellence and innovation in physical therapist education, we saw brilliant, caring, and deliberate ways in which learning occurred through and with the human body as teacher, including students' bodies, the bodies of patients, the bodies of teachers and mentors, and the bodies of peers.19,21 We also discovered that the broader sociopolitical and sociocultural context of movement was weak or absent. We posited that this moral aspect of movement represents the shadow side of our signature pedagogy.19,21

We made 3 recommendations to further develop how we exploit our signature pedagogy20: (1) Acknowledge our signature pedagogy, have it become part of our discourse; (2) make that signature pedagogy explicit everywhere learning occurs; and (3) what do we mean by “body” in “the human body as teacher?”

I will spend some time exploring the third recommendation. Is it the physical, mechanical, biologic body of anatomy and physiology? Is it the body as experienced by the person living in and with that body? It has to be both. The 3 apprenticeships and our signature pedagogy provide guidance on how to design learning and teaching so that graduates integrate both of these meanings of body and movement into practice. We need to be soundly grounded in the science of movement and in the moral dimensions of movement in its broader context. We need to be explicit about this in education, practice, and research.

Because we are talking about educating physical therapists who are experts in movement, there is no question students need to be held to high standards of excellence and learning to develop habits of the head and of the hands. The apprenticeship of the heart asks us to contextualize learning into the world of the people seeking physical therapy everywhere and in every way that learning occurs: whether it is a classroom discussion, a laboratory practice, in a simulation scenario, or in clinical learning experiences where contextualizing movement into the person's life seems more intuitive. Not just in the courses that teach the “soft skills” of interpersonal communication and cultural aspects of care, but every course. Although I hate the phrase “soft skills,” I used it intentionally so that I can ask, can we please stop using that phrase?

Whether through written examinations, papers, or practical examinations, discussions, cases, and examples, our questions, feedback, and discussions need to:

  1. represent the diversity of bodies and where and how they move with respect and care;
  2. explore, question, and reinforce the intersubjectivity of movement and learning to reason through the patient's movement (or laboratory partner or simulated patient);
  3. reflect rich descriptions of the person and the meaning of movement in that person's life and the sociocultural and sociopolitical environment in which moves;
  4. stress the importance of and engage in discussions about the type of touch, the comfort of that touch, the meaning of facial expressions, of the underlying resistance to or acceptance of movement, and the privilege of touching the person and helping them move;16
  5. make instructor and learner clinical reasoning, assumptions, judgments, and observations explicit particularly reasoning about, with, and through movement;16,22
  6. reflect the narrative, ethical, and collaborative reasoning that are evident or absent in the encounter and connect those to the meaning of movement to that person or community of people.23-27

In these ways, developing habits of the heart becomes the integrating apprenticeship through which clinical and technical aspects of movement become grounded in movement's moral dimension to develop the habits of the heart that our profession requires.

THE HUMAN EXPERIENCE: FROM DETACHMENT TO ENGAGEMENT

Now, I will discuss the phrase, “to improve the human experience.” Here is my question: What will it take to fully integrate what it means to be part of the human experience into being a physical therapist?

In an editorial in the journal Physical Therapy, Alan Jette28 wrote about physicians as canaries in the health care coal mines who are providing advanced warning about the effects of mental and emotional exhaustion, cynicism, and loss of productivity. Confronted with the challenge of not being able to meet their purpose of meaningful work with patients, they suffer “moral injury.”29 Jette called attention to the work of the National Academy of Medicine to develop systems-based approaches to create a health care environment that supports clinician well-being.30 Here is a perspective from AJ:

it's hard to practice in a totally collaborative manner when we have so many time constraints. … pretty much every patient who's not there for an initial evaluation is double booked … it's hard to really be fully collaborative … it's very, very difficult … I'm trying to figure out how to maintain my ideals and what I wanted to do in physical therapy while also continuing to practice

AJ who has been in practice barely 2 months aptly describes the pressures of practice and maintaining her ideals.

Students frequently tell us about their encounters with clinicians who are cynical, judgmental, or operating on autopilot. They encounter physical therapists whose biases and coping mechanisms are on the surface and often have difficult experiences with patients, colleagues, and students. How these physical therapists choose to cope with a system that does not support their well-being and the well-being of patients and what students learn from them are of great concern. Clinical instructors tell us the exact same thing about students and that is also of great concern. We are on a 2-way street. Yes, we need to improve the system. We also need the courage to have the difficult conversations with our colleagues and students whose biases and assumptions are on the surface and destructive to our patients and learning communities.

We can go back a century to uncover another concern about our stance toward patients and the human experience. When health professions education transitioned into universities in the early part of the 20th century, claims of professional expertise grounded in science rose to prominence over those of relationships built on community trust.12 The risk is that a scientific stance toward patients can lead to objectification and distance, often expressed as detached concern.31

Our choice about how we wield the power of decision-making, professional judgment, information, and communication reflects a moral choice. Picture, if you will, the flow of energy, information, and power between the physical therapist and patient. Is the dominant flow from practitioner toward patient? Or, is there a more equal interchange? Zachary had this to say:

The themes from my education especially my clinical education. It's definitely a medical model where the clinician is in charge and the patients are to do what they are told, when they are told and how they are told. I think that's the implicit paradigm that our profession works off.

Zachary relates the powerful messages he learned about the patient-therapist power dynamic as a student.

If the underlying beliefs of the physical therapist about her practice are that of the expert who dispenses knowledge and directs the patient encounter, we are in the world of clinician-centered practice that can be contrasted with person-centered care shown in Table 1. Here is what AJ had to say about one of her clinical instructors who was person-centered:

I had one … CI (who) was really embodying how to be a collaborative practitioner. Really took the patients story and ideas and priorities and goals first … she always goes back and says, “OK from our evaluation these are … the goals that I wrote for you based on what we talked about. … What do you think about that? Do you think that's a reasonable timeline? Does that resonate with you? Is that a goal that you want to work on?”

Table 1
Table 1:
Clinician-Centered Care Compared With Person-Centered Care32,p 39

This clinical instructor made a significant impact on AJ's practice. She reinforced the importance of collaboration that AJ brought with her. AJ offered that this CI was the exception during her clinical experiences.

I am not suggesting an abdication of our expertise, but rather a shared commitment to a partnership and patient-centeredness. In a collaborative, person-centered care, narrative reasoning becomes more important because we come to appreciate the person's stories about their illness, what it means to them, and how their cultural perspectives, values, and beliefs relate to their experience.33,34 When we can reach a mutual understanding of what ought to happen, we realize our responsibilities to one another and our responsibilities to express caring.33,34

Here is how Zachary saw his practice change after his health coaching program.

My metric started being have I listened today. Have I really heard my patients today? Did I really understand where they are coming from? And as my internal metric of success started changing my patients started getting better too. Maybe understanding what is going on with them would be a key … to be more effective. I started hearing quotes like, “You know, for a white guy you are alright.” That's when I started going, OK I must be on to something here.

Sometimes people bring additional challenges into the clinic or hospital that result in a larger gradient of power and steeper paths to understanding. Those challenges could be limitations in communication because of pathology or language, cultural practices, and beliefs based on their faith or country of origin, immigration status, homelessness, or mental health problems such as addiction or bipolar disease. In these situations, it can feel daunting or even impossible to provide person-centered care.

Imagine encountering these challenges when you are burned out, exhausted, and cynical. Then, to complicate it further, what if the person who walks into the clinic brings with him one of those challenges that triggers your biases, whether they are explicit or implicit? What if the person challenges your beliefs about personal responsibility for health? To add 1 more complication, suppose you are working with a student who is eager to learn how experienced clinicians handle these challenges, and there you are. The student is watching, and the patient is saying things that you find offensive.

We will consider pedagogies that develop habits of the heart to improve the human experience. The recommendations from the PTE-21 study relevant here are found in Table 2.20 These recommendations address (1) the importance of making our commitment to patient-centeredness explicit in teaching and learning, (2) establishing a strong moral foundation for the profession, and (3) the need to develop moral agents who act with courage to address substandard practice and address sources of moral injury in practice. My colleague and dear friend, Laurie Hack, in her MacMillan lecture, did a brilliant job addressing the importance of wisdom and moral courage.35 I will offer 3 additional perspectives relative to apprenticeships of the heart and the human experience: (1) our relational stance with patients and communities, (2) generosity, and (3) mindfulness and curiosity.

Table 2
Table 2:
Recommendations PTE-21 Study20,21 Relevant to The Human Experience

As opposed to a scientific, technical stance of detached concern, I believe we need an explicit, intention to develop habits that express engagement and respect for the purpose of connecting about what is significant to the people we serve. I acknowledge that it can be tough going to connect at that human level in the face of suffering, pain, or injustice and the time constraints and structures of practice.

I am going to turn to Martin Buber and I and Thou36 for some guidance here. Buber distinguished between the detached world of objective experience that he called “I-It” and the world of relationship that he called “I-Thou.” Buber described how applying a label, even something as simple as naming eye color, or classifying, such as “that person is overweight” creates separation and detachment. Our examination and diagnosis epitomize naming and classifying. The person's uniqueness fades in this form of objectified observation and we can lose the sense of “Thou”—a person, in relationship and part of our community.36,37

Buber did not deny the validity of the objective, experienced world in which we live. However, he asserted it is in “I-Thou” where we encounter one another in caring relationships that creates the communal life of our human experience. I am asking us to explicitly and intentionally develop dispositions and habits in which we truly see and embrace patients as people in relation with and in the broader context of their lives from the stance of I-Thou. Because our work requires us to name and classify, to diagnose, we have to develop students' metacognition about their self-awareness, presence, and attending as well as about their reasoning and thinking. Zachary illustrated these concepts when he said:

I'm dealing with patients who have lived in an almost entirely different society than what I've lived in. Just in terms of the physical space—the neighborhood. I didn't live in that neighborhood from a metaphorical standpoint or a literal standpoint. Their experience was not my experience. Their knowledge of systems and how things work is very different than mine.

Arthur Frank,38 when making the case for generosity as foundational to the relationship between health care practitioner and patient, argued that Levinas offered a philosophic approach to our relationships with patients who recognize the asymmetry of relationships that exist in the world. Because we have an obligation to put the patient's interests above our own and because of our professional expertise, there is an asymmetry inherent in health care, creating a relationship with “the other.” When we are chosen to care for the person who seeks our services, we are called on, as neighbors, fellow citizens and, in our case, as physical therapists to act with generosity because of the relative privilege we are afforded. We are also called on to act with humility and respect, but we cannot have the same expectation of generosity, humility, and respect from the patient toward us. We need to make this so clear to learners: Patient care is not about you. It is not about me. It is about this person we call a patient. Generosity includes the expression of caring through touch and aptly connects optimizing movement with the human experience through the apprenticeship of the heart.

The third area in the apprenticeship of the heart and the human experience is mindfulness and curiosity. Epstein,39 in his work on mindfulness, makes the case that focused attention is a moral choice we make in our encounters with patients because we give importance to what we pay attention to. And now, the electronic medical record draws our attention away from the patient, so we can record the data we gather through our objective examination and capture the charges from the visit. AJ described her experience with documenting this way:

I see my co-workers documenting more than I do during some of their sessions which if you are working with two people simultaneously during their session it just means you are not as able to be attentive as much....

She is confronting a tough situation. The same holds true in education. What we pay attention to becomes important and reflects moral choices, and we need to make those choices explicit with learners.

Epstein makes the case that developing curiosity is essential for mindful practice. He describes curiosity as an enduring, essential human trait for survival and for thriving.39 I tend to agree. Who was the first curious person to figure out how delicious artichokes, bleu cheese, and uni are? In health care, curiosity drives us to know what “makes the person tick.” Epstein makes the case that curiosity is

more than mere experience: It links heightened attention (“something's not quite right”) with self-awareness (“I'm feeling uncomfortable”), knowledge (“this situation could be dangerous”), and exploration (“I wonder what's going on”)39p. 41

Ronald Epstein has what he calls “8 leaps” that he carries with him in practice:

From fragmented self to whole self

From othering to engagement

From objectivity to resonance

From detached concern to tenderness and steadiness

From self-protection to self-suspension

From well-being to resilience

From empathy to compassion

From whole mind to shared mind39p.187-190

There is a part of Zachary's story I have not shared yet. As we talked, I noticed he was curious, generous, self-reflective, and humble. I wondered where that came from, so I asked. He responded that he was home schooled for K through 12. In addition, he related it to the diverse, inclusive faith community that he belongs to. We cannot expect generosity, curiosity, humility, and self-reflection to just happen; learning experiences and assessment of learning has to be designed so these are explicit to students.

If you have not already done so, it is time to institute intentional, explicit pedagogies that develop habits of the heart in which future professionals

  1. move from detached concern to the world of relationship with authentic person-centered care;
  2. approach the care of patients with generosity, humility, and respect without any expectation of what we receive from the patient;
  3. develop mindfulness, attending, and curiosity; and
  4. exhibit metacognition about their self-awareness, presence, and attending as well as about their reasoning and thinking.

If there is anything I've learned in my years of teaching and what we know from evidence about learning is that we need to make our learning outcomes explicit and the intent of our methods overt.40 We need to engage students in all forms of learning and interchange about these important, yet difficult topics. In a study of ethical situations that students encounter, the most important finding was that the ethical problems are typically not mentioned, let alone discussed.41 The findings from our study also suggest we have room for improvement here.20,21

We also need to engage at the organizational level so our collective wisdom is expressed throughout our communities of practice to develop workplaces not only where moral injury is nonexistent and where clinicians are healed, but where we flourish because that will benefit us and our patients. As innovative, energetic people, we can take the time to create work and learning environments in which we express habits of the heart and improve the human experience. Epstein,39 riffing on Ecclesiastes, refers to a cord of 3 strands—individual, collective, and institutional—that is not easily broken, and our efforts have to occur in all 3 domains if we are to be effective.

TRANSFORMING SOCIETY

My questions about transforming society are as follows: What parts of society are we committed to transforming and how? How are we creating a shared vision of how we will transform society?

I have talked about developing habits of the heart in relation to optimizing movement and the human experience, and now I will talk about it in relation to transforming society. I am going to start by telling a story, courtesy of Dr. Camara Phyllis Jones. Dr. Jones is a professor of medicine and public health at Morehouse School of Medicine. She is a fierce, national advocate for health equity and justice in the United States. She is brilliant, and 1 aspect of her brilliance is her ability to use stories and metaphors to create shared understandings about difficult topics. She has a 5-minute YouTube video on the Cliff of Good Health through the Urban Institute.42 To the reader, I would recommend stopping to watch the video and then resume reading the article because Dr. Jones is such a good storyteller that a written summary cannot do it justice (Video, Supplemental Digital Content 1, https://www.youtube.com/watch?v=to7Yrl50iHI)

This video raises these questions relative to our profession:

  1. Is treating illness and injuries a core component of our work as physical therapists?
  2. Is reducing the impact of illness and injuries a core component of our work as physical therapists?
  3. Is preventing illness and injuries a core component of our work as physical therapists?
  4. Is addressing the social determinants of health a core component of our work as physical therapists?
  5. Is addressing the opportunities, stressors, and forces that arise from social, political, environmental, and economic factors that push people closer to the edge of the cliff of good health a core component of our work as physical therapists?

[A show of hands during the lecture revealed unanimous agreement with the first 3 questions and fewer affirmative responses to the last 2 question.]

Regarding those last 2 questions, we can examine them from different perspectives. Perhaps your perspective is that of our shared, communal responsibility to one another and achieving health equity, if so, then I think this is our work and our responsibility. Perhaps your perspective is that of upholding the ethical principle of beneficence, wanting to give our patients the best care possible, the ethical principle physical therapists' value the most in their clinical decisions.43 If so, then this is our work. As Zachary learned, our patients will not be as likely to improve despite the professional and postprofessional education, if we do not make this our work. Perhaps your perspective is primarily economic, if so, then, the more people who have health insurance, transportation to get to our clinics, and arrive there rested and ready to participate, the better it is for our practices and the better it is for patient outcomes.

I firmly believe that we have to be concerned with these upstream fundamental social and structural causes of health inequities; our patients, our communities, and our society depend on it. We have to be part of the movement to dismantle them.

Here is what Zachary had to say about the social determinants of health.

I started seeing social determinants of health really as the story behind the story. The stories patients were coming to me with … that's the story that we needed to get to. That I as a health care provider with this immense education and skill set can leverage my voice to make changes upstream not just changes downstream.

Zachary witnessed the effect of segregation, transit policies, and education, and he made the choice that the upstream factors are his responsibility as a physical therapist

Where do we begin? Let's start with the students who enroll in physical therapy education. We have to start there because we have a problem with diversity in the physical therapy profession.44

Table 3 provides data on the people in PTCAS who identify as white (not of Hispanic origin) with those who identify as people of color, for example, African American/black (non-Hispanic), Latino/Hispanic, American Indian/Alaska Native, Asian, Hawaiian/Pacific Islander, and 2 or more races/ethnicities and other.44-47Figure 2 compares applicant and admission percentages between all people of color, including those who identified as 2 or more races/ethnicities, with white people. The percentage of people of color in the accepted pool is smaller than the percentage of people of color in the applicant pool. Racial and ethnic diversity decreases as one goes from people who apply to people who are admitted. This is true when one looks at the data for each racial or ethnic group in Table 3. The largest margin of difference is among African American/black applicants followed closely by Asian and Latinx/Hispanic applicants in the most recent years. I worry a great deal when I see trends like this because a serious implication is that we have biases or structures in admission that disadvantages people of color.

Table 3
Table 3:
Percent of all PTCAS Applicants and Accepted PTCAS Applicants by Race and Ethnicity by Yeara
Figure 2
Figure 2:
PTCAS Applicant and Accepted by Race and Ethnicity44-47

Demographic trends in the United States reveal that the percent of white high school students is declining over the next decade.48 This trend suggests that our applicant pool could decline and our benefit to society could weaken if we do not act aggressively, now.

A reasonable person can ask, “Why is this important?” Or a reasonable person might make a rational conclusion that if every graduate is culturally competent and oriented toward improving the human experience and optimizing movement in the way that I described today, then we can transform society. However, evidence suggests otherwise. Here are 2 examples. In a recent study in medicine, African American/black men accepted preventive services from African American/black male physicians more frequently than from white male physicians.49 We know that medical students from medically underserved and underrepresented communities are more likely to return to those communities to practice.50,51 Research evidence suggests that preparing graduates who are culturally competent is necessary but not sufficient to adequately address the health care needs of the people seeking medical care.52,53

Simultaneous with diversifying our profession, we need to promote health policy research that helps us understand how to achieve an equitable distribution of physical therapists in medically underserved areas and how to better serve the diversity of people we encounter in practice. Here is what AJ envisions for her future:

I'll be involved in a number of different projects; … Some of the main questions I have are in terms of queer and trans experiences of physical therapy. … questions of trauma informed care. …. People of color who are patients and their experiences of physical therapy.

AJ is framing the types of questions that will guide her future clinical and research work.

Every program must sincerely and deeply commit to diversifying their student body. What we mean by diversity ought not to be French vanilla ice cream versus vanilla ice cream versus extra creamy vanilla versus homemade vanilla ice cream. Albeit, a diversity of ages, a diversity of undergraduate majors, and previous work experience is nice, but it is not the commitment I am suggesting we need to make. I am suggesting a commitment that is more like making it the entire grocery store.

There is no question that diversity enriches our world, our society, our communities, our schools, our lives, and our profession. We know that people of color are underrepresented in physical therapy education and practice. We do not know if people with disabilities, people in the LGBTQIA+ community, or people from a wide perspective of faith orientations are underrepresented in our profession. We also do not know if people who grew up in poverty, who are the first people in their family to attend college, or who are from medically underserved areas are underrepresented in our profession. We need to understand those dimensions of diversity, and we need agreement about what meaningful, significant diversity brings to our profession, and more importantly, to the people we serve and who grant us the privilege and right to practice. There are 2 recommendations from the PTE-21 study that address this issue.20

  1. Academic institutions must take a leadership role to create more diverse and inclusive learning and practice environments for the profession to have a positive impact on addressing the social determinants of health.
  2. APTA and American Council of Academic Physical Therapy (ACAPT) must make an intentional, public, concrete effort to increase the diversity of students and faculty.

I will address how the profession can take a leadership role at the systems level. Yes, there is a pipeline issue that we have to wrestle with. However, we cannot place all of the blame for our lack of diversity on that pipeline. It is time we affirmatively state that our ability to meet our larger social purpose and serve the people who need our expertise is dependent on more diverse and inclusive learning and practice environments. Physical therapy students need to look like our society in every way possible, so our future workforce looks like our society, too.

Every program needs to consider how they will implement holistic admission practices that value diversity. My guess is that there are faculty members who need quantitative evidence to justify efforts to diversify your student body. Then, to bolster the moral argument, do the homework. If you have not already done so, investigate the causal relationship between quantitative prerequisite data, especially grade point averages and test scores and graduation rates and other outcomes. If the range of GPAs is incredibly narrow ask, “I wonder why that is?” and go find out. Ask whether you need the Graduate Record Exam (GRE) scores, given there is evidence that it is discriminatory on noncognitive factors.54 Once you have the evidence- Act- But it will not be easy- racism and prejudice, usually implicit- exists among faculty and traditions are hard to overcome.55

How does a prerequisite for experience in physical therapy clinics disadvantage prospective students of color or who are from lower socioeconomic backgrounds? Do these hours even matter? It is a little secret of mine that I had never set foot in a physical therapy clinic until my first clinical experience as a physical therapy student. I understand that we cannot make inferences from anecdotal information from one person, but still, if you interview, are you absolutely certain they are 100% free of implicit or explicit biases? Has your faculty discussed its views on diversity, difference, justice, and equity in the profession? Do you have admission criteria that advantage diverse applicants who wish to practice in underserved areas, or who have a mission of health equity? It is time to have these difficult conversations. ACAPT, APTA, and the Education Leadership Partnership (ELP) have a commitment to diversity, including holistic admission training, and we can continue to learn from our colleagues in other health professions for ideas on how we can improve.56-58

Just like there is a 3-dimensional cliff of good health, there is a 3-dimensional cliff of success in higher education in which the fences or nets are missing and some people are being pushed closer to the edge. We need to pay attention to the structural factors that may reduce the chances of success in a Doctor of Physical Therapy program and dismantle those. As we increase diversity, we need to ensure that students from underrepresented groups or who experienced those fundamental social causes of inequity are successful. The most important thing we can do is create an environment where we do not tolerate intolerance and the norm is inclusion that is expressed through respect, collegiality, and humility. Ensure that students who want to can pursue avenues that take them out of the silo of the physical therapy program and connect with affinity groups or community organizations that provide support mechanisms to create a sense of belonging and connection to their personal mission. Nicole Christensen, the Chair of the Department of Physical Therapy at Samuel Merritt University, told me about a student of color who was struggling with whether she should study for an examination or go to a “Students of Color Collective” meeting. Nicole sensed she was so emotionally attracted to going to the meeting that she would be distracted if she did not go to the meeting and basically asked her a question that gave the student permission to go. The student returned beaming and full of excitement and did well on the exam. As an added benefit, these connections would also decrease the emotional burden on faculty of color in the program who are often expected to be the support resource for students of color.

AJ: I've done some more racial justice-based work and as a white person it's very important to be very collaborative and taking the lead from the people who are most impacted. Translating that into health care taking the lead from the people who are most impacted by health disparities and who are receiving the services is important.

AJ eloquently expresses the values of collaboration, particularly as a white person and listening to the people who are most effected. Faculty development at the program, institutional, and professional level that is aimed at eliminating bias, racism, and microaggressions would be a start.56

Having a more diverse profession in and of itself is insufficient if we are to transform society. This brings us for the final time to the apprenticeship to develop habits of the heart. In our study of excellence in physical therapist education, we saw many examples of community-based programs that serve the neediest people.19-21 As we noted, sometimes these efforts seemed to be more strongly connected with the learning needs of students than with the needs of the communities, but perhaps that connection was not made explicit. It wasn't clear that students were engaged in understanding the underlying social structures that lead to the health disparities and inequalities they witnessed. Four of our recommendations to enact our social contract and fulfill our moral responsibility to society are found in Table 4.20,21

Table 4
Table 4:
Recommendations From PTE-21 Relevant to Transforming Society20,21

To summarize these recommendations:

  1. Our team believes that eliminating health disparities and addressing health inequity is our work.
  2. As academic institutions, we have a unique responsibility to our communities.
  3. At the systems level, our organizations can set priorities that address these important issues.
  4. We need to develop expertise among faculty and models and guidelines that will ignite our ability to address these topics in professional education.

There are several opportunities our programs have to address the social determinants of health and the underlying foundational social causes. The 2010 Lancet Commission report, “Health professionals for a new society: Transforming education to strengthen health systems in an interdependent world”59 is required reading for its examination of the global needs for health and health care. Their recommendations for creating a health care workforce capable of meeting 21st century demands fell into 2 categories: transformative learning and interdependence in education.

Let's start with transformative learning. Informative learning develops the necessary knowledge and skills and formative learning develops the professional dispositions and habits of being a member of a profession. Transformative learning develops leadership among graduates who can be “enlightened change agents.”59, p 1924 Transformative learning prepares graduates who are inquisitive, analytic, creative, and interdependent learners. They can synthesize and critique learning and practice systems and develop creative strategies to improve both. Interdependence implies that learners and faculty, programs and institutions (1) value collaboration and shared knowledge and learning, (2) capitalize on networks and partners, and (3) engage with community members and entities to strengthen the relationships between learning, practice, and people's health needs.

Transformative learning and committing to interdependence mean, as we recommended from our study of excellence,20,21 that we:

  1. strengthen the partnership between academic and clinical learning environments,
  2. that we emphasize the development of adaptive learners,
  3. that we develop meaningful competencies throughout the continuum of professional to postprofessional education, and
  4. that we use the evidence in the learning sciences, and we strengthen that evidence.

The world, including health and health care, is a complex place, and I don't mean complicated—I mean complex. It is characterized by

  1. a large number of interacting components, without central control,
  2. by interdependence and interconnectedness,
  3. by emergence and nonlinear change;
  4. the whole is greater than the sum of the parts; and
  5. the behavior of the system cannot be explained or predicted from the behavior of the individual components.60-62

Transformative learning means developing practitioners who are adept at complex systems thinking so they can excel in the U.S. health care system. Developing enlightened change agents means that we have to design learning that is logical and clear, but that emphasizes nonlinear relationships. Program outcomes need to reflect developing students who are creative, analytic, and critical.63 Developing enlightened change agents also implies our curricula need to include opportunities for meaningful, contextual interprofessional learning that emphasizes leading change in these complex systems. It comes back to learning that leads to curiosity, humility, and inquiry but from the perspective of transforming the complex worlds of health care and society.

There is excellent work occurring in health care that opens new possibilities for how we address the social determinants of health and the underlying upstream factors that cause health inequity.53 The model shown in Figure 3 identifies the education, organization, and community resources necessary for lifelong learning so that health professionals can address the social determinants of health.53Figure 4 places that model within the broader context of the causes of the social determinants of health and the impact on health equity. It also captures the importance of workforce development so that we can reduce health inequity. If you have not done so already, use these models to drive curriculum development and, if you are preparing a CAPTE self-study report, add this report to the evidence that your curriculum is based on current literature.

Figure 3
Figure 3:
Framework for Lifelong Learning for Health Professionals in Understanding and Addressing the Social Determinants of Health.53 Reprinted with permission from the National Academies of Sciences, Engineering, and Medicine. A Framework for Educating Health Professionals to Address the Social Determinants of Health. Washington, DC: The National Academies Press.
Figure 4
Figure 4:
Conceptual model for strengthening health professional education in the social determinants of health.53 Reprinted with permission from the National Academies of Sciences, Engineering, and Medicine. A Framework for Educating Health Professionals to Address the Social Determinants of Health. Washington, DC: The National Academies Press.

Although understanding the “facts” of the social determinants of health and health inequities is important, it is insufficient if our graduates are to be transformative change agents.52,59,64 We need to move from a cultural competence framework to one of critical consciousness that emphasizes the relational nature of practice and a reflective awareness of power and privilege. We need to implement pedagogies in which students question the underlying foundational causes of those health inequities and think creatively about restructuring power and privilege.52 That critical consciousness needs to orient students to a commitment to address the fundamental social causes of health inequity in service to patients, our communities, and society. These are habits of the heart that we must strengthen if we are to transform society.

We need to advance the concept of developing structural competency.65,66 Structural competency leads to practitioners who understand, analyze, and address how upstream factors such as food delivery, housing and zoning, trade, and immigration affect downstream health outcomes such as hypertension, depression, psychosis, and obesity.

We can develop 5 core structural competencies,65,66

Zachary: I worked very closely with the department of transportation. … We talked about bus stops, we talked about cross walks. We talked about sidewalks. They appreciated the input from a physical therapist who is a self-proclaimed movement expert. … That's direct work on the upstream factors.

  1. recognizing the structures that shape clinical interactions—a discernment competency in the clinical environment;
  2. developing an extra clinical language of structure—a competency that moves thinking beyond clinic into community;
  3. rearticulating “cultural” formulations into structural terms—a reframing competency that moves beyond attributions to individuals or groups to broader society;
  4. observing and imagining structural interventions that can or could address those structural causes—an empowering competency of creativity, action, and advocacy in the face of what may seem like insurmountable problems; and
  5. developing structural humility—a competency of curiosity, openness, and reflection to consider how deep-seated structural factors effect health.

Zachary made the connection with the transportation department in a true interprofessional way where our expertise in movement makes a difference.

Phillipe Bourgois and his colleagues across public health, medicine and anthropology66 developed a clinical instrument that screens for structural vulnerabilities; those inequities that result from power and privilege in social structures and hierarchies. Table 5 describes the 8 dimensions of the structural competency screening tool developed by Bourgois et al and the corresponding screening questions. There are follow-up probes should the clinician receive an answer that merits it. When we screen for these structural vulnerabilities, our ethical responsibilities require that we can connect people with the necessary community resources to address the vulnerabilities. That means stronger connections between our programs, our clinics, and our communities as we describe in our recommendations. Zachary learned how the social determinants of health effects patient care on his first job. Many programs offer clinics in underserved communities. We can leverage those experiences, so students have the same learning experiences as Zachary did when he connected with community agencies.51,67

Table 5
Table 5:
Domains and Questions in a Structural Competency Screening Tool From Bourgois et al66

Any program that is offering community-based care to underserved populations can

  1. move to an interprofessional collaborative care model if not already there,
  2. reorient the purpose to reflect community needs and community participation if not already done,
  3. make explicit to leaners the intent to develop the professional disposition that incorporates concepts of transformative change for health equity if this is not occurring,
  4. emphasize longitudinally to create a connection to the social determinants of health and the upstream structural factors,
  5. collect outcome data that examines the relationship between outcomes and the social determinants of health and structural vulnerabilities, and
  6. partner with community agencies who have resources to address upstream foundational structural causes of poor health if you do not already have them.

There are also specific opportunities to help us transform society at a systems level. There are examples in nursing and medicine that advance their social mission and develop professionalism that are not high-cost programs.57,58 We need to continue to learn from and with our colleagues across health professions' education and practice. Accreditation can be a force for transformation across health professions education as evidenced by trends related to interprofessional education, systems-based learning, and quality and safety.59,68,69 Professional schools are trustee institutions because they prepare future professionals who are responsible for meeting society's expectations and needs.5 As trustee institutions, we have a particularly pivotal role in strengthening our social ties and commitments. If your program's mission does not already explicitly state a commitment to prepare graduates who are able to meet our broader, significant social purpose then what are you waiting for? Our graduates will demonstrate that we are meeting our mission because they have developed habits of the mind, the hands, and particularly, the heart, into their very essence as physical therapists. Imagine if CAPTE had a requirement that our missions, as trustee institutions, must demonstrate how we achieve our significant social purpose. Better yet, imagine if every program's mission committed to fulfilling our significant social purpose because it means doing the right thing.

I am a hopeful, optimistic person who believes in the power of the individual and, more importantly, in our collective power as transformative agents for enlightened change. We can link our arms and engage our hearts and travel together toward our vision. We are a community of hopeful, optimistic people who deeply believe we can make a difference by developing habits of the heart.

Thank you.

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    Keywords:

    Professional formation; Professionalism; Physical therapy; Person-centered care; Social determinants of health

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