Lynn Snyder-Mackler, PT, PhD, ScD, ATC, SCS, FAPTA
Lynn Snyder-Mackler, PT, PhD, ScD, ATC, SCS, FAPTA, for more than 25 years, has been a leader in developing evidence-based approaches for the rehabilitation of knee injuries, educating new physical therapy professionals and mentoring future rehabilitation scientists. She has received almost all of APTA's distinguished awards and is an international leader in physical therapy.
Holding several positions and appointments at the University of Delaware, Dr Snyder-Mackler is Alumni Distinguished Professor of Physical Therapy, Academic Director of the Delaware Physical Therapy Clinic, Faculty Athletics Representative, and Adjunct Professor of Biomedical Engineering. She is also a visiting researcher for the Norwegian Research Center for Active Rehabilitation.
Dr Snyder-Mackler earned a bachelor of arts from Johns Hopkins University, a certificate in physical therapy and a master of science in organizational behavior from the University of Pennsylvania, and an ScD in applied anatomy and physiology from Boston University.
Named a Catherine Worthingham Fellow in 2003, Dr Snyder-Mackler has earned many other APTA honors, including the Eugene Michels New Investigator Award, Golden Pen Award, Chattanooga Research Award, Marian Williams Award, Helen J. Hislop Award, Orthopaedic Section Steven J. Rose Award, and Section on Research John H.P. Maley Award.
46th Mary McMillan Lecture
I thank President Rockar and the Board of Directors for honoring me (Fig. 1). While I may be in doubt that I deserve this honor over others, there is no question of my happiness in receiving it. We in Delaware have had a tough couple of weeks. Steve Cope, who used his innovative harness systems to give mobility to those with disabilities, whose test kitchen was our new University of Delaware physical therapy home at STAR Campus, died after a very brief illness on May 20. Our colleague and friend, Seema Sonnad, a world-renowned health services researcher who codirected the Value Institute at Christiana Care in Delaware, one of the nation's largest, integrated health care systems, died suddenly last week of cardiac arrhythmia while running an ultramarathon, and the beloved friend of my son and son of my friend, Beau Biden, left us last Saturday. Delaware and our country mourn. May their lives be an inspiration.
Lynn Snyder-Mackler at NEXT in National Harbor, Maryland.
Here I am, the 46th Mary McMillan lecturer. No one starts his or her career planning for this moment. Consequently, when the call comes, far more than a year in advance, one goes through stages—first shock mixed with pride, then life goes back to normal, because for a few months, no one else really knows. After last year's NEXT, and “The Announcement,” there was shock mixed with pride again, followed by a few months of chaos or “my search for meaning.” Luckily, the American Physical Therapy Association (APTA) has deadlines, or for an eternal procrastinator like me, this stage could go on for a long time. Ideas flew around in my head—after all, this opportunity only comes once. What do I really want to say? And, did anyone say it already? But slowly, there was a growing sense of comfort and familiarity with who I am and the message of my lifetime of involvement in physical therapy. Who am I? I am a physical therapist. That's always my first answer. A physical therapist and researcher, a clinician-scientist. And so the story unfolds.
I am also a daughter, sister, mother, widow, and grandmother. The past few years have held a lifetime of events and emotions: graduations, travels, weddings, births, and deaths; my mother's dementia; she is a woman disappearing…all surrounded by the blessing of ordinary days that, well, are never really ordinary.
My family, many of whom are here today, and those who have fallen off the raft are my heart. My son, Alexander, and his wife, Laura, and my precious baby, Sam; my son, Noah, and his girlfriend, Kelsey; and Michael, my partner in work and life.
My mom and dad, Scott's late parents, our siblings' nieces and nephews and grandnieces and grandnephews.
Scott's crew, my extended family, especially those who shared our home, Jill and Bob, Jen and David, Andrew and Brittany, Airelle, Ang, Marty and Doug, helped Scott continue to live a productive life until the end and now continue to enrich my life.
My Delaware family, big and bold, in physical therapy and out. The old guard, Stuart Binder-Macleod and Tara Manal, and all of the faculty and clinicians who followed, my dear friends, and a special thank-you to our Provost, Domenico Grasso, and Deputy Provost, Charlie Riordan, for making the effort to be here and support me.
My cronies, I will talk about you later, but Tony Delitto, who not only knows this whole talk but has been my sounding board for cockamamie ideas for 35 years, deserves a special shout-out.
My collaborators, Michael, Tom Buchanan, May-Arna Risberg, who is here from Norway, Stefano Della Villa, and others who add richness, depth, expertise, and a whole lot of fun to my work.
All of my current and former physical therapist students and residents, including the 60 in the back from my Orthopedics class who are on break for this conference. You inspire me.
And last, but also first, my academic family. Everyone in science has forebears and progeny. I have a lot, in my physical therapy professional education and as a professor and a clinician-scientist and as mentor. It is the latter group to whom I dedicate this lecture: those physical therapists who chose to study and work with me as PhD students, postdoctoral students, or young faculty as they found their way as clinician-scientists, including the 7 physical therapists who as PhD students comprise Smack Lab 2015.
While a true joy of the past 12 months was the birth of Sam Mackler, to be candid, he is not my first grandchild. More than a decade ago, I got an email from Kelley Fitzgerald: “Congratulations, Grandma!”—Sara Piva had successfully defended her dissertation. So let's begin…at the beginning.
Thirty-five years ago, I graduated from the University of Pennsylvania's Physical Therapy Program in the School of Allied Medical Professions (SAMP) with a graduate certificate in physical therapy. It closed the next year. The University of Pennsylvania was preceded and followed by other top-tier universities closing similar programs, Case Western Reserve University and Stanford University among them. Eugene Michels recounted the comments of a faculty member from another discipline discussing the phasing out of SAMP at the University of Pennsylvania, “The individual said, in effect, that…occupational therapy and physical therapy had no place at the university because they were not serious intellectual disciplines.”1 Michels continued, “The remark was based on an assessment of the literature available at the time. The remark still smarts. It was justified…and the justification has not yet been fully put to rest.”1 Even now, more than 25 years after Mike's article appeared, the justification has not been fully put to rest. The solution lies in training, developing, and supporting a large cadre of clinician-scientists in physical therapy.
The clinician-scientist, physical therapist clinician-scientists, those with formal training in both clinical practice and rehabilitation research, are uniquely trained to ask and answer the important clinical questions that drive our practice forward. Training larger numbers of physical therapist clinician-scientists, mentoring and supporting them in rich clinical research environments, and setting high bars for their productivity can kill this beast once and for all.
What are the barriers to clinicians embarking on formal research training, continuing with postdoctoral training, entering the academy with the intent of becoming investigators, and finally becoming those investigators and contributing to the science that is the bedrock of a profession? In recent years, a number of organizations have outlined obstacles to maintaining the pipeline of physician scientists, classifying them as an endangered species. We have similar issues in physical therapy. Trainees and early-career physical therapist clinician-scientists across the spectrum of the pipeline face challenges, including leaving clinical practice and lack of support at key training transition points. We have been warned that “in an era of health care reform and an environment of increasingly sparse NIH [National Institutes of Health] funding, these challenges are likely to become more pronounced and complex.”2 I will discuss the barriers to and present some solutions for the development and support of a robust physical therapist clinician-scientist workforce.2,3
What are the barriers to entry into formal research training for DPT students and practicing physical therapists? I see 3 main obstacles: debt, wanting to practice clinically, and unfamiliarity.
According to the Institute for College Access and Success (TICAS), average undergraduate student debt is approaching $30,000.4 The APTA estimates that DPT schools cost a mean of just over $50,000 for public in-state programs, and the mean cost for both public out-of-state programs and private universities is approaching $100,000.5
More than 85% of students borrow, at least in part, to pay this tuition.6 Asking a new graduate to continue for 3 to 5 more years, not incurring any additional tuition expenses, but being paid only about $22,000 per year in stipend is a large obstacle.
The National Center for Medical Rehabilitation Research of NIH has a program of training grants that have been awarded to doctoral programs that train physical therapists. Both the University of Delaware and Northwestern University have DPT/PhD programs that defray the costs of the DPT portion of the program, reducing the loan burden for the students who enroll. Although most institutions will not have this option, what all institutions can do is offer scholarships to promising students who will enter PhD training after DPT school, with payback mechanisms in place for those who do not follow through.
Most PhD students, however, do not matriculate directly from the DPT. Most are returning clinicians, who, like most of my contemporaries and I did, have burning clinical questions they want to answer. Giving up a good salary and entering an uncertain path of clinical research takes drive and tenacity. It is hard to explain to almost anyone. One of my former doctoral students recounted a conversation with her family about leaving her job as a clinic director in a large sports and orthopedic clinic to become a full-time PhD student in our Biomechanics and Movement Science Program. So, you'll make more money, right? No, she said, in the end, probably less. You have to want to learn to do research. You do not get a PhD to teach. The PhD gives you formal research training; it is a degree in research. Clinicians without formal research training who try to do clinical research always run the risk of spinning their wheels; collecting data in an insufficiently rigorous manner for it to be useful, often making them hate clinical research. Getting research training is an answer. But it is not easy. The fact that these students are in their late 20s or early 30s when they enter the PhD programs brings unique challenges to undertaking formal research training, only one of which is financial. Later on, I will talk about social and biological challenges and dispelling the illusion of work-life balance, but now I am still talking about money.
One wonderful advancement of the last few years is the extension of the NIH loan repayment program to DPTs who enter research careers. The NIH wants to encourage outstanding health professionals to pursue careers in research. Currently, the NIH loan repayment program provides annual educational loan repayment for scientists, including DPTs, conducting clinical research. By participating in research, the NIH can provide the physical therapist clinician-scientist with up to $35,000 of qualified loan repayment per year. I am confident that, if we work together, we can find other ways to reduce the debt burden of these promising students as well. Perhaps the Foundation for Physical Therapy will consider a loan repayment program for these promising young physical therapy researchers.
We all went to physical therapy school to become practicing physical therapists. The lure of clinical practice is strong. I have mentored many PhD students over the years, only 2 of whom were not physical therapists. In every case with the physical therapists or those in training, the pull of clinical practice was a topic of conversation regularly. I am a practicing clinician. Mostly, when I do consults in the clinic, it is for patients with knee injury, specifically anterior cruciate ligament injury and posttraumatic knee osteoarthritis. But I also still consult on patients with shoulder problems, a clinical interest of mine. Moreover, I talk with the clinicians, am a faculty member in our residency programs, and have contemporary clinical practice experience. I understand the questions and problems that face practitioners today and see myself and my team of PhD students and research physical therapists as partners with our clinical colleagues in asking and answering important clinical questions. We need to train clinician-scientists, and what that means first and foremost is that we need to make sure that our PhD students are clinicians—good, insightful clinicians. As mentors, we must support continued clinical growth of our young scientists.
A physical therapist clinician-scientist is ideally a practicing clinician who spends the bulk of his or her time doing research. We are involved in teaching, administration, and clinical activities. We are especially dedicated to generating new knowledge. Our role is important because we identify novel and clinically relevant questions in the clinic and have the knowledge and tools to study these questions in basic science, translational research, observational and clinical trials, epidemiology, and health services research. We then take these results back to the clinic.7
Those of us who train physical therapists in our PhD programs must commit to fostering their continued clinical growth. The best way to do this is to model the behavior ourselves. But regardless of whether the mentor is currently practicing or not, the mentor needs to let the students know that he or she values the clinic and wants to help the student become an expert clinician.
DPT students and clinicians also may not enter PhD programs simply because they do not know formal research training exists. Most physical therapist students being trained today do not have exposure to faculty doing clinical research. They do not know about PhD training for people like them. They do not know about it, in part, because the vast majority of physical therapist education programs exist outside of research-intensive institutions and fewer than half of Commission on Accreditation in Physical Therapy Education (CAPTE)–accredited core faculty have PhDs. The CAPTE 2012–2013 faculty survey shows that the number of core faculty in DPT programs with a research doctorate increased from 40% in 1997 to only 47% in 2013—7% in 16 years.8 Only 21% of core faculty describe themselves as actively engaged in scholarship. The mean percentage of time core faculty spend on scholarship is just over 20%.8 So it is not surprising that many DPT students simply do not know about these opportunities or how great the need is for well-trained clinician-scientists in physical therapy.
All programs can at least educate their students that a career as a clinician-scientist is a possible career path for DPTs. Programs can promote a physical therapist scientist career using the ground breaking studies currently being produced by physical therapist clinician-scientists. Departments can set specific program goals. At the University of Delaware, we set a program goal in our 2008 strategic plan that 10% of the graduating class will enter postprofessional training after graduation. We meet or exceed this goal every year by modeling clinical specialization via our clinical faculty, who are all American Board of Physical Therapy Specialities (ABPTS) certified in at least one discipline, and, most importantly, exposing our DPT students to the myriad of opportunities that await them in residency and PhD training by integrating the 30 or more physical therapists doing residencies or PhDs at the University of Delaware into our DPT curriculum. I am proud to say, with our class that will graduate in December 2015, we have 2 committed to the PhD program and 3 to residency already! All programs with PhD and residency programs can do this. Those programs without one or both should take the time to educate their students about these postprofessional opportunities. The CAPTE should encourage these behaviors.
PhD students and residents are powerful young mentors to our DPT students, but we need strong, productive faculty mentors to model the rewards and realities of a career as a clinician-scientist to graduate students, postdoctoral students, and junior faculty. We have a responsibility to mentor those who are professionally younger: to model what it means to be an academician in physical therapy. As an academician in a professional discipline, our roles also include service to the profession, especially generating important new knowledge.
In research and professionally, we look to those who inspired us, who led. We all have professional forebears. To my group of young faculty struggling to become clinical researchers in the 1980s, Steve Rose was our mentor—a word that is used far too casually these days. Mentor, counselor, guide, teacher. To mentor…to lead, to navigate—a powerful word, a powerful construct. He mentored us as young professionals, encouraging our participation in Association activities, particularly the Research Section and our content sections such as Sports and Orthopaedics. He encouraged our attendance at meetings. He encouraged us to help each other, as scattered as we were across the country (“You need cronies!” he would say).9 Back then, long-distance calls COST MONEY! There were times as we were finishing our dissertations that we ran up hundreds of dollars in long-distance phone calls. There was no Internet. But we made a network. We kept in touch. We supported each other. We still do. The group grew over the years. Steve's “Young Turks”—this cadre formed the backbone of the NIH CORRT (Comprehensive Opportunities in Rehabilitation Research Training). It provides funding for new investigators in junior faculty positions to acquire the research skills necessary to become independent investigators. Funded by the NIH K-12 mechanism and led by Michael Mueller, Tony Delitto, and Stuart Binder-Macleod, CORRT is a collective effort of 9 universities: 3 lead institutions (Washington University School of Medicine, University of Pittsburgh, and University of Delaware) and 6 partnering institutions (Boston University, University of Colorado–Denver, Colorado State University, Emory University, The Johns Hopkins University, and The University of Iowa). Collectively, these institutions have a rich history of training rehabilitation clinician-scientists. The mentorship continues.
I skipped from graduate school to the present, but there were a lot of years in between, first being mentored and then mentoring. In the late 1980s, the University of Delaware physical therapy program was saved from closing by a grassroots effort of our alumni. A new chair, Dr Paul Mettler, and 4 junior faculty, Drs Binder-Macleod, Scholz, Davis, and I, were hired in rapid succession. The clinic, classroom, and lab shared one space in the basement of our old building. We were a program, not a department. There was no PhD program, and we had no residencies. The MPT program was in its first year. The clinic was free. This was the fall of 1989. We worked side-by-side and grew the program. Within a year, we moved into the newly completed lab, classroom, and office space. Our clinic took over the basement space and transitioned to a full-time, fee-for-service clinic. By 1994, we were a department, and the PhD program in biomedical science was approved.
Internal grants and a grant from the Foundation for Physical Therapy got my research off the ground in 1990. I got my first NIH grant, a small R15, in 1994, a pilot R03 in 1997, and submitted my first big grant, an R01, in 1999, which was not funded. I resubmitted it in 2000, and it was scored “on the bubble.” Terri Chmielewski, then a graduate student in the lab and that former clinic director I talked about before, was so much fun to mentor. Terri would hide fun goals in her progress reports to me such as “dance like Janet Jackson” in between “get my SCS” and “publish my first paper.” She and I worked on the second resubmission as the funding cycle came and went on the bubble proposal. One of her other, nonscience serious goals was to go to Rome to see the Polish pope. Well, in the middle of the chaos, away she went. When she returned, to no news on the grant, she said, “I'm offering my papal blessing to the grant proposal.” Well, a few days later, the project officer called from NIH and said that they had found some extra money and my grant was going to be funded. Last year, I was tempted to submit it to the Vatican as evidence of one of the miracles required for Pope John Paul II's beatification! There are lots of great pieces to this story. Have a sense of humor. Don't give up. The only way to be sure you do not get funded is not to submit. Be nice to your graduate students. Believe in them, so they can believe. All of their goals are important to them. Help them triage and prioritize, but don't squash.
That grant, 3 years ago, after 10 years of continuous funding, was awarded a MERIT (Method to Extend Research in Time) Award allowing for 10 additional years of funding, the pinnacle of NIH funding for an individual investigator. From the Foundation for Physical Therapy to the zenith of NIH funding. And I am not alone. Our generation of clinician-scientists and our academic progeny are rocking the physical therapy world.
Most of my PhD students have been women. My postdoctoral students and young faculty K-award mentees are more evenly split. Two-thirds of physical therapist students are women. Although approximately 60% of core faculty are women, we comprise fewer than 50% of the tenure track faculty and even fewer of the tenured positions. I promised I would get to the work-life balance illusion and what it means to model the realities of a career as a clinician researcher in physical therapy. Here we go.
Many have studied this phenomenon. It is pretty clear that, in this day and age, women who apply are as likely to be hired into tenure stream positions in physical therapy as men. There is no evidence of discrimination in review of articles or grant proposals either. But, as put more eloquently than I ever could by Wendy Williams and Stephen Ceci, 2 of the foremost researchers in the area of women in STEM (Science + Technology + Engineering + Mathematics) faculty, “The tenure structure in the academy demands that women having children make their greatest intellectual contributions contemporaneously with their greatest physical and emotional achievement, a feat not expected of men. When women opt out of full-time careers (or research careers) to have and rear children, this is a choice constrained by biology that men are not required to make. To the extent that these choices are constrained by biology and/or society, and…a women's talent is not actualized, then we most emphatically have a problem”10 (Fig. 2). Yes, we do.
Percentage of postdocs who switched away from an emphasis on a career as a research professor as a function of children and gender. Reprinted from: Ceci SJ, Ginther DK, Kahn S, Williams WM. Women in academic science: a changing landscape. Psychol Sci Public Interest. 2014;15:75–141, with permission of Sage Publications.
So in the interest of full disclosure, I'd like to talk to you a little bit about the illusion of work-life balance and the importance of fulfilling work in a full and happy life of an individual and family.
First, if you who think we who have been on this stage always keep all our various balls in the air, you are seeing the illusion. We often keep the balls in the air, and the ones that fall are just hidden from view, dented and momentarily forgotten. We are here because we play to our strengths and find teammates (family members, baby-sitters, friends, colleagues, and graduate students among them) whose contributions complement our own at work and at home.
Johns Hopkins Professor and Nobel Prize winner Carol Greider was, by many accounts, including hers, folding laundry and about to head off to an early morning spin class with friends when she got the call from Sweden. According to The Washington Post, several days later, when she heard that President Obama had won the Nobel Peace Prize, she thought to herself: “I bet he wasn't folding laundry.”11 The struggles transcend the Academy. Norah O'Donnell, the former NBC and CBS chief White House correspondent and current CBS anchor, wrote a few years ago about having a meltdown when planning her daughter's birthday party, “Face painting and the moon bounce, I can't do this!” Until her husband reminded her, “Relax, don't worry. It's not your skill set. You're a great reporter.”12
I love my family, and I love my work, and I am OK at laundry and early morning exercise, but I was no good at decorating birthday cakes or making collages. Thanks to baby-sitters and preschool teachers and the bakery, my kids had birthday cakes and paper turkeys on the windows at Thanksgiving. They also had trips around the world and met lots of interesting people at home and abroad because the things I am good at gave me and my family opportunities. We all have our successes and failures, our ups and downs. But realize, we cannot do it alone. Completion rates (%) for doctoral degrees range from the low fifties in the humanities to the sixties in science and engineering. Perseverance does you well, but only goes so far. Working really hard and digging in to solve problems do not ensure success. Succeeding in research is not just collecting and interpreting data and writing papers. You can do that, do it well, and fail spectacularly. To survive in a ferociously competitive culture depends on strategic alliances. To advance, a young scientist needs to get included on significant projects, preferably with an established mentor. This is our job as mentors, to include.
There is burgeoning literature that studies why many who actually complete the PhD step off the academic bandwagon then or after postdoctoral training. A worrying number of men and even more women leave academic research in the transition from doctoral or postdoctoral fellows to faculty. Among both sexes, those who have children are those who are least likely to consider becoming a principal investigator, and within this group, women are even less inclined than their male counterparts. Institutions can change this paradigm.13,14
Students dropping out of PhD training, not retaining PhDs in the Academy, and losing faculty in the pretenure years are problems we all struggle with. Investing in young researchers is time-consuming and resource consuming. We hire potential. We want them all to reach that potential and then infuse another generation of clinician-scientists with the goods to contribute to the scientific progress of our profession. At our university and many others, we are grappling with these issues and coming up with solutions.
Since 2011, at the University of Delaware, we have had parental accommodation for PhD students. The graduate Student Parental Accommodation Policy provides assistance to students during a pregnancy, postpartum, during an adoption process, or following an adoption placement. This policy makes it possible for students to receive time extensions for the completion of courses, exams, and other degree requirements. This policy also makes it possible for students to be released from normal teaching or research responsibilities for whatever that period is. Finally, this policy provides a mechanism for departments to receive central funding to hire a temporary replacement for any student receiving a stipend with an excused parental accommodation absence.
One of the most common policies adopted by colleges seeking to help their professors who are young parents is allowing them to “stop the clock” so that they get extra time before the tenure review that typically is based on 6 years of work. In theory, this benefit lets new parents devote more time to their children without fear that it will hurt tenure reviews. In practice, many academicians, men as well as women, have been afraid to stop the clock and feel that taking advantage of this benefit will stigmatize them and hurt their chances. A series of reports have urged universities to find ways to take away that stigma, so that more mothers and fathers feel comfortable stopping the clock.
Our university, like many others, has recently shifted from an “opt-in” policy, where the pretenure faculty member must request the year from a hierarchy of Chair, Dean, and Provost, to an “opt-out” policy where all new parents get an extra year before tenure review—automatically.
“Stop the clock” is among a group of already implemented and recommended elements of the University of California Family Friendly Edge initiative.15 Active service-modified duties (ASMD) is a period during which normal duties are reduced to prepare for and care for a newborn or a child newly placed for adoption or foster care. Faculty are expected to meet some portion of their normal duties; it is not a leave of absence. For tenure track faculty, the modification of duties is normally partial or full relief from teaching, without the assignment of additional teaching duties before or after. Campuses fund centrally the cost of hiring replacement teachers. Other planned initiatives include a guarantee to make high-quality child care and infant care slots available to tenure track faculty, particularly new hires; re-entry postdoctoral fellowships to encourage parents who have taken time off to return to the Academy; encouraging faculty search committees to discount familial-related resume gaps in their consideration of faculty candidates; the development and publicizing of existing school-break childcare and summer camps; establishing an emergency backup child care program and a reworking of the academic calendar; and scheduling of departmental meetings to fit with day care and school schedules. This may seem pie in the sky, but even if institutions do not implement all of these proposals, at least they are thinking about them and how they affect recruitment and retention of these terrific young clinician-scientists.
Finally, we have to increase the scholarship and clinical research opportunities available in academic physical therapy programs and couple support for young scholars with high expectations of scholarly productivity.
Forty of the 107 universities that are classified as Research 1 universities (very high research activity) in the Carnegie Classification of Institutions of Higher Education16 have CAPTE-accredited physical therapy education programs.17 To flip that around, only 40 of the more than 250 accredited and candidate DPT programs are in Research 1 institutions. A handful more are in institutions that are classified as Research 2 universities (high research activity). So more than 80% of physical therapist education programs are in institutions without a vigorous research culture or infrastructure. In the last CAPTE fact sheet on physical therapist education programs (2012–2013 Fact Sheet), roughly 2,300 peer-reviewed articles were published that year by the 238 accredited or developing physical therapy programs, with articles per program ranging from 0 to 71.8 Being a bit of a data dog, I used the Web of Science to investigate how skewed these data are. Fully one-quarter of those articles were published by 20 programs in Research 1 institutions that are also in the top 30 of the US News and World Report physical therapy graduate school rankings: 25% of the articles published by 8% of the programs, and half of those were published by faculty in just 5 programs (Fig. 3). That means that the other 218 programs averaged fewer than 7 articles per program, and a large number reported no articles. Some advocate for all physical therapy education programs to support high-quality scholarship and the generation of new knowledge. Without closing more than three-quarters of the physical therapy education programs in the country, that will never happen. We cannot unring that bell, and I will argue that for the problem I pose, this is not the answer.
Scholarly productivity in research institutions.
At the very least, the 40 programs in Research 1 institutions carry a unique responsibility, one that, in my opinion, not all are meeting. The programs in the Research 2 institutions bear a burden as well, and I come to a similar conclusion reviewing their publically available research productivity data; many are not contributing to the research enterprise that will define us as a profession for the next generation. They must.
The 40 programs in Research 1 institutions must step up their efforts, provide physical therapists in PhD programs with rigorous clinical and scientific training, hire and support young researchers, and model clinician-scientist practice. There are an estimated 200 faculty openings in DPT programs in the United States; approximately 25% of those are to fill slots in developing programs, and none are in Research 1 institutions. Charles Magistro, in his Mary McMillan Lecture delivered 28 years ago, said, “We will rest comfortably when we can defend unequivocally the services we render…. That defense can be formulated only from scientific proof and not empiricism. Until we are better prepared to defend the services that we render, our professional future is in danger…. If my assessment of the importance of the faculty shortage…is correct, then I would propose that we leave no stone unturned as we search for the resources to resolve this issue.”18(p1730) His words appear quite prophetic in hindsight.
Most DPT program directors have never done programmatic research or gone through a research mentorship process. They are under pressure to fill vacant faculty lines from a very slim applicant pool. They need the personnel to get the business of the educational program done (ie, teaching, service, and clinical practice). Too often, in an attempt to “jump start” the research effort of a department staffed by clinical and teaching faculty, they recruit and hire a new doctorally trained person as the “designated researcher” of the department. This effort is doomed to failure. It is impossible to produce meaningful research in an environment where there is no collegial support or infrastructure or the teaching expectations are inordinately high.
Even when DPT programs are in research institutions, they often reside in teaching-intensive allied health colleges. As Michels wrote, “The allied health professions that exist in the university settings were, almost without exception, admitted to the realm of academia through the back door…faculty members in the allied health professions were given appointments, promotions, and tenure without having to demonstrate the credentials of scholarly productivity demanded of their colleagues in other disciplines.”1 Again, 25 years later, there is more truth than fiction to his words. This has to end. Faculties in research-intensive universities must raise the bar, hire potential, support their young researchers, and promote only those who are impactful.
Teaching loads should be adjusted to include supervision of entry-level student research as teaching in institutions where that activity occurs. Supervision of entry-level research projects is not a research effort on the part of the faculty member. Rothstein noted that “junior faculty in physical therapy often find themselves supervising many student research projects…(and consequently)…do not develop their own research efforts.…[H]ow long can we afford to burden faculties with the task of supervising large numbers of student projects…?”19(pp332–333) Apparently, the answer to his question is “A long time.” Although this practice is most prevalent in programs outside of research-intensive environments, surprisingly it has not disappeared from the ranks of the Research 1 cohort. It must.
The late Father Timothy Healy, Jesuit, President of CUNY and later of the New York Public Library, wrote about the scholarship teaching debate in The Washington Post in 1988 when he was the President of Georgetown, “The debate is quite simply founded on a false premise. The two activities, teaching and scholarship, are not incompatible, even less opposed. It is true that the first work of any university is…instruction…. It is not true that this teaching bears no relation to research and scholarship…. All other goods of the university flow from its scholarship…. When a student sees…in class or lab the excitement as well as the stress of discovery, when in his later and graduate years he actually shares in problems that lie on the edge of knowledge, all this can turn his learning upside down, make it live and breathe…. That works both ways. Scholarship keeps the professor himself alive, gives him confidence in his own exposition and usually makes him blessedly unafraid to acknowledge ignorance or even error.”20
Being unafraid to acknowledge ignorance or even error. That is the tagline of a clinician-scientist.
DPT education programs, especially those in Research 1 institutions, must rise to the occasion to recruit and support the well-trained clinician-scientists graduating today. In our institution, our young tenure track faculty receive generous start-up packages, dedicated research space, and protection from heavy service. Workload is 65% research and 25% teaching, which translates to one course and some contribution to another course per year and to service, generally at the department level and to the profession. One of my current doctoral students has just received a virtually identical offer from another of the Research 1 DPT programs. They are being flexible with her start date; she is pregnant with her second child and finishing her dissertation. This is what a department does to hire a young clinician-scientist with great potential. But this support must be coupled with both departmental and college leadership, mentorship, and high expectations to see the potential realized.
Once again, there are groups that have studied what characteristics of the individual, the institution, and leadership translate to faculty research productivity. For the individual, motivation to create new knowledge is the greatest predictor of research productivity. Motivation, the drive to explore, understand, and advance and contribute through innovation and discovery, drives success.21 Conversely, those who are not motivated choose to leave research careers, most often, in physical therapy, to join a faculty where there is no research culture. This is as problematic for us as a profession as are those who are compelled to drop off the academic bandwagon for family reasons. Resources for training physical therapists as clinician-scientists are scarce. We cannot afford for well-trained, nascent physical therapist clinician-scientists to leave the research enterprise. In a recent review of our DPT/PhD training grant (which was funded, by the way), the fact that “A few of the graduates have selected to be on faculty at institutions that are not research intensive and…this choice may impact future productivity” was enumerated as a weakness. The more clinician-scientists we train who move into DPT programs where they are neither clinicians nor scientists, the weaker we will become as a profession.
Institutional characteristics that are associated with research productivity include having a research emphasis and a research culture; providing strong mentoring, often by more than one mentor (by established scholars in health sciences, engineering, health services and other disciplines for research, and by others professionally and in teaching and navigating the institution), is essential to the success of young clinician-scientists. In these institutions, research is rewarded equitably in accordance with defined benchmarks of achievement, and there is assertive participative governance.21
Characteristics of the chair- and dean-level leadership that contribute to research productivity of the faculty include being highly regarded as a scholar, having a “research orientation,” and having internalized a research-centered mission. But most importantly, these are leaders who set high expectations for all and value their ideas.21
Stanley Paris in his McMillan Lecture asked, “[where] is it best to invest our precious research dollars?”22(p1550) I will answer him. The Foundation must not invest in faculty who work in institutions without these aforementioned characteristics! The Foundation must serve its mission to seed promising young clinician-scientists by funding only those who work and have the potential to thrive in environments that have a research culture, institutional support, and priorities for research and provide strong scientific mentoring. The available data from the Foundation show some remarkable success, but almost without exception the seed money never grows and, therefore, does not help the faculty develop a research program with sustained contributions to physical therapy unless the awardee is in this type of environment.
I have spent my professional life first as a clinician and for the past 25 years as a clinician-scientist in just such a challenging and supportive environment. I have been supported and continue to be supported by department chairs with the characteristics I just described and by an institution that shares our department vision and invested in our clinical and research excellence. I have, as Steve Rose admonished, cronies, inside and outside of the institution. I postulate that it is not surprising then that I have been successful. Being a physical therapist, though, my motivation comes from those who have entrusted me with their care. It comes from my patients' success or failure, thumbs up or thumbs down. A simple question has driven my professional life. My patients ask “When can I walk, run, drive, play again?” and I want to answer that question. I have spent the past 30 years studying the spectrum of common knee problems, from anterior cruciate ligament injury to end-stage knee osteoarthritis and knee replacement. What muscle function and movement problems occur in patients with knee injury or disease? How do they affect function? What can we do about it? How do we know the effects of what we do? The answer to that last question, by the way, is simple. Ask the patients. Test the patients. Follow up with the patients. Synthesize the information—come up with some answers…and more questions. Find out what it all means for clinicians and patients; what we know now and…what we are missing. I will run out of breath before I run out of questions—what a lucky girl I am. It is my hope that these words will inspire some of you to live the same dream. I am finally getting to the title, and the end, of my lecture. Isaac Asimov said, “The most exciting phrase to hear in science, the one that heralds new discoveries, is not ‘Eureka!’ (I found it!) but ‘That's funny….’”23 It is as true in life as it is in science. So, don't strive for the Eureka moment—look for the “that's funny.” Don't try to be perfect. It's very true that the perfect is the enemy of the good. Don't try to keep all the balls in the air. One will always be lying on the floor broken. Fortunately, you can always pick it up, smush it together, throw it back in the air, and almost no one will notice. Just don't let it always be the same one. As Charles Wheelan wrote in his book, 10½ Things No Commencement Speaker Has Ever Said, “Don't try to be great. Being great involves luck and other circumstances beyond your control.”24 Be solid, do your best, find a good team to lead or to be part of, use your talents, work hard and effectively. Make an impact! Indeed, there are challenges to an academic life, but nowhere else could I have turned a young clinician's wonder about why the thigh muscles don't work well after knee surgery into a fulfilling and successful career. Confucius was right, if you have a job you love, you'll never work a day in your life.
Footnotes
The 46th Mary McMillan Lecture was presented at NEXT: Conference & Exposition of the American Physical Therapy Association; June 5, 2015; National Harbor, Maryland.
- © 2015 American Physical Therapy Association
