Carole B. Lewis, PT, DPT, GTC, PhD
Carole B. Lewis, PT, DPT, GTC, PhD, has focused throughout her career on the continuous improvement of clinical care provided to older adults. Dr Lewis is an adjunct professor at the George Washington University Medical Center Department of Health Care Services and continues to work in private practice. She serves as president of Great Seminars and Books and Great Seminars Online and for 33 years has been editor-in-chief of Topics in Geriatric Rehabilitation, which won the Association of American Publishers' Award for the Most Outstanding Issue of a Scientific Journal. She earned a DPT from MGH Institute of Health Professions, a PhD in health education from the University of Maryland, an MS in gerontology from the University of Southern California Leonard Davis School, an MPA in health care management from the University of Southern California, and a BS in physical therapy from The Ohio State University.
Dr Lewis has held 24 consultation positions in clinics and workplaces and with third-party payers. One of the first researchers to determine that older adults are able to exercise safely and can realize major improvements in outcomes when prescribed appropriate exercise, Dr Lewis has published extensively in the field of aging, with research published in journals such as Archives of Physical Medicine and Rehabilitation and the New England Journal of Medicine. She is author of more than 20 textbooks on aging, including what may be the first text on aging and rehabilitation and one of the first on functional assessment (Aging: Health Care's Challenge: Interdisciplinary Assessment and Treatment of the Geriatric Patient, now in its fourth edition; Geriatric Clinical Strategies; Geriatric Physical Therapy; Orthopedic Assessment and Treatment of the Geriatric Patient; The Geriatric Exercise Kit; The Functional Toolbox I & II; The Balance Book and Osteoporosis Exercise Book; The Prevention and Wellness Toolbox; The Orthopedic Outcome Toolbox; Health Promotion and Exercise for Older Adults; and Improving Mobility in Older Persons: A Manual for Geriatric Specialists). She also coauthored a book for the lay public titled Age-Defying Fitness.
Dr Lewis' accomplishments include receiving APTA's Lucy Blair Service Award; the Academy of Geriatric Physical Therapy's highest honor, the Joan Mills Award; and the Academy's Clinical Excellence Award. A Catherine Worthingham Fellow of APTA, she has represented APTA at the White House Conference on Aging and Mental Health and has volunteered for many local and national offices, including serving as president of the DC Chapter and the Academy of Geriatric Physical Therapy (then the Section on Geriatrics of APTA, of which she is a founding member). Chosen as one of the 10 Outstanding Young Women in America, she received the American Medical Association's National Women in Medicine Award in 1994 and the Gerontological Society of America Excellence in Rehabilitation of Aging Persons Award in 2014.
47th Mary McMillan Lecture
Have you ever had an odd twist of fate that devastated you, but led you to something better?
When I was a teen, I was desperate to become a social worker. I imagined all of the good work I could do. To make my dream a reality, I volunteered relentlessly and even won the volunteer of the year award for my region. Look at that—it is only 15 seconds into the talk, and she is already bragging! I was sorely disappointed, distraught really, to not receive the paying job I was promised at the venue where I had volunteered. But I quit whining, dusted off my wounded young self, and took the only summer position I could find—working with children as an unpaid assistant to a physical therapist at United Cerebral Palsy Center of Greater Cleveland. I loved it!
Planning is definitely important, but when expectations become too rigid, they kill possibilities. A twist in the road changed my future, and I'll be forever grateful. How many times has that happened to you? At first you see this twist as a huge setback, but later, much to your astonishment, it is an unexpected and welcome opportunity.
My story in physical therapy is recognizing and committing to some extraordinary opportunities.
Mary McMillan: “Carole, oh Carole, it is me, Mary. First, let me say, ‘Congratulations.’ It's so nice to finally see a clinician giving this lecture. I think the last real clinician to give this lecture was that young whippersnapper Charlie Magistro back in 1987!”
Lewis: “Mary McMillan, so nice to meet you, and thank you for mentioning Charles Magistro. He is the bright shard in our living past, and he will be missed. Now, I've never met you, but I'm sure Marilyn Moffat knew you, she knows everyone.”
Mary McMillan: “Marilyn…she is much too young to have known me. My question to you is, ‘Why should I, and all of the other therapists in this room, bother to listen to what you have to say today?’”
Lewis: “Whoa. You don't pull any punches do you? But it's a fair question. Before I answer, let me say thank you for all you have done for our profession, from working around the world to starting our national association. Now you, and everyone else in this room, want to know ‘What's in it for me?’ My goal is to challenge you to think about yourselves and our profession in new ways, to entertain and inspire you to actively participate in shaping our future selves.”
Mary McMillan: “Hmmm. That sounds pretty good. Proceed.”
Lewis: “Thank you.”
Before I begin, I want to thank the American Physical Therapy Association (APTA), especially the 2015 Board of Directors, for choosing me for this honor (Fig. 1) and for the Academy of Geriatric Physical Therapy for nominating me, and an extra thanks to all my dear friends and colleagues who wrote letters of support. I also want to recognize all of the previous McMillan Lecturers, and I am truly humbled to now be one of them. I would like to thank my incredible business partners Dr Molly Laflin and Neila Waugh. They enable me to do more than just my 9-to-5 job. Their personal enthusiasm for life encourages me to write, teach, research, and create. Also, I offer a sincere appreciation to my amazingly talented and supportive faculty at Great Seminars and Books and Great Seminars Online. To my children, Madison and Gerald, who despite semi-neglect, have somehow grown up to be healthy, kind, and beautiful people inside and out. You know I love you more than anything. To my second family of friends and colleagues of APTA who have added so much to my personal and professional journey. To George, thank you for enriching my life…and for driving at night. To Lynn Allen Colby for seeing something in me and nurturing my professional growth at The Ohio State University. Finally, I want to express my gratitude for all of the older adults who have inspired me throughout my life, from that first trip to Miami Beach with my grandparents at age 5 to now. I have learned so much about courage, strength, wisdom (and Bingo) from all of you. Here is a picture of my grandmother, grandfather, and me. I am the one with the funny-shaped head (Fig. 2).
Carole B. Lewis at APTA's NEXT Conference & Exposition; June 10, 2016; Nashville, Tennessee. Photo credit: David Braun Photography Inc.
Dr Lewis (circled) with her grandmother and grandfather (arrows).
When Mary McMillan started our professional organization in the United States in 1921, how long were people living? Take a guess.
Now, take a moment to think about YOU. How long do you think you will live? Stand up and turn to your neighbors and ask them how old they think they're going to be when they die.
Life expectancy in the United States in the early 1900s was 47 years. In the 1920s, at the birth of our professional association, life expectancy was 54 years. As you can see, we are living much longer in the 21st century1–7 (Fig. 3).
Life expectancy at birth. Available at: http://www.cdc.gov/nchs/data/hus/2014/016.pdf.
Life expectancy is increasing not just in the United States; it is a global phenomenon. And it has huge implications for health care, in general, and physical therapy, in particular.
The statistics are compelling, but they do not tell us what is important to older adults. I am reminded of a story I heard many years ago from Dr Ken Dychtwald, an outstanding speaker and leader in gerontology. What follows is my embellishment of his story. While pursuing his master's degree, he worked in a program for seniors. He was paired with an older couple, and every Saturday for 4 months he served as an advisor to them in the areas of physical, mental, and emotional well-being. For the sake of anonymity, I will call this couple Sadie and Max. One day, 3 months into the program, Sadie pulled Ken aside and said, “I have news. I'm going to divorce Max.” Ken thought, “Oh my, there goes my A.” He took a deep breath, and asked why. Sadie said that there were 3 reasons: “One, I don't love him anymore. Two, our sex life is terrible, and that bothers me a lot. Three, he is a jerk.” Ken thought about the reasons. Max seemed lovable enough; he had not gotten to the sex section yet; and for her third reason, Sadie was right, Max was kind of a jerk. Then Ken asked, “But why now, after all these years?” Sadie's response was one of the most provocative statements I have heard in the last several decades, with significant implications for physical therapy. She looked at Ken and said, “When I married Max, life expectancy was 59 years. I'm 70 years old now. I'm as strong as a horse. I'm going to live another 20 years, and I will be darned if I am going to live it with that jerk!”
People are living longer and they will be darned if they will live with the pain in their knee or with a torn rotator cuff that leaves them unable to move. When I got into physical therapy in the 1970s, people were not living as long. When someone had arthritis of the knee or hands at age 60, physicians would tell them to take nonsteroidal anti-inflammatory drugs (NSAIDs) and live with it. Today, we know that NSAIDs are killing us.8–11
The answer is not medication. Listen to those commercials: “And the side effects are extreme diarrhea, incapacitating headache, loss of teeth and good looks, and DEATH.” I think APTA should buy the first commercial at the Super Bowl. It should look something like this (see video).
Older adults are not always good candidates for surgery. The best approach to alleviate the distress of many chronic problems is physical therapy.
I have a question for you: “What percentage of physical therapy patient care time do you think is spent with patients over the age of 65 years?”
As you can see, the percentage of therapists working with older adults is above 50% in most settings (Fig. 4). This statistic is from 2006. Because of the steady increase in life expectancy in the past few decades, these numbers would probably be even more dramatic today.12
Mean percentage of patient care time spent per week with patients in each age group. SNF=skilled nursing facility, ECF=extended care facility, ICF=intermediate care facility. Source: APTA Practice Profile 2006.
What percentage of new graduates' first job is in geriatrics?
I could not find current studies to answer this question, and I knew I could not call the students of today because they do not answer their phones, especially if an adult is calling. However, I did find Larry Nosse's study from the 1990s that sheds some light on this topic. He found that a quarter of the respondents, as students, intended to work with older patients, but, as practitioners, more than 60% worked with this population.13
What is our profession doing to address the needs of our current older adults and the future “silver tsunami”? Which, if you are not aware, is the huge influx that will occur as each year more and more of the baby boomers hit age 65 years. This phenomenon began in 2011 and will continue well into 2030.2
To put it bluntly, we are not prepared. Physicians have published numerous studies revealing inadequate training in geriatric medicine.14–19 The question is, “Have we, as a profession, given this important aspect of our training the attention it needs and deserves?” I contend NO!
What percentage of physical therapy education programs have a course dedicated to pediatrics?
What percentage of physical therapy education programs have a course in geriatrics?
To answer these questions, I conducted an email/phone/website survey of every physical therapy education program in the country. I was surprised by the results because when I ask therapists in my classes how many of them had a course in their professional training dedicated to geriatrics, barely a quarter of the class raise their hands, and, prior to 10 years ago, it was less than 10%. I found that in 2015, 64% of the schools had a dedicated course in pediatrics and 42% of schools had a dedicated geriatric course. Many of the schools with programs in geriatrics began them within the last 10 years, whereas the pediatric programs had been in place much longer.
Demographic projections (Fig. 5) clearly indicate population growth among those aged 65 years and older. In our lifetime, this segment of the population will, in all likelihood, increase more than any other group.7
Percentage of world population under age 5 years and aged 65 years and over: 1950 to 2050. Data are based on the medium fertility variant of United Nations population estimates and projections. Available at: https://www.census.gov/content/dam/Census/library/publications/2014/demo/p23-212.pdf.
Geriatrics is where our profession works. Yet, we are not adequately training our therapists to work with this population.
One possible reason we see so few courses dedicated solely to geriatrics could be that physical therapy for older adults is believed to be ineffective. Does physical therapy make a difference in outcomes for older adults? Obviously, if physical therapy for this population is not beneficial, there is no reason to teach it in the schools or after graduation or even to give this care to this population. What does research tell us about the effectiveness of physical therapy for older adults? Countless studies have come out in the field of geriatrics in the last 2 decades that clearly demonstrate the benefits of physical therapy. I am a data person, myself, and I am pleased to share with you the results of a few of these studies.
In 1994, Dr Mary Tinetti and colleagues published one of my favorite studies, demonstrating that physical therapy decreased the cost of medical care.20 The main component of Tinetti and colleagues' study was physical therapy. Their program resulted in a significant reduction in the risk of falling among older adults in the community and a cost saving of $1,947 per person. The experimental group received more care, but saved money overall because the control group fell and was injured at a much higher rate than the experimental group. There was a dramatic increase in the cost of care for the control patients and a decrease in quality of life. We are cost savers in the health care system, and we need to publicize this!
Is physical rehabilitation for older adults in long-term care effective? Findings from a systematic review by Forster et al21 showed that physical rehabilitation in long-term care is effective. They reviewed 49 trials involving 3,611 patients whose average age was 82 years. They found a dose-response relationship, which means, the more physical therapy patients received, the better they did. In addition, in 2016, Jung et al22 reviewed data from almost 500,000 Medicare beneficiaries and showed that more hours of physical therapy in skilled nursing facilities (SNFs) improved outcomes.
Even though research demonstrates the effectiveness of care in SNFs, there has been criticism about the quality of care in these facilities. But who is at fault? If we are sending students out unprepared for this population, perhaps the problem is not the providers, who hire therapists who have graduated from accredited programs and passed their licensing examinations yet may not be well trained or tested on the best care for older adults.
Despite this, people in nursing homes get better from what we do.21–24 Skilled nursing facilities were a place to die in the 1970s; rehabilitation barely existed in SNFs back then. Now, studies show that SNFs give people hope and a means to live their lives with quality, vigor, and enhanced independence.
I would like you to think about how you want to live your life. Would you like to be sitting around in a nursing home with mauve pillows and a loud TV in the background, or would you rather be an independent, active older person traveling around the world, a community leader, a grandparent able to sit on the floor with your grandchildren because of physical therapy? If our association and our peers do not back us in our efforts in these arenas, older adults will be the ones who will suffer.
One more study, the US Preventive Services Task Force recommendation statement published in the Annals of Internal Medicine in 2012, recommended physical therapy and vitamin D as the only 2 efficacious interventions after an exhaustive review of the literature on preventing falls in community-dwelling adults aged 65 years or older.25 Then in 2015, JAMA Internal Medicine published a well-controlled randomized trial that revealed vitamin D was not effective in reducing falls, but that physical therapy administered by a physical therapist more than halved the incidence of injurious falls.26 Yet, the article, editorials, commentaries, and media attention focused only on the lack of efficacy of vitamin D and not on the effectiveness of physical therapy. Why were we not all over this? We really undersell what we do as a profession, on all levels.
Given the clear benefits of physical therapy for older adults, the statistics about the number of therapists working in the area of geriatrics, and the anticipated increase in the geriatric population, every physical therapist and physical therapist assistant education program should include at least one mandatory course dedicated to the topic of geriatrics, and every faculty should include at least one geriatric specialist. Our schools need to graduate clinicians who are prepared to do what many, if not most, of them will be expected to do, and I hope want to do.
I believe that the first step to help people “want” to work in geriatrics is exposure and education. Working in geriatrics is challenging and stimulating, and it forces therapists to think and to use all of the evidence that is available to obtain positive outcomes for patients who might not do well with lesser care. Therapists working in geriatrics have to practice at the top of their game to get results. I LOVE IT! It is hard work, but so rewarding, and it truly is the future.
Bringing meaningful change to older adults does not start at age 65 years, or even 50. It begins when we see a patient at age 30 years with a forward head, and we teach thoracic mobilizations and exercises to prevent camptocormia, or as some call it, “head drop,” at age 70 years.27 Too often I hear my older patients ask, “Why didn't someone tell me this sooner?” We need to show the world what we can do to help people age successfully.
Imagine what you will be like when you are 90 years of age. Do you see yourself as tired and sedentary, or do you picture someone like Grandma Moses, Janet Travell, or Florence Kendall (Fig. 6). Each of these women lived vibrant, meaningful lives well into their 90s. Grandma Moses painted her first picture at age 91 years and her most famous picture, Rainbow, at age 101 years.
(Left to Right) Grandma Moses, Janet Travell, and Florence Kendall. Grandma Moses: Grandma Moses painting in her garden, 1944, photograph by Ifor Thomas. Copyright © 1946 (renewed 1974) Grandma Moses Properties Co, New York. President John F. Kennedy's physician Dr Janet Travell (at the microphone) briefs the press on the President's illness. White House media network electrician, Cleve Ryan, stands at far left. Fish Room, White House, Washington, DC. Photo credit: Abbie Rowe. White House Photographs. John F. Kennedy Presidential Library and Museum. Boston. Florence Kendall (photo courtesy of the American Physical Therapy Association Archive).
I will never forget seeing Florence Kendall at age 90 years dancing at the Foundation Dinner Dance. I had the honor of knowing and working with Dr Janet Travell, John Kennedy's physician and author of multiple texts on myofascial trigger points. She sent my office so many patients that one of my colleagues said, “Let's take her to dinner.” She was 93 years old at the time. Before the food arrived, she taught all of us an examination technique I still use today.
Even though they tend not to live as long as women, I do not want to leave out men. So what do you think of those Stones? Mick Jagger is 72 years old and runs around the stage like a 16-year-old.
Aging is not just about “them”—it's about us. And as much as we might try to postpone or deny it, we are all aging. We need to take action now to ensure that we age successfully. What are the attributes of successful aging? In 2014, Wong et al published an insightful article titled “The Well-Being of Community-Dwelling Near-Centenarians and Centenarians in Hong Kong: A Qualitative Study.”28 They found that a positive attitude was crucial to success and that most of the successful centenarians retired at very old ages and perceived their work as most important to their life histories.
Do you see your work in physical therapy as a crucial piece of your life history? Does our profession give us that warm, inner sustained glow that makes it as important as other parts of our lives? If you want to be happy now and a successful ager, it should. Physical therapy is a wonderful profession, and if you do not believe that, you need to explore why.
What gives you that glow? For me, it is seeing patients surpass expectations, not just having them enjoy my company. One of my most difficult patients was also one of the most rewarding. Her physician called me and said I should schedule lots of extra time for her first visit, and when her husband followed her in with a shopping cart of charts and articles to read, I knew why. With a great deal of work, and much to the amazement of her referring physician, she progressed from being wheelchair bound to performing as an ice-skater at age 70 years.
I was proud to help this woman achieve her goals, but the memory that I hold closest to my heart is that of a brilliant, creative, and charming gentleman who could find humor in any situation, even rehabilitation. I worked with him after his stroke until he was walking safely and able to finish his last book. Several years later, I got a call from his family when he had come home for hospice care, and they feared he had very few days left to live. They asked if I would like to visit. As I drove to his house, I called my sister, my anchor, and told her how sad I was that this might be the last time I would see this awe-inspiring person and that he might not even know me. I arrived and was told he had not been responsive for most of the day. I crept into his room with trepidation. His now delicate body blended into the bedsheets. This was so different from the robust comical icon I knew from a few years ago. I sat on the edge of the bed and began talking to him. Within minutes, he became lucid. He sat up, leaned forward, took my hand, and whispered, “I love you.” Then he peacefully laid back down. He died 2 days later. I got into my car with tears streaming down my face and immediately called my sister as I sat in my car sobbing and relaying the details of my visit. My sister, not to miss a beat, said, “Are you sure he knew it was you?”
Does your glow come from a letter from a former student describing how he saved a life by identifying a deep vein thrombosis from the clinical prediction rule you taught him, or doing a sacroiliac mobilization that helped a woman walk from a hospital bed in the emergency room, pain-free? Is it finding a new way to keep a good clinic running, or rewarding an employee who has excelled, or finding significance in a study you know will change the clinical practice of our profession? These are just a few of the moments that make physical therapy a crucial part of our lives. We need to embrace these feelings, take them in, and share them with others.
We must always think to the future. Wayne Gretzky got it right when he said, “I don't skate to where the puck is, but where the puck is going to be.”29 We cannot be OK with where we are now. We need to think ahead, plan ahead, and take steps now to practice at the top of our license. We need to be ravenous lifelong learners.
My path to becoming a ravenous learner began after I graduated in 1975. I decided to work in California at LAC-USC Medical Center in the hopes of working with Dr Renee Cailliet, author of a very popular series of books that I enjoyed while in my physical therapy program at The Ohio State University. The very first day on the job, I walked up to Dr Cailliet and said I was a new graduate and I had come all the way across the country to work with him. He looked at me and said, “Thanks.” I think he thought I was stalking him. Several weeks later, there was a page for me in the clinic. I went down to Dr Cailliet's office, where he was examining a patient with back pain. He invited me in and had the man perform several trunk movements, and then he turned to me and said, “What do you think?” I was shocked and unprepared. Stunned and a bit uncertain as to what to say, I looked at him and said, “Think? You mean we're supposed to think?” When we both got done chuckling, he took me through the evaluation, and it was a memorable learning experience.
We have come a long way since 1975, when doctors wrote detailed prescription that we blindly followed. Therapists today would not be caught off guard when asked to think through a patient's problem, and I believe that is, in large part, due to how much the schools have improved the quality of education.
Physical therapy education programs are engaged in continuous improvement. This is the kind of tablet I used when I was in school (Fig. 7). This is what students use today. [Holds up an iPad.] The tablets students use today are powerful tools that are changing the nature of education.30 I have been so impressed with the ability of this technology to engage students and increase learning that my latest gerontology textbook will be published by Wolters Kluwer exclusively as an eBook, which, with one click, will allow students and practitioners to understand content on a deeper level through demonstrations, interviews, and access to research summaries that indicate and reveal the strength of the evidence. You can even click on this picture of a patient or the name of an author and get their stories.31
Dr Lewis notes the difference between tablets then and now, at APTA's NEXT Conference & Exposition. Photo credit: David Braun Photography Inc.
I look forward to the day when these new technologies make it no longer acceptable to base clinical decisions on textbook proclamations that do not address the level of confidence supported by the available research.
Many of the McMillan Lecturers, including me, have addressed issues related to physical therapy education, and I believe the schools have risen to the occasion and have improved dramatically. I believe that the most serious educational problem we face as a profession occurs after school is out. This is where we fall down.
Jules Rothstein's editorials in PTJ embodied this message. I loved Rothstein's editorials—so much so, that I was moved to write him a fan letter. He ignored me. As Jules stated in his McMillan Lecture, we must be “problem-solving professionals who often perform with excellence.”32(p1821) Substandard care will destroy our profession, but where does inferior care come from? Some have postulated that the source is the schools. I say that the source is ubiquitous and omnipresent, waiting to steal our ethics at a tired or human moment until one act becomes a litany of behavior without recourse. In other words, we graduate students at a high level, and then—possibly due to the pressures of the job or financial disincentives—the quality that was evident at graduation slowly slips into substandard care that is accepted at some level.
When I started working as a physical therapist, the evidence for what we did was almost nonexistent. Now, there are so many studies, it is hard to keep up. We are in an era of knowledge explosion.33 What are your favorite sources for evidence? Turn to your neighbor and share one. Ten would be better, but if you or your colleagues cannot name at least one source for reputable clinical evidence, or if your neighbor said USA Today, we have a problem. Physical therapy is changing rapidly. Those who do not keep current with research-based evidence drag down the entire profession.
How long will our profession be plagued by charismatic gurus who preach testimonial-based interventions instead of promoting therapy grounded in solid research? Therapists love learning new techniques, but in their eagerness to help their patients, they are sometimes too trusting and not discerning enough regarding the evidence supporting those techniques. I believe we have worked hard to get away from that kind of thinking. But I still see continuing education programs that frighten me. I witnessed a continuing education course recently in which the instructor told his audience that exercise was bad for all older adults. He quoted 2 obscure research studies to support his opinion. This is appalling! Yet, I see “online courses” worth 10 credits that are no more than a homework paper from an undergraduate. Ten credits of what? Or my favorite: “Cheap CEUs.” We want to be valued, yet we stay current professionally by getting the cheapest CEUs we can? How would you feel about any health care practitioner that you went to for an important issue who thought so little of his or her ongoing education that he or she followed the quickest, cheapest route to fulfill state licensing requirements?
Academicians have worked hard to increase the value of physical therapy. But do our educators teach students the value of ongoing, meaningful education after graduation? When patients graduate from rehabilitation, every good therapist tells his or her patients that they must continue to exercise for the rest of their lives. When therapists graduate, their time in school is over, but, as professionals, it is incumbent upon them to continue to learn for the rest of their lives. What happens when our students leave school?
Many believe that this is where “bad” clinicians can thrive. But what are we doing to make the situation better? If we allow courses to be approved that are based on bad information, we will have bad clinicians. I give a standing ovation to states that really care about continuing education: New Jersey, Wisconsin, Ohio, and Florida. Even though my Great Seminar companies dread all the work in your application process, we respect the emphasis on quality. I also feel strongly that the accreditation process should not reside within any one organization and certainly not those that deliver continuing education, as this conflict of interest could compromise the quality that must be vigilantly monitored by entities without financial interest.
We need to be sure our therapists are continuing to learn, even “master clinicians.” A true “master clinician” knows that he or she does not know it all and is always open to new educational experiences. For example, some therapists in outpatient offices treat a large number of older patients but do not take the time to learn important considerations in evidence-based interventions for older adults and may not be giving effective care to this population. I have sat next to too many older adults on airplanes hurt by well-meaning but ill-informed therapists who had not taken the time to improve their skills in geriatrics.
Take continuing education related to what you do, and do not take every continuing educational offering from the same person or even the same company; mix it up. Learn something new; embrace the changes that new evidence-based ideas bring. Schools, employers, and colleagues need to stress the importance of ongoing, worthwhile education after graduation. All states should mandate and take the time to monitor the quality of continuing education. Change requires effort and feels like a risk. Yet, if you risk nothing, you risk everything.
Lastly, I want to talk about the future of physical therapy. As George Burns [1896–1996] said, “I look to the future because that is where I am going to spend the rest of my life.” The APTA tagline begins with the words, “Move Forward.” That is exactly what we need to do. The health care system is broken, and, without our input, it will not be fixed properly. It is unfortunate that the system we live in was designed by 50-year-old men in business suits and not 87-year-old women in walk-up apartments. You can get 911 to respond in 9 minutes or less almost anywhere in the country if you have a heart attack, which is fantastic, but will physical therapists be paid enough to work with someone so that he or she can get up the stairs independently?
The core of our profession and our professional organization is clinical practice, yet I think that sometimes, in the midst of addressing the needs of researchers, administrators, and educators, it is too easy to lose touch with the day-to-day reality of the clinician. Thus, I recommend that APTA establish an ongoing Clinical Enhancement Committee to identify ways that we can nurture, recognize, and involve more clinicians in meaningful ways. We need to establish partnerships of equals among academicians, researchers, policy developers, and clinicians dedicated to producing outcomes usable in the field. Research without widespread clinical application is pointless, and diffusion of innovations will not happen without these partnerships. All too often, researchers view clinicians with condescension. Clinicians feel as though researchers preach to them and are out of touch with life in the trenches. Yes, we would all love the option of spending 3 hours conducting thorough examinations and interventions that include flawless extensive documentation of all of the information we know is important. But we do not get paid for doing that. Help us get paid for that, and then we will listen.
Clinical care has changed dramatically in the last several decades. The efficacious tools we had available to us back then included goniometers and our hands.
Today, physical therapists should be using the plethora of professional tools currently available, not just those that they learned about in school. One area that comes to mind is functional assessment. I published a compilation of functional tools in 1989, and many early adopters bought the book. Unfortunately, few ended up using functional assessment tools in their practice.34 It was not until 2013 when the Centers for Medicare and Medicaid Services (CMS) mandated the use of functional tools as part of functional limitation reporting that physical therapists actually made this part of their arsenal. Functional examination and interventions are what we do. Why did it take a CMS regulation to get everyone on the bandwagon? That is embarrassing. Let me give you another example.
Strength and exercise are not only interventions; they are also diagnostic. Studies have shown that radiographs are less indicative of functional decline than a dynamometry muscle test.35,36 I contend that every physical therapist should be using dynamometry to accurately measure strength and function and to demonstrate incremental change.
Dynamometry examinations also should be performed annually (similar to a dental checkup) or when a person notices a problem. What could be more eye opening to a therapist and motivating to an individual than to administer a test that clearly demonstrates below-average strength for a muscle group compared with the norms for that age group? Dynamometry identifies a problem early that can be fixed noninvasively.
This examination tool has been around for decades, yet most clinicians and even some researchers do not use it. How can we say we are experts in this area if we do not use state-of-the-art technology?
The solution to many functional problems is exercise. It may seem easy to administer, but it is not a pill. It is not a quick fix, but rather a timed, incremental, and long-term approach perfected through expertise and skilled patient motivation. Yet, many of our peers in medicine and the general population view exercise as generic. No physician would give every patient an aspirin for every problem. That is malpractice. Hence, telling patients to “exercise” without seeing a therapist who can prescribe the appropriate exercise, monitor the patient so that the exercise is performed correctly, and progress the patient is also malpractice.
We have got to sell this every time we see a patient, a medical peer, or the media. As Dr Robert Butler [former director of National Institute on Aging] stated, “If exercise could be packed into a pill, it would be the single most widely prescribed and beneficial medicine in the nation.” We are the prescribers of that powerful medicine!
Exercise and functional assessment are just 2 examples of where we need shake ourselves out of our complacency. We must continually expand our professional toolboxes, and we must be confident, loud, and supportive of our unique therapeutic skills.
So, to summarize. And Ms McMillan, were you paying attention?
Mary McMillan: “Carole, I would not have missed it for the world.”
Here is my call to action—my “take-home message”:
Dedicate a course as part of the core curriculum to geriatrics in our physical therapist and physical therapist assistant schools. Do not keep this important part of our practice as the neglected stepchild. Prepare our students for where they will work.
Commit to ravenous lifelong learning. Seek out educational opportunities that will improve our skills, expand our professional toolboxes, and move the profession forward. Commit to learning something new at least monthly and encourage our students and colleagues to do the same.
Refocus on the clinician as the center of our profession. Create partnerships that include us as equals in research, policy development, education, and awards.
Embrace the unprecedented professional and personal opportunities presented by our aging population. I put to you the proposition that ageism is prejudice against not just our current patients but against our future selves. Age acceptance recognizes that one can be active, involved, curious, and a full participant in life until the very end.
On this concluding note, let me invite you to Move Forward for a bright future self.
Footnotes
The 47th Mary McMillan Lecture was presented at NEXT: Conference & Exposition of the American Physical Therapy Association; June 10, 2016; Nashville, Tennessee.
- © 2016 American Physical Therapy Association
