THE NOT-SO-IMPOSSIBLE DREAM - TENTH MARY MCMILLAN LECTURE
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Tenth Mary McMillan Lecture
The Not-So-Impossible Dream
M y overriding dream is that physical therapy
shall achieve greatness as a profession.
HELEN J. HISLOP, Ph.D.
Since the inauguration of this lecture a
dozen years ago, there have been scholarly
critiques of physical therapy history, philos
ophy, education, and therapeutics.
The lecturers have been physical therapists
who have placed their indelible mark on this
profession—those who have proudly received
the torch p assed on by Mary McMillan and kept
its flame burning brightly for the future.
Thus, 1 am filled with gratitude, responsi
bility, and humility. If you insist I f ind a word
for it, I can—paralysis. But 1 am fortified also
by this challenge, this opportunity, and this
honor. Helen J. Hislop, Ph.D.
1 acc epted the challenge because of the debt
I o we to this Association for the fullness of life
moral style, its determination to exist, and its
it has given me, and in respect and honor to
capacity t o endure.
you, my associates, who handed me the torch.
Thomas Jefferson said, "Every man should
In selecting the title for this address, "The
have a dream. Every dream should have a
Not-So-Impossible Dream," I reflected on a
purpose."
vision I h ave for a great profession—one unified
My purpose in sharing a dream with you is to
by shared values, shared beliefs, and shared
be found in th ese paraphrased words of Pericles
attitudes. These shared experiences a nd dreams
speaking to the Athenians:
are what give a profession its tone, its fiber, its
Fix your eyes on the greatness of your
Dr. Hislop is Professor of Physical Therapy, profession as y ou have it before you day by
University o f Southern California, Ran cho Los Amigos day-; fall in love with her; and when you feel
Center, 129 33 Ho rton Street, Downey, CA 90242. her great, remember that her greatness was
The tenth Mary McMillan Lecture was presented at
. won by people with courage, with knowledge
the fifty-first annual conference of the American
Physical Therapy Association, Anaheim, CA, June of their duty, and with a vision that all things
15-20, 1975. are possible.
Volume 55 /Number 10, October 1975 1069IDENTITY CRISIS therapy has a soft underbelly because its
science is in disarray. This disarray leaves it
Physical therapy today is in the midst of a open to attacks against its inadequacies—attacks
crisis of identity; it is, indeed, a profession in from medicine, attacks from government, chal
search of an identity. During fifty years, we lenges from fiscal agencies, and questions from
have passed quickly through an age of t olerance, the consuming public.
to a golden age, and most recently to an age of But, most of all, physical therapy is vulner
survival. Despite all o ur recognition, despite allable because somewhere along the way it has
our acceptance, despite all o ur disclaimers, we lost the sense of its elemental identity.
have not arrived and our survival is not assured. Physical therapy is on the defensive and it
Physical therapy needs to appreciate how cannot speak with one voice because of the
essential distinction is to survival. Over five difficulty stemming from its. failure to define
generations, we seem to have forgotten why our and agree upon what physical therapy is.
founders sought recognition. A society, a What are the fundamental and unique con
profession without a sense of the past for which cepts of this discipline? What are physical
it has respect, lacks identity and regard f or the therapists? Who are they? What do they do?
future. How do they do it? What results are expected
This, of all times in our history, is a time forfrom whatever it is they do?
strong identification. We m ust ask ourselves if Physical therapy has yet to document its
in our attempt to develop in multiple directions own conviction about its value to total health
we h ave assumed a cloak of unidentifiability; if care and to demonstrate its commitment to
in our rhetoric we have transmogrified our develop, teach, and apply its scientific prin
ideals; and if in our desire for acceptance we ciples as effectively as possible.
have become victims of self-made delusion.
Who, my friends, if not we ourselves, is to The Genetic Forces of Identity
speak for the spirit and essence of physical
therapy? Establishing a strong identity is n ot a There are two cardinal forces that create the
question of restriction. Rather, it is a matter of genetic heritage of a group, that imprint its
who is to say what we can do, what we will do, quintessence in the archives of knowledge—the
and what we must do. forces which act ultimately to carve out the
The intellect is vagabond and our present identity of the physical therapist.
condition fosters restlessness. We neglect the The first is the centrifugal or outflowing
history of ideas and the need for identity at our force which arises from the basic motivations
peril. If we deny them, we may be ingenious and purposes of the group. The centrifugal
technocrats, but we are also ingenious Philis force in physical therapy springs from a
tines and guilty of intellectual treason. people-helping desire linked with a motivation
I hope you will pardon me if I bear down to manipulate the human body to achieve more
hard on the adrenal glands of this profession, acceptable modes of function. The science and
but we have something worth fighting for and I humanism we employ to achieve our ends are
hope to stir up your concern. The generation the vectors of this force, and the magnitude of
growing up in physical therapy needs some of either vector may be large or small.
the spirit and spunk of Mary McMillan. But as we attempt to see ourselves, we are at
There are outside forces which are working the same time viewed by our fellowman. This
to retard our progress, even toward our gives rise to the centripetal or converging force
destruction, but these external forces have little that acts upon us. Its vectors are our contribu
penetration power in themselves. It is our tions to the individual patient and to the
internal fragility, our laxness, that establishes welfare of man. It arises in the anthropocosmos
our vulnerability. In the words of Pogo, "We in which we c onduct our affairs and can reflect
have met the enemy, and they is us." either warm winds of approbation or shivery
The reason for physical therapy's vulnera blasts of rejection. We cannot escape this
bility is that it is relatively defenseless against centripetal force for it is the respect given b y
the leviathan of modern science. Physical those we serve for that which we are.
1070 PHYSICAL THERAPYWe can use these two forces—one which
represents the profession and the other the
function of the profession—to carve a con
ceptual framework for physical therapy.
• FAMILY
It is time for physical therapy to lay claim to
the title of profession. It is time for physical CO \\
therapy to decide whether it wants to develop o.
o
• PERSON
tl
to the fullest those distinctive contributions for
which it has been recognized or whether to o
accept secondary status as the ultimate fulfill
ment of its purposes. To paraphrase Lewis —— SYSTEMS
Carroll: o
+-»
The time has come, it may be said a>
to dream of P.T.'s role c • ORGANS
t!
of life and limbs, and hearts and minds, k.
of sciences and goals. ©
I present these views as provisional, as your
>
o
• TISSUES
H
interpretations should be. Our equity in ideas
should be in their continued refreshment and
not in their eternal verity. For truth changes as
new knowledge sheds light on old shadows. • CELLS
So we address ourselves to the question,
"What is physical therapy?"
Fig. 1. The hierarchy of systems for study and
WHAT IS PHYSICAL THERAPY? analysis of human structure and function as
they relate to physical therapy.
Physical therapy is knowledge. Physical ther
apy is clinical science. Physical therapy is the If we view man as a natural system after the
reasoned application of science to warm and manner of Laszlo and others,1"4 we find a
needing human beings. Or it is nothing. The hierarchical pattern which can be used to define
precise role of science in physical therapy is not the science of physical therapy and its applica
often understood and no coherent philosoph tion (Fig. 1).
ical overview exists to guide the growth of the Each of the levels in this hierarchy is a
profession. In the spirit of dialecticism, there subsystem of the level ab ove, as well as being a
fore, may I present several premises upon which system in its own right. Information flows
I believe such a philosophy can be founded. freely up and down the system, and there are
The basic postulates are these: simple and complex feedback loops for inter-
1. Pathokinesiology is the distinguishing clin level and intralevel exchange.
ical science of physical therapy. It is the The person level of this hierarchy is of itself
study of anatomy and physiology as they a natural system as well as being part of the
relate to abnormal human movement. It larger hierarchy. At the person level, man
presents a theoretical base broad enough to expresses himself in all things from primitive
afford a rational explanation of human emotions to the most abstract theory with, and
motion disorders. Physical therapy in this through, motion. Without motion there is no
context contains a body of scientific and communication, no interpersonal reaction, no
empiric thought that can be applied to the development of society.
treatment of a wide variety of disorders. Health may be defined as the smooth
2. Physical therapy can claim the unique functioning of these interrelated systems,
privilege of placing the role of exercise in whereas disease results from any perturbing
health and disease in its proper scientific force which upsets the balance within one level,
focus and perspective. or between levels.
Volume 55 / Nu mber 10, October 1975 1071FAMILY ANTHROPOLOGY
PERSON PSYCHOLOGY
SYSTEMS PHYSIOLOGY
ORGANS ANATOMY
TISSUES HISTOLOGY
CELLS CYTOLOGY
Fig. 2. The basic sciences can be correlated with each level of the
natural system.
Conveniently, each level in the hierarchy altered at any level, homeostasis is disrupted
coincides with one of the basic biological and adaptations must take place to restore
sciences, which provides a solid foundation for some degree of balance. The alterations in
its adaptation in, and contribution to, physical motion may be hyperactive, hypoactive, or
therapy (Fig. 2). externally restrained and static. If the disrup
In applying the principles of motion to this tion is at the higher levels, signs of disuse or
natural system, it becomes obvious that all of incoordination ensue at lower levels. If motion
the structures express their function in motion ceases at lower levels, the result might be
(Fig. 3). Some of the more common expres destruction of a function or even death of the
sions of this motion would be Brownian person. Thus, there are many degrees of
movement at the subcellular level, blood flow perturbation, and subsequent adaptation may
at the tissue level, reflexes or postural adapta be total, partial, or nonexistent.
tion at the systems level, and purposeful work Motion is a concept that must be viewed
or play at the person level. When motion is beyond the purposeful contractions of skeletal
PERSON LOCOMOTION
SYSTEMS REFLEX ACTIVITY
- I .
ORGAN$ MUSCULAR CONTRACTION
TISSUES BLOOD FLOW
CELLS PHAGOGYTOSIS
Fig. 3. Motion occurs at every level in the human organism.
1072 PHYSICAL THERAPYFAMILY FAMILV
PERSON PERSON
TISSUES TISSUES
CELLS CELLS
Fig. 4. The realm where physical therapy is Fig. 5. Humanism is a correlate that must be
effective in the hierarchy of the human considered with the science of physical therapy
organism occurs between the tissue and person for the profession to meet its social goals.
levels.
muscle initiated by a c omplex nervous system. the person or the tissue—possessing no unique
Within this concept of biological motion we can tools for intervention at these levels.
construct a paradigm for physical therapy. Humanism is an intrinsic attribute of ther
apy, and as such it is an intrinsic element of
physical therapy (Fig. 5). Humaneness places
A Model of Physical Therapy
highest value on the person level of the
hierarchy, and physical therapists, in common
Conceptually, physical therapy by virtue of with other health practitioners, must retain a
its heritage, its science, and its available holistic view of the patient, even when their
technology is called to intervene when a therapeutic efforts are directed at a low er level
perturbing force or a potential disturbance of the natural system.
manifests itself in a motion disorder that is Examples of system perturbations, their
amenable to externally applied therapy. This effect, and the point of therapeutic interven
externally applied therapy is, for the most part, tion may be drawn using vectors in one
some form of controlled exercise or stimulus to direction to display the forces of disease or
induce movement; or it may be a means to ease injury and vectors in the countervailing direc
the perturbing force by judicious application of tion to display the forces of therapy (Fig. 6).
physical agents, such as those which increase Only the most simple influences are illustrated
blood flow or promote gas and fluid exchange. in the Figure, but one should keep in mind that
The purpose of physical therapy is to restore changes at one level can influence alterations at
motion homeostasis to the person or his all levels, and what may be external to the
subsystems or to enhance the adaptive capac tissue is in ternal to the organ, and so forth. The
ities of the organism to permanent impairment perturbing force may be very precise to one
or loss. The realm of physical therapy in this hierarchical level, such as a fracture, or it may
hierarchical system is between the motion be very b road, such as the extensive trauma of a
disruptions that occur at a tissue level and those motorcycle accident.
that manifest themselves in a most complex A burn is an example of tissue destruction
manner at the person level (Fig. 4). which may have profound effects at all levels
The physical therapist may have an influ (Fig. 6). Wide tissue destruction causes endo
ence on the family at the upper level and the crine responses which give rise to such stress
cells at the lower level, but only through either signs as gastric ulcers. Interruption of the
Volume 55 /Number 10, October 1975 1073PERSON —IMMOBILITY 4 ACTIVE
T EXERCISE
o
SYSTEMS-*- CONTRACTURES 4 PASSIVE
T EXERCISE
SPLINTING
ORGANS STRESS SYNDROME
BURN^ TISSUES -*• DESTRUCTION 4 DEBRIDEMENT
Fig. 6. An illustration of the effect of a perturbation at the tissue level
The burn causes disruption at four levels as indicated by the arrows
pointing toward the right. Intervention by physical therapy to
counteract the perturbing forces are indicated by arrows pointing
toward the left.
normal functioning of the skin leads to scarring, organ level, but he can use techniques for
contractures, and body fluid imbalance. At the positioning and splinting to reduce the sequelae
person level, there will be some decrease or loss of contractures and prevent deformity or
of function of the part or of the person as a reduce edema. The application of a v ariety of
whole. Emotional responses are reflected at the forms of active exercise—active implying the
person level and these, in turn, have a d isrupt person's consent and cooperation and, there
ing influence on the dynamics of the family and fore, involving his conduct-will counteract the
even beyond. effects of immobility, both general and specific.
Intervention by the physical therapist occurs In the example of a coronary thrombosis
at three specific levels. Debridement and all (Fig. 7) with its myocardial infarction and
that goes with it is used to promote healing of decreased cardiac output, the patient suffers
tissues. Other than aiding the salutary healing, from disruption of his normal energy supply
the therapist has no specific tool to use a t the and is m ade further inactive by angina and fear.
PERSON —• FUNCTION LOSS 4 TITRATED
T EXERCISE
SYSTEMS —ENERGY
DEPLETION
CORONARvORGANS —• MYOCARDIAL
/ INFARCT
o
TISSUES —• DISEQUILIBRIUM
Fig. 7. The disrupting force is a coronary thrombosis which causes
disruption at four levels. Physical therapy has direct influence only at
the person level, but this influence produces beneficial effects at lower
levels if patient cooperation is achieved.
1074 PHYSICAL THERAPYPERSON —• WALKING LOSS 4 GAIT
TRAINING
TRAUMA) SYSTEMS —LIMB LOSS { PROSTHESIS
ORGANS
TISSUES —• DESTRUCTION
Fig. 8. Trauma in the form of a lower limb amputation is an example of
a perturbing force at the systems level which is counteracted by
prosthetic fitting and gait training.
The only level wh ere the physical therapist has founders, and from their knowledge of body
influence is through an exercise program care movement and exercise grew t he applications of
fully titrated to match the patient's physiologic exercise to pathological conditions; thus, again,
resources. the purpose we serve is to restore motion
An example of perturbation at the systems homeostasis.
level would be the loss to the musculoskeletal So, then, the stage is set to place the science
system of a limb (Fig. 8). The resultant that is p hysical therapy in our model. We may
decrease in locomotor ability is managed by term this science pathokinesiology to distin
limb replacement with a prosthesis and gait guish it from kinesiology, which is t he science
training and its accompanying exercise program of normal human motion. The components of
at the person level. the science derive from several an atomical and
Physical therapy, then, may be viewed as a
pyramidal structure which has its foundations
in social and cultural needs (Fig. 9). PHYSICAL THERAPY
The people who are attracted to physical
therapy have a deep caring for people and,
beyond this, an altruistic drive for service to
people.
In common with all health professions,
physical therapy also has a scientific foundation
which springs from the needs of the sick and
the injured. Our particular foundation does not
include all of the basic sciences but it does draw
significantly from several, including anatomy,
physiology, pathology, biochemistry, bio
physics, and psychology.
Each health profession came into being to
meet a special social need. That need, or the
purpose of the professional discipline, should
be identified. Physical therapy was founded to
provide restorative services to persons who
suffer physically handicapping conditions. The
wellsprings of our origins are rooted in physical Fig. 9. The pyramidal structure of physical
education, for that discipline gave us our therapy.
Volume 55 / Nu mber 10y October 1975 1075physiological substrates including pathoki- faith. Everything we do, everything we propose
netics, biomechanics, neuropathology, and ex will be scrutinized as never before. To convince
ercise physiology. others of our aptitude, we must prove to
At the apex of our model is the clinical ourselves that our methods work. Are our
application of our science—therapeutic exercise. wondrous efforts a result of sound method or
This concept emphasizes our uniqueness and is do personality and human interaction explain
not intended to encompass more peripheral, away or create patient improvement?
but important, contributions to patient care. We are confronted on all sides with thera
By definition, then, physical therapy is a peutic endeavors which mix scientific fact with
health profession that emphasizes the sciences quasi-scientific hypothesis. Others have become
of pathokinesiology and the application of quick to condemn us—and they have justifica
therapeutic exercise for the prevention, evalua tion because we have not demanded rigorous
tion, and treatment of disorders of human and careful studies of unorthodox concepts—in
motion. fact, we perpetuate the attitude of condemna
tion because in our naive eagerness, we permit
Fragility of Clinical Science the promulgation of untruths or part truths and
confer honor and respect where we admit we
Where physical therapy is fragile is in lack of do not understand.
precision of its intervention procedures. There I suspect that we cannot continue to count
are no specific answers to the what, where, on help from our neighbors in other disciplines.
when, how much. Basmajian put it succinctly in It is going to be up to us to manage this science
an article in the June 1975 issue of Physical of ours by exploration and hard thinking.
Therapy when he said science is n ot the virtue There are no scholarly professions today
of physical therapy but rather its virtue lies in which do not have doctoral programs in their
an intensive interpersonal relationship with own discipline. The time is now to support
individual patients. This, my friends, is not doctoral education in pathokinesiology or
enough for our survival. physical therapy. In physical therapy, the
After fifty years, the science of physical advances in our field of endeavor are being
therapy is entering its infancy. A great diffi made, not by us but by others, and in this state
culty in developing the clinical science of we are reduced to being mental pickpockets
physical therapy is that we treat individual simply because we do not have organized
persons, each of whom is made up of situations programs to develop our own science.
which are unique and, therefore, appear incom This fact was cl early and succinctly pointed
patible with the generalizations demanded by out to us by Worthingham in her study of basic
science. education in physical therapy, 1966 to
In reality, however, humans have common 1969.5 That study, which could have had the
fundamental traits and they share experiences, impact of a latter-day Flexner report, should
values, and life styles which make statistically have sparked an educational revolution in
predictable responses possible. This makes physical therapy. Instead, bits and pieces have
clinical science possible. The time has come to at least prodded the forces of slower evolution.
give to the study of the responses of the living I am an optimist about what all of this means
human being the same dignity and support now for us. I believe that we have the power to
given t o the science of parts, animals, and petri shape the future in ways that will vastly
dishes. improve our condition. On the other hand, we
The determination of the profession to retain also have the power to destroy our profession
a viable place in the health care system with a as we know it by wandering without a strong
vigorous economic base compatible with the identity.
nation's resources, and to improve the quality The value of physical therapy to the total
of patient care must, for the indefinite future, health care of the public can be assessed onl y
necessitate a large, continuing research and within its value s ystem. Only when the science
development enterprise. is established and proclaimed will physical
This enterprise will not be taken on blind therapy cease to be palliative, adjunctive,
1076 PHYSICAL THERAPYelective, or an arena of last resort for the If the capacity for logical thought and
patient. scientific values is not acquired early, there is
If we .will have the conviction and the little hope such qualities will surface later. This
courage to proclaim once and for all what lack already has given rise to serious implica
physical therapy is and then act on it, the tions:
centrifugal forces generated will cast an ever-
lengthening shadow across the pages of human • Essential growth dependent upon accurate
history. analysis of patient needs is not occurring.
• The practitioner is more artisan than scien
The Centripetal Forces of Identity tist, and only a scientist can integrate
successfully the multiple variables expressed
The centripetal forces which cast the char by an impaired human being.
acter of physical therapy arise from the value
systems of the society we serve. Thus, to assess
the value of professional activities, one can Do not think I am crowning science as the
propose criteria that arise from outside the only important value. But, those in physical
profession—that is, from the judgments the therapy who do not comprehend the advances
public makes regarding a professional discipline. of science seem to fall back on the convention
Such external criteria ask of any given p rofes that the scientist is inca pable of sympathy and
sional activity that it have meaning and compassion—as if scientific accuracy and hu
relevance in th ree spheres: manism were mutually exclusive.
Sensitiveness toward people is not blunted
1. Scientific merit—which ju dges the degree to by science. Science is not inhumane. The
which the discipline understands its role and scientist and the humanist must complement
each other in the same individual to balance the
achieves its purpose
2. Humanistic merit—which judges the relation equation for excellence in care.
To weave a fresh fabric for each new patient
ship between the therapist and the patient
with the warp of man's primal empathy and the
3. Social merit—which judges whether the
woof of man's intellectual understanding—this
services provided aid social goals
is the final and permanent art of physical
therapy—its apotheosis.
My dream, simply put, is that physical
3. We must elevate the role of the clinician.
therapy will merit a secure and valued role in
Physical therapy in its essence is an inter
our society when measured against these cri
action between two human beings in a
teria. cybernetic loop—physically, physiologically,
and psychologically. Success in the clinic
What Must We Do? depends on constant interaction between
therapist, patient, environment, and ever-
1. First we must set up absolute standards of changing requirements. It depends on the
clinical performance rather than remain lost ability of the practitioner to assess the
in the morass of relativity. To be sure, such changing requirements and to apply his
standards are good only for today and not science, which is exacting and demanding,
forever, but the whole history of man through meticulous practice and persistent
indicates that when standards of conduct (of study.
any kind) gradually decay, permissiveness To a clinician, treatment is n ot only impor
leads to total decline. tant, it is p aramount. The care of the patient is
2. We m ust produce scholars in human patho- the ultimate, specific act that characterizes a
kinesiology. Not every therapist can become clinician. It differentiates him from all o thers.
a scholar in the true sense, but every Its obligation is transmitted as the heritage of
therapist can be imbued with an understand the profession. Its performance is his unique
ing of science as it is applied to physical contribution to mankind. If treatment is un
therapy. important or takes a secondary place, a
Volume 55 / Num ber 10, October 1975 1077clinician has no useful purpose for his exist specialists, but with caution and with realiza
ence. tion that our world of knowledge is so small in
Just as t he work of talent leads to success, so relation to our universe of ignorance. The
may success lead away from the endeavor strength of this innovation will depend upon
which conferred it. Most clinicians eventually proof of clinical competence. Specialization
are bogged down with the by-products of their should not be a drain from the grass r oots of
own successes. They are given large depart general service. It should transfuse into the
ments which must be administered; invitations commonweal realistic and vital promises of
come for lectures; more and more visitors are higher quality patient care. The pattern of
received; correspondence grows voluminous; specialization should encompass broad areas of
meetings replace care of the patient. practice so that knowledge is not partitioned so
Eventually nothing is left but interruptions. minutely as to build in myopic views of patient
Clinical skills are fragile and they must be care.
practiced to be preserved. Those clinicians who In advocating specialization as an option in
elect to become involved in other endeavors clinical practice I am aware of its problems. The
must exercise great care to avoid e ntropy else major criticism leveled against specialization is
patient care be relegated to a position where that by trying to solve complexity it creates
the patient becomes the forgotten man. some degree of isolation. The corpus of
For the physical therapist who wishes to knowledge keeps breaking in ever smaller
remain a career clinician there should be subdivisions, each tended by persons who,
incentives, economic and otherwise, to reward unless offsetting influences are exerted, may be
his proficiency and contribution to patient inarticulate and even unaware of other efforts
care, which is what physical therapy is all in their own profession. The wisest specialists
about. The advent of the physical therapist will, of course, never lose sight of the bewil
assistant to take care of less demanding dering complexity of man. In disease o r health,
procedures frees the clinician to direct his man cannot be understood piecemeal, even if
attention to the development of our clinical he has to be studied that way.
science. Specialization is one idea whose time has
If you want a bee to make honey you do not come for the clinician. The kind of clinical
issue directives and protocols on carbohydrate practice I envision for the specialist cannot be
metabolism and solar navigation. You put him ordered or commanded. The best we can do is
together with other bees. If the air is right, the recognize it and encourage it in the sensitive
science will come in its own season, like pure few—to prevent its inhibition by too much
honey. teaching, its submission by too much dogma, its
extinction by too much ritual.
Clinical Specialization The clinical specialist should be the clinical
scientist and demonstrate that clinical science
The momentous and great advances in and its methods stand successfully over all
medical science of recent years have had an others in the advancement of knowledge.
impact and have introduced changes that Indeed, it is my dream that clinical specialists,
perforce should modify our practice. It is only born in science, nurtured in reason, seasoned in
natural that the explosion of knowledge should practice, and blended with compassion will
outstrip the capacity of any practitioner to begin to deal in physical therapy with questions
encompass the entire field. The need for some that long have challenged the human intellect
kind of specialization is upon us because and the human spirit.
society has served fair notice that it anticipates
more complete and higher quality health Strategy for Survival
services. To respond, physical therapy must
come out of its long diastole and recognize new The place of physical therapy is in the stream
modes and new methods for the practitioner. of patient care, not on its banks.
It is my dream that this profession embark The role of the clinician represents a chal
upon structured programs to train clinical lenge that will, of necessity, be met in one
1078 PHYSICAL THERAPYfashion or another, and it can be better met if bird in your hand. You ask me is it dead or we face it forthrightly. It is old knowledge in alive; I answer, it is as you will." Scotland that the sheep who stand on a rise of The future of physical therapy is in your ground and face into the storm survive, while hands. To each mind is offered its choice those which huddle together for warmth in the between ideas and somnolence, its choice low places frequently are suffocated in the between questing and resting. Take which you snowdrifts. please. You can never have both. What will h appen to us, I wonder, if we deny the value of the primary clinician, if we distort GREATNESS our identification by denying use of skills which take years to accrue through long and My ov erriding dream is that physical therapy intimate contact with patients and countless shall achieve greatness as a pr ofession. clinical dilemmas. Our aims may be noble, our virtues ad Physical therapy is in deeper trouble than mirable, our sins minimal, and our practice most realize, for we have no real strategies for moral, but without the saving merit of a mending our ways, for adapting to change- habitual vision of greatness, its attainment is only tactics aimed at simple survival. impossible. If we do not achieve greatness, what Unless the best trained of our constituency we d o or what we believe do es not matter. We are willing, no, eager, to retain their clinical shall be no more noticed than sand dropped orientation in direct care of the patient, it is and buried with more of its kind at the bottom difficult to see from whence the push toward of the hourglass of time. the steady improvement of quality will c ome. Physical therapy stands at what could be the That, indeed, would be the ultimate tragedy, beginning of a new era; an era in which science for if our glimpse of the future finds us as is o ur quest and humaneness our expression; an powerless as we are today to answer the clinical era in which physical therapy can constitute a questions, I'm afraid there will be no future. bridge over which science and man's dignity Only because there is hope for the eventual maintain contact. improvement of quality can we retain optimism The issue is cle ar: if greatness is a goal, it will for the ultimate effectiveness of physical take great thinking and consummate honesty to therapy. achieve it. Why will we survive? How will we survive? I have spoken to the crisis of identity with Just this. By providing a unique and distinct which we are afflicted. Now is the time to burst service t o the people—service no t equaled in its out of our lassitude with an explosive force that excellence, breadth, or comprehensiveness by others do not credit to us. any other group. Our distinctive recognition as a profession is We have a choice. Either we assume control not the contribution of a single measure but a of the science of physical therapy or we fail to concept of health care, the touchstone of which take that responsibility and see our profession is the identifiable clinical science of patho- become increasingly irrelevant, redundant, and kinesiology. its practices deteriorate. Physical therapy cannot achieve its best Perhaps I can best illustrate my remarks by purpose until that clinical science is elevated to this fable from an unknown source: A cynical preeminence in that purpose. In turn, we m ust man walked up to a wise p hilosopher one day elevate the clinician to a level of pr imacy. There and said, "You who are so wise, I ask one is no more important task today than to question. I have a bird in my hand. Tell me, is provide him with newer knowledge, newer the bird dead or alive?" tools, a strong, defensible identity so that The philosopher thought for a moment. "If I Longfellow's words might describe him fit say to him that it is dead, the live bir d will fly tingly, "Staunch and strong, a goodly vessel away; but if I say to him that it is alive, he will that may with wave and whirlwind wrestle." clench his fist, crush the life from the bird, Our end is our own to be won by our own open his hand and show me a dead bird." So endeavor and held on our own terms. The the wise man said to the cynic, "You have a reality of our tomorrow will depend very much Volume 55 / Nu mber 10, October 1975 1079
upon the quality of what you think on, for as For
Marcus Aurelius said: the soul of a profession is We are the music makers
tinged with the color and complexion of its and we are t he dreamers of drea ms . . .
thought. Yet we are the movers and shakers
of t he world forever, it seems.6
Be scientific but not callous
Be humanistic but not soft
Be independent but not isolated To dream the impossible dream? To fight the
Be professional but not narrow unbeatable foe? No, my friends.
Be judgmental but not dogmatic
Be vocal but speak with one voice We mil be great.
Be dreamers but not drifters. This is the not-so-impossible dream.
REFERENCES
1. Laszlo E: The Systems View of the World. New 5. Worthingham CA: Study of basic physical therapy
York, Braziller, 1972 education. Phys Ther Part I. 48:7-20, 1968; Part II.
2. Yates FE, Marsh DJ, Iberall AS: In Behnke J, 48:935-962, 1968; Part III. 48:1195-1215,
Challenging Biological Problems. New York, Ox 1353-1382, 1968; Part IV. 49:476-499, 1969; Part
ford University Press, 1972 V. 50:989-1031, 1970; Part VI. 50:1315-1332,
3. Sheldon A, Baker F, McLaughlin CP: Systems and 1970
Medical Care. Cambridge, M.I.T. Press, 1970 6. O'Shaughnessy AWE: Ode: We Are the Music
4. Brody H: The systems view of man. Perspect Biol Makers. In The Oxford Book of Victorian Verse,
Med 16:71-91, 1973 Oxford at the Clarendon Press, 192 5
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