21st Century #Physicaltherapy Curriculum

November 18, 2013 by

As Thanksgiving approaches, I wanted to practice a version of the gratitude letter by expressing my thanks to many of you for your activism and support over the past few weeks. Thanks to all of you who attended our session at PPS on “What Patient’s Want” including many of the live tweets from NOLA-much appreciated.  @DavidBrowder and I presented analysis of an extensive conjoint study on the important attributes from a service perspective that patient’s deem the most important. Many of you have encouraged us to do a webinar on the material and what the research has to say about those service factors-we will, stay tuned.  Thanks also to many of you who took advantage of the wonderful and glamorous @karenlitzNYC’ and her brilliant virtual conference replay which includes my annual PPS chicken & waffle breakfast tweep @Jerry_DurhamPT talking about patient conversion. This virtual conference was at the same time as PPS!  Lastly, thanks to @SnippetPhysTher who continues to facilitate #solvePT on twitter every tues evening. Her most recent topic was on supporting your colleagues (summary HERE). On that front @PTPubNight has gone from debate to action by getting PT’s together with PT Pub Night’s going on all over the place!  What a time to be a Physical Therapist!

I would like some feedback and thought on #physicaltherapy skills of the 21st century-the next generation curriculum for entry level students as well as residency and fellowship trained PTs.  There is no questions regarding clinical decision making, basic science, evidence-based practice, and hands on manual therapy with deliberate practice as a basis, (a topic I hope to explore more deeply for at Manipalooza 2014). However, this gets to just half of the equation and in some cases produces a PT that is bent on being a fixer rather than a helper or sever (to use Naomi Remen’s language).  Here are some curriculum adds that I would like to see (an am interested in yours). No particular order:

1. “Non-sales” Selling to use Daniel Pink’s term from his latest book, To Sell is Human. With the combination of education and health services (he refers to as Ed-Med) contributing to the largest component of the job market, it will be imperative to educate and train effective.  How about this gem from his book, “physical therapist helping someone recover from injury needs that person to hand over resources-again, time, attention, and effort-because doing so, painful though it can be, will leave the patient healthier”. Yes, we are all in the selling business-let’s embrace it and learn how to do it to the benefit of our patients.
2. Developing High Quality Connections. While I want into some detail on this post, it deserves emphasis because a critical component of the patient-therapist interaction is the connection or relationship that is established. Research also shows that HQCs facilitate an individual’s recovery and adaptation when suffering from loss or illness (Lilius, Worline, Maitlis, Kanov, Dutton, & Frost, 2008).

3. Empathy.  A partial ingredient of both #1 and #2 above. Covered Here and Here.  Replicated research demonstrates that empathy can be trained and is often in need of replenishment.  PT curriculum might include adding back a humanities course or two to entry level PT (realize that sounds heretical). More than simply perspective taking, empathy is a complex multiple construct in need of a deeper dive by all healthcare providers.

4. Teamwork/collaboration and other tacit knowledge skills. In school, when somebody uses a classmate’s help on a test, it is called cheating. In real life, using your colleague and co-workers help is essential to success.  Such “softer” skill sets are seriously lacking in new PT entrants in my opinion-in part because they just spent most of their clinical education trying to satisfy an employer’s workplace shortage (ok, over stating here but nevertheless some modeling and mentoring would be helpful).

5. Leadership training-particularly resonant leadership and emotional intelligence.  This underlies all of the above.  One half of the battle is working in an environment beset with rules and regulations and the other half is overcoming your desire to lambaste your patient’s shortcomings.  Coursework in dealing in both is a start.



11 Responses

  1. Zack Duhamel says:

    Great thoughts Larry, as a current first year DPT student its interesting to see that most of the changes that you would like to see are almost “attitude-shifters.” I don’t know if that makes sense, but I think you are right on with the fact that our education needs to have a big emphasis on the other (perhaps the bigger half) of a good PT which is the patient interaction part.
    Great stuff. Thanks.

  2. Rachael Lowe says:

    Great post Larry, nice shout out to all that’s been going on recently and interesting thoughts for developing curriculum. I would like to see more consideration for global health. Non-communicable diseases are the worlds largest (growing) health burden and we are in a great position in our clinician-client interaction to effect the required lifestyle modification to combat these conditions. Being a profession with core values in movement and exercise we are in the best position to tackle one of the key elements that underlies all non-communicable diseases – increasing an individual’s physical activity. This has become all the more evident to me recently following my participation in a global health course (, together we can make a difference.

  3. Wow, Larry. Nailed it.

    I think the empathy part is the most overlooked and underrated secret to success in our profession, and I have been concerned for some time that we are losing some of that in our quest for greater technical skill.

    I was fascinated when I read recently in a book called Givers and Takers that radiologists do a measurably better job interpreting CT scans when they are accompanied by a picture of the patient. How can that little bit of an insight, in this case, just a picture, of a person make a difference? Think of the advantage we have as PTs… We have one huge advantage compared against most other niches in healthcare: we have the opportunity to actually develop a relationship with our patients.

    Well done.

  4. Jim Plymale says:

    Larry -

    Great set of observations. I guess we’re asking our aspiring caregivers to exhibit emotional intelligence as you state in the last point. I know that in most businesses, these traits are highly prized. Empathy is one of the key components of emotional intelligence in the interpersonal composite and should be well balanced with assertiveness in the self expression composite. A lot of graduates in many fields come out believing they know the answers before they even understand the questions. We call this the “seek to understand before being understood” skill at Clincient.

    I also love the idea that someone who aspires to provide care be able to “sell” the benefits of their care, their “product” to the potential buyers or “patients”. This is becoming so much more important as healthcare decisions become more consumer driven.

    Collaboration and teamwork are to be highly prized on any team. We never stop learning and growing and most of that comes from transfers of knowledge and experience in the relationships we have.

    One of the things we’ve done is using profiling tests when we hire that look for behavioral traits such as emotional intelligence and other behaviors beyond just the experience or skills required to do the job. It’s made a huge difference in finding not just the right skills, but the right people.

    Great comments!

  5. Evan Raftopoulos says:

    Hi Larry, can emotional intelligence / resonant leadership be taught and developed using traditional methods (ie skill training) that you also seem to embrace without a question when you say “hands on manual therapy with deliberate practice as a basis” ? I think when we are talking about developing emotional intelligence we are much above the level of traditional skill training as taught in PT schools, fellowships, and events that celebrate and exaggerate(in my opinion) the importance of MT skill development (eg “manipalooza”). I’m interested to hear your thoughts about this.


    Evan Raftopoulos, PT

  6. Selena Horner says:

    Thank you for the mention, Larry.

    I look back at my education and one thing that was missing was an opportunity to work with others outside of the PT department/class. What would happen if students/residents were provided the opportunity to collaborate and work with other departments on a mutual project outside of class time?

    What if nursing was trying to head up an outreach project focused on people who have diabetes? What better way to create impressions and relationships by having the PT Department reach out to the nursing department and create an opportunity for PT students to assist in strengthening the outreach project?

    What if the Osteopathic Department wanted to head up an outreach program focused on a pre-joint arthroplasty educational session? What would happen if the PT Department reached out to the osteopaths to suggest collaboration that would help the orthos succeed and improve the outreach program?

    And then, not only that… how cool would it be for the PT Department to reach out to the marketing department and have PT students work with marketing students on a collaborative project? Amazing messages could be created.

    I suppose, what I am really trying to convey… eliminate the silos. Imagine what would happen if PT students intermingled with various departments either assisting or being assisted?

    I know you mention empathy with patients…. imagine if the educational system allowed various majors/minors/grad students to have empathy for each other? What would happen?

  7. John Ware, PT says:

    I think these deficiencies in the PT curriculum that Larry very clearly and eloquently identifies are actually peripheral to the core deficiency, which is the lack of understanding of how and why our patients hurt. You can’t empathize with an individual who is afflicted with something you don’t understand. You can’t provide leadership in an area of health care in which you lack a firm grasp on the fundamental concepts and theories that explain how and why it happens.

    Furthermore, the deficiency in knowledge of pain is trans-professional. Indeed, it pervades the culture, which in large part explains the pain epidemic we are facing. Medical and nursing schools don’t adequately prepare their students with respect to the extant science relevant to pain any better than PT schools do. Therefore, attempts at teamwork across disciplines is fraught with roadblocks and frustration as the various professionals talked past each other in their acquired language of ignorance.

    One of the main reasons the silos exist is because each profession has its own way of applying lipstick to a pig. I’m reminded of that popular parable of the blind men explaining what an elephant is by each of them grasping a different part of its body. They all get it wrong.

    Finally, I think a key feature of emotional intelligence is communicating in terms that evoke the difficult balance between competence and humility from those with whom you are trying to build an alliance- whether it’s inter-professional or therapist-patient. With my patients who are suffering with pain, this means striking that very precarious note between the uncertainty inherent in the multidimensional pain experience and the confidence that I can help them in their recovery. In a way, I have to convince them to expect- even to seek – the unexpected. That’s not a simple proposition.

    It boils down to trust in the end. Are we doing everything we can to build trust in physical therapy as a profession from our patients and colleagues in health care? Are the words we use- in the clinic, in advertising, on the continuing education circuit- accurate and demonstrate we are serious and competent? Are our ideas and arguments well-formulated and based on solid principles guided by science?

    I think we need to ask those questions individually, in our professional circles, and as a profession as a whole.

  8. Kory Zimney says:

    I would agree with all the many things you pointed to Larry and others that should be added to PT schools. I’m wondering what should be taken out so these things can gain more attention?

  9. Thanks Larry! As Jerry said, “you nailed it,” or at least part of it. I think all of your topics are great, but I think #5 is the most “under served” or talked about! So few of the PTs I meet and talk to today want any type of leadership position or role. I talked with a PT on Maui yesterday who is dying for PTs that want to manage or work in a growing practice in “Paradise!” I could not believe it, how could any new PT not want to work or manage in Paradise!

    I love the idea that you mention that we all are in the sales/influencing roles and that we need to co-laborate with our patients and help them find their own best solutions!

    Blessings to you and all you love and care about! RJ

    • carmen maria romero PT says:

      was thinking about your reply and post over the holiday. There is a factor that may contribute to the lack of thriving leadership amongst PTs, that has not been mentioned yet. It may be addressed in the DPT leadership tract for EIM, but certainly not in the general PT curriculum. This factor is gender. There was a whole week discussion about gender and leadership on NPR a few months ago. They presented fascinating and evidenced based research that continues to show the discrepancy between women versus men in leadership positions. I think the data has some bearing on health care and the leadership as historically physical, occupational therapy, nursing careers have tipped to the female side. Physical therapy I think is more even, but at least in leadership, the shift into gender equality is still sluggish. According to the latest studies research continues to show that compared to men, women are required to supersede their potential with accolades and degrees, etc in order to receive the mentorships, considerations or opportunities to move into management and leadership roles. Studies show that the relationship in general is inverse for men. Although degrees, experience, and accolades are impressive in general ,for the most part, studies continue to indicate that men are chosen because their managers or executive leaders see “potential”.
      Another interesting fact the latest research shows is that women are natural collaborators, innovators and lean empathically. Therefore, they are seeking positions that allow for more than just an upgrade in management and salary. They are looking for environments where these values would be seen as a strength and utilized to better business.
      They are less likely to choose a management environment that is autonomous or hierarchal structured.
      Lastly, and this was astounding, that although the research is solid on the ROI value of women in middle management, executive leadership and or board placement, companies and boards are less likely all things being equal to choose a women over men. Profits are shown via research on gender leadership to exponentially increase having just one female in leadership or present on a board.

      Provocative topic and I think one worth open discussion and integration into any curriculum and future vision of the PT profession
      CM PT

  10. carmen maria romero PT says:

    I agree with Selena. There is not enough “cross pollination” across degrees, careers and institutions. Which stunts the capacity and possibility of our students to cultivate creativity and innovation. Healthcare is typically not seen as a meca or source of creativity yet there are painters, poets, musicians and innovators amongst us. Some have broken through and have become some of our most inspiring leaders and innovators, but why so few??

    So how do we push physical therapy to its tipping point, and create a new generation of PTs that not only receive the foundations of evidenced based care but also the foundations to develop and thrive with “restless intellectual curiosity, deep optimism, the ability to accept repeated failures as the price for ultimate success, a relentless work ethic and a mindset that encourages not just ideas, but action”???

    I would suggest that design theory and innovation training go well with empathy, leadership, teamwork and your humanities pitch Larry. It even translates well to global health which I am also passionate about
    Rachel. Think of empowering the rural, underserved and disabled to innovate and create their own culturally accepted and inspiring exercise regimens…you get exercise, empowerment and excellence in health but even more spectacular they created it themselves!

    Education expert Sir Ken Robinson had an interesting comment on traditional schooling and creativity. “We’re now running a national education system where mistakes are the worst things you can make. Education is the system that’s supposed to develop our natural abilities and enable us to make our way in the world”

    Randy Komisare, venture capitalist, states, “what distinguishes pockets of entrepreneurship is not their successes but the way they deal with failure.
    In cultures that encourage entrepreneurship, there is a greater appreciation and understanding of “constructive failure”

    Imagine a PT school with classes where you meet for rapid innovation cycles, where you can test ideas, experiment with solutions, share, and practice open collaboration before you graduate and go into a heavily structured regulated environment….would be awesome…and an interesting next 50 years…The PTPub nights could be a post professional take on innovation forums??

    All the quotes and ideas of human driven design theory come from IDEO and the at Stanford. The founders, Tom Kelley and David Kelley, wrote a book called Creative Confidence, which has sparked this conversation, excerpts and sharing of these ideas.

    One last interesting piece is how a hospital in London, London’s Great Ormond Street Hospital chose to work on efficiency because of chaotic patient handoffs. They asked a Ferrari pit crew to coach the hospital staff members. Imagine what a killer creative open approach to instill new behaviors! As per the Wall Street Journal “The Ferrari inspired changes reduced technical errors by 42 percent and information errors by 49 percent.”

    IDEOs partner and consulting associate professor Chris Flink put it succinctly when he said, “The personal resilience, courage, and humility born of a healthy failure form a priceless piece of their education and growth”

    Yes, most student these days will graduate with extensive debt, but if we can expose them to the power of creativity, constructive failure and rapid innovation then we will, as the elders of a rapidly changing profession, leave a legacy of resilient compassionate excited human beings that just happen to be awesome PTs:)

    Carmen Maria PT poet educator facilitator and creative engine

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