Physical Therapy Educational Programs, 1947-61
Lieutenant Colonel Barbara R. Friz, USA (Ret.)
On 31 December 1959, 80 percent of all physical therapists assigned to Army hospitals were graduates of the Army Physical Therapy Course. Such a high percentage vividly reflects the importance of this educational program not only as a source of physical therapists to staff Army hospitals throughout the world, but also as a significant influence on the quality of the overall physical therapy program.
Reactivation of the Army Physical Therapy Course
The year was 1946--Army hospitals were closing, patient loads were dwindling, and the ratio of physical therapists to patients was becoming ever greater. Finally, the supply exceeded the demand and, for the first time since 1922, the Army found no need to conduct a physical therapy course. The program was, therefore, discontinued.
But this plethora of physical therapists was to be short lived. Foreshadowing another personnel shortage was the termination of Army of the United States status on 30 June 1948.1 All Army of the United States officers had to apply for a Reserve commission or be released from the service. To many the thought of such a commission evoked furtive fears of indefinite retention on active duty, a prospect most were not willing to accept. As expected, the attrition rate was high. In the 3-month period from 1 April to 30 June 1948, the number of physical therapists on active duty dropped from 253 to 197, a number which fell short of requirements and which threatened to become even smaller. Once more the Army needed additional physical therapists-this time to care for the peacetime soldier and his family.
It was soon evident that help from civilian sources was not forthcoming. Wartime experiences had given new status to this specialty, and civilian jobs, once scarce, were now plentiful. Despite the large numbers trained by the Army during World War II and the ensuing release of hundreds to the civilian market, physical therapists were nationally in short supply. Furthermore, physical therapists, like most of the population in the country, were just beginning to enjoy the flavor of postwar prosperity and to relax in the anticipation of con-
1Department of the Army Circular No. 27, 3 Feb. 1948.
tinued peace. Generally speaking, thoughts of military service were relegated to the realm of oblivion.
The Army, mindful of its pledge to provide the best medical care for the soldier in peace as well as in war, was again faced with the prospect of training its own professional personnel. Foreseeing just such an eventuality, The Surgeon General had started planning as early as February 1948 for the reactivation of a physical therapy course.
The first plan was to reactivate the school in its former traditional setting at Walter Reed General Hospital, Washington, D.C. Diverting this line of thought, however, was the fact that in 1946, the Medical Field Service School had been moved from Carlisle Barracks, Pa., to Brooke Army Medical Center, Fort Sam Houston, Tex. Concentrated here were Army instructors, laboratory facilities, libraries, classrooms, and the clinical material of Brooke General Hospital, all of which would serve well the interests of the physical therapy program. With this in mind, The Surgeon General decided that the location of the school would be at Fort Sam Houston in picturesque San Antonio.
Plans progressed rapidly and, on 13 May 1948, verbal approval to implement the physical therapy course was granted by the Organization and Training Division and the Personnel and Administrative Division, General Staff, U.S. Army. By dint of intensive effort and hard work, the Program of Instruction was completed in the Surgeon General`s Office in June 1948 and immediately submitted to the Commanding General, Brooke Army Medical Center, for approval and publication.
On 7 July 1948, the course was formally announced:2
Class No. 1 of a training course for Physical Therapists will commence on 1 November 1948. The course is divided into two (2) phases of approximately six (6) months` duration each: The first or didactic phase will be conducted at the Medical Field Service School, Brooke Army Medical Center, Fort Sam Houston, Texas, and the second or applicatory phase which follows immediately, will be conducted at selected Army General Hospitals.
Students selected for this training were to be commissioned as second lieutenants in the Women`s Medical Specialist Corps Reserve.
Col. James E. Tate, MC, Chief, Physical Medicine Service, Brooke General Hospital, became medical director of the course. Maj. Ethel M. Theilmann, with 6 years` experience in directing physical therapy courses, was appointed technical director and Capt. (later Lt. Col.) Beatrice Whitcomb was named her assistant.
On 6 September 1948, 11 eager and somewhat bewildered young women arrived at the Medical Field Service School to attend the Basic Medical Department Female Officers` Course before starting the physical therapy course. Inasmuch as they were impatient to begin their professional studies, the interposition of an 8-week military course was greeted with meager enthusiasm. Alleviating their disappointment, however, was 38 hours of instruction in physical therapy, substituted for 38 hours of comparatively irrelevant instruction normally presented
2Circular No. 85, Office of The Surgeon General, 7 July 1948.
in the basic course. This arrangement afforded the students a tantalizing peek into their future profession and also freed 38 hours to be used for clinical observation and practice during the didactic phase.
While the first class of physical therapy students were busy with studies at the Medical Field Service School, the staffs at Fitzsimons General Hospital, Denver, Colo., and at Walter Reed General Hospital were feverishly preparing a clinical applicatory program in anticipation of the arrival of five students at each hospital in May.3 At the same time, the Surgeon General`s Office was sparing no effort in assuring a smooth integration of the two phases. Subsequently, the American Physical Therapy Association was invited to send a representative to the appropriate installations to evaluate the program. In March 1949, Miss Barbara White, Educational Secretary of that organization, visited the Medical Field Service School and Fitzsimons General Hospital. (Walter Reed General Hospital was not visited until November 1949.) An excerpt from Miss White`s report on the Medical Field Service School follows:4
The program is well organized and administered. The medical and physical therapy staff assigned to the Medical Field Service School is selected on the basis of past experience and interest in educational programs. There is close cooperation between the school staff and the hospital staff. There are frequent conferences between the heads of the different departments concerned.
The report on Fitzsimons General Hospital facilities and the proposed program was primarily descriptive and included several helpful suggestions for conduct of the forthcoming clinical phase.
Although the overall tone of Miss White`s report was favorable, she criticized the lack of dissection material and included a recommendation that cadavers be provided for dissection in the gross anatomy classes. With this comment, she "zeroed in" on a trouble spot which had plagued the faculty since the inception of the course. All efforts to obtain cadavers that first year were futile. Despite repeated entreaties to the Texas Anatomical Board, that august body, it seems, had better plans for their corpora and refused to relinquish even one. At one point the possibility of either abandoning the course or moving it to another location was considered; a substandard course could not be sanctioned by The Surgeon General. As an interim measure, it was finally decided that the deficiency could be sufficiently compensated during the second phase by giving the students a minimum of 28 hours of dissection demonstration by an anatomist. This was subsequently accomplished. In her report, Miss White also recommended an exchange of visits between the physical therapy director at the school and the supervisors of the student`s work during phase II in order to better integrate the first and second phases; however, because more propitious methods were possible, this recommendation was never acted upon.
3One of the eleven students had been dropped from the course.
4Report, Barbara White, Educational Secretary, American Physical Therapy Association, subject: Physical Therapy Course Conducted by the Department of the Army; Installation Visited 17-19 March 1949.
The course was approved by the Council on Medical Education and Hospitals, American Medical Association, in June 1949, 16 months after planning started. Undoubtedly, the experience gained by the Army in conducting previous physical therapy courses for many years contributed to the relative ease and speed with which the program was established and approved.
The year`s educational efforts were climaxed by a conference on the physical therapy training program held in the Surgeon General`s Office on 27 and 28 June 1949. Attending the conference were Lt. Col. Edna Lura, Chief, Physical Therapist Section, and Maj. (later Col.) Harriet S. Lee, Surgeon General`s Office; Major Theilmann, Medical Field Service School; Maj. Elsie Kuraner, Chief Physical Therapist, Fitzsimons General Hospital; Maj. (later Lt. Col.) Agnes P. Snyder, Director, Physical Therapy Course; and Capt. Barbara M. Robertson,5 Chief Physical Therapist, Walter Reed General Hospital. Col. Emmett M. Smith, MC, Chief, Physical Medicine Consultants Division, Surgeon General`s Office, and Col. Emma E. Vogel, Chief, Women`s Medical Specialist Corps, also participated in the conference.
In October 1949, 9 of the original 11 students in the first class were graduated and received their certificates from the Surgeon General`s Office. In November 1949, 14 students were enrolled for the second class, thereby attesting to the prospect of the programs continuing for an indefinite time.
The curriculum of the Army Physical Therapy Course was designed to meet the requirements of a professional curriculum as outlined in the "Essentials of an Approved Physical Therapy School" by the Council on Medical Education and Hospitals.
As in all courses conducted at the Medical Field Service School, the curriculum was in the form of a "Program of Instruction," a detailed publication which included the title of each course subject along with the lesson plan number, the scope of each unit of instruction, the type of instruction, and the pertinent references. Course title terminology underwent several changes through the years. For instance, applied anatomy became functional anatomy and then kinesiology. Table 19 presents the curriculum content with changes for the years 1948-50, 1953, and 1959. The changes in title terminology are not shown.
Curriculum content remained relatively constant; however, changes in emphasis, coinciding with professional developments in the field, affected the distribution of hours. The shift in emphasis was especially noticeable in the therapeutic exercise course where procedures were increasingly directed toward total rehabilitation of the patient. Physical reconditioning, now administered by physical and occupational therapy, was also incorporated in the course.
5Later Lt. Col. Barbara R. Friz.
In an effort to introduce the students to a clinical situation as early as possible, the didactic phase was kept at a minimum number of weeks. When the program was first implemented, the clinical practice period consisted of 23 weeks out of the total 49 weeks with 270 hours of formal instruction projected into the second phase, to be taught mostly by physical therapists. It was the intent of The Surgeon General that the residents in the physical medicine service at the two hospitals would also participate in the teaching program and be responsible for the following subjects:
Physical therapy as applied to-
Except for roentgenology, these hours were all supplementary to instruction previously presented in phase I. In reality, the courses were taught, for the most part, by medical officers in services other than physical medicine.
Despite the well-delineated scope of instruction presented in the program, the instructors in phase II encountered considerable difficulty in maintaining continuity in presentation of material. Further, as Colonel Smith noted at the June 1949 conference, the shortage of medical officers in general hospitals created problems which often prevented the instructors from appearing in the classroom at the designated time. These observations led to the transfer of the subjects in question to phase I instruction.
In 1950, when the Korean War created an immediate demand for stepped-up utilization of personnel, the Medical Field Service School responded by effecting an overall class time cut of 15 percent, thereby shortening phase I of the physical therapy course from 32 to 27 weeks. The total length of the course remained the same, however, and subjects which were slighted in the concentrated schedule of phase I were reinforced by supplemental instruction in the lengthened second phase. Paradoxically, 75 hours of the instruction taken from phase II were added to this accelerated first period, a change made possible only because the working week in Army training programs was increased to 44 hours during the emergency situation. The curtailment of phase I also canceled all clinical practice and the students were catapulted into phase II without any experience whatsoever in clinical situations--"it was like learning to type without a typewriter," declared one frustrated student. In 1953, the changing world situation again affected
training policy and permitted the restoration of 2 weeks to phase I as well as the incorporation of 82 hours of clinical observation and practice in that phase. During the critical period from 1951 to 1953, two physical therapy classes were conducted each year.
The 1953 Program of Instruction showed an unrealistic jump of from 5 to 38 hours in the course on physical medicine and rehabilitation.6 The content, thereafter, was directed toward application of physical medicine procedures to the various conditions treated rather than procedures per se.
In 1955, the Council on Medical Education and Hospitals recommended an increased number of hours in both physiology, therapeutic exercise, and tests and measurements. To add more hours to an already bulging schedule would have expanded it to precarious proportions and was unthinkable to both students and faculty. It was decided to meet the additional requirements in physiology by adding 3 semester hours to the prerequisites for selection of students. Although the recommended additional hours in both therapeutic exercise and tests and measurements were in reality amply provided for in terms of supervised clinical experiences, they were not reflected as such in the Program of Instruction. These hours were, therefore, delineated and incorporated in the phase II curriculum.
Students for the 1948 class were selected by a committee of officers designated by The Surgeon General from applicants who presented the following basic prerequisites:7
a. Have completed a course and hold a degree with major emphasis on physical education from an accredited school or university.
c. Have reached their 21st but have not passed their 26th birthday on the date of appointment in the Women`s Medical Specialist Corps of the Officers` Reserve Corps (fig. 125).
d. Make an application for extended active duty for a period of two years * * *.
If selected, students were required to sign a statement of their intentionto apply for a commission in the Regular Army after satisfactory completionof 2 years` active duty and if otherwise qualified. Such an obligation,however, proved to be a deterrent in recruiting students and was removedin February 1952.8
The requirement of a physical education major stemmed from the time physical therapy was emerging as a new specialty in the United States. Physical education was then considered the educational background of choice because (1) the physical education curriculum included science courses basic to the study of physical therapy and (2)
6The number of hours in this subject are included with those of clinical medicine, table 19, p. 449.
7See footnote 2, p. 446.
8Department of the Army Special Regulations No. 605-60-50, Changes 1, 12 Feb. 1952.
FIGURE 125-A new student officer, 2d Lt. Joicey Putnam is "pinned" by her parents, Brig. Gen. P. A. Putnam, USMC (Ret.), and Mrs. Putnam at a ceremony at Fort Myer, Arlington, Va. (U.S. Army photograph.)
many physical therapy techniques and procedures had been adapted from those used in physical education. From 1922 to 1943, the Army had consistently adhered to the prerequisite of a major in physical education. In the meantime, civilian schools were finding that other courses, especially those strong in the biological sciences, provided an excellent foundation for physical therapy. In 1944, the Army capitalized on this experience by liberalizing its prerequisites to include a major in the biological sciences (ch. VI, p. 172). In 1954 and in ensuing years, no definite major was stated as a prerequisite, although a specified number of hours in biological and physical sciences and in psychology were required. As in other professional fields, the liberal arts subjects were considered particularly desirable.
The wide variance in academic standards of colleges and universities throughout the country presented a major problem in evaluating the scholastic record of the student. The rating of the school represented was taken into consideration whenever the information was available, but in many instances, it was impossible to accurately assess the scholastic standards of a specific school. Another considered factor in evaluating applicants` records concerned the misleading grade point average
of the physical education major. Because of the many subjects in the physical education curriculum which required mainly physical skills, the overall average often reflected a distorted picture of academic ability. To offset this possibility, a separate grade point average was computed from the science and psychology prerequisite courses.
Despite the pitfalls of evaluation, the scholastic record proved to be the single most valuable criterion in selection of students. It was observed that students whose academic records averaged below 2.5 (Scale: A=4.0) found great difficulty in maintaining the standards at the Medical Field Service School. Because the selection board was unable to interview applicants, it was dependent on comments by procurement officers and members of college or university faculties for information relative to personality traits and social acceptability. A photograph and an autobiography which accompanied the application supplemented other data and sometimes proved to be a deciding factor in selection of the student. Selection of students for the physical therapy course was restricted to women, because only Regular Army qualified individuals were accepted in the physical therapy course, and during this period under consideration, Regular Army commissions in the Army Medical Specialist Corps were extended only to women. Further, the limited quota of male physical therapists in the Army was easily filled by young men subject to the draft and the Army believed it imprudent to offer this costly program to men when qualified male physical therapists were readily available.
In January 1953, in compliance with policies recommended by the Council on Medical Education and Hospitals, the board of officers in the Surgeon General`s Office decided that the selection of students should be made in cooperation with the medical and technical directors of the physical therapy course at the Medical Field Service School. The board was to convene on 12 February 1953. Although the meeting never materialized, the applicants` records were sent to the Medical Field Service School for review and evaluation as well as for recommended lists to be categorized as "principals," "alternates," and "not considered for appointment."
The entire idea was abruptly aborted the following year when the Chief, Personnel Division, Surgeon General`s Office, wrote to the Commandant, Medical Field Service School, that "In view of the time factor and additional administrative procedures necessary to be accomplished in order to commission participants * * * it is not deemed feasible to forward applications to your command for review and recommendation."9
The entire responsibility for selection of students thereby reverted to the board in the Surgeon General`s Office. By coincidence, since 1954, each Chief of the Physical Therapist Section had previously
9Letter, Col. H. W. Glattly, MC, Chief, Personnel Division, Office of The Surgeon General, to Commandant, Medical Field Service School, Brooke Army Medical Center, 22 Apr. 1954, subject: Recommendations for the Selection of Participants for the Physical Therapy and Occupational Therapy Course.
served as Director of the Army Physical Therapy Course. As a permanent member of the board, she contributed, on the basis of her experiences, pertinent and valuable information relative to the criteria of selection. If this situation no longer held, it was believed imperative that the incumbent director of the school participate in selection of students.
Phase I: The Medical Field Service School
The Medical Field Service School (fig. 126), home of the Army Physical Therapy Course, figures prominently in the gamut of memories for many officers of the Army Medical Service. Located in San Antonio, there were both attractions and distractions to divert the study-weary officer. Golfing, tennis, bowling, and swimming were among the activities easily accessible on the post. Tours to the many historical and uniquely beautiful spots in Texas as well as to the cities and haunts of colorful old Mexico were arranged by Special Services. Fort Sam Houston was also a crossroads for Army Medical Service officers and here old friends often met, making "socializing" an especially active pastime.
At the school itself, however, business and hard work were the order of the day and the challenge of its motto, "To Conserve Fighting Strength," was answered by a program of intensive study and research. Students spent long hours in the classrooms and laboratories (fig. 127), interrupted periodically by a frantic dash to "the pit"10 for a gulp or two of coffee, the sustaining life force of the day.
At noon each day, all classes stood formation, followed by a brief period of drill. The physical therapy students with their colleagues, the occupational therapy students, performed intricate maneuvers in precision time--much to the delight of the balcony bystanders who assembled regularly to observe the activities in the quadrangle. To the Medical Field Service School audience, these lady soldiers were the "Rockettes." Surprisingly, the lady soldiers appeared to honestly enjoy this midday break--in fact, one former student was heard to comment that the marching was the one thing she missed most after leaving the school. It was the only active militaristic duty the physical therapy students were required to perform.
Students were required to wear uniforms only during the school day and occasionally to a formal military function. In practice clinic (fig. 128), they wore the hospital gown, slacks, or white shirts and shorts. Mornings when the students went to the hospital for clinical observation and practice, they always were pleased and proud to wear a gleaming white hospital uniform--it seemed to give them a feeling of being part of the professional group.
10Familiar name for the Medical Field Service Officers` Club, located in a dimly lit and sprawling basement of one of the school buildings.
FIGURE 126-Background for a new career. (Top) The Medical Field Service School, Fort Sam Houston, Tex., location of the first tour of duty for physical therapy students. (Bottom) "The doorway to learning."
FIGURE 127-Classroom and laboratory activity, Medical Field Service School, Fort Sam Houston, Tex. A. The physiology instructor, 2d Lt. David G. Reynolds, MSC, demonstrates a point by use of a simple experiment. B. The physiology laboratory, 1957.
F 127-Continued. C. The anatomy instructor, Lt. Col. Archibald R. Buchanan, MC, whose talent for drawing helps illustrate a point. D. Neuroanatomy keeps students busy for many hours. A "lab" session. (U.S. Army photographs.)
FIGURE 128-Students practicing and experiencing therapeutic procedures they will soon be applying to patients. A. Electrical stimulation being applied by a fellow student. B. Simulating a common physical disability, students practice transfer from sitting in a wheelchair to standing between parallel bars.
The present-day Medical Field Service School originated in Washington in 1893 and was relocated at Carlisle Barracks in 1920. After it was moved to Fort Sam Houston in 1946, it was reorganized to incorporate and absorb all the independent Medical Department schools giving specialized instruction to Army personnel.
The Medical Field Service School provided systematic progressive training and educational programs for Army Medical Service personnel in professional, technical, administrative, and military subjects which pertained to the Army Medical Service. A large resident faculty selected from highly qualified officers was available to conduct the many courses of instruction for medical officers, dental officers, veterinary officers, nurses, dietitians, occupational therapists, physical therapists, and enlisted personnel. Supplementary teaching staff was procured from civilian sources and from other Army installations.
Except for fiscal year 1954, attendance at the physical therapy course was preceded by a basic course in military instruction, known variously as the Medical Department Female Officers` Basic Course, Officer Orientation Course, Medical Service Women Officers` Basic Course, and the Army Nurse Corps Officers Orientation Course. In 1948, the course was 8 weeks in length. In September 1950, it was decreased to 4 weeks, and when the 8-week course was resumed in October 1952, the physical therapy students did not attend. Instead, 34 hours of military instruction was incorporated in the physical therapy curriculum, an ill-conceived plan which overburdened both student and faculty. As a result, an arrangement was made whereby the subjects which concerned physical therapy were presented within the first 4 weeks of the basic course and the physical therapy students attended only during this period.
This preliminary instruction provided the students with an orientation to the military and an adequate background of information to guide their military behavior and activities as U.S. Army officers. The students were introduced to subjects pertaining to military history, organization, and administration, as well as to practical lessons in military customs and courtesies and wearing of the uniform. Instruction in drill was presented during this time.
The weeks spent in basic training were generally carefree and the course required little outside preparation. With an abundance of available escorts, most students tasted liberally the joys of an unusually active social life, and many a physical therapy student met her future spouse during basic training at the Medical Field Service School. Professional ambitions, however, were temporarily thrust into the background and the abrupt transition to a program of concentrated study was sometimes frustrating and difficult. Eventually, the physical therapy faculty started a counseling system and regularly scheduled inter-
views gave the student an opportunity to consider events in realistic perspective.
Because the Army Physical Therapy Course was the primary source of physical therapists assigned to Army hospitals, it was considered of more than usual importance that the professional education of the students be of the highest quality possible, and because the faculty is generally conceded to be the most important element in an educational system, the selection of a faculty member was accomplished only after the most careful scrutiny of her qualifications. It was determined that this individual should be highly qualified in her professional specialty, must be interested in and motivated toward the field of teaching (fig. 129), must have the ability to function in the capacity of teacher according to sound principles of education, and should, preferably, have experience in the field of education.
All physical therapists who were selected for assignment at the Medical Field Service School had completed courses in graduate study. All physical therapy directors assigned to the school between 1949 and 1960
held a master`s degree. Of the 11 physical therapy instructors assigned since the beginning of the course, 7 had earned the master`s degree, and by 1959, all physical therapy faculty members held the master`s degree, indicating an upgrading in the educational qualification of these individuals. The majority had previous teaching experience ranging from a prolonged period of several years to a relatively limited amount, such as practice teaching.
The basic and medical sciences in the course were taught by specialists in these fields--physicians, physicists, anatomists, and physiologists--usually assigned to the Medical Field Service School and sometimes on a permanent basis with civilian status. Physicians from Brooke General Hospital also assisted in the medical sciences (fig. 130). Guest speakers of national and international renown were invited to give lectures in an area of their specialty. For instance, Colonel Vogel came regularly to the school to speak on the history of physical therapy in the Army. Among the many guest speakers were Khalil G. Wakim, M.D., physiologist from the Mayo Clinic, Rochester, Minn.; Marian Williams, Ph. D., physical therapist and anatomist from Stanford University, Palo Alto, Calif.; Miss Signe Brunnstrom, physical therapist; and Robert L. Bennett, M.D., Medical Director, Georgia Warm Springs Foundation, Warm Springs, Ga.; and James G. Golseth, M.D., Pasadena, Calif. (fig. 131).
Extracurricular professional activities played an appropriately im-
FIGURE 131-James G. Golseth, M.D., an authority in the field of electrodiagnosis and therapy, explains the operation of the electromyographic machine. Left to right: Maj. Vann S. Taylor, MC, Assistant Director, Department of Physical Medicine, Medical Field Service School, Fort Sam Houston, Tex.; Dr. Golseth; and Maj. Agnes P. Snyder, Director, Physical Therapy Course. (U.S. Army photograph.)
portant part in the educational advancement of the physical therapy instructor at the Medical Field Service School. By virtue of her assignment, the physical therapy director of the course assumed membership in the Council of Physical Therapy Directors, a national organization which met biannually to discuss trends and developments occurring in and affecting their professional and educational fields.
Each year one or two representatives of the physical therapy faculty attended an institute sponsored by the American Physical Therapy Association and the Office of Vocational Rehabilitation (now Vocational Rehabilitation Administration). The topics selected for discussion were of vital concern to all those engaged in physical therapy education.
The proximity of Brooke General Hospital allowed the school faculty
to take advantage of professional activities at that installation. Close liaison was maintained with the physical therapy staff at the hospital, particularly at the time the students were engaged in clinical observation and practice. During the late spring and summer months when there were no physical therapy classes in session, instructors were encouraged to work in the physical therapy clinic in order to retain proficiency in their skills, to gain insight into situations as related to teaching, and to keep attuned to changes and trends.
To conduct a completely professional course in a military educational institution is, admittedly, a unique and perhaps an incongruous situation. It proved to be a surprisingly compatible one. The application of certain military procedures in the conduct of the physical therapy course revealed both advantages and disadvantages and it would be difficult to say which outweighed the other.
The Medical Field Service School required that faculty members prepare lesson plans for each hour of instruction. Initially, the plans were to be written verbatim, a reflection of the methods used in the rigid military training necessary in the accelerated programs of World War II. This type of plan, however, was contrary to accepted educational principles, because its inflexibility precluded the exploration of free and creative thinking and limited the opportunity for the interchange of ideas essential to the vitality of a professional course. Another militant practice which distressed the faculty members was the oral presentation of examination questions to a board of officers, bearing the well-deserved label of "murder board." The questions had to be approved by this board before being given to the students. For a professional person to be cross-examined by individuals, who although excelling in their own field were usually unfamiliar with the specialty, was rightfully interpreted as uncalled for effrontery by those selected to fill teaching positions.
Fortunately, both the verbatim lesson plans and the examination of instructors were eliminated with the arrival of new directors who supported accepted principles of professional education. In fairness to the staff at the school, it must be stated that no pressure was put upon the physical therapy instructors to adhere unrealistically to the lesson plans.
Although the verbatim lesson plans were eliminated for the physical therapy course, detailed plans in outline form were still required. This in itself was a reasonable requirement in view of the necessity of long-term planning and possible emergency expansion. To the distress and frustration of the instructors, however, minor changes relating to format, numbering, and so forth were constantly being requested. With several hundred lesson plans to change, this became a time-consuming proposition and instructors felt strongly that this was detrimental to their own development and to their teaching proficiency because it deprived them of time that could have been spent more profitably in professional study and in diversified reading, essential activities in the development of the teacher.
Classes were scheduled 3 months in advance and posted by the instructor on boards which reflected the subject, date and hour, classroom, and instructor. Such a system assured not only careful planning but also a reasonable balance in the distribution of hours and the appropriate sequence of subject matter.
It is evident that the physical therapy instructors at the Medical Field Service School carried a heavy load of responsibilities other than those related to class preparation and actual teaching. The Program of Instruction became their responsibility following the initial writing. A bulletin for the course was prepared and published biennially. Course outlines for each subject were written and kept up to date. Compilation of extension courses also demanded considerable time. In 1951, a third faculty member was added to the staff because of the increased load of two professional classes per year. When the number of classes reverted to one per year in 1954, the third member remained in order to provide a faculty whose size was in keeping with the magnitude of the workload.
Time to develop standards of excellence in a program of this type called for tours of duty beyond the normal 2- or 3-year periods. Major Snyder served two separate tours for a total of 6 years and Major Robertson was assigned for 5 consecutive years.
The following is a roster of the physical therapy faculty at the Medical Field Service School from 1948 through 1960.
Maj. Ethel M. Theilmann 1948-49
Maj. Agnes P. Snyder 1949-53
Maj. Barbara M. Robertson 1953-58
Lt. Col. Agnes P. Snyder 1958-60
Lt. Col. Elizabeth J. Davies 1960-
Capt. Beatrice Whitcomb 1948-49
Capt. Genevieve S. Beard 1949-50
Capt. Beatrice Whitcomb 1950-52
Capt. Frances M. Davison 1951-53
Capt. Martha M. Boger 1952-55
Capt. Mary S. Lawrence 1953-54
Capt. Mary E. Frazee 1953-54
1st Lt. Sarah B. Dempster 1954-56
Capt. Mary E. Frazee 1954-57
Capt. Rachel H. Adams 1957-60
Capt. Corrine L. Strong 1957-59
Capt. Patricia Wakefield 1959-
Maj. Joan H. Perry 1960-
Facilities and equipment
Until 1955, the practice clinic where the students spent almost half their time was located in a building about a half mile from the school,
thus necessitating bus transportation. During World War II, this clinic had been an operating physical therapy department and was well equipped for teaching purposes. A large classroom was available upstairs. Another classroom at the school was assigned to physical therapy students for their exclusive use. Although the clinic itself was satisfactory, travel was time consuming and transportation was not always dependable.
In 1955, after many months of frustrating effort to get space for a practice clinic at the Medical Field Service School, the physical therapy faculty was delighted to learn that a large area (far beyond expectations) was available on the third floor of one of the quadrangle buildings at the school. Capt. (later Maj.) Martha M. Boger drew up the plans for renovation. They included a spacious clinic, an exercise room, an air-conditioned classroom, office, lounge, shower and lavatory, and storage rooms. When Captain Boger left, Capt. (later Maj.) Mary E. Frazee took charge of getting the work completed. The sparkling new clinic (fig. 132) was ready for occupancy in January 1956 when the students returned from their Christmas vacation. Since that time no complaints have been heard about facilities except perhaps an occasional groan from a faculty member wearily mounting the two long flights of stairs to the clinic.
Physical therapy equipment was always adequate at the school and became superior as the latest devices and machines were added from time to time. For the most part, training aids and visual aids were limited only by the instructor`s lack of imagination. When the course was first started, the Armed Forces Institute of Pathology, Washington, D.C., constructed mockups of equipment to be used for practice. Later, training aids were supplied by the Graphic Arts Section at the Medical Field Service School which provided both simple and elaborate types. Even the platform behavior and mannerisms of the instructor were studied in order that colors complementary to his personality could be used in developing the training aids. Films, tapes, filmstrips, and slides had only to be ordered by number to have them delivered at the appropriate hour in the appropriate classroom and accompanied by a projectionist. Mimeographed material could be ordered and distributed to the students before class, during class, or any other time, as desired. A professional library was maintained in the students` lounge, but all students were free to use the well-stocked libraries at the Medical Field Service School and at Brooke General Hospital.
Although it took more years than expected, the school was eventually well supplied with cadavers. This was achieved only through exhaustive efforts on the part of the anatomists at the Medical Field Service School, especially Walter E. Sullivan, Ph. D., and Virginia Harrison, Ph. D. An enlisted physical therapy specialist was assigned to the clinic to assist the instructors in their teaching chores and to supervise policing the area.
Phase II: Hospital Clinic Experience Programs
Early clinical experience (fig. 133) may well be the most important and crucial period in the life of the professional person. It becomes a measuring stick against which future attitudes, procedures, standards of performance, and behavior will be evaluated. In this phase, the teaching process becomes more active in nature-the student participates independently, he observes, he sees changes as the result of treatment, and evaluates what he sees.
FIGURE 133-Clinical experience in the hospital. (Top) Students gather around while an instructor demonstrates a point in muscle testing, Brooke General Hospital, Fort Sam Houston, Tex. (U.S. Army photograph.) (Bottom) A student at Walter Reed General Hospital, Washington, D.C., experiences the satisfaction of helping this patient along the road to recovery.
With this in mind, the Army physical therapy program of the past decade increasingly stressed the importance of the clinical experience. Not only was clinical observation and practice started earlier in the school year, but more attention and planning were directed toward this area of instruction to insure continued application of sound teaching principles. Lecture courses were gradually disappearing in phase II, giving way to informal discussion-type classes with emphasis on student participation and independent study.
Selection of installation
The capacity of a facility to provide a rich and challenging clinical experience is a primary consideration in selection of the hospital where the student may pursue his professional studies following a concentrated academic program. To assure breadth of experience, the hospital must provide a group of patients representing a wide range of medical conditions; to provide depth of experience requires a large patient load; and to provide appropriate and stimulating learning experiences calls for a professional staff whose interests embrace both physical therapy and education.
In consideration of these criteria, a memorandum from the Surgeon General`s Office to the General Staff, U.S. Army, dated 13 April 1948, stated that selection of Army general hospitals for clinical applicatory training was to be determined on the basis of (1) the exact numbers of students enrolled, (2) the location, number, and type of patients requiring physical therapy, and (3) the availability of physical medicine personnel qualified as instructors.
The Surgeon General`s Office decided that Fitzsimons and Walter Reed General Hospitals met the specified requirements and these installations were subsequently selected to conduct the first clinical applicatory programs, starting on 23 May 1949.
Although criteria for selection appeared to be fully met at the time, a visit to Fitzsimons General Hospital by Colonel Smith, in 1951, prompted him to recommend discontinuance of the program at that installation because it did not provide sufficient experience in the treatment of orthopedics, amputations, and peripheral nerve injuries. This recommendation led to transfer of the program to Letterman General Hospital, San Francisco, Calif.
The stepped-up program at the Medical Field Service School following the outbreak of the Korean War resulted in the implementation, in 1952, of a third applicatory program at Brooke General Hospital. Since that date and until the present time, Walter Reed, Letterman, and Brooke General Hospitals continued to conduct the clinical applicatory phase. In 1952, 1953, and 1954, two classes per year were conducted at each hospital to accommodate the output of students from the Medical Field Service School.
Personnel responsible for conduct of clinical applicatory phase
In charge of the students and the teaching staff at each of the three hospitals was the student supervisor, a physical therapist. Although the chief physical therapist in some instances acted in this capacity when the program first started, in more recent years a highly qualified physical therapist with educational as well as clinical experience was designated for this position. The student supervisor was responsible for the entire program, including administrative and organizational details, setting up classes, delegation of instructors, staff orientation, and counseling and evaluating students.
Experience has shown that the position of student supervisor must be filled by an individual of wide professional attainment in the field of physical therapy and at least a broad understanding of the principles of education. She must have ability to organize, to pull the efforts of the group together, to understand and observe teaching principles, and to be capable of creating learning situations for the student. Within recent years, a sufficient number of Army physical therapists had earned the master`s degree to allow selection of instructors from this group. It appeared that the physical therapist who had just completed graduate study was unusually well suited to work with a group of students. She was imbued with enthusiasm, enjoyed a fresh or renewed insight into the nature of her profession, and brought stimulating ideas not only to the students, but to the staff as well.
The importance of selecting physical therapists of the highest caliber to staff the hospital where the applicatory phase is conducted cannot be overemphasized. The relationship of the student to each staff member as well as to the staff as a unit constitutes one of the dominant influences throughout the second phase. In questioning physical therapists who were graduated from the Army course, one is amazed at the thoroughness and severity with which each staff member was scrutinized and judged in light of what the student expected a physical therapist to be. The students were especially sensitive to attitudes and behavior of the graduate, particularly toward the patient, the doctor, and the student herself. If the physical therapist did not measure up to the standards the student set for her, the impact was one which apparently was not easily forgotten. Years later,11 an amazingly vivid and intact picture of shortcomings and imperfections was conjured up without difficulty. Most students, however, were forcibly impressed by the deep interest of all instructors in their well-being and success.
There has been a trend in Army physical therapy clinics within the past few years to involve every member of the staff in the teaching
11Survey of graduates (1947-60) conducted by the author.
program. Even the least experienced of the group was requested to teach a minimal number of 2 or 3 hours. This participation seemed to draw the group closer together and unite their efforts toward the professional advancement of the student. Further, it helped to earmark those physical therapists who had unusual aptitude for teaching and whose performance warranted further education. The attitude of the various staff members toward the student program is worth noting. Solicited comments from 21 supervisors and chiefs of sections pertinent to staff attitudes included "most enthusiastic," "excellent," "all worked hard," "most were stimulated," "eagerness and cooperation," and "excellent and enthusiastic."12 Certainly these comments speak well, not only for the student supervisor, but also for the chief physical therapist whose support of the program must be complete and unchanging.
One of the important factors in staff acceptance of the students was the excellent orientation program conducted before their arrival (fig. 134). Staff physical therapists were sometimes given reviews in skill areas in which they felt insecure. The student program was presented and discussed in detail with members of the staff; outsiders were called in to speak on subjects related to education, teaching skills, and interpersonal relations. In one instance, young medical officers contributed to the planning and preparation of certain aspects of the program. Enlisted men assigned to the physical therapy clinic were also present at the meetings, so they would know what to expect and act accordingly. Pertinent written material was distributed to the staff, as indicated.
The medical officers of the physical medicine service contributed their services by teaching some of the classes. They instructed in the administration and application of physical medicine procedures and presented lectures in electrodiagnosis and electromyography. In several instances they conducted the Journal Club and assisted the students in overcoming any deficiency which might have occurred in the academic phase. The Chief, Physical Medicine Service, serving as the medical director of the program, worked with the student supervisor during implementation of the program. He helped to plan the curriculum, to set up the classes, and to coordinate instruction with other medical officers. When the overall program was well established, he acted more in the capacity of a consultant, and the student supervisor, for the most part, arranged the programing.
Throughout the years the medical officers in all services showed keen interest in the student program and were most cooperative and willing to assist. As has been noted previously, the only difficulty arose when busy doctors could not get away from emergent situations to conduct classes for which they had been scheduled. Other hospital personnel contributed generously with their time and talents in the training of these young students--especially those in the surgical service, the orthopedic service, the nursing service, the American National Red Cross, and in occupational therapy.
12Survey of chiefs of sections and student supervisors conducted by the author.
Orientation to professional activities in the hospital
A good understanding of the overall management of the patient is essential as a basis on which the physical therapist can intelligently and understandingly exercise professional judgment. To provide this background of knowledge, the training program must include an opportunity for the student to observe and participate in certain activities other than those directly related to physical therapy.
In accomplishing this, a portion of the phase II program was devoted to such activities as attendance at ward rounds, clinics, and meetings. Ward rounds were attended by all students and provided real learning situations. The doctors conducting the rounds were usually pleased to include the physical therapy students in the discussion. This not only made the clinical experiences more meaningful, but alerted the student to areas of her profession in which she must be knowledgeable and proficient.
Students were permitted to observe surgical procedures. During the early hospital experience, it was considered desirable for them to see at least one orthopedic operation (usually an arthrotomy of the knee), one neurosurgical procedure, thoracic surgery, and in some instances,
plastic surgery. Some students observed brain surgery, some heart surgery, and some the introduction of an intramedullary nail.
The Journal Club which was held during the clinical phase promoted an interest in journals in the professional and scientific fields. Attention was given to use of the medical library, abstracting articles, and speaking before groups. Usually a project, such as a report on literature research presented before the staff, climaxed the activities of the course. Several students abstracted articles which were accepted by their professional journal. Students were encouraged to attend professional meetings and to participate in all activities related to the physical therapy or medical field. They assisted in making exhibits, in planning staff meetings, and in community activities. Under the direction of Maj. (later Lt. Col.) Elizabeth J. Davies, a group of students at Letterman General Hospital completed a research project, "The Use of Ice for Increasing Joint Range of Motion," later reported in the Student Section of The Physical Therapy Review. Orientation to the military was continued during the clinical affiliation. Students attended or participated in hospital and military activities, such as receptions, athletic activities, social functions, and military ceremonies.
To broaden their experience, the students made field trips to hospitals and rehabilitation centers in the area. Those at Fitzsimons General Hospital were assigned to local civilian hospitals for short periods of clinical practice. Although work with children greatly increased because of the increasingly large military dependent load, an attempt was made each year for the students to either visit or have some clinical experience at a civilian children`s hospital.
Integration of Phase I and Phase II
Characteristic of professional educational programs is the need for effectively and smoothly integrating the theoretical with the applicatory aspect. In civilian physical therapy programs, the proximity of the school and the clinical affiliation lends itself readily to the achievement of this objective. In the Army, the far-flung geographic locations of the participating installations present the added challenge of overcoming a distance barrier. Recognizing this element of remoteness as a potential disadvantage, the Surgeon General`s Office, early in 1948, evolved and implemented a carefully devised plan to facilitate integration of the two phases. Major Lee, representing the Surgeon General`s Office, visited both the Medical Field Service School and the hospitals selected to conduct the applicatory phase and assisted in the establishment and coordination of the course. She also appraised all participants of the overall purpose, goals, principles, and relevant activities of the entire program.
To further insure a unified concept of the program and to assist supervisors and instructors on the clinical level, a manual entitled "Clinical Practice Guide for Physical Therapy Students" was compiled in the Surgeon General`s Office and published early in 1950. It dealt
with supervision and evaluation of students, student interviews, and report forms.
Although not prepared specifically for the same purpose, the Program of Instruction required for all courses at the Medical Field Service School contributed significantly to the smooth coordination of the two periods. It served as a guide for the clinical teaching staff as well as the school staff, and provided both with an overall concept of the entire curriculum.
Educational meetings, both military and nonmilitary, afforded valuable guidance and instruction for those involved in the program. Each year at the conference of the American Physical Therapy Association, the School Section conducted well-planned meetings, many of which were geared to the needs of the clinical supervisors. Both student supervisors and school directors were invited to participate in several of the institutes sponsored by the association and the Office of Vocational Rehabilitation.
Probably the one thing that contributed most significantly to the successful integration of the student program was the annual meetings of the Medical Field Service School physical therapy faculty and the student supervisors and instructors from the three hospitals. Such a meeting was initially held in 1955 and was later made an integral part of the program.13
This 3-day meeting afforded a real opportunity for the participants to reiterate the basic philosophy of the school`s educational goals, to discuss the conduct of the course and related problems, and to explore creative and visionary ideas and, in turn, the possibility of their realization. Student supervisors who at various times attended these meetings were: Capt. (later Maj.) Dorothy L. Kemske, Maj. Ethel Coeling, Capt. (later Maj.) Nannette Keegan, 1st Lt. (later Capt.) Esther Day, Major Davies, Maj. Ruth Ellinger, Maj. Amelia Amizich, and Maj. Dorothy Peterson.
Inasmuch as the physical therapy course was monitored by the Surgeon General`s Office, visits to the Medical Field Service School and to all hospital affiliations by the Chief, Physical Therapist Section, Army Medical Specialist Corps, provided an opportunity for evaluating the program and encouraging a high level of instruction.
Between November 1948 and January 1960, 15 classes of the Army Physical Therapy Course were conducted and 229 students were graduated. Of the 255 who entered the course, 26 failed to graduate, making an attrition rate of 10.4 percent, excluding the foreign students. Only one of the four foreign students who entered the course received a certificate of completion. Foreign students were enrolled in the school from time to time because of Army policy to accept these individuals for
13Administrative Letter No. 621-100, Office of The Surgeon General, 12 Oct. 1960.
training in selected courses. The school, therefore, was obligated to accept the students although their qualifications did not always meet Army standards. Usually they were given certificates of attendance. A total of 13 Air Force students were accommodated in four classes from 1950 to 1953, but this arrangement was no longer possible when an influx of Korean War casualties increased the demand for Army physical therapists. Four general hospitals conducted the clinical applicatory phase--Walter Reed, 14 classes; Brooke, 11; Letterman, 11; and Fitzsimons, 3.
The fact that the Army Physical Therapy Course was of necessity the primary source of physical therapists on active duty from 1948 to 1960 seemed justification enough for its existence. The wisdom of the Army`s conducting a professional course of this nature was further borne out by a number of other factors which it seems pertinent to record here.
Whether palatable or not, it must be acknowledged that, except for male physical therapists subject to the draft, civilian trained physical therapists were generally not interested in coming into the military service. The reasons were complex and are inappropriate for discussion in this section. The fact remained, however, that any likelihood of an adequate supply of physical therapists from civilian sources was extremely remote as amply demonstrated by the futility of diligent efforts in this direction.
Periodically, the suggestion was made that physical therapists could be trained in civilian programs subsidized by the Army. In consideration of such a plan, it seemed prudent to first determine the nature of the product desired. The Army physical therapist must function in a dual role--that of (1) an Army Officer and (2) a professional person. Preparation for such a dichotomous function would seem best served by the unique combination of a professional program conducted in a military setting. Precisely such a program was the Army Physical Therapy Course. Students were oriented to the military throughout the entire educational period, thus providing them with an understanding of the basic concepts of military service not possible in civilian programs. Other than the initial basic course, the orientation was not time consuming--actually, it was provided largely by the military setting itself. Nor was there any reason why such a climate should detract from the professional excellence of the program.
There were other very practical reasons for retaining the physical therapy course. Army graduates, when released to a Reserve status, added to the pool of Reserve officers available for recall to active duty in the event of a national emergency. The value of this Reserve force was well illustrated at the outbreak of the Korean War. The constantly depleted number of officers in the Reserve pool weighed heavily in consideration of this point.
An ongoing progressive and dynamic program geared to the possibility of expansion was considered a distinct asset in the event of mobilization. An up-to-date curriculum upon which to build a new course was
considered far superior to one which was used perhaps 10 years ago, then put on the shelf, and never looked at since. The pool of instructors became larger, more experienced, and more diversified as the result of an ongoing course. These and other factors exemplified the readiness maintained when the educational program was in progress.
Distribution of teaching responsibilities to the three large hospitals had far-reaching effects on the entire Army physical therapy program, directly affecting approximately 25 percent of all Army physical therapists in any given year. The impact of the student program on the respective staffs resulted in a higher standard of performance as each tried to provide as model a program as possible. Quality of workmanship improved as the staff was challenged by the presence of students. Improvement in quality of patient care followed. This upgrading of performance was recently confirmed by a questionnaire requesting physical therapists in key positions to state the effects of a student program in the hospital. There was unanimous agreement as to the positive effects.
The patient load of the Army hospital has come more and more to resemble that of a civilian hospital thereby providing a wide range of experience. It should be pointed out that although the Army Physical Therapy Course was only 1 year in length, as far as its formal status was concerned, students remained in the Army for an additional year during which they either remained where they were or were assigned to another large hospital where supervision and in-training programs continued, a course of action which further insured superior preparation.
The years from 1948 to 1960 saw numerous changes take place in the Army Physical Therapy Course--most of them minor in nature and brought about through expediency or as a readjustment to external pressures. But upon closer inspection, another more intangible, consequently less obvious change could be discerned. Teaching "by the numbers" was gradually giving way to teaching by principles, teaching routines were slowly being replaced by problem-solving methods, the scholarly classroom lectures were heard less frequently, and more and more the students` voice could be heard, questioning, discussing, expressing opinions on subjects stemming from the learning experiences of the classroom and the clinic, or arising from independent study.
As the fifties wore on and numbers of Army physical therapists profited from the academic atmosphere and graduate study, the physical therapy faculty became, not only more sophisticated in principles of education and their application, but also more critical of the status quo and more aware and analytical of their own philosophy of education as well as that of mature educators in the field. Instructor knowledge-ability in these areas became even more beneficial in terms of curriculum content. To delete subjects which were taught since the beginning
of physical therapy; to change the character of curriculum and its content; and to make sweeping changes consistent with the findings in the fields of science and education took courage, confidence, and vision; attributes which were becoming increasingly noticeable among the instructors, especially the younger ones.
But to succeed in the pursuit of excellence takes time, so that little can be accomplished in this direction in a 2- or 3-year tour of duty, particularly by the neophyte instructor who must spend an exorbitant amount of time in preparation for classes. Nevertheless, the philosophic tone set by the faculty of the Army Physical Therapy Course at the beginning of the sixties was hopeful and visionary and seemed to herald bold and challenging changes in keeping with the unfolding developments of the time.
In 1949, a course for enlisted personnel was implemented at the Medical Field Service School and the physical therapy staff assumed the responsibility for its conduct and instruction. The course was meant to relieve hospital physical therapists of the duties connected with on-the-job technicians` training which had been conducted in Army hospitals for many years.
Prerequisites for the course varied somewhat through the years. Initially, a score of 100 or higher in the Army general ability tests was required. By 1951, this was lowered to 90. Previous training or experience as either a medical or surgical technician was required. The applicants could have no record of emotional instability. Also considered was the applicant`s interest in the care of patients and his ability to adjust to a hospital environment.
The underlying principle in conduct of these courses was to include in the course of study sufficient material of the right kind to enable the technician to assist the physical therapist in an intelligent manner. Technicians were trained to assume a wide range of clinical responsibilities which included clerical duties, maintenance of supplies, care of equipment, and elementary level treatment of patients.
The program of instruction (table 20) remained relatively unchanged during this entire period. The program developed into an extensive one, from which 379 students were graduated from 21 classes during the years 1949-60 (table 21).