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APTA President Sharon L. Dunn, PT, PhD, Board-Certified Orthopaedic Clinical Specialist, addressed the House of Delegates, June 11, 2020.

Madam Speaker, delegates, and APTA members, I am grateful for this opportunity to address you tonight in these unprecedented times. The presidential address and the House of Delegates are longstanding rituals in our association's history, but never have we conducted them like this.

I am delivering this address from our media center at LSU Health-Shreveport to the sound of silence. You are receiving this address wherever you are — spread across the country and time zones, staring into your computer in a quiet workspace, or just as likely from the kitchen table of a hectic home, surrounded by family members doing the same thing we're all doing right now: adapting to our unusual new normal.

The first confirmed case of COVID-19 in America was reported on January 21. Less than two months later, there were confirmed cases in all 50 states, President Trump declared a national emergency, large public gatherings were canceled, schools were closed, and Americans were instructed to stay at home in most instances.

The pandemic has affected our country much like the coronavirus affects the human body: Some have incurred no substantial impact, while others have been devastated.

Pandemic experts have advised that the best way — really the only way — to halt a pandemic without a cure is to discontinue its spread through physical distancing, sheltering in place, quarantine, and all those other terms that are now part of our daily vernacular.

But even in these technologically advanced times, our tightly connected world cannot sustain itself without human contact — not indefinitely. Thus, some point to potential economic catastrophe as an emergency with its own health implications, and they express fear that the measures to contain the virus could be even more damaging than the virus itself.

How we feel about that debate is likely determined by how this pandemic has affected our own lives and those of our loved ones.

No doubt, the actions taken and not taken in response to this pandemic will be long analyzed, and whatever the low point of this global crisis proves to be, they will inspire a lot of coulda-shoulda-wouldas with the benefit of hindsight. That's inescapable and understandable. It's how we learn and improve.

My hope is that as we discuss this pandemic, now and into the future, we all remember that the coronavirus did not come with an easy-button solution, and that its many dire consequences are all things we would have preferred to avoid.

The impact of the pandemic on our physical therapy profession has been as varied as the profession itself.

Some have worked long hours in the ICU, learning crucial lessons in real time, while treating some of the most compromised people. Others have seen their hours significantly reduced or their jobs eliminated.

Some practices closed their doors proactively, determined to flatten the curve. Others had their doors closed by economic necessity.

Many clinicians pivoted to telehealth — a change made much more challenging than it should have been due to the overly restrictive regulations that APTA has been advocating to eliminate for years.

Meanwhile, our students missed out on clinical rotations and in-person lab time, and the graduating classes of 2020 will add to their significant student loan burden the daunting challenge of finding stable employment in a disrupted health delivery system.

Watching all this unfold has been at times heartbreaking, and at other times inspiring.

History's most consequential moments are often woven from threads of tragedy and triumph. This one is no different.

At times like this, it's worth recalling that our own profession's history is familiar with adversity on a global scale. In fact, we originated from it.

Our profession and association are rooted in the aftermath of the first World War and grew up throughout the second.

One of our association's founders almost 100 years ago, and our first president, was Mary McMillan — the first reconstruction aide sworn in during World War I, who spent much of World War II providing care while being held as a prisoner of war in the Philippines and China.

In 1946, Mary — or "Molly" as they called her — attended our association's 25th anniversary in Blue Ridge, North Carolina, and shared her memories of the tumultuous early years of our association with the calm and dignity of a natural born leader.

She closed her remarks by reading what is now a well-known poem by Douglas Malloch called Good Timber that includes the following stanza:

"Good timber does not grow in ease,
The stronger wind, the tougher trees;
The farther sky, the greater length
The more the storm, the more the strength."

Right now we are in the midst of a storm in the shape of a health crisis, and my question to you is how will we grow through it?

Likely, some things that seemed significant a few months ago already have been revealed to be less essential and should be allowed to uproot and drift away. But at our core we must remain firmly planted.

On March 17, APTA's Board of Directors released a statement about patient care and practice management during COVID-19, encouraging physical therapists to "use their professional judgment to determine when, where, and how to provide care, with the understanding this is not the optimal environment for care, for anyone involved."

We issued that statement at a time of great turmoil, when uncertainty was at its peak and new recommendations were being issued at national, state, and local levels seemingly every few hours. The Board knew our statement would be received with varying opinions, from support to dismay.

Some hoped we would call on all outpatient clinics to close their doors in order to protect workers and flatten the curve; they thought our guidance missed the mark.

But as I talked to members of our physical therapy community who felt this way, I heard a recurring theme: Many physical therapists feel they do not own their clinical decision-making and that they wanted the association to make decisions on their behalf.

That should be a point of concern for all of us.

Let me be absolutely clear: Their outcry was not evidence of some moral or ethical failure. This sentiment was expressed by people concerned first and foremost about the safety of their patients — by PTs who felt that to "first do no harm" in an environment typically involving close personal contact, in context of a virus with asymptomatic carriers, meant suspending care was the only justifiable option for many of their patients.

And, of course, that's what should be done if, in your professional judgment, you believe that the potential risks of care outweigh the potential benefits.

No, what their concern revealed is that too many in our profession feel their care is not determined by their own professional judgment — even though our license obligates it, even though our commitment to evidence-based care demands it, even though we have spent decades fighting for our right to make patient-centered decisions based on their needs and specific circumstances, and even though we have justifiably bristled at payment and regulatory restrictions that assume that all patients in a given situation are the same.

If this pandemic revealed anything that must change — quickly and significantly — that's it.

Employers who are impeding physical therapist's judgment must stop. Physical therapists who are conceding their professional responsibility must reclaim it. And all of us must begin talking about this openly, not in an attempt to castigate individual practices or clinicians but out of the determination to live out our most sacred values.

I don't pretend it's simple. But that doesn't make it less necessary. Good timber does not grow in ease.

This crisis also demands that our association adapt, to figure out ways to support a profession that could find participation in APTA even more challenging.

Already our association has demonstrated its value. For several weeks starting in mid-March, traffic to APTA's website tripled. The strength of our federated model was exemplified by an outpouring of expert resources from our chapters and sections. And whenever confusion and misinformation on social media threatened to take over our profession's grasp of the regulations of the day, APTA was there to provide clarity we could count on.

In a time of great need, APTA proved to be the trusted leader for the physical therapy profession.

If you want a case study about the importance of membership, look no further than what happened with telehealth.

Longtime advocates know that progress in this arena is typically measured in years, sometimes even decades. But COVID-19 accelerated the pace, and over a few weeks our profession's ability to deliver telehealth evolved rapidly — and not by happenstance.

Along the way there was that peculiar period when CMS added therapy codes for telehealth but failed to recognize physical therapists as telehealth providers. Not long after, CMS included physical therapists in private practice among providers who can furnish telehealth — as well as PTAs working under their supervision.

But this happened only because of the tremendous relationships developed by our advocacy staff and the action of thousands of members who wrote letters to amplify our voice.

None of that change happened on its own, and when COVID-19 softened the ground, our strong national association was essential to capitalize on the opportunity.

To everyone who supports APTA through membership and engagement, thank you. You have contributed to what we have been able to deliver.

But I am speaking now to everyone in our profession. To members and potential members. To PTs, PTAs, and students. To clinicians, researchers, and educators. To those whose sense of professional purpose has been sharpened by COVID-19 like steel on steel, and to those who have doubts about their future.

Society needs us.

It needs us to care for patients who have complications specific to COVID-19. It needs us to provide alternatives to surgery to keep people out of hospitals unnecessarily. It needs us to help people improve their strength and balance and prevent life-threatening falls. And it needs us to keep people active, because while fitness doesn't provide immunity, it certainly improves overall health and resilience.

Serving society amid a contagious pandemic requires bravery and selflessness, yes, but also thoughtfulness. If clinical practice emerges from this crisis looking like it did going in, we will have missed an opportunity to grow and learn.

Again, we must look to our history.

The polio epidemic plagued our country to some degree from about 1919 to 1955. As with COVID-19, it caused symptoms so mild that carriers were unaware they had it — and it caused death.

The paralysis it inflicted in some fit no clear pattern. Sometimes all but one muscle in a group would be paralyzed. Sometimes only one muscle.

Over the decades, multiple treatment approaches and philosophies emerged. It was a time of iron lungs, Hubbard tanks, and rocker beds. It was an era of hot packs and hydrotherapy. It was a period of dispute between Sister Kenny and Henry and Florence Kendall, among others, as rehabilitation providers debated such things as what and how much to stretch their patients.

Hindsight is a wonderful but dangerous thing. It's easy now, and indeed instructive, to reflect on all the things that could have been done differently and to wonder how much better the results may have been.

But we must remember that the participants were living that history as it was being written, as we are today, but at a time when new information was shared over months, not seconds.

In 1947, the Kendalls wrote in APTA's Physiotherapy Review, then the name or our association's journal, that "When someone asks 'How do you treat poliomyelitis?', there is no specific answer because every patient requires a different approach in treatment."

Broad universal guidance would have been impossible then, too. And finding out the path forward took time and collective effort.

The Kendalls wrote: "We are all seeing the same symptoms, the same disease, the same problems in muscle imbalance and deformity, and, to a very great extent, the same type of end-results. ... Discussions all too often center about differences between 'new' and 'old' forms of treatment. Let us instead discuss what is good and bad, using scientific medical knowledge and clinical experience as the basis for our reasoning."

That advice is as relevant today as it was in 1947. And just as the polio epidemic propelled physical therapy forward, I believe our current health crisis can do the same.

I hope it creates a world in which barriers to our care are permanently removed and physical therapists and physical therapist assistants consistently perform at the top of their license — with evidence, confidence, moral agency, and clarity of purpose.

I hope we take this opportunity to advocate for ourselves — not just with Congress and regulators but with other health disciplines, to demonstrate the value we add to create a healthier society.

And I hope we embody the unflinching courage of our foremothers.

Before Mary McMillan spent about two years in internment camps, where she contracted beriberi and herpes zoster, and where she battled her own pain while using buckets to create makeshift hot packs to care for others, she was in Manila when Japan attacked Pearl Harbor in 1941.

She found the Army hospital in Manila, immediately volunteered her services, and began caring for the wounded as Japan invaded the Philippines.

Not long after, on New Year's Eve, a call came over the radio that the Japanese army had reached Manila.

As recounted in a 1944 article in Physiotherapy Review, Mary's "first thought was of the supplies of drugs, instruments, beds, and bedding in the Army hospital which could fall into the enemy's hands. She called the Red Cross, who were unable to send for them. So Miss McMillan — never daunted — 'borrowed' a truck and with three women drove to the hospital and filled it with supplies and turned them over to the local Red Cross chapter.

"These supplies helped to keep the camp hospital going many months," the article states before adding, "they had acted not a moment too soon, for within a half-hour the Japanese took over."

There are two key verbs in that story.

The first is "borrowed," which in any recounting of this act of heroism always appears in quotes — the implication being that Molly didn't exactly ask for permission when she took that truck.

The second is "acted." In a time of crisis and danger, in a time when there were no easy answers, Mary McMillan acted.

How fitting it is that Mary McMillan is the first great pioneer of our association. From the start, APTA has been defined by those who act.

Before I go, I want to take you back to 1946 again, to APTA's 25th anniversary when Molly read Good Timber and said that physical therapy had given her a "very full and satisfying life."

Just before reading the poem, one the great first teachers of physical therapy in this country offered a lesson:

Mary said, "A physical therapist should keep up with the latest in her profession so that when new things come along she is aware of them, so that she may be of greatest service to her patients."

"She must believe in herself, for without this, others cannot have faith in her. She must have faith in herself, and that does not mean cocksureness, that all too frequently comes from ignorance.

"A physical therapist must never let her patients go without hope, and I do not mean false hope either, I mean real hope. Because hope helps to chase away fears."

Then, in words that were destined to stand the test of time, she added:

"Of course, it's not always easy. There will be hard knocks. It is the hard knocks that help to bring out the best timber in us. Who wants a soft job, anyway?"

To the physical therapy community of 2020, we are months away from the start of our second century.

As much as ever we are in need of bold, brave, trailblazing members of action to lead the way.

We are in need of you and each other.

The wind is strong. The sky is high. But we are made of good timber.

Thank you.

Addendum

Following the recorded address, President Dunn made the following comments to the House.

Good evening, delegates.

I recorded that speech two weeks ago today, because — consistent with past years — we want to share the address with our members beyond the House of Delegates livestream.

At the time it was impossible to imagine anything could seize our collective attention quite like COVID-19. And yet here we are today, in the midst of two raging storms — one a viral disease of the pulmonary and microvascular system, and the other a vile disease of the soul — both attacking the very fabric of our country and our basic needs for community, for safety, and for each other.

Yesterday I published a message on racism and systemic inequality in America. To get it into the House record, I'd like to share parts of that now:

Fixing racism in America is an American problem. We cannot pretend to live our country's values while racism persists, and it is our duty as citizens to address the gap between what we say we stand for and what (and who) we will stand up for.

And what of our physical therapy community?

If simply speaking about the problem solved the problem, we would already have solved this. Sadly, this is not a new conversation.

Our positions — established by our members — are clear. As PTs and PTAs we respect the inherent dignity and rights of all individuals. We are against discrimination. We are for addressing health disparities.

What's left to us — to all of us in our community — is to live those values through action.

That means finding ways to address social determinants of health, which include discrimination. That means making strategic investments to support diversity, equity, and inclusion. That means, as I said in my 2018 presidential address, listening and learning and doing whatever it takes to ensure that as a profession and association "no one feels like an outsider anywhere within our bounds."

The unrest in our country is a response to more than George Floyd, or Ahmaud Arbery, or Breonna Taylor, or the disproportionate effect of COVID-19 on racial and ethnic minorities. It is a response to generations of death, despair, fear, and suffering.

PTs and PTAs cannot solve those problems alone, but, make no mistake, this crisis is at our front door. In mid-March, physical therapy visits declined as people stayed indoors to protect themselves from a dangerous external force - COVID-19. We must accept that a similar devastating force — systemic inequality for racial and ethnic minorities — keeps many people from receiving our services every day.

There is nothing healthy about racism. It's a disease of the heart and mind that has infected not just people but customs, systems, and laws. There is no vaccine. We must be the cure.

George Floyd. Ahmaud Arbery. Breonna Taylor. We need to say their names.

We also need to take a hard look at who we are as a country and what we tolerate or dismiss as someone else's problem to address.

We should not be surprised about the national response and protests; what we should be surprised about is that this festering frustration had not spilled over long before now.

Beyond specific senseless deaths, there is growing data revealing a staggering divide in the COVID-19 death rate between black Americans and the rest of the nation.

New figures compiled by the nonpartisan APM Research Lab released last Wednesday under the title Color of Coronavirus reveal mortality rates at 2.4 times higher for blacks than whites in this country.

These statistics have been attributed to social determinants of health and difficulty accessing health care, but we should call it what it is: a systemic injustice of our health delivery system.

Our mission calls on us to build community. Our core values include Compassion and Caring and Social Responsibility. Our Code of Ethics calls on us to "advocate to reduce health disparities and health care inequities."

There is no question about what we say we stand for. There is only the question of if we will stand up and put action behind our words.

Mary McMillan showed us the way. We need to prove that we have what it takes to follow her lead.

We won't fix this today, or by the end of this House of Delegates. And we won't solve it with words. And we certainly won't solve it on social media.

But one thing we can do right now, in this strange environment where hundreds of us have gathered together and no one is in the same room, is to reach out to someone who looks different than us and create space for authentic, hard, and uncomfortable conversations.

The status quo isn't going to work. It demands change. We need to prove we're authentic enough to face that fact.

We all have biases. We also have hearts capable of compassion and grace, and that's the muscle that needs strengthening right now.

It will take individual discipline, but it's only together that we'll improve our communities, profession, and association.

So, I'll wrap up by echoing how I ended my recorded message, because the words still apply.

To the physical therapy community of 2020, we are months away from the start of our second century.

As much as ever we are in need of bold, brave, trailblazing members of action to lead the way.

We are in need of you and each other.

The wind is strong, and the sky is high. But we — all of us — are made of good timber.


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