Abstract
Florence Clark, PhD, OTR/L, FAOTA
Today, I want to talk with you about the idea of competition and how a competitive spirit can help us secure the power needed as we race toward our Centennial Vision (American Occupational Therapy Association [AOTA], 2007). It should be no surprise to you that some people call me competitive. Let me tell you how I became this way, and why embracing the competitive spirit is essential for realizing the vision we have for our profession and for projecting “Occupational Therapy in High Definition” in this revolutionary decade of health care reform.
Here I am at about 9 years old. For you students from the YouTube generation, this is what, once upon a time, was called 8 mm film. You can ask your parents about it. During cold Brooklyn winters, I went ice skating with my family at the Prospect Park ice rink. But as you can tell, I wasn’t satisfied to simply skate in circles; I was determined to perfect my spins, attitudes, and turns. Essentially, I competed with myself. Like many other childhood occupations, simply the thrill of developing competency and skill was motivation enough. And I was always aware of fashion. How about those earmuffs?! Summer sports were also a particularly significant childhood occupation of mine. As many younger siblings so often do, I was driven to keep up with my older brother. If he was going to swim, jump, and splash, then you can bet I was, too. From a very early age, this spirit of healthy competition was a regular aspect of my winter and summer leisure occupations.
When I was 11, our family moved to Deer Park, Long Island. As a teenager there, I spent many hot, humid summer days at Geiger Lake. Like most teenagers, I experienced my share of adolescent growing pains. I wasn’t popular, and I was convinced the boys were not attracted to me. While the popular girls were lounging on the beach or cooling off in the water, I was usually hanging out by the ping-pong table in front of a run-down refreshment stand. And that’s also where a contingent of hard-core table tennis guys always hung out. I had developed into a pretty good table tennis player by practicing with my brother on the table we had in our 1950s-style, split-level home. But it was at Geiger Lake that I started really competing with the boys. That’s where I developed my “killer serve” and strengthened my competitive spirit. And I did not like to lose. On the occasions when I did lose, it made my desire to win even that much stronger. I think I could have given Forrest Gump a run for his money. But in all sincerity, I did beat many of those boys, and I was proud of that. This teenage competitive spirit to succeed has served me very well throughout my career as a practitioner, an educator, and a scientist.
Here is one example that comes to mind. In 1989, I was 43 years old and a newly appointed department chair. I was at a meeting to defend my proposed budget. Sitting at the table were many university administrators from the highest level, including our provost. He fired question after question at me, but instinctively I found myself slamming back one clear and compelling answer after another. In this game of verbal ping-pong, my competitive spirit fortified me against intimidation. And I left the room knowing I had scored a victory.
I do not use the word victory accidentally. We achieve victories both collectively as a profession and as individuals in our day-to-day work settings. We achieve victories when we carefully document the occupational therapy we provide our clients and receive reimbursement from payers unquestioned and without denial. We achieve victories by securing a research grant or being chosen to serve on a powerful committee at our academic institution. And we achieve victories when, through advocacy actions, we successfully prevent encroachment on our scope of practice by those who are not sufficiently prepared to do what we do best. Victories are won sometimes through teamwork but always through competition. And yes, although we may not admit it, we even compete with one another. We do think about who among us will be promoted in workplaces, who will be selected to chair our educational programs, who among our scientists will receive the next big grant, and which private practice will be able to recruit the best graduates. In short, as we strive for excellence—let’s be frank—we compete! And there’s nothing wrong with that.
A competitive spirit, if ignited throughout our collective presence, will ultimately drive innovation, improve practice, and bring about occupational therapy’s competitive edge in health care reform. This competitive edge will propel us further forward to realize our Centennial Vision. As occupational therapy practitioners, I know we sometimes have trouble with this concept of competition. It is a great credit to our professional values that occupational therapy attracts people who, at their core, are kind, compassionate, and honest and believe in fair play and cooperation. But these attributes can coexist with a competitive spirit. They are not mutually exclusive. I know we don’t like to toot our own horns or shine a light on our personal and professional achievements, even when other professions may publicly claim superiority to occupational therapy. But if we take a moment now to further explore the competitive edge, it might make us all more comfortable with the concept.
Let’s go back to classical times. Most of you know the ancient Greeks embraced the idea of competition through athletic contests. Although the true origins are lost in the mists of Greek mythology, many of the early contests were held every 4 years at a major temple at Olympia, and the Olympic Games were born. Several centuries later, the Greek philosophers Aristotle, Plato, and others pondered the larger meaning of these Games. They asked, How does exercising the physical body strengthen personal character? Does a truly virtuous life, by definition, require athletic training? What virtue is gained from competition?
These philosophers concluded that competition and virtue are intimately related. To become truly excellent, physical training in preparation for competition inherently required athletes to develop their personal character. The philosophers had a word for this excellence—arete—which means to reach the highest possible human potential. They believed that the competitive spirit was critical to the acquisition of arete, or excellence.
I would like to illustrate this idea of arete, or excellence, by the example of not a Greek, but rather a Philadelphia icon—none other than Rocky Balboa. At the beginning of the movie Rocky (Avildsen, 1976), Rocky is a depressed and downtrodden boxer. Yet we still like him. We like him because he talks sweetly to his turtles and fish. We like him because he sees the inner beauty of and falls in love with a shy and plain woman and builds her self-confidence. In short, Rocky, in many ways the ultimate underdog, is also a very complicated human being. He combines caring and competition, sensitivity and toughness, humility and confidence—all of these dichotomies exist in one person. So when a once-in-a-lifetime opportunity comes along, Rocky seizes it. He knows in his heart that he cannot beat the world champion Apollo Creed, but with arete he commits himself to going the distance, and to the very end, he honors this commitment. Not only does Rocky develop physically, but we witness the transformation of his whole being. His story is one that exemplifies the cultivation of arete. We witness how competition fosters personal excellence.
But the concept of arete was not limited only to athletic competition. Aristotle and the Greek philosophers believed that it was possible to achieve arete beyond physical feats occurring on literal playing fields or in literal sporting arenas. When cultivated by the spirit of healthy competition, arete can be realized across all dimensions of human life, including work, rest, and play. Although it is thousands of years old, we can still apply the concept of arete to contemporary practices of occupational therapy.
When we help provide the perfect resources and build the optimal skills necessary for a person with mental health issues to successfully engage in community life, we are practicing arete.
When we create exemplary programs that account for life’s complexities and contingencies, such as redesigning the lifestyle of an older person so she may truly age in place, we are practicing arete.
When we expertly structure the just-right challenge in a sensory integration clinic for a child with autism, we are practicing arete.
When each of us develops individual personal excellence in our everyday work setting, we together sharpen the competitive edge of occupational therapy. Like the ancient Greeks training for the Olympics, the competitive spirit will make us Olympians. Or, just like Rocky Balboa, the competitive spirit will prepare us to enter the ring with our own Apollo Creeds.
In the many arenas where health care reform is being debated and implemented, we need to be in the ring. We need to persuade the decision-making authorities that occupational therapy must be a centerpiece component of health care reform. And yet, even though we practice arete and compete with one another every day, many occupational therapy practitioners hesitate to think about their work in terms of a competitive edge. Notice that I say compete with, not compete against. There’s a significant difference between the healthy spirit of competition that makes all of us perform better and the destructive spirit of competition that focuses on crowning winners and humiliating losers.
So I am not saying that it is not important to play nicely with others. It most certainly is, especially in this era of health care reform when the emphasis is clearly placed on interprofessional collaboration. But when we let others take occupational therapy for granted or exclude us from initiatives in which we should be key players, it’s not “playing nice”—it’s “playing dead!”
Last year, in my inaugural address (Clark, 2010), I suggested we are sleeping giants. And I am repeating that message this year. It is time for every one of us giants to wake up. We must stop letting others muscle their way onto powerful committees in our work settings at the expense of occupational therapy. We must resist staying silent when our voices need to be heard to ensure better service. We need to submit plenty of National Institutes of Health (NIH) grant applications so that our perspective becomes understood and valued by study section members. We must seize leadership positions in health care reform when our skills and expertise make us the best ones for the job. This competitive spirit will allow us to be seen as worthy collaborators and team members rather than as support personnel eclipsed by competitors who may be more assertive at best and arrogant at worst.
Please understand. I can’t stress enough that we must remain cooperative team members. This has always been one of our key strengths. It is our nature, the fundamental yeast of our collective psyche. Let’s face it—we’re nice! But a rowing team on the Schuylkill River can’t win the race without all members of the crew being equally valued. The same principle applies to health care, whether in practice, research, or education. And just as each person on a rowing team is equally necessary, so, too, is equality required on interprofessional teams to achieve excellence. If we awaken our competitive spirit, we will position occupational therapy as a more powerful profession. As a consequence, the teams on which we play in health care reform will realize better outcomes. And then, in the end, it will be the consumer who is the ultimate winner.
You’ll remember, from my address last year (Clark, 2010), that I said each one of us is a vibrant pixel and together we form a picture of our profession in high definition. Everyone knows how fond I am of the occupational therapy in high definition analogy. Just as HDTV is literally fueled by electricity, HDOT requires power, literally. We can achieve the Centennial Vision and continue to bring our practice into high definition only if we band together and embrace our collective power. Each pixel, as vibrant as it might be, cannot stand alone. We must form collectives and cohesively populate, pixel by pixel, those high-resolution screens. There is safety in numbers, but more importantly, there is power. Being a more powerful profession will mean
Having the power to influence health care policy and secure our place in emerging medical homes and accountable care organizations;
Including occupational therapy as a standard of best practice rehabilitation;
Having a sufficient revenue stream to support our services in elder care, mental health, early intervention, and autism;
Strengthening our voice in national agendas regarding obesity and other major threats to the health of all Americans;
Affirming our unique and invaluable contributions to health care and societal needs, for which no other profession could ever substitute; and
Ensuring reimbursement streams to support the skillful and complex work we do every day.
The list could go on and on!
Thanks to all of our hard work, we are positioning occupational therapy to have a competitive advantage and grow in this decade of health care reform. I truly believe that if we practice, do research, and teach with vibrant high-definition clarity, our competitive edge will undoubtedly grow. Our distinct approaches throughout our many areas of occupational therapy practice can converge to form a unified image.
But we must also take what I call our “pixel power” to the rooms where power is brokered; to the meetings where the public is asked for input on new policies; to political parties, where we can become candidates for public office; to the Chamber of Commerce and private business sector; and to the arms of local, state, and federal government. All of us must come together in these brand new ways. And each one of us will be a pixel in the widescreen, crystal-clear, and vibrant high-definition picture of occupational therapy. This diversity of our various collective strategies will give us traction and heft and heighten occupational therapy’s competitive advantage.
There is no better time than now for the public to be awakened to the special value occupational therapy brings to health care. I was recently thinking about how the profession of physical therapy gained public visibility during the polio epidemic in the 1930s, 1940s, and 1950s. At that time, the big question was whether children stricken with polio would walk again. When the President of the United States, Franklin Delano Roosevelt, contracted polio and used a wheelchair, the physical therapy at Warm Springs gained national acclaim for helping turn his tragedy into triumph. For decades later, most of society thought the bulk of rehabilitation concerned restoring a person’s ability to walk.
Fast forward to 2011. Now society not only knows, but truly believes that when walking stops, life still goes on. We see wheelchair users like journalist John Hockenberry proudly proclaim their chairs are extensions of their bodies. We see athletes like action-sports star Aaron Fotheringham, who was born with spina bifida, build a larger-than-life cult following and break world records with his 50-foot wheelchair backflips. There is an entire industry focused on building the latest and coolest wheelchair technologies. The public now knows that restoring ambulation is only one among a vast array of rehabilitation goals. More than ever before, the public “gets it.” It understands that rehabilitation is about getting back to life, to family, to work, and to community—living life to its fullest, no matter what.
After the tragedy that befell Arizona Congresswoman Gabrielle Giffords, the focus was not on whether Congresswoman Giffords would walk again; it was on whether she would be able to run again—that is, run for public office. Millions of Americans wondered whether she would be able to return to the life she previously had, to the roles she used to fulfill: congresswoman, stepmother, wife. These realms of community reintegration, engagement in life, and doing the things that make life worth living have always been occupational therapy’s focus.
More than any other health or wellness profession, we understand that hope still glimmers in the darkest hour. That’s because we are witnesses to—and champions of—the fundamental power of daily occupation. We know that because of the transformative potential of everyday activities, from life-shattering tragedy can come life-restoring triumph. This knowledge must be widely and repeatedly shared with the public.
I believe that just as physical therapy came to be better understood during the polio epidemic, occupational therapy will obtain heightened public understanding during these times when the incidence rate of polytrauma and traumatic brain injury is growing exponentially. That’s because, with these conditions, it’s getting back to everyday living that matters, both for the individuals and for society as a whole.
There are several other areas of practice today, apart from health care reform, that provide occupational therapists with a competitive edge. Let’s start with hand therapy. When I was an occupational therapy student, occupational therapy practitioners were the only professionals who performed this service. And today, we still shine by fabricating the perfect custom splint, providing the optimal tailored intervention, and using our aesthetic sense to provide best practice in this area. And what is most special is that our approach fully takes into account the person’s agency and needs for his or her life passions and life requirements.
Consider also our work in autism, autism spectrum disorders, and sensory processing disorders. Occupational therapist Grace Baranek, influenced by A. Jean Ayres, now leads an NIH-funded postdoctoral training center to prepare career scientists in the area of sensory processing and autism. And what a compliment it is to our profession that the theory on sensory integration, which originated in occupational therapy, is now infused into so many complex interventions for children with a wide range of developmental disorders—a population very much on the mind of our policy makers.
We also have a clear competitive edge at this very time in our work with wounded warriors. Modern medical advances coupled with the newest generation of weapons technology means that warfare has become more survivable than ever, but it results in record numbers, combinations, and types of injuries. Most of these are life-changing. Our therapies provide our brave fighting men and women the means to truly continue to live their lives to the fullest.
And this is nothing new. Practically as long as there have been occupational therapists, we have been by the side of veterans. Did you know that during the Second World War, the majestic Ahwahnee Hotel at Yosemite National Park in California was temporarily repurposed as a rehabilitation center for that generation’s wounded warriors who served in the Navy? The largest space in the hotel was specifically dedicated to occupational therapy. The military brass didn’t do this simply because they just liked the occupational therapy practitioners; they recognized our competitive edge and demanded expansion of our services!
Think of this: Occupational therapy is the only profession that primarily focuses on the fit between a person—any person—and his or her environment. What about all the Boomers who want to age in place and continue safely driving their cars? We are trained to analyze what it takes to enable people to do things like this and to continue to live happy, healthy, and productive lives, no matter what. Our primary focus is not on helping people to walk or move better; it is on moving with them, being beside them, problem solving and solution finding with them as they move through the unfolding chapters of their lives.
However, let’s be crystal clear: Like Rocky Balboa, we now have a once-in-a-lifetime opportunity to demonstrate and enhance our capabilities by flexing our metaphorical muscles. This unprecedented opportunity is health care reform. We must explicitly show the American public that no other field comes close to doing what occupational therapy does best. Occupational therapy must be made universally visible and widely understood. Every athlete knows that training only goes so far; the competitive edge must be enacted with tactics and strategy on game day.
What is occupational therapy’s playbook? What are the “plays” we must enact to be successful? Here’s a preliminary list:
Let’s get the word out that we have already published studies that show occupational therapy’s effectiveness in areas such as chronic disease management, caregiver support, dementia care, and prevention.
Let’s increase the number of grant applications we submit to NIH.
Let’s use our extensive experience in home health care to demonstrate our effectiveness in fall prevention and in decreasing other risks associated with 30-day acute care rehospitalizations.
Let’s work on our documentation. In talking with people whose work is to review Medicare claims, I’m told we hesitate to fully document the familial, cognitive, and occupation-based aspects of our interventions. Instead, we have a tendency to overemphasize motor-based components. Is this because we lack confidence, have been intimidated, or simply don’t think we can get reimbursed for all that we do? I have been advised by these experts that we can get paid for the multifaceted practices for which we have been prepared and in which we believe. We just need to stand up as a collective and own the appropriate words. Let’s figure out how to do this.
Along these lines, let’s make sure that insurance companies and other payers provide sufficient coverage for our services. Our competitive advantage is that thanks to AOTA advocacy, we already are designated an essential health benefit in the health care reform law.
Let’s make clear and tell everyone about the work we are now doing in innovative areas like telemedicine, in helping people embed the latest technology in their lifestyles, and in providing customized and personalized care.
And let’s get those of you who are leaders in large health care systems planning to convert into accountable care organizations to insist on being at the table where policies are determined and power is brokered.
In making these plays, let’s not be intimidated by other professions that claim to be more evidence-based. Many of you will attend Dr. Kenneth Ottenbacher’s (2011) plenary session tomorrow, “Evidence-Based Practice and Knowledge in the Era of Health Care Reform: Opportunities for Occupational Therapy,” and will learn first hand of his recommendations to do engaged scholarship. But it’s not enough to produce and know the evidence. We must enter the power circles that determine exactly what kinds of evidence count. As someone who has been spending nearly two decades implementing large-scale randomized controlled trials on hundreds and hundreds of participants, frankly, I was surprised to learn that in education, an evidence-based practice can be established simply on five single-subject design studies.
We need to partner with consumers who have experienced the value of occupational therapy. Shonda Schilling (2011), our conference keynote speaker, is an example of someone who can speak powerfully to the personal impact of occupational therapy. She told us how occupational therapy makes a difference for her son, Grant, who has Asperger’s syndrome. The competitive edge of occupational therapy enables us to help children like Grant live life to its fullest. And together with those who have personally benefited from our services, we need to be intensely involved in advocacy.
The title of the theme song in Rocky is “Gonna Fly Now” (Conti, Connors, & Robbins, 2006). And I’ve been talking today about excellence and our competitive edge. But I need to point out that I believe occupational therapy started flying in 2003 with the adoption of the Centennial Vision (AOTA, 2007). Whether you realize it or not, when you do anything to help implement the Centennial Vision, you are embracing excellence and sharpening our competitive edge.
But we can do better. Look at how AOTA membership has grown since adopting the Centennial Vision (Figure 1). Are we competing to have the largest proportion of members compared with any other professional association? Let’s spread the word and become an army that recruits our coworkers to join AOTA.
AOTA membership.
Look at how the American Occupational Therapy Political Action Committee (AOTPAC) annual fund has grown since the Centennial Vision (Figure 2). Even considering the economic recession of the past several years, AOTPAC funds from 2010 still exceeded the receipts from the boom years of 2005. Let’s make 2011 the best year ever.
AOTPAC giving.
Take a look at how attendance on AOTA Capitol Hill Day has grown (Figure 3). Are you engaged in political activity? Do you know the local, state, and national politicians who represent you? Can you get on a first-name basis with them, like Pennsylvania Occupational Therapy Association President Cathy Dolhi is with U.S. Senator for Pennsylvania Bob Casey, who welcomed us during this Conference’s Opening Ceremony? Being at the political table when key decisions are made and informing those present of the ways in which occupational therapy positively affects the lives of people is the “fast track” for inclusion in health care reform.
Capitol Hill Day attendance.
Look at how student AOTA membership has proliferated since the Centennial Vision was implemented (Figure 4). Let’s compete to achieve 100% this next year.
AOTA student membership.
As your professional association, AOTA is performing many functions that help maintain our competitive edge. We are educating the public through aggressive public relations. We are maintaining our competitive edge through strong advocacy both in Washington and in our state capitals!
Look around this hall. AOTA’s Annual Conference & Expo is one of the largest single gatherings of occupational therapists in the world! And 2011’s Conference is one of the biggest and best ever!
Among us today are so many champions. As an example of a champion from Rocky’s hometown, I’d like to tell you about someone who has truly helped establish occupational therapy’s competitive edge. Her trajectory of excellence on behalf of our profession began through early projects funded by the American Occupational Therapy Foundation. By embracing science as the means of empowering more competitive practice, her research, along with that of her team of coinvestigators, has led to new ways of approaching the profound problems associated with aging, dementia, Alzheimer’s disease, and caregiving. As a result, many lives will hopefully be changed for the better. She could have shied away from competition, but instead she chose to embrace it. Her hard work has placed Thomas Jefferson University at the forefront of occupational therapy research and practice with the founding of Jefferson Elder Care.
This legacy symbolizes the kind of competitive excellence I have been talking about today. Ladies and gentlemen, Dr. Laura Gitlin is the perfect example of an occupational therapy Olympian.
No doubt, some of you are wondering why I chose to highlight Dr. Gitlin’s work. There are certainly many other scientists whose excellence is worthy of recognition. However, I think Dr. Gitlin’s work is truly representative of ways of embracing excellence by pushing the competitive edge. She has purposefully worked to provide an occupational therapy–specific contribution to the science of aging. Last month, she provided testimony to the U.S. Senate Special Committee on Aging regarding establishing occupational therapy’s unique role in dementia care and caregiver support. Let’s have a round of applause for Dr. Laura Gitlin.
Each of you here today has the potential to be an occupational therapy Olympian. Whether in research, education, or practice, the first step is to practice arete and strive for everyday excellence.
Let’s get fired up! We are excited to show the world the difference that occupational therapy makes in people’s lives. Isn’t it time for each one of us to embrace our inner champion and make it happen? Isn’t it time to sharpen occupational therapy’s competitive edge? Isn’t it time for us to strive as we never have before, to face our competitors, and to truly go the distance?
So I ask each of you to fire up your competitive juices!
Practice with arete!
Awaken, if you are a sleeping giant. Seek excellence and cultivate your power!
Now is our time to fly!