If you have built castles in the air, your work need not be lost; that is where they should be. Now put the foundations under them.1(p303)— Henry David Thoreau, 1854
The expressions are not novel or infrequent. Most assuredly, we've all heard them: quite regularly, in fact. Occasionally, we hear it from our offspring and from our children's classmates at graduation parties and other casual social events. We even hear it from our colleagues' children when they swing by the office or clinic, and often, we hear it from many of our patients during the course of our work days. Athletic training educators frequently hear it from teenage students shopping for colleges and speaking of potential career choices while sitting in our offices or touring our campus facilities. And yes, quite commonly, and perhaps even increasingly, we hear it from our own athletic training majors during advising sessions or candid conversations about their future plans:
“I am going to medical school.”
“After I finish my athletic training degree, I am going to physical therapy school.”
“I'm taking the necessary prerequisites so that I can go to physician assistant school.”
“I am going to nursing school so that I can become a nurse.”
To be sure, we've all heard young adults expressing their desire to become an athletic trainer (AT) or even to study athletic training, but one thing I've never heard, not even once, is “I'm going to athletic training school.” Why isn't that a “thing,” I wonder?
Why are so many of our peer health professions referred to in such majestic manners, while the athletic training profession is still relegated to such a utilitarian status in this day and age? Why is it that bright and energetic young people, typically without forethought, say, “I want to go to medical school” in order to become a physician, yet others say, “I am going to be an athletic trainer” when stating their intention to become an AT? Perhaps, just perhaps, it is a sign of a bigger problem that has yet to be appreciated by a profession working hard to better define and carve out its true identity.
If it's true that we've advanced as a profession, if we truly deserve to be considered more than technicians, and if we are vital to the health care of today's athletes and active individuals, then why don't we hear bright and talented students use the powerful expression for our own professional education programs? Why aren't athletic training schools part of today's common vernacular, as are dental and nursing schools? Further still, why don't we ourselves refer to our own professional programs of study as athletic training schools to denote what we do and who we are educationally? In this day and age, why don't we call our own educational apparatus athletic training schools rather than the standard acronym used by so many: ATPs [athletic training programs]? And why, I ask, does it matter to each of us, to our profession, and to our collective futures?
Is focusing on the inclusion or exclusion of the term school merely semantic? Perhaps not. Is it simply about institutional organization or structure? Perhaps not. I think, rather, that it's a sign (or a symptom?) of a much larger problem for the profession of athletic training—an ontologic and epistemologic malady that we have yet to accurately diagnose. And as we all know, if we don't first properly diagnose a condition, how can we expect to create or apply effective interventions?
I'm not referring here to the visual or physical school—to institutional organization charts or actual bricks-and-mortar structures. Nor am I positing that all professions possess equal historical or practical status in society or that athletic training should be considered on par with the medical profession. What I'm trying to articulate is much deeper, more esoteric, and more discursive. What I'm concerned with here is our culture's concept of what a professional school is or what the term school invokes in our psyches when preceded by such words as medical, dental, or even physical therapy. What I'm thinking of here are the lofty connotations and affirmative imagery summoned in the minds of many when they hear medical school and the like. If your daughter announces over dinner that she “wants to go to medical school,” you probably aren't thinking about the institutional or physical infrastructure that makes any particular medical education program an actual, on-paper school where the teaching and learning physically and intellectually occur. You are undoubtedly not thinking about the Webster or Wikipedia definitions of school. Instead, you are more than likely beaming with pride over her inspiration, diligent work ethic, and academic abilities, and you can't wait to announce to your family, friends, and colleagues that “My daughter is going to medical school!” For scope of thought, we can easily replace medical with dental, nursing, or even physical therapy and get the same instinctual and emotional reaction.
Those professions have all rightly earned their lofty status in our professional and social worlds, no doubt, but I'm wondering why athletic training isn't included in this province of respect and admiration. Clearly, most ATs believe we should be walking in such impressive circles, but why don't the larger aspects of our society think so? For cultural theorist Pierre Bourdieu, the lofty, almost mythical status that schools of law, medicine, and dentistry project can be viewed as a prime example of what he operationally defined as cultural capital.2 Bourdieu's notion of cultural capital is apropos if we appreciate the idea that our culture reserves the use of school for these highly regarded professions because they better or more fully represent the totality of formal knowledge and skills that one has acquired and uses to demonstrate competence, credibility, and position in professional settings and societal contexts. Put simply, for whatever reason or combination of reasons, perhaps athletic training just does not yet have the professional chops to be a full-fledged member of the professional health care elite—at least not in the eyes of some.
Clearly, schools of law, medicine, and dentistry are institutions specifically designed and equipped to deliver highly specialized and complex bodies of knowledge with the collective mission of fulfilling their respective social contracts with the public. Concurrently, we can thus appreciate that their respective professional bodies have, over time, duly earned the cultural capital they enjoy, both historically and practically. However, the same case cannot be made as easily for our close colleagues in physical therapy. This observation has brought me to the realization that perhaps it's not the physical or visual representation of a professional school that delivers a profession's status; rather, it's about possessing a certain critical mass of cultural capital in the profession itself.
According to the Commission on Accreditation in Physical Therapy Education Web site,3 93% (220 of 236) of accredited physical therapy education programs today exist and operate as departments within larger colleges or schools of health sciences or in schools of rehabilitation sciences alongside other health care professions (such as occupational therapy). Only a few (n = 16) exist as independent professional schools. Yet despite the reality that actual physical or organizational schools of physical therapy are clearly not very common across our national landscape, I wonder why it is that so many aspiring physical therapy students refer to physical therapy school when declaring their educational and professional intentions? At this point, perhaps we need to acknowledge the idea that the profession of physical therapy has garnered the requisite amount of cultural capital needed for such public reverence.
Maybe then, at least part of the reason athletic training is not considered in the same light as physical therapy is in part due to the system we have designed for ourselves or at least have allowed to be designed for us. Arguably, many forces and events (and nonevents) over the past 3 or 4 decades have played important roles in shaping both the utility and identity of the athletic training profession today. A more critical and archaeologic look at our educational history and practices might be helpful in better understanding just how it is that we got here—to wherever here is for athletic training. For example, our disciplinary roots as academic programs born from departments of physical education, kinesiology, exercise science, and even education have arguably played a large part in shaping who we are today and how we work, both positively and negatively, as athletic training educationalists and, thus, as practitioners. Another prime example is the historically low number of faculty dedicated to our educational programs, many with limited levels and scopes of clinical expertise or educational acumen. When we consider our colleagues in physical or occupational therapy, it is not difficult to appreciate the potential limitations of such skeleton faculty, charged with delivering increasingly dense and complicated curricula over the past few decades. No doubt other events and dynamics have contributed to our lack of cultural capital, but space and time constraints herein preclude a full exposé on the matter.
However, please allow me one small and contemporary example to make my point regarding athletic training's deficit of social capital and our profession's struggle to occupy the space we deserve. I was recently looking into what other institutions are planning to do with their master's degree programs and came across a large, research-intensive university that had an interesting announcement from last spring on its Web site. This university already possesses both a medical school and a school of rehabilitation sciences containing both physical and occupational therapy programs. Yet, despite the presence of comparable and highly related professional health care programs within a specific school of rehabilitation sciences, this institution's brand-new master's degree program in athletic training is being organized within its department of exercise and nutrition sciences, which is further contained within the school of public health and health professions. Given the chance to put their new program wherever they choose, the administration opted to align their clinically based health professions graduate degree in the department of exercise and nutrition sciences. Why, I wonder, would this institution's administration not place their new clinical health care degree in their existing school of rehabilitation sciences, alongside established occupational and physical therapy programs? Could it be that that in their minds at least, athletic training lacks the cultural capital required to garner such recognition and placement? Personal correspondence in January 2018 with the administrators in charge of this institutional decision revealed that the athletic training master's degree program was placed there for more than a couple of revealing reasons: (1) historical precedence or “that is where it was before” (the institution previously had an athletic training major in the department of exercise and nutrition sciences), (2) because the chair of the exercise and nutrition sciences department wanted the program to increase student enrollment numbers in the undergraduate degree programs (as feeder programs), and (3) “It aligns well with our exercise sciences program that feeds physical therapy and now has a strong sports performance tract.” From where I sit, it is difficult to appreciate how any of these perspectives contribute to the idea that the athletic training profession has made it in the health care professions world, at least not in an academic sense.
This made me question further how many schools of athletic training actually exist in today's academic landscape? As of this writing, I'm not aware of any such designations. In contrast, how many athletic training programs across the country are hidden in full sight in similar ways, consigned to exist within related but somewhat misplaced departments and camouflaged by other quasi-related professions? In the interest of candor, the athletic training program I direct is embedded within our Department of Exercise & Sport Sciences, which is further housed in our School of Health Sciences and Human Performance. Note here, as is the case with many others across the nation, athletic training is not even included in the name of the department that houses us, thereby effectively hiding our accredited professional program from clear view. In fact, our athletic training program is the only accredited health care program in our entire school of health sciences that is not its own independent department. Further still, athletic training education is the only health care profession in our school that is not chaired by one of its own professionals (an AT). As a result of our particular institutional pyramid, neither physical therapy, occupational therapy, nor speech pathology have the recognition or identity challenges that athletic training (still) has because they each have something that athletic training apparently doesn't yet have—the minimum amount of cultural capital needed to justify their professional position and associated educational space.
A few progressive athletic training programs have carved out more pioneering spaces at their respective institutions, perhaps representing a ray of hope. Several have merged with physical therapy (for example, Moravian College, Boston University, and Marquette University), and a few have aligned with medical colleges or schools on some organizational level (University of South Florida and The Ohio State University). Leading the way, Old Dominion University appears to be the only institution in the country that possesses a School of Physical Therapy and Athletic Training, merging the 2 adjacent professions into 1 professional school.4 I fear, however, that these examples represent an extreme minority of cases across our professional landscape and that my personal institutional example is more the norm. It is also true that newly proposed Commission on Accreditation of Athletic Training Education standards for the professional master's degree will require all athletic training education programs to be housed in schools of health sciences (or comparable institutions) and that all accredited programs will be required to have a minimum of 3 dedicated, specialized, and experienced faculty members driving the new degrees: small steps in the right direction, but it remains to be seen if they will be enough to produce greater cultural capital for the profession.5 But I wonder if 1 or 2 administrative standards will really be enough to better define and illuminate who and what we are to our health care contemporaries in physical therapy, occupational therapy, and medicine or to our future professionals, the high school students pondering what kind of health care professional they want to be, and thus, what kind of school they want to pursue? The question therefore becomes this: Will accreditation reform and the master's degree requirement help the athletic training profession accumulate the cultural capital that is required to advance the profession beyond technician status? Will they alone move our profession beyond our tired and age-old trainer and brain-drain problems?
If we are honest with ourselves, we should admit that we don't truly know what precise impact the master's degree requirement will have on our actual professional practice, on the individual level regarding clinician expertise, or on the larger, professional level regarding our 49 state practice acts and legal domains of practice. If we are to be successful in reengineering and reimagining our professional system so that it results in greater cultural capital, we will need to do 2 specific things, and we will need to do them well and fastidiously. As a profession, we need to quickly and determinedly produce entry-level clinicians who possess even greater skill and knowledge sets that enable them to transition to expert practice faster than current graduates. To do this, our larger educational body must doggedly focus its curricular and andragogic endeavors toward the inculcation of expert behaviors and clinical practice. All athletic training educationalists (program directors, clinical coordinators, and faculty and clinical preceptors) need to rewire both their curricula and their approaches to teaching and learning by using the principles and findings from evidence-based health care education. This is not an easy task to be sure, but a plethora of evidence from medical education, in particular, can shed considerable light on that process and effective methods for doing so. Interrelatedly and interdependently, the greater, larger profession of athletic training must prove that it has advanced its epistemologic and professional authority and legitimacy to the public, governmental agencies, and other health care professions—an outcome that can only be accomplished if we first tackle and succeed in our educational rewiring. Increasing our social capital will thus require the energy, focus, and resolve of our entire profession, educationalists and noneducationalists alike.
If we are successful in doing both of these things, our cultural capital will rise to a level on par with that of our peers in physical therapy, nursing, and medicine, and perhaps then our health care peers and public and state and federal regulators will finally take note and expand our cultural capital to even greater heights. Perhaps a pleasant consequence of increased cultural capital will be that we keep more of the best and brightest students in our profession. In the 12 years that I have directed my current program, 40% of our alumni have left the athletic training profession within 5 years of practice to go to medical, physician assistant, or physical therapy school. Effectively, this means that 4 of every 10 students we graduate into the profession leave to pursue greater, or at least a different kind of, cultural capital after dipping their toes in the water of our profession. Maybe we will know that our cultural capital has increased when fewer of our highly trained young professionals drift into physician assistant or physical therapy studies immediately after graduation or after only a few years of professional practice.
In reference to Thoreau's eloquent prose from Walden, the professional body of athletic training needs to clearly define and build the necessary foundations to support our vision for the future—a profession flush with cultural capital or our “castle in the air.”1 If we are successful in building the requisite pillars of support in the coming years, then perhaps the athletic training education process will be more readily identified as a professional school than as ATPs. As a stepping stone toward that castle, ATPs may no longer be camouflaged in or by overarching departments of education, kinesiology, health, physical education, or exercise or nutrition sciences. And in due time, one such measure of professional and systemic success will be that high school and undergraduate students alike will say, “I am going to athletic training school.” Perhaps we will know that we have made it when our daughters surprise us in proclaiming “I want to go to athletic training school to become an athletic trainer.” If any of this happens in proximate time or space, the profession of athletic training will know that it has cultivated and garnered the social capital required to accomplish such growth; it will have built its long-sought castle in the air. But this achievement can only be accomplished through diligent work that is deliberately focused on the development and documentation of individual and professional expertise: the supporting pillars needed to enhance our social status.
Clearly and most definitely, the castle and the pillars are interconnected and even interdependent. If our educational body can produce greater levels of professional expertise and clinical capabilities in our future clinicians, and if the larger professional body can continue to advance its medico-scientific body of knowledge and evidence, athletic training will begin to accumulate the social capital necessary to give depth, color, and shape to our castle. There is, for sure, a great deal of work to be done, much of it brand new and some of it likely to be messy and arduous. As a professional body, we must continue to articulate, define, and substantiate our professional body of knowledge in order to better illustrate and justify who we are and what we do.6 Further, we must continue to generate, disseminate, and be guided by relevant evidence regarding best practices in all of our interconnected domains of professional practice (clinical, regulatory, and educational) to better legitimize our professional condition and position in the health care world.7 Doing so requires ongoing, authentic, and collaborative communication; energy and creativity; and the will to negotiate and challenge the status quo in the name of progressive professional change.8,9 Lastly, athletic training educationalists must cultivate and leverage greater academic governance over both our individual and collective futures. We must find ways of securing and exerting more control and authority over our educational programs, our institutional identities, and our locations. As Casiro and Regehr10 highlighted in their instructive and highly relevant article on governance in medical education, the complex interrelationships inherent in health care education programs (institutional, programmatic, professional, legal, accreditation, etc) require complex and explicit functions of governance that include 3 critical dimensions: authority, decision making, and accountability. Clearly, all athletic training program directors have discernible levels of accountability for program success, and they have varied levels of decision-making power that depend on their local circumstances and spaces. But when it comes to the first requirement of governance, authority, I can't help but think that our level of social capital is directly related to our level of authority. I know that in my particular space and place, my profession's lack of cultural capital impacts the level of governance I possess. In administering a highly effective program that has been in existence since 1975 and that resides in a department of exercise and sports science, I do not currently have the authority necessary to address the intersecting challenges I face as an athletic training educationalist looking to advance clinical expertise and generate the social capital necessary to move our profession forward. As a professional body, we must be willing to investigate, explore, and construct new ways of doing and being if we hope to build our castle in the air and secure the social capital required to hold up that castle. The setup to Thoreau's quote opening this commentary helps frame this larger conversation1(p303):
I learned this, at least, by my experiment; that if one advances confidently in the direction of his dreams, and endeavors to live the life which he has imagined, he will meet with a success unexpected in common hours. He will put some things behind, will pass an invisible boundary; new, universal, and more liberal laws will begin to establish themselves around and within him; or the old laws be expanded, and interpreted in his favor in a more liberal sense, and he will live with the license of a higher order of beings.
If we are successful in this endeavor as a collective professional body, both in articulating our castle in the air and in constructing the pillars needed to support that idyllic structure, we will have taken earnest and durable steps toward cultivating the cultural capital we seek and rightfully deserve: the opportunity to hear our educational programs referred to and considered in the same vein as our esteemed colleagues from medicine, pharmacy, nursing, and physical therapy. Wouldn't that be an amazing educational and professional outcome for us all? In Thoreauvian parlance, perhaps we will then be met with unexpected success and perhaps even, we can soon live with the license of a higher order of beings.