As director of the post-professional Online Doctor of Clinical Science (CScD) in Occupational Therapy (OT) program at the University of Pittsburgh, Dr. Pam Toto speaks authoritatively about the program's mission. In the interview below, Toto explains why OT practitioners benefit from this post-professional doctoral degree program. "Given how complex the profession has become, we just don't have enough time to cover it all at the master's level," Toto says, clarifying that by "it all," she means a deep dive into evidence-based practice, implementation strategies and change leadership.
It wasn't always this way; in fact, Toto began practicing occupational therapy right after earning her bachelor's degree from the University of Pittsburgh. However, she eventually realized she needed further education to manage "the complexity of health care" in a system that is "broken in significant ways." Later, she earned her PhD en route to a career that includes clinical gerontology, teaching and academic leadership.
Toto oversees Pitt's Online Doctor of Clinical Science in Occupational Therapy, housed in the nation's third-best occupational therapy graduate program, according to US News and World Report. In addition to the CScD in OT degree, the 100% online program offers a one-of-a-kind Advanced Practice Certificate in Implementation of Evidence in Clinical Practice, conferred upon completion of the doctorate or earned as a standalone credential. More important than the certifications, however, are the skills and knowledge students acquire through the program, enabling them to improve care delivery and impact health care practice on a large scale.
You've practiced occupational therapy for over 30 years. What's been the most significant change to the profession since you began working?
The stakes have grown higher in health care. In part, it's because health care has become more of a business. Consumers are more savvy than ever. Everything is more complex. Clinicians not only need to be good clinical providers but also must understand the health system. You have to understand policies, learn the business and advocate effectively for yourself and your clients. You also have to demonstrate value to your stakeholders: your boss, your health system, the federal government and the consumer.
"A lot of people come to our occupational therapy program frustrated because they don't know how to achieve success for their clients or for the health system."
In addition, the opportunities have become much broader. I started as an occupational therapist with just a bachelor's degree. I subsequently added a master's degree because the complexity of health care demanded it. Now, in some scenarios, the profession is moving to an entry-level doctoral degree.
You mentioned the need for OTs to demonstrate value. How can they do that?
30 years ago, occupational therapists typically had one customer or one stakeholder—the patient. Today, we're operating in a system with a lot of stakeholders. Part of being successful is understanding what is important to those stakeholders and how to package what you're doing without changing it. As you track your work, you need to remember to indicate its value to stakeholders.
What is the most challenging element of the CScD in OT program? What's your advice to prospective students on how to prepare for these challenges?
We're on an upward trajectory for all of health care, not just for occupational therapy. People enter these fields because they want to help—they want to make a difference. That's certainly noble, but too often, occupational therapy practitioners become burnt out or frustrated because the real world doesn't match their idealized vision.
Throughout health care, there's a significant gap between evidence created by best practices and what's happening in the world. A lot of people come to our occupational therapy program frustrated because they know how to provide the best service, but the reality isn't matching their expectations. They don't know how to achieve success for their clients or the health system.
That's where the CScD program comes in. Our program empowers occupational therapists to develop advanced leadership skills, implement evidence into practice and transform clients’ lives and the profession of occupational therapy.
"You have this knowledge. How do you translate it into use? That's called implementation—and it's a heavy focus of our curriculum. How do you take evidence and implement it in the real world?"
You mentioned evidence-based practice. A lot of occupational therapists guide their practice based on experience. Is there a gap between what evidence-based practice indicates and what OTs gravitate toward?
Evidence-based practice encompasses several elements. First, it looks at what the best evidence indicates. It also includes the clinician's experience; we don't discount that. Finally, it includes the client's values and goals. All of those pieces factor into the mix to generate the best outcome.
New evidence is regularly produced—but that new evidence doesn't always enter the mix. It could be because the clinician doesn't know about it, or the clinician doesn't know how to implement it. Or, they may be in an environment that doesn't support practices indicated by the new evidence. That's partly the researchers' fault because research should be designed in a way that's usable in real life. It's also the health system's fault.
There are no simple solutions. It's not just a matter of teaching occupational therapists what the evidence indicates. You have this knowledge, but how do you translate it into use? That's called implementation—and it's a heavy focus of our curriculum. How do you take evidence and implement it in the real world? How are you more successful at being a change agent, matching what's current and what's best in conjunction with your experience, and with the client's values?
A recurring struggle in many master's programs is that students graduate with technical skills, but lack the agility to apply technical principles, theories and solutions to various scenarios. How does Pitt get ahead of this?
A lot of health care master's programs don't include any business courses. If you think about a business curriculum, it's all about selling and making the person understand the value of what they're selling. There is none of that in traditional health care curricula.
Pitt's curriculum educates on implementation, understanding stakeholders and understanding change theory. You can work as hard as you can, but if you're swimming upstream forever, you're going to get tired. You have to understand the current and how to utilize the current so you have more staying power.
"We teach students to be better consumers of evidence in a very practical way...We teach them how to package their ideas and measure outcomes."
How does the curriculum tackle this?
It does it methodically. We lay foundations. We teach clinicians how to understand research and evidence in very practical ways. We teach students to be better consumers of evidence in a very practical way.
We also teach them the foundation of implementation and what that means. We help them realize that they're not crazy—that this is hard, and they aren't the only ones experiencing frustration with putting good ideas into practice.
We encourage students to draw on where they work or hope to work. Most of our coursework is project-based, where students actually work through something they've experienced. They have that personal edge, and then they can add their own concepts. From there, we teach them how to implement a quality improvement project or be a change agent. We help them understand the theory of change and how much to expect from the start, to find the person who's their biggest champion before trying to be David fighting Goliath. We teach them how to identify stakeholders. We teach them how to package their ideas and measure outcomes.
It culminates in a capstone project, which may be experiential or research-based. In our curriculum, we don't choose their project. We pair students with a faculty mentor, and we encourage them to choose a project that's meaningful to them and will advance their career upon graduation.
Can you provide examples of capstone projects?
It depends on the student and whether they want to advance in their own company or they're trying to move to a different company. We've had some students complete data-based projects where they're not trying to actually change something in a setting. Instead, they're trying to understand a problem or come up with a data-based solution. Maybe they know that their clients end up coming back to the hospital or don't really leave the nursing home because of x reason, but they can't prove it, and nobody will listen to them. That can be a project, but that would be more of a data project.
One student worked as a clinician in a large rehabilitation system and felt that a traumatic brain injury unit wasn't training caregivers enough to take their loved ones home. This student found inconsistency in the amount of training they gave to families. She tracked it and she did a chart audit and then, based on best evidence, she developed a training program and a system to better track and encourage clinicians and family members to take advantage of training before the person left. That was a huge project that's still being used today. It truly transformed the way that the rehab system provides caregiver training while someone's in inpatient rehabilitation.
Another student was really interested in helping transition adults with intellectual disabilities who graduate from the education system at the age of 21. These adults want to be employed, but employers may not be willing to hire them. There are many benefits to hiring someone with an intellectual disability: they're great loyal workers, and they don't quit, if you train them on a job that's kind of repetitive and they get really comfortable. They can become very accomplished at that, but the employer doesn't know how to tackle the process. This student developed a job training program in partnership with employers and persons with intellectual disabilities. She did that with a nonprofit in the Pittsburgh area and created a whole pilot that just needs funding to get off the ground.
What soft skills are required to become a successful OT?
All occupational therapists need to have good listening skills and be empathetic—not sympathetic, but empathetic. You must be team-oriented and client-centered: you have to understand your client, their wants and needs. Then you combine that with what you know and how to get them to achieve their needs.
There are a lot of different types of occupational therapists, and I think that each should be a leader in their own right. If you want to be a change leader, you also need to know how to handle difficult situations and frame your message. It goes back to salesmanship. We have a whole class on the business of communication. Most students who come into our program are more attracted to that course than almost any other.
How can a student know whether they have what it takes to move into a leadership role?
You don't need to be in a leadership position to influence change. You could simply become a more effective clinician. Typically in occupational therapy, you start as a staff therapist with the opportunity for growth—even if it's the clinical ladder. Then you become a clinical lead or a clinical mentor to other clinicians. That's a leadership role, too. You could be a manager, or you could be an educator or you could contribute to research.
There are many different types of leaders, and our program advances each and every one of them. We have people in our program who don't necessarily want to be leaders, but they're frustrated with being prohibited from providing the best services to their clients. We have students in school systems; we have students in our program who have been in practice for 30+ years. I don't know that they want to advance, but they're tired of their school administration not letting them purchase the latest assessment tool or try a new technique to help students succeed in the classroom. I don't know that they intend to be leaders in a traditional sense; they just want to be more effective agents of change. All good occupational therapists want that.
You attended Pitt for your bachelor's, master's, and doctoral degrees. What is it about Pitt that keeps you coming back?
When I first started at Pitt, I did not know that I wanted to be an occupational therapist. After my first semester, I found occupational therapy. It was the perfect profession for me. Also, I fell in love with the University of Pittsburgh while I was a graduate student. I became an ardent alumna and I always knew that I wanted to go back for education.
I thought I wanted to go into hospital administration. I pursued my Master of Science degree from Pitt because I knew it was a great academic university and it was local. I continued to live in this region and I started to do some adjunct teaching. I never had intentions to be a researcher or educator. I actually planned on being a clinician for the rest of my career, but I pursued a PhD because I was frustrated in clinical practice by the very things we're discussing.
I received my board certification in gerontology and was a professional speaker, making headway on the national level and telling people what best practice was. But, in my own practice, I wasn't really able to implement change at a larger level. Even if I was delivering great occupational therapy practice, my employer wasn't saying, "Hey, let's hire three more occupational therapists." They acknowledged my success, but not my profession's success.
In the end, I thought I had no choice except to become a researcher. I decided I had to find evidence to highlight the value of occupational therapy in helping older adults because it didn't seem to be happening. I felt as though I could retire, and I would not have made one dent in society. That's how I ended up at Pitt, because Pitt offered me an opportunity for that PhD.
In the process, I discovered implementation was my true calling. From day one, I used to fight with my academic advisor. I'd say, "I don't care how we get this person to fall less, we already have mechanisms. Why aren't we doing it?" In retrospect, I've always been interested in implementation.
Last question: Why get a CScD?
Given how complex OT has become, we just don't have enough time to cover it all at the master's level. Occupational therapists treat across the lifespan. We treat NICU babies to patients who are 115 years old. We study the physical body, cognitive science and the whole environment. We have such a breadth of knowledge that there's not a lot of time for depth. That comes at the doctoral level.
The CScD in OT is the right degree program for experienced OTs. You have to go out and live a little bit, get a little bit of experience to better understand what's missing, get a little bit scuffed up and then come back. That gives you the sense that the health care system isn't working, that it's broken in significant ways. It also gives you the desire to fix it.