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Editor's Notes |
Outside the Shinto shrines of Japan there are small trees that seem to be perpetually in bloom, with oddly shaped white flowers made by human hands. The flowers actually are papers containing fortunes that are given in exchange for what we would call an offering. If you take the fortune home, it is supposed to come true. If you leave the fortune behind, it is not supposed to come true. The limbs of the trees are where all of the bad fortunes end up. To ensure a good future, then, all you need is enough money to keep buying new fortunes until you get the tomorrow you want today. Given the current state of physical therapy, a system such as this might be helpful. Suddenly our future does not seem as certain as it did only 1 or 2 years ago.
For several decades, some physical therapists argued—largely unheeded—that our future did not depend on meeting the demand for therapists as though we were the latest Christmas toy in short supply. A great profession cannot thrive on being this year's Beanie Babies or Tickle-Me-Elmo! Too much time and effort were spent on addressing what was clearly a short-term need. We took home the wrong fortune. We would have been better off leaving it behind, tied to one of those trees.
We gloried in the demand for our services and grew dependent on being courted with jobs and sign-on bonuses. In institutional settings we created therapist hierarchies that were antithetical to professionalism. We had as many titles as the hospital library! Efficiency took a backseat to therapist satisfaction because a lost employee was an economic nightmare, due either to missed charges or to the cost of contract workers. Demands for data on outcomes and on effectiveness were viewed as pie-in-the-sky requests made by impractical researchers who just did not understand the pressure of waiting lists and real-world clinical practice. Ironically, now the chorus from clinic owners and managers is that we need data, we need outcomes, we need proof!
Schools metastasized, and, like any metastatic mass, they were undifferentiated and drained the vitality of the host. As a result, many of our academic faculty members were poorly equipped to function as clinical teachers and contributors of new knowledge. We noticed a faculty shortage, but as with the physical therapist shortage, the heart of the issue was missed. We needed competent faculty members, and there just were not enough to go around. Faculty members, even when competent, fell under the same spell as their colleagues in the clinic did: In the face of shortage, expectations are diminished. Most of our academics produced little scholarship and added nothing to our knowledge base. Had they been faculty members in almost any other department or profession they would have been given their walking papers, but instead we routinely saw people rewarded and promoted with few scholarly achievements to their credit. Many became department heads.
We promulgated the myth that faculties exist only to teach and that a primary attribute of a good teacher is to be liked. The truth is that faculties exist initially to prepare therapists for practice, which means that faculty members should have cutting-edge knowledge, expertise, and competence—hence their need for advanced education in the areas they teach. More than one generation of new physical therapists was given the canard that faculty should "care" about them and that caring alone meant that faculty was fulfilling its responsibility. But caring also should mean knowing, and challenging others to know and grow. Above all, those who truly care about students should not allow themselves to be drawn into the academic world until they are prepared for it. Just as I would want a caring surgeon, I would want a caring faculty member, but in each case competence and capability would have to come first.
Instead of developing a cadre of physical therapists who could draw on a vast body of evidence to manage patients in a way unique to our profession, we produced therapists because clinical directors asked for them, because schools liked the money they could bring in, because legislators wanted happy applicants—because of a dozen other reasons that had little to do with health care or creating a permanent niche for the good work that physical therapists do.
Who is to blame? The answer isn't simple. Many point to the American Physical Therapy Association or the Commission on Accreditation of Physical Therapy Education (CAPTE). Perhaps the Association could have done more, and perhaps CAPTE could have done more, but most of their critics don't understand that these two groups are limited in what they can do. Ironically, the quick response of critics to blame APTA and CAPTE is a diagnostic indicator of the major problem. Living in the land of plenty has seduced too many therapists and faculty members into always expecting "someone else" to solve their problems.
Physical therapists, not APTA or CAPTE, encouraged school proliferation. Clinical educators—believing that they were helping people—made room for clinical education spots when new schools arose. This allowed the existence of schools that in truth do little honor to our profession and that in the end produce therapists who give substandard care. People with dubious credentials joined faculties, and school directors came on board with little academic experience. As long as the communities of interest thought they were getting enough therapists, it was all viewed as progress. We as a profession put growth and expediency over thoughtful planning.
Blame all of us! Did we fight against the establishment of second-rate schools in inappropriate settings with faculty members who we knew would never be hired with similar credentials in any other mature profession? Did we take the leadership in eliminating interventions that either were shown to be ineffective or could have been better given by others? While we fostered specialization, did we ask for evidence of its benefits? More recently, we have begun the process of approving residency programs—but again, we have no data to suggest that such programs lead to any measurable improvement in care.
Now we have too many new graduates. (However, our plight is trivial compared with what other health care professionals are experiencing.) We hear about unemployment, though the numbers are unclear. Unemployment is a personal tragedy for anyone who desires to practice his or her chosen profession, but it may not be the profession's catastrophe. Perhaps now we will finally face the challenge that we ignored for nearly 2 decades. As our profession grew, we failed to give up those activities that no longer required our level of knowledge and skill. We were forced to stop treatments such as thermal modalities that could have been given in a more timely and less costly manner by others. Only reluctantly did we stop considering every person who ambulated as a candidate for physical therapy! We are not meant to be companions on walks, but skilled practitioners whose skills are needed only when analysis and meaningful improvement are desired. As a group, however, we always seemed to be on the side of expansion, with little or no discussion of limitations.
Some would argue that as the market for our services shrinks, this is a bad time for the implementation of postbaccalaureate education as a mandate by the year 2002. Many would further argue that it is an especially bad time to promote and implement the professional doctorate, the DPT. These arguments, like those heard during the shortage, are the reactions of people who fail to understand that the only road for professional survival is to grow in quality, to produce evidence that we make a difference in health care and that we do it in a cost-saving fashion. If we cannot provide this evidence, we will be rightly viewed as overeducated (and most likely overpaid) for much of what we do and undereducated for what we should be doing.
I fear that as we face new economic challenges, reactionaries will have the loudest voices—and what we need now are visionaries, not a chorus of chicken littles. There are those among us who can move us in the right direction. Don't allow the dialogue to be dominated by those with self-interests that differ from the profession's interests!
In this month's Journal there is an article about the DPT. Some people believe as I do that the DPT can provide a means toward developing the kind of therapists that the health care system cannot live without (and I place emphasis on the can). The degree provides the opportunity for us to do the right thing, but better practitioners are not guaranteed by the presence of the degree. The mediocrity of so many master's degree programs has proven that.
Normally an article such as the one by Threlkeld et al would be accompanied by a commentary. This time, there is none. That's because we want to hear from you. If you agree about the DPT, write to us with your commentary. If you disagree, this is a chance to make your case. But if you remain silent, you can no longer blame others for the direction our profession takes. Wishing at shrines may be just the thing for some folks, but as things stand, I doubt whether we have a singular idea about what would be best to wish for—and no profession can survive with that level of ambiguity.
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