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Editor's Notes |
Last month, I urged all physical therapists to become activists, but the truth is that political activism has gotten a bad name lately. Politicians have become our piñatas. Not only are they festive decorations on special occasions, but they are convenient targets for anyone who wants to vent some anger or receive some goodies. As with piñatas, all you have to do with politicians is hit their weak spots.
Few things in life provide more immediate gratification than do piñatas, which essentially reward someone for delivering a critical body blow. One major difference between piñatas and politicians, however, is that we use wooden sticks on piñatas, whereas we use PACs (political action committees) on politicians. In any case, we have precious little sympathy for either the politician or the piñata.
As the new millennium really begins, we Americans are sharing a collective migraine over the recent presidential election. Perhaps the chaos of election night and the days that followed were meant as part of a cosmic joke. I prefer to think that we received a carefully crafted message. We are a nation whose attention span seems to grow shorter each day. We forget that politicians should be more than decorative icons, more than animated piñatas who are dressed for success and capable of providing goodies. Politicians should be—and (surprise!) often are—amenable to meaningful discussions about health care and the needs of their constituents.
Perhaps out of a tortured need to make sense of the recent election activities, I also find a message for physical therapists, a message that can be viewed either as an apocalyptic warning about our profession in the new millennium or as a clarion call for us to change. In last month's Note, I contemplated what our profession should not be doing in the coming years, and I expressed hope that we will be able to move beyond undoing the cruelty and harm that humans visit on one another. I believe that we, as health care workers, should attempt to diminish not only the effects of evil, but the evil itself—the pathology that we call human evil, which harms bodies and tortures minds. The lessons of this recent election remind us that anyone who proceeds without data and appears to act only in self-interest gets the abuse normally reserved...for a piñata.
In the election's aftermath, our nation shares a collective confusion that is unprecedented in our history. All of a sudden reliability is not an esoteric concept. Lawyers talked (though without using the term) about the need to have operational definitions for decision making during what I jokingly have called the "examination" phase of ballot counting. Validity also was central to the dialogue as people debated about how to discern voter intent.
Lack of knowledge played a role in the election's aftermath. We learned for the first time that many experts on balloting (none of whom appeared to have anything to do with either party) have long known that the hand counting of ballots provides the most accurate numbers and that hand counting is recognized in an overwhelming majority of the states as the best method to settle electoral disputes. Apparently, however, these experts saw no need to warn the public that hand counting might be necessary in a close national election. Knowledge that goes unused offers little benefit to society. A little activism could have saved us from endless quibbling after the fact.
So it is in physical therapy.
For almost 3 decades, arguments have been made that, to effectively treat patients, physical therapists must be able to classify conditions so that we form clinically manageable groups. There have been pleas to use scientifically credible measurements and to stop relying on anecdotes and the opinions of self-anointed experts.
A measurement is "objective" when it is reliable, and sometimes machines are not as good as competent humans in generating reliable measurements. This has all been described in APTA's Standards for Tests and Measurements in Physical Therapy Practice.1 Reliability is something to be shown through data collection, not through divination or fancy machines. This should not surprise us. Instead, it should inspire us to conduct the research necessary to show which of our measurements are reliable and valid and therefore can be used to guide effective treatment.
Our profession and our association can be proud because we have a research agenda (Clinical Research Agenda for Physical Therapy2) that recognizes the need for credible information for decision making. Measurement is a high priority—apparently a higher priority for us than for those who oversee the voting process. But like those officials, we will be the target of criticism and derision unless we actually use our knowledge. When we have evidence, we need to use it and become activists, not to represent our interests but to represent the interests of our patients and society.
The election was painful for Americans because we have become accustomed to instancy, including instant knowledge. Patience is a lost virtue, and long-term commitment seems like an endangered species. To determine how to manage patients, we need not only financial resources but patience and commitment. As we enter this new millennium, our profession has to be able to survive periods of uncertainty. We should not seek shelter in simplistic and potentially erroneous answers.
Practice in the new millennium will require us to leave behind primitive—though comfortable—behaviors. I use the word "primitive" to describe anything for which we lack evidence. Change for the sake of change is faddism. Failure to change in the face of new knowledge is to be obstinate and professionally irresponsible and suggests that a practitioner is no longer worthy of being considered a professional.
What we do not need is to follow those who suggest we need research to prove that our interventions work. They are looking for fool's gold. What we need is evidence to guide all aspects of patient management, including the choice and use of measurements and the determination of prognoses and diagnoses as well as the selection of interventions. Knowledge should guide our behaviors. Research findings should not be used only as an excuse to justify what we would have done anyhow. We need research and evidence to guide us, and that means that each of us must be more active than ever before. We should be professionally and morally bound to know about the latest evidence and to be intolerant of those colleagues who refuse to provide care based on evidence.
The English author Penelope Fitzgerald wrote, "If they don't depend on true evidence, scientists are no better than gossips."3 If, in the coming years, physical therapists fail to use evidence and fail to demand that all of their colleagues follow suit, they will be no better than charlatans who promise rewads and good health to those who offer the most money.
I see two potential time lines for our profession. In one, we fight for survival because we seek to defend rather than to understand. In the other, we shape new dimensions in practice, including innovative approaches for assisting new generations of patients.
Which time line will we follow?
References
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