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Editor's Notes |
julesrothstein@apta.org
Frequently within these Editor's Notes and other communications among physical therapists, we discuss the "massive changes" taking place in health care. We, and "we" certainly includes this Editor, often act as though the current chaos will lead to either a health care apocalypse (with redemption of the just) or a reprise of the destruction of Sodom and Gomorrah, with case managers and health care administrators cast in the role of those about to be destroyed by a downpour of brimstone. As we attempt to characterize what has occurred to health care, and specifically to our profession, we search for images and adjectives that have (to illustrate my point) a "massive" impact. No word seems too pretentious.
Health care is in crisis, and our profession does indeed face challenges unlike any we have seen before. But our ability to function and thrive does not depend on making Chicken Little appear prone to understatement or becoming so focused on today's problems that we reach new levels of myopia. Perhaps we should focus more on providing solutions than on characterizing the problem.
The American Physical Therapy Association belongs to the World Confederation for Physical Therapy (WCPT), an organization with member groups from about 86 countries. I am fascinated by the perspectives that I have found among physical therapists from many of these WCPT-member nations. Although many of the issues that we face today also are confronting therapists elsewhere—sometimes with more dire consequences—elsewhere there seems to be a less frenetic response to the threats. Perhaps part of our nation's greatness lies in the exuberance we bring to issues, and, if so, I suggest that this is a mixed blessing. We can learn from our colleagues from other countries.
In the United States, we now scramble to justify our existence through outcome measures and efficacy studies. People for whom the term "randomized controlled clinical trial" once was as irrelevant as financial planning for the third millennium now banter about RCTs and bemoan the lack of them. When we look to other WCPT-member countries, we can see similar trends—but also some interesting differences.
We in the United States have long prided ourselves on what we believed was our worldwide leadership in professional education, having led the way with degree programs and postgraduate education. But we have failed to note that, despite these apparent pioneering efforts, we have not led the world in adding to the science and scholarship of practice. Given the number of physical therapists in our country, we should be dominating the world's physical therapy and rehabilitation literature in terms of research, especially research that illuminates physical therapist practice and guides practitioner behavior.
As best as I can determine—through my informal counts of people submitting to this Journal and people publishing in other journals—the United States, on a per capita basis, barely makes it into the top five countries for producing research that illuminates physical therapist practice. I contend that we do not notice our low levels of production because of the enormous size of our membership. Apparently, our focus on attaining higher degrees and presumably better education for new physical therapists has not had a concomitant effect on the academic community that educates our new therapists. Research productivity among our academics remains woefully inadequate. The voyeuristic approach of having every professional student conduct projects has done little to help practice. Instead, it has afforded some faculty members a Wizard-of-Oz curtain behind which they can hide and cover up their inadequacies.
The claim that a professional degree such as the DPT prepares people for a tenure-track rather than a clinical-track career also promises to do little to further our growth. Populating our faculties with people with DPTs—instead of maintaining a balance of academic faculty members (with research training) and clinical faculty members (who may include people with DPTs)—will not help our profession develop a scientific basis and, in fact, has the potential to facilitate our return to technician status. We need the DPT, and we need better-prepared clinicians. As a supporter of the DPT, I believe that the degree was never intended, by itself, to prepare an individual for scholarly inquiry and clinical research. To use the DPT in lieu of a research degree would mean that we have again missed the purpose of professional education: to prepare people for practice—the most scientifically based practice possible—and to have new therapists attain this competence soon after graduation. Preparing people for practice is tough enough without expecting the same degree to prepare people for research careers.
If, as many of us believe, the United States has led the way in attaining new heights of educational levels for new therapists, why do we trail behind other nations in scholarly output? First, I would argue that education and scholarly output are not clearly linked here, or, as our jargon goes, they are not correlated. The reasons are many and discussion would exceed the limitations of this note, but the situation needs to change, and there are both small and big things we can do to foster change. Consider, for example, the model of the Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden), which recently completed the Fifth Nordic Research Symposium in Physiotherapy, held in Reykjavik, Iceland.
These meetings, which convene every 3 years in one of the Nordic countries, bring together researchers to share ideas and develop collaboration. To my knowledge, no such meeting has ever been held in North America. To suggest that annual APTA meetings or the joint meeting with the Canadian Physiotherapy Association meet that need is to miss the point. Research-only meetings are not meant to attract every physical therapist. This is pragmatic, not elitist. A time to focus on research helps all therapists, but not all therapists find it interesting or can use their limited resources on such sessions.
The focus of the Nordic meeting is on research and, most importantly, applied clinical research—particularly evidence-based practice. Despite national boundaries and language barriers (no, not all Nordic people speak languages that can be understood by all other Nordic people), these meetings have been going on for more than a decade.
In this country, we have taken rhetoric to new heights in characterizing health care. We also have many people working day in and day out to make our profession better through research, inquiry, and education. This does not mean, however, that we cannot learn from people elsewhere. Ironically, in order for the researchers at the Nordic conference to understand one another, they have to resort to a neutral language—English. Physical therapists' needs, the profession's needs, and patients' needs transcend not just national boundaries but also linguistic barriers, and when there is a will, there is a way. A mechanism can be found for the free exchange of ideas.
When Nordic people first came to North America 1,000 years ago, they were weary Vikings. They didn't have time to leave their mark. Today, the Nordic countries have something different to offer us. It may be a little gentler than Leif Eriksson, but it has powerful possibilities.
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