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Guest Notes |
Dr Craik is Professor and Chair, Arcadia University, Glenside, Pa, and formerly served as Deputy Editor of Physical Therapy
 | Introduction |
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I had told the students that in their careers—beginning with their physical therapist education—they would have to develop a "high tolerance for ambiguity." The musician's response to this was "wo[e], major, wo[e]," a phrase that continues to be echoed throughout our profession about the need to develop a tolerance for ambiguity. Perhaps the presence of ambiguity is related to independence in clinical decision making, growth of knowledge, and professional maturation. We didn't need a tolerance for ambiguity when we were told what to do. Now, ambiguity provides the context as we search for meaningful ways to identify the best examination procedure or the most effective intervention. First, we had to recognize and accept ambiguity. Now, we should be seeking knowledge to reduce that ambiguity.
I began clinical practice in 1972. Then, a singular "proper" procedure was expected when working with patients in rehabilitation. The physician examined the patient, conducted the evaluation, and provided the therapists with a specific prescription. The prescription detailed each intervention—including the duration, frequency, and intensity of every aspect of that intervention. The therapist performed the prescribed intervention and reported progress at team meetings. Nothing was viewed as ambiguous. When I questioned the need for such specific "orders," the chair of rehabilitation medicine reminded me that I was employed in a teaching hospital where the mission included training medical residents. The boundaries of my role in the plan of care were unquestionable. I railed at the chair's response, asking why someone like me—with a master's degree and knowledge and skills related to examination, evaluation, intervention—was even hired. And I could not believe that physical therapists were willing to practice under such constraints. Ambiguity wasn't what stymied me. Lack of authority was what stymied me.
When I began teaching in the mid-1980s, my mission was to teach the students to think independently when performing an evaluation and to assume more responsibility in designing the plan of care. Granted, practice had become more complex by then. More tests and measures were available, and they were specific to diagnoses. A host of new interventions had been developed. Although more information was available, it usually was confined to textbooks, and we did not routinely rate or rank its quality. So, we asked our students to develop a tolerance for the unexplained.
How many times did the students ask for specifics, and how many times did we say, "It depends"? I am not certain that we provided a path or an algorithm to help them understand what "it depends" on—as a profession, we were still figuring that out. We emphasized the unique aspects of each person. The process of critical thinking was translated into performing examinations with a myriad of special tests to result in a unique evaluation and a unique—often "secret"—special intervention for each patient. "Protocols" were rejected because we thought that they demeaned us as professionals and that they did not require independent thinking.
Characteristics or aspects that were similar across patient populations or that could be defined as principles were purposefully ignored or downplayed. In moving "out from under" the prescriptive model of practice and striving for independent practice, we were losing sight of the need to develop principles or practice guidelines. I was dumbfounded when one faculty member challenged this approach by suggesting that, if we knew what worked for a particular diagnosis, we could all use the same examination and intervention procedures! The faculty member's insight preceded the article that was published in the Wall Street Journal describing how 5 different physical therapists managed a person with a knee problem in 5 different ways.2 In my opinion, this article emphasized to consumers that physical therapists were uncertain (ambiguous) about the optimal plan of care.
Almost 30 years after my entrance into the field, we have made major progress in reducing some of our professional ambiguity by attempting to develop guidelines. A Normative Model of Physical Therapist Professional Education3 and the Evaluative Criteria for Accreditation of Education Programs4 define minimum knowledge and skills for the physical therapist entering the profession; all physical therapist students should receive a common knowledge and skill set. The Guide to Physical Therapist Practice5 delineates the boundaries within which physical therapists design and implement plans of care for patients/clients who are classified into specific practice patterns, lists tests and measures used in examination, and lists interventions. The Guide's elaborate laundry list seems overwhelming at this time, but at least we have begun to gather information so that investigators can start to classify, discard, or rank practice expectations.
The reliability and validity of measurements used in examinations and in measuring outcomes are being investigated. Randomized controlled trials are being conducted on physical therapist interventions. Patients are being classified based on commonalities, and critical pathways are defining the common aspects of interventions for particular groups of patients. APTA's Clinical Research Agenda for Physical Therapy6 details some of the major areas in which ambiguity exists in clinical practice and puts forth hypotheses for clinical investigators to test. The Foundation for Physical Therapy provides money to train new investigators and is striving to organize seasoned investigators to work together to answer questions that will reduce some of the uncertainty in practice. A number of federal agencies are funding other physical therapist investigators who are focused on understanding the mechanisms that, in turn, will help us understand why and how our practice works.
No, I am not a complete Pollyanna. None of the documents I mention is perfect; each is a work in progress and will change. But physical therapists finally are determining and addressing patients' needs in the manner that I expected when I first entered the profession. So, what about ambiguity?
Ambiguity can be a positive driving force for the student, faculty member, and clinician. Investigators might be enthusiastic, for example, about the uncertainty regarding the optimal method to reduce muscle weakness, and they might seek an approach to contribute knowledge about enhancing force-generating capacity. Researchers might be challenged by not knowing whether constraint of the uninvolved limb or repeated use of the involved limb accounts for reduced disability and, therefore, might design experiments that will help to resolve this ambiguity. How can the rest of us get infected with similar enthusiasm when recognizing that there is no clear answer?
The goal is, of course, to stamp out ambiguity! But this still requires us to accept—rather than ignore—uncertainty. Areas that are ambiguous have to be defined, information from a variety of sources of knowledge has to be gathered. We are mastering those two steps. The next step is where we waver: We need to determine the adequacy of the information, and, if the information is adequate, we need to use it to reduce the uncertainty.
Can students stop being passive learners of facts (which, by the way, probably aren't facts) and instead seek to classify the information that is related to uncertainty with particular procedures? Can educators abandon the textbooks that state "facts" and that fail to point out the areas of ambiguity or to raise questions about the adequacy of supporting data? Can practitioners stop expecting practice-related decisions to be black and white and instead get excited about delving into the literature or reviewing clinical databases to look for guidance? Can we, as a profession, engage in discussion—and, yes, even debate—about the probability of success for a particular intervention given a set of circumstances and the available evidence? When we search the literature or talk to our peers and fail to find adequate evidence to support the use of a particular test, can we abandon that test for one that does have predictive validity? When evidence exists to support a particular intervention that we are not using, can we forsake what is comfortable to apply the intervention that has the support of data? And, if the reported intervention doesn't work as it was reported in the literature, can we seek plausible explanations through dialogue with our peers? Can we demand adequate evidence before we embrace the newest outcome measure, assistive technology, or intervention?
Many of us continue to want black and white and are frustrated with the gray. The frustration about change, about too much information, and about the lack of easy answers can result in an attitude of "shutting down," "digging in," "giving up" or a general unwillingness to seek the best or the optimal. But ignoring ambiguity won't help our patients, the individual therapist, our knowledge base, or our profession.
We are poised to clarify constructs to guide the practice of physical therapy. We are poised, not to develop a tolerance for ambiguity, but to reduce the amount of ambiguity. Rather than bemoaning the ambiguity in clinical decision making, let's recognize that the choices are unclear and enjoy the process of gathering data to clarify those choices. This process requires each of us to determine whether what we "hold dear" is based on tradition or evidence, to abandon unsupported methods, to try something new or different, and to communicate new information with peers.
In the 1970s, ambiguity was reduced because we were told what to do. Today, we can reduce ambiguity because we can use knowledge to inform our decisions. Not...wo[e], major, wo[e], but yea[h], major, yea[h].
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