Autonomy or professionalism?

What is the true measure of a person or a profession? Is it a stated list of principles, beliefs, or skills? Or is it the behaviors that are manifest for everyone to see--the deeds that exemplify a commitment to something beyond the moment?

For almost a century, physical therapy as a profession has struggled with its identity. We have often allowed others to define our profession based on what physical therapists do rather than on who they are and how they regularly function. This topic again comes to the fore as we examine the education credentials needed for practice and the laws and regulations that limit our ability to serve our patients.

As I expressed in a previous Editor's Note, (1) I believe that our call for autonomous practice is a terrible mistake. In today's health care environment, no one is truly autonomous--nor should anyone want to be autonomous when we consider the meaning of the word: "having the right or power of self-government; undertaken or carried on without outside control: self-contained; existing or capable of existing independently; responding, reacting, or developing independently of the whole." (2) "Autonomy" conveys arrogance. Our profession has developed a specialized definition of "autonomous"--one that removes most of its noxious qualities and focuses instead on the attainment of professionalism and professional recognition --but few outside our profession will have the ability or the time to find that out.

Our calls for autonomy for our profession have become like chants at a political rally. The emotion-laden word "autonomy" evokes a powerful visceral response, but it lacks depth and meaning. Instead of using that tainted word as a rallying cry for a future vision, let's consider what we are really trying to achieve and how we may best move forward.

In many settings, we have been denied the professional recognition that would allow us to perform at the highest levels, and, in general, reimbursement schemes have discriminated against our profession and our provision of cost-effective direct care. Rallying around the word "autonomy" will not change these conditions. Instead, we need to implement a new phase of professional development and behavior. For example, regardless of whether there is treatment without referral in a given state, physical therapists will continue to interact with physicians--interacting, we hope, more as equals than as subservient followers of orders. Are these interactions more likely to be based on personal relations between physician and therapist, on respect earned over time for clinical capabilities, or on the initial expectations of the physicians?

Cardiologists do not need a referral to see a patient, and they rarely are the point of entry for patients. The nature of specialist services, including many of those offered by physical therapists, means that referral will always exist to some extent. In an ideal world, referral will co-exist with direct access, and an understanding that collegial interaction is part of the referral process will help us learn how to grow as a profession. At the end of a physician's training, referral to a cardiologist under certain circumstances will make sense because the physician has become well aware of the cardiologist's role in health care--and, therefore, the referring physician will have at least a minimal set of expectations regarding what the cardiologist can and cannot do. Likewise, shouldn't physicians be aware of the physical therapist's role and have a minimal set of expectations regarding what the physical therapist can and cannot do?

Most academic health centers, where physicians and most health care administrators are educated, offer physical therapy services. Few of these services, however, exemplify the interactive structure that is almost universal in other health care professions. The term "academic health center" implies links among service delivery, research, and teaching. Too often, though, those links exist for almost every health care profession except physical therapy.

Physical therapist professional education programs are usually apart from the clinical services, and the unified model of the education program under the leadership of an individual with advanced academic and clinical training is almost nonexistent. Less than a handful of our education programs are so well integrated that faculty members--who teach the next generation of practitioners--are expected to also be practitioners in the institution that houses the school. Academic rank and clinical excellence are not linked within physical therapy the way they are linked within other, more established health care professions. Because we dichotomize physical therapists into teachers and practitioners, there is little appreciation among our teachers for the science of our practitioners, and little appreciation among our practitioners for the practicality of our teachers. Indeed, the model under which we function in these vital academic settings is almost always that used in the education of technicians.

Our failure to demonstrate a professional model of physical therapist education in academic health centers means that those whom we would have treat us as equals often are educated in environments that indicate we are not equal. Physical therapy clinical programs are often run by bureaucrats or administrators rather than by physical therapists--therapists who would have achieved leadership because of clinical excellence and scholarship. Does clinical excellence among our leaders matter? Think about it from a patient's perspective. In seeking a specialized health care service, who among us would seek out a neurosurgeon who works in a department where the chief is known for administrative skills? We would be even less likely to seek care from neurosurgeons who were responsible to a supervisor who was a member of another profession. The issue is not autonomy, but identity.

Professionalism demands that we develop a body of knowledge and use it under the leadership of those who are first and foremost viewed as physical therapists. Academic programs should be led by scholars with adequate credentials and records of achievement, and the same should be true for our clinical enterprises. When we have school directors with dubious credentials and no record of scholarly activity in academic health centers, we send a message that we have not yet arrived as a profession and therefore cannot claim to be equal to more mature and more independent professions. What happens when our school directors are not recognized for clinical excellence by other members of the health care team who are being educated at an academic health center?

We should never have less-than-high-quality care in any setting, but when less-than-high-quality care occurs where other health care professionals can see our deficits, the damage is doubly felt. Education and clinical programs in academic health centers should assert our competence as a profession. We should abandon the notion of autonomy in favor of a more appropriate claim to professionalism and respect: a claim made not through words but through actions that model superb practice and cutting-edge education. Just as the DPT will mean little unless it represents a degree that better prepares practitioners, the notion of autonomy will ring hollow unless there is a deeper meaning that is exemplified by the manner in which we practice.

Superb physical therapy is often provided in academic health centers--but not always. Many practitioners in these settings are unable to use the literature or to engage in dialogue that would demonstrate excellence. Whether we work in academic health centers or not, we need to remember that it is within these environments that our colleagues in health care are first exposed to physical therapists. Unless we model exceptional practice in these environments, we will indoctrinate our future colleagues with an image of our profession that is far less than ideal and that may even be antithetical to our aspirations as a profession. We can talk about autonomy, or we can provide examples of professionalism that will render such discussions unnecessary. Change in the structure and function of our schools that are housed in academic health centers--and integration of our clinical services with our education and research efforts--will do more to advance our recognition than will any call for autonomy.

How can we best achieve a full measure of professional recognition? Ironically, by being less autonomous from one another and from other health care professionals in the places where people learn. Through our actions and interactions, we can develop legions of supporters in other professions, including critical decision makers in positions of power, or we can develop a reputation as ego-driven malcontents. Which will it be?

Jules M Rothstein, PT, PhD, FAPTA Editor in Chief

References

(1) Rothstein JM. Autonomy and dependency. [editor's note]. Phys Ther. 2002;82:750-751.

(2) Merriam Webster's Collegiate Dictionary. 10th ed. Springfield, Mass: Merriam Webster Inc; 1996.

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