Changing times.

Reflecting on my years of practice and the articles in this month's journal, I know how Dorothy felt when, following her landing in Oz, she said, "Toto, I have a feeling we're not in Kansas anymore." I suspect this same observation can be made by every generation of physical therapists. Many of us find ourselves no longer in the world that attracted us into our profession. But the purpose of this Note is not to mourn the past or even to decry the onslaught of new problems, but rather to celebrate our willingness to face those problems.

Two papers in this issue deal with children with fetal alcohol syndrome (FAS), a condition we never identified when I began practice. The articles do not provide a guide for treatment, but rather affirm the presence of this syndrome and the need for physical therapists to consider their role in the care of children with FAS. The existence of this syndrome and our increased ability to identify children with FAS reflect not only advances in technology and science, but also our increased willingness to confront preventable diseases arising, at least in part, from societal ills. We must, of course, question whether we as a society are really willing to supply the resources that it will take to prevent FAS and rehabilitate those with the syndrome. The question of resource allocation is part of the change that has occurred during my professional lifetime.

For many of us who joined the profession decades ago, the enemies were clear. They were disease, violence, accidents, and similarly obvious evils. All patients presented challenges, and all needs were to be met. Admittedly, while that was the stated philosophy, the poor, ethnic and racial minorities, and many of the elderly were excluded from the largesse that seemed inexhaustible. But it was a silent exclusion, one that often escaped public dialogue and social conscience. Now, in an era of resource limitations, defining problems becomes more difficult. Our main focus on our individual interactions with patients remains, but our ability to work with those patients is constrained and threatened. Societal issues are the unwelcome, but ever-present, visitor in the treatment booth.

Even as we are challenged to consider our role in the treatment of children with FAS, a role that would in part be met by therapists working in institutional settings, we are also told in this issue that fewer therapists seem happy in acute care settings. For years, we have heard hospital administrators and physical therapy directors bemoan the growing shortage of therapists in acute care settings. In this issue, an article by Curtis and Martin and a series of commentaries help us understand why this may be so, but they cannot be viewed in isolation. Curtis and Martin clearly see an important role for the educational community in promoting the acute care setting as a desirable workplace. The commentators offer additional insights, but anyone who reads the paper must also conclude that part of the problem lies in the way acute care is administered.

Just as we look to the schools to better prepare therapists to work in acute care settings, so must we also look to our institutions to modernize practice behaviors so that physical therapists can be as professional in acute care settings as they are elsewhere. The difficulty of attracting therapists to work in acute care settings is multifaceted, reflecting professional and societal issues. No one means of addressing the problem will work, and finger pointing by any single group will more likely lead to fatigue of upper-extremity muscles than it will to solutions.

To further highlight the changes we must examine within and about our profession is an article from the Netherlands on diagnosis and treatment, the first research I have seen that examines whether physical therapists guide their treatment behavior based on the diagnoses they make. The implications of the paper and the issues raised in the accompanying commentaries are of great importance to our profession. For example, I cannot help but wonder whether our new-found focus on assessment, evaluation, and diagnosis does not further make the acute care setting less desirable as a workplace.

Fetal alcohol syndrome, shortages of therapists in acute care settings, and diagnosis were not issues that were in the forefront when I became a therapist. Now, issues such as these seem to overwhelm us. But then again, I think about the remaining two articles in this month's Journal, each dealing with the reliability of clinical measurements. This, too, was not a topic that was discussed very much when I graduated from physical therapy school. Today, we are less likely to be self-satisfied with our roles in the health care system, and the articles in this issue reflect the need for examination and reexamination. We have passed from the stage of passivity into activism. Our research now challenges us to look at the quality of measurements, just as the other articles in this issue challenge us to examine who we are, where we work, and who we will serve.

For some of us, the changes in our profession may seem overwhelming and a reexamination of our professional commitments may be in order. Others of us may draw solace from the constancy of change. For me, the turmoil carries its own message. Looking at physical therapy as a profession, I am reminded of Spencer's observation that "A living thing is distinguished from a dead thing by the multiplicity of changes at any moment taking place in it." By that standard, we are very much alive.