Footprints.

Footprints Having stood before you so often as Speaker of the American Physical Therapy Association's House of Delegates, I feel almost like an impostor to be here as the 1989 Mary McMillan Lecturer. I must confess, it is with great trepidation that I stand before you without my gavel in my hand, and I have an almost uncontrollable urge to call this meeting to order! When notified of this award, I had difficulty believing that it had really happened to me. Then when reading the nomination support provided by my good friends in the Texas Physical Therapy Association, I felt like the old lady in the nursery rhyme who said, "Oh me, oh my, can this be I?"

I am extremely grateful to be here and even more grateful that so many of you have chosen to be here also. I do hope that those with whom I share this honor are pleased to have me join their ranks and that something I say will be worthy to honor the memory of that legendary lady, our founding president, Mary McMillan.

I would be remiss if I did not thank some individuals who, to my great pleasure, are here today and without whose long-term support I might not be: Frances (Abby) Abendroth, who, although disliking meetings and detesting Roberts' Rules of Order but loving physical therapy, treated some of my patients, took care of my dog, and even cared for my mother so that I could go off to do APTA work; Jeanne Schenck, who, early in my career, insisted I attend district and chapter meetings and kept recommending me for activities in those components in such a way that I was ashamed to refuse to accept them; and my two sisters, Frnces Doidge and Shirley J Wood, PhD, who are not only sisters but also two of my very best friends. They always seemed to believe, and to make me believe, that I could do anything that I set my mind to do. Unfortunately, it did not always, work out that way, but I do thank them.

I wish to take this opportunity to thank all those who have served and those who currently serve on the APTA Board of Directors. They have made so many contributions. Board members spend an inordinate amount of personal time serving this Association, and they deserve our thanks. The proposals and policies developed by them for consideration by the House of Delegates, after much work and debate and even some compromise, have led to the advancement of our profession and our Association.

Of course you know that I cannot stand here without thanking all who have been delegates to our wonderful House of Delegates. The tremendous amount of work produced and actions taken are a matter of record, but it would be totally out of character if I did not give some advice to the delegates. It is imperative that all delegates continue to accept the responsibilities given to them by the Bylaws to determine the policies, the ethical principles, and the activities of this Association. It is their deliberations that must determine the direction the profession will take as well as its fate. We have an excellent Headquarters staff, which is vital to our existence. They do make a huge contribution. But there is a chain of command. Headquarters staff must continue to answer to the Board of Directors, and the Board of Directors must answer to and follow the mandates of the House of Delegates. Delegates must remember that they have the right, and sometimes the duty, to modify or reverse a decision of the Board of Directors. Our leaders, both staff and Board, should and do guide, but the members of this Association must never, ever, abrogate their responsibility for directing this Association in ways that will improve and preserve both it and the profession of physical therapy.

For all of my physical therapy professional life I have been a clinician, which, incidentally, is the only thing I wanted to be. For me to speak on methods of research or education or to prognosticate the future of the profession based on such methods would not only be foolish, but also impossible. Patients and their treatment have been my focus, so I will speak about patients and our responsibilities to them and ask you to consider the effects that our actions will have on them.

I quote a most familiar verse from Henry Wadsworth Longfellow's poem "A Psalm of Life": "Lives of great men all remind us/We can make our lives sublime,/And, departing, leave behind us/Footprints on the sands of time." [1]

I grew up in northern Indiana just a mile from Lake Michigan, and I remember the dunes along its shores. If one walked up on the hills where there was fine, dry, sugary sand and wind, our footprints were not distinct and the shifting sands and blowing winds soon made them disappear. When walking in the wet sand at the edge of the lake, the footprints were well defined but washed away by the very next wave. Yet there was always one area where the sand was just wet enough and the waves not quite reaching where one made deep, distinct footprints that stayed intact and could be followed a long way. What kind of footprints will be in the physical therapy profession today follow? What kind of footprints will we leave? I have much regard and admiration for you, my peers, and for all that is accomplished in the health care field by physical therapists. Please accept that as a "given" as I share with you some of my concerns. I must ask your indulgence if I use the word "patient" too often. We all know that physical therapists interact with many individuals who are not "patients," and that the profession encompasses much more than treatment. However, my concerns about our profession have to do with the effects of our actions on those we evaluate and treat.

What should guide our profession in the direction it takes, and by what should it be judged? Physical therapy is a service profession and as such has no acceptable reason for being except to affect individual needs by the treatment or prevention of disease and disability. Patient are our focus! Without them, we are nothing! They are our reason for being!

The ultimate criterion that must be used in determining the education of physical therapists and physical therapist assistants, the policies of our Association, our practice settings, our scope of practice, our standards for practice, and, very importantly, our professional ethics must be: "Is the focus on, and will the end results benefit, those we serve?" Every action we take as individual physical therapists or as an Association, every policy we develop and every plan for change we make, must be evaluated within this content.

Before making any decision, we must first ask, "What benefits or detriments will the patient derive from this decision?" We must subscribe to the theory that what is good for the patient is good for the physical therapist, is good for the Association, and thus is good for the profession. To rearrange that series in a way that puts the physical therapist or the Association before the patient can only invite disaster.

I have some concerns about the responsibilities of independent practice. You all remember that the House of Delegates, in 1985, adopted the policy that "A physical therapist may be the entry point into the health care system for evaluation, treatment, and prevention." [2] Practice acts in 23 states now permit treatment without medical referral, and 17 additional states permit evaluation under that same condition. I sincerely hope that soon all states will enact laws that provide for our independent practice. But I do have concerns.

In his article entitled "Whistleblowing in Physical Therapy," John Banja wrote, "As physical therapists grow more autonomous, their responsibility to the patient, the profession, and medical consumers increases." [3] We all would agree, but I wonder, are we each accepting and fulfilling those responsibilities? Are we even in agreement as to what those responsibilities are?

In the Twenty-Second Mary McMillan Lecture, Charles Magistro mentioned one when he said, "I am convinced that one of the primary reasons the specialty of physical medicine and rehabilitation failed to control physical therapists was because they did not lay hands on patients or deal directly with their problems. We physical therapists never must permit our profession to be jeopardized by failing to provide those services that justify our existence." [4]

Yes, the physical therapist must deal directly with the patient and his or her problems. If we are to be successful as independent practitioners, we must not only provide those services that justify our existence, but we must do so better than anyone else. Just announcing that a particular treatment or field is within our scope of practice and then jealously guarding it is not enough. We must prove to the consumer that we do it the very best -- in an ethical manner -- at reasonable cost.

I ask you now to consider a responsibility that comes with independent practice and that is newer to the physical therapist. I believe that it is now our responsibility, even though we have danced around the meaning of it and even avoided the use of the word. The House of Delegates' policy calls it "evaluation." I call it "diagnosis." When I think of the word diagnosis, our definition of it, our debate over it, and even our avoidance in using it, I think also of a verse in James Russell Lowell's poem "Stanzas on Freedom": "Let liars fear,/Let cowards shrink,/Let traitors turn away,/Whatever we have dared to think that dare we also say." [5]

Some say no medical diagnosis is necessary because the physical therapist just evaluates and interprets the results of that evaluation. Our House of Delegates' policy is that we may establish a diagnosis within the scope of our knowledge, expertise, and experience. So we speak of a physical therapy diagnosis that somehow is supposed to be different from a medical diagnosis. My friends, a diagnosis is a diagnosis is a diagnosis, no matter what euphemism is used! In support of independent practice, one of the oft-proferred premises is that physicians, when referring or prescribing, often do not include a diagnosis, provide a wrong diagnosis, or give a "nondiagnosis." This premise is true, but does that create the corollary that it is appropriate for the physical therapist to initiate treatment under the same circumstances? If physicians treat symptomatically, does that give us the unequivocal right to do so?

Can you possibly consider that to treat a patient symptomatically is fair to the patient? These are people you are treating. They are not syndromes or cases or backs or legs, but living, breathing, bleeding, hurting humans. If there are those of you who do not wish to consider the patient, perhaps you will at least consider yourselves. In this litigious society, how will you defend your treatment? How will you defend yourselves? When you are the individual's first point of entry into the medical system, and you evaluate and refer, all is well. But if you plan to evaluate and treat, you had better know what you are treating and have a defendable opinion, an accurate diagnosis!

If we are to be effective in independent practice, we must diagnose! Let us dare to say it! So the physicians will be unhappy. We have not progressed from being handmaidens of the physician to independent practice by keeping physicians happy! To diagnose, we must have the knowledge. The physical therapy schools must educate students so that all future physical therapists will be proficient in this arena. That, of course, creates a big problem for the schools. I do not wish to debate the issue of who among us currently practicing are qualified to diagnose. Each of you must make that decision for yourself. I sincerely hope when you do make it, you will do so with concern for top-quality care and with grave concern for the patient.

Let us now consider the role of the physical therapist in today's world. The shortage of physical therapists in all probability will exist into the next century. That shortage, coupled with the high cost of medical care and some physical therapists' attitude that "professionals" should not perform "hands-on" treatment, causes me great concern. Some propound the theory that the physical therapist's time is too valuable to be spent treating patients or to be physically present at any time in settings such as nursing homes to supervise physical therapist assistants. They believe that physical therapists must become administrators of patient care rather than the doers of physical therapy.

I remind you of the words of Charles Magistro, just quoted, and some words by other Mary McMillan Lecturers: Florence Kendall--"The chief role of the physical therapist should always be that of a clinician," [6] Helen Hislop--"The care of the patient is the ultimate, specific act that characterizes a clinician. It differentiates him from all others. Its obligation is transmitted as the heritage of the profession," [7] and Nancy Watts--"The most important choices we make as physical therapists are those we make about treatment for our individual patients." [8]

In recent years, the physician-patient relationship has been transformed. Too many physicians spend far too little time with the patient, order tests without listening to or adequately examining the patient, and then order medicines without even waiting for the results of those tests. Are some of us following those footprints? Is technology being substituted for technique? Are many of us failing to use our special skills and our special knowledge? Are we assigning the patient to physical therapist assistants or physical therapy aides without proper evaluation or a plan for treatment and then providing inadequate supervision?

Does anyone remember when physical therapists locked horns with the physiatrists over their philosophy that it was necessary and proper for the physiatrist to be the intermediary between the primary physician and the physical therapist, regardless of the expertise of either? We believed that this step was an unnecessary waste of the patient's time and money. Are some of our members now abdicating their responsibilities to properly supervise the physical therapist assistant, yet still claiming they are providing the service and reaping the financial reward? Is this attitude not analogous to the old attitude of the physiatrist?

We created the position of the physical therapist assistant because there was a shortage of physical therapists and we truly wanted to meet the need for a high quality of physical therapy. Our Association has passed policies on their role and supervision and spent much time revising and updating those policies. The Guide For Professional Conduct, in interpreting Principle 3 of the Code of Ethics, covers delegation of responsibility and lists nine separate criteria for adequate supervision. Members of this Association are required to abide by the Code of Ethics. Yet, I wonder, are all of our members meeting those requirements?

Physical therapist assistants are taught to expect the required supervision, and most would prefer to have it. If many of them are allowed or required to work unsupervised in settings that are neither profitable nor challenging to the physical therapist, to work in limbo with supervision being done rarely or--worse yet--by chart only, and to treat when there has been no evaluation by the physical therapist before treatment is initiated, should they not soon decide that it would be best to do so legally? With the outcry against skyrocketing medical costs, will legislators be willing to amend statues to permit them to work independently in nursing homes and home treatment settings? Will they permit them to work with the supervision of nurses or medical practitioners? We need this valuable group of people to continue to be our assistants, properly supervised by us, if were are to have any chance of meeting the physical therapy needs of the population and of controlling the quality of physical therapy.

In their book Medicine on Trial, Inlander et al express the belief that it is appropriate for nurse practitioners (NPs) and physician assistants (PAs) to practice independently in primary care situations, and then they state, "Physicians will want NPs and PAs to act in their original roles as the bridesmaids of medical practice. But rather than remain overworked but underpaid bridesmaids, NPs and PAs have broken off to become brides in their own right, moving into jobs left open by physicians who have left them for greener, more lucrative pastures." [9] There is a lesson here for us. Please, let us not follow those footprints!

Another of my concerns has been about physical therapy practice acts. I have long wondered about their efficacy and whether there was a paucity of complaints to the state agencies responsible for enforcing them. I wondered whether we were more willing to report nonlicensed indivicuals purporting to practice physical therapy than we were to complain about violations of the laws by our peers.

Many years ago, when the Texas Chapter of the APTA was striving to obtain legislation to license physical therapists, there was much resistance by physicians. Texas was one of the last states to be without licensure, and I truly believed, at that time, that the public was well protected by such laws. Hoping to convince the physicians of that, I decided to collect information on the number of complaints and the disciplinary actions taken in all the other states. Surprisingly, most state agencies replied to my letters of inquiry, and, also surprisingly to me, the compiled replies showed few complaints filed against physical therapists, few disciplinary actions taken and, if my memory serves me correctly, only one license suspended. Needless to say, that survey never reached the hands of the opposition.

This year my wondering took a different turn. Having often listened to an agent for malpractice insurance discuss the cases filed against physical therapists, I wondered if there were any correlation between malpractice suits filed against physical therapists and disciplinary actions taken by enforcement agencies. I again undertook to collect information. Letters were sent to the licensing agencies of the 50 states, the District of Columbia, and the commonwealth of Puerto Rico asking not for names or specific cases, but for the numbers of complaints filed against physical therapists and the disciplinary actions taken in the years 1986, 1987, and 1988. This time only 19 agencies responded, 1 of which interestingly replied that the public was not entitled to this information. The response was not satisfactory, but I was not even that lucky in obtaining information on malpractice suits. The APTA Headquarters has this information, but for a number of reasons would not release the information to me. The complaining insurance agent put nothing in writing. The little I learned was probably not worth the time and postage spent, but may be of some interest. Three agencies reported no complaints in that three-year period. The combined complaints of 11 states totaled 32, and 2 other states each reported 20 complaints. Two state agencies reported many complaints, but did not differentiate between those filed against physical therapists and those filed against chiropractors, beauty salons, and others in capacities of that nature.

There were about 50 disciplinary actions taken, which varied from letters of warning, advice on how to correct the problems with a requirement of proof of that correction, warnings, fines, suspensions, and--again--one revocation. For the year 1988, 15 agencies reported a total of 41 complaints and 15 disciplinary actions. In that same year, the APTA's Judicial Committee reported 26 separate complaints, with 16 cases being closed with no disciplinary action, one member reprimanded, and two members expelled. For comparison, according to the manual Effective Physician Oversight: A Prescription for Medical Licensing Board Reform, "In 1985 only 406 physicians' licenses were revoked in the entire country--less than one tenth of a percent. Even that represents an increase of almost 60 percent from the previous year (1984) when only 255 licenses were revoked." [10]

My last survey--and I do mean last--did not procure much information, but when one considers there are 38,220 active members in this Association as well as many practicing physical therapists who do not belong to the APTA, the little information it did provide, examined along with the Judicial Committee's report, might let one conclude that we are running parallel with medical practice in an unenviable way.

I am not going to bore you with examples of wrongdoing. I suspect each of you can provide your own stories about physical therapists whose prime mover is money, therapists who cover up shady deals with innovative contracts and creative accounting, therapists who have learned so well how to document for reimbursement but have not always provided the services, and many other unethical activities.

I do hope that you agree with me that we need a good study. I understand that some enforcement agencies are now informing the APTA's Judicial Committee of actions taken against our members, which is a step in the right direction. We need to know what the true picture is and what the correlation is between complaints to the Judicial Committee and those to licensing boards. We also need to know the disciplinary actions taken by enforcement agencies and what the correlation is between those actions and legitimate malpractice suits. If the information warrants, we need to act.

Physical therapy today is big business and should be administered just as efficiently as any other business. It should also be financially rewarding. Many of our peers have proven that they can provide ethical and good-quality care and still be financially successful.

We each dare not follow or pemit other physical therapists to follow the footprints of some in the medical profession--footprints that lead to ineptitude and to unethical practice. It is not uncommon these days to read headlines such as "Good Riddance to Bad Doctors," "Dangerous Doctors," and even "License to Harm." It is even more common to hear spoken complaints about inappropriate or inadequate treatment, personnel who do not care about or listen to the patient, and the soaring cost of medical care. Books are being written by physicians about physicians' ineptitude, greed, and malfeasance. Consumers are being implored to stop accepting the physician's word as gospel, to demand information, to become involved in their own medical care, and to participate in the enforcement of rules and laws pertaining to hospitals, practitioners, health care professionals, and laboratories.

I would highly recommended that each of you read books such as The Solid Gold Stethoscope, a satire by Edgar Berman, MD; Confessions of a Medical Heretic, by Robert S Mendelsohn, MD; and Medicine on Trial, by Inlander et al. [9] Those books paint a frightening picture of how many in the medical profession have traded honesty for hoards of money, have traded caring for certificates of deposit, have traded effectiveness for efficiency, and have traded technology for time. They paint a picture that must not be allowed to happen to physical therapy. You are the ones who must not let it happen!

The medical profession has not adequately controlled its practitioners. Is the physical therapy profession also failing to do so? Are we acting as if the unconscionable is also the unmentionable? I am not suggesting that a large proportion of our members are unethical, because I do not believe that. Nor am I proposing that we look over each other's shoulders as we go on a witch hunt for unethical and illegal acts. I am proposing that when we learn of such acts, we not look the other way and keep silent, and by our silence give tacit approval. We each need to remember the following lines from Ogden Nash's poem "Yes and No" as we examine our tolerance for inferior treatment and unethical behavior: "Sometimes with secret pride I sigh,/To think how tolerant am I;/Then wonder which is really mine,/Tolerance or a rubber spine." [5(p635)] Tolerance or speaking out? The choice is yours.

If licensing laws for members of a profession are indeed designed to protect the public and not intended for the enhancement of that profession (and I am afraid the jury may still be out on that), and if our Code of Ethics is worth the paper on which it is printed, then the laws and the Code of Ethics must be enforced. Let us not wait until there is a general uproar about physical therapy, as there is now about medicine, before we act. Independent practice gives us the exhilaration of making our own decisions regarding our patients and their treatment, but we must always remember that we also have the awesome responsibility for providing legal, ethical, high-quality care. And that legal, ethical, high-quality care must have a direct relationship to the standards and ethics of this Association and to the requirements of the practice acts.

The physical therapist who provides inferior care, treats unnecessarily or excessively, overcharges, supervises physical therapist assistants or physical therapy aides improperly or not at all, or makes unethical financial arrangements is legally and morally responsible for his or her acts. However, must not the members of the profession who tolerate such acts bear some of the blame?

Even though it is true that most of our members are ethical, by allowing such acts to go unchallenged are we, in the eyes of the public, each reduced to the lowest common denominator? Not only can unethical, immoral, and illegal actions be potentially damaging to the consumer, but they also compromise the integrity of our entire profession. They must not be tolerated. Please, see that they are not.

This Association can and must create the right environment for ethical practice and must know the results of its efforts. I suspect right now many of you are thinking, "You can't legislate morality." Of course we cannot legislate morality, but individuals are often only as good or as bad as the educational, cultural, and societal conditioning they receive. If we, as individual physical therapists and collectively as an association, expect our peers to be ethical, there is a much better chance that they will be ethical.

Henry David Thoreau, in "Civil Disobedience," stated, "It is truly enough said, that a corporation has no conscience; but a corporation of conscientious men is a corporation with a conscience." [11] Can we not be a profession of conscientious individuals and thus a profession with a conscience? Would it not be fitting and wonderful for the physical therapy profession to be a model for ethical medical practice?

What path will we take? Let us not take one that others have made--one that could lead to greed, egocentricity, ineptitude, technology without concern, and useless or nonexistent treatment. Instead, let us make our own path by using the criterion that our focus is on and our end results must benefit those we serve. Then let us follow along that path, proving that our reason for being is to serve our patients and that effective, ethical physical therapy is congruent with financial success.

What footprints will we leave on the dunes of the medical world? Let them be deep and distinct and show purpose in their direction ... footprints that will not be washed away by turbulent waters or blown away by winds of change ... footprints that can be followed. Let those who follow them find that they lead to an honorable, worthwhile, caring, and financially rewarding profession. Yes, let them lead to a profession with a reputation for excellence and a tradition of morality.

References

[1] Le gallienne R: The Le Gallienne Book of English and American Poetry. New York, NY, Garden City, 1935, p 50

[2] Applicable House of Delegates Policies. Alexandria, VA, American Physical Therapy Association, 1985, p 54

[3] Banja JD: Whistleblowing in physical therapy. Phys Ther 65:1683-1686, 1985

[4] Magistro CM: Twenty-Second Mary McMillan Lecture. Phys Ther 67:1732, 1987

[5] Fadiman C: The American Treasury. New York, NY, Harper & Brothers, 1955, pp 566, 635

[6] Kendall FP: Fifteenth Mary McMillan Lecture: This I believe. Phys Ther 60:1437-1443, 1980

[7] Hislop HJ: Tenth Mary McMillan Lecture: The not-so-impossible dream. Phys Ther 55:1069-1080, 1975

[8] Watts NT: Eighteenth Mary McMillan Lecture: The privilege of choice. Phys Ther 63:1802-1808, 1983

[9] Inlander CB, Levin LS, Weiner EC, et al: Medicine on Trial. New York, NY, Prentice Hall, 1988, p 163

[10] Effective Position Oversight: Prescription for Medical Licensing Board Reform. Washington, DC, American Association of Retired Persons, 1987

[11] Thoreau HD: Walden and Other Writings. New York, NY, Garden City, 1970, p 281

R Wood, BS, PT, resides at Rt 2, BOS 216, Eureka Springs, AR 72632 (USA).

This article is based on the Twenty-Third Mary McMillan Lecture presented at the Sixty-Fourth Annual Conference of the American Physical Therapy Association, nashville, TN, June 11-15, 1989.