Professionalism in Physical Therapy PDF

FM.qxd 1/18/05 1:03 PM Page iv 11830 Westline Industrial Drive St. Louis, Missouri 63146 PROFESSIONALISM IN PHYSICAL THERAPY: HISTORY, PRACTICE, & ISBN 1-4160-0314-2 DEVELOPMENT Copyright © 2005, Else...

FM.qxd 1/18/05 1:03 PM Page iv 11830 Westline Industrial Drive St. Louis, Missouri 63146 PROFESSIONALISM IN PHYSICAL THERAPY: HISTORY, PRACTICE, & ISBN 1-4160-0314-2 DEVELOPMENT Copyright © 2005, Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 238 7869, fax: (+1) 215 238 2239, e-mail: [email protected]. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com), by selecting ‘Customer Support’ and then ‘Obtaining Permissions’. Notice Physical therapy is an ever-changing field. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the licensed prescriber, relying on experience and knowledge of the patient, to determine dosages and the best treat- ment for each individual patient. Neither the publisher nor the author assumes any liability for any injury and/or damage to persons or property arising from this publication. International Standard Book Number 1-4160-0314-2 Acquisitions Editor: Marion Waldman Developmental Editors: Jacqui Merrell and Marjory I. Fraser Publishing Services Manager: Linda McKinley Project Manager: Gail Michaels Designer: Amy Buxton Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 FM.qxd 1/18/05 1:03 PM Page v This book is dedicated to those early physical therapists whose commitment and vision shaped the foundational concepts of professionalism in physical therapy and to our personal professional mentors, whose insight and professional generosity have contributed to our own professional development, which is the foundation of this text. v Reviewers Lisa L. Dutton, PT, PhD Associate Professor of Health Sciences Dean, College of Health Professions The University of Findlay Findlay, Ohio Matthew Hyland, PT, MPA, CSCS President, Rye Physical Therapy and Rehabilitation Rye, New York Part-time Faculty, Member Mercy College Physical Therapy Dobbs Ferry, New York David Lake, PT, PhD Department of Physical Therapy Armstrong Atlantic University Savannah, Georgia George Maihafer, PT, PhD Chair, School of Physical Therapy Old Dominion University Norfolk, Virginia Anne Thompson, PT, EdD Armstrong Atlantic University Savannah, Georgia Camilla M. Wilson, PT, PhD Department of Physical Therapy Wichita State University Wichita, Kansas vii Foreword Professionalism in Physical Therapy: History, Practice, & Development is a comprehen- sive resource that explores the multifaceted professional roles and the professional development of the physical therapist in the United States. Drs. Swisher and Page challenged themselves to write a scholarly text to discuss professional roles and pro- fessional development, review the history of the profession within the health care systems in which it has operated, encourage us to think about our future in terms of our history, analyze the five roles of the physical therapists established in the Guide to Physical Therapist Practice, and identify principles and issues that should guide pro- fessional decision making in today’s and tomorrow’s practice arenas. They certainly have met their challenge in this most comprehensive resource. The book begins with the historical perspective of the professional role of the physical therapist and takes us through the many definitions and models of profes- sion and professional. The fluid concepts of individual and collective professionalism are stressed. The section on the history of the profession looks at our development as it occurred within the contexts of the social events, health care and legislative activi- ties, and medical milestones from 1910 to the present. The book also includes a ret- rospective analysis of the evolution of ethics within the profession and a discussion of the contemporary practice issues facing the profession, including the Doctor of Physical Therapy degree, specialist certification, direct access practice, physical ther- apist assistants, the Guide to Physical Therapist Practice, and the political action activi- ties of the American Physical Therapy Association (APTA). The next five chapters of the book look at the five roles of the physical therapist that have been identified in the Guide to Physical Therapist Practice: patient/client manager, consultant, critical inquirer, educator, and administrator. The historical perspectives, the dimensions of these roles, and, when available, the ethical and legal issues concerning the roles are presented. The chapter on patient/client management starts with the activities of evaluation, diagnosis, and prognosis and progresses to information on discharge planning and discontinuance of care. Outcomes, clinical decision making, referral and interper- sonal relationships, and the technological advances that may affect patient/client management are explored. The chapter on the physical therapist as consultant covers the roles in that arena, as well as the consulting process, consulting fees, the traits that make a good con- sultant, and the importance of trust in the consultative relationship. The chapter on critical inquiry begins with a history of physical therapist involve- ment in this area and progresses to evidence-based medicine and outcomes research. The role of the staff physical therapist is examined in light of using research, publishing case reports, assessing new concepts and techniques, and serv- ing as a research subject. Guidelines for critiquing research reports and assessing products and courses are also included in this chapter. The chapter on the physical therapist as educator probes the many contemporary educational roles. These range from the physical therapists who provide instruction to patients/clients to tenured professors in institutions of higher education. Teaching ix x Foreword opportunities in the clinic, continuing education courses, and the academic environ- ment are all delineated. Theories of teaching and learning are also discussed. The chapter on the physical therapist as administrator stresses the roles now com- mon to all physical therapists in practice, including billing for services, documenta- tion, and delegation and supervision of support personnel. This chapter includes theories of organization, management, and leadership. The varied responsibilities of first-line managers, midlevel managers, and chief executive officers are presented. The APTA Standards of Practice are some of the many figures provided. Each of these five chapters finishes with interesting, thought-provoking case sce- narios that challenge us to examine the roles of the physical therapist from profes- sional and ethical perspectives. The last part of this book explores the organizational, political, and cultural con- texts of professionalism in the U.S. health care system and professional develop- ment, leadership, and exemplary practice as it pertains to the physical therapist. Projecting into the future, the authors examine the potential of the APTA to influ- ence the individual, institutional/organizational, and societal realms of physical therapist practice. The book is easy to read, contains many tables and figures, and at the end of each chapter includes questions and/or case scenarios for reflection on the content. Drs. Swisher and Page are two exemplary teachers and mentors who have written an outstanding, very thorough book that I would recommend to all physical therapist practitioners and physical therapist students. It is always a pleasure to see how effec- tively background knowledge and skill come together to provide a truly unique resource. Marilyn Moffat, PT, PhD, FAPTA, CSCS Professor, Physical Therapy Department New York University Preface We became interested in writing a text on professionalism in physical therapy because of the challenges we faced in teaching the depth and breadth of issues and skills that are included in this umbrella topic in physical therapy curricula. A major challenge in teaching this topic was the paucity of written resources to assist stu- dents in learning this material. Over the years in academics and clinical practice, we have seen many changes that have provoked questions about how the profession of physical therapy and our professional roles have been evolving. We have been particularly interested in the impact of those changes on the day-to- day efforts of physical therapists. As faculty who are preparing graduates to make their efforts professional in the bigger context of the systems in which they work, understanding those changes and their impact becomes essential. This is especially important as the profession of physical therapy moves toward a doctoring profession. Therefore we felt a need for a text that could provide a framework in which to organize content related to physical therapy as a profession, the professional roles of physical therapists, and their development as professionals. We hope that the text is of value to faculty who may be responsible for all or part of this content and to cur- riculum committees as they define this thread of content in their programs. We hope that students will become actively engaged in the content through the questions for reflection and scenarios in each chapter. Physical therapists seeking an update on their profession, especially through the eyes of the American Physical Therapy Association’s Guide to Physical Therapist Practice, will find this text valuable as a reflection on the profession’s past as well as fuel for thought on current professional issues. Physical therapists who are begin- ning to explore opportunities beyond direct patient care will gather some insight into administration, consultation, and teaching. The development of this text has been an enriching experience that has been a major part of our ongoing professional development. We have listened to our clinical colleagues about the challenges they face in providing quality patient care, we have listened to our fellow teachers discuss the challenges of teaching professionalism, and we have listened while our colleagues in many components of the American Physical Therapy Association debate important professional issues. This text is for them, from them. These interactions stimulated our thinking about professional- ism, and we hope that the resulting text reflects the complexity of many issues that face physical therapists and the profession as a whole. We thank all of the people—students, colleagues, patients—who have made us pause to think about some aspect of professionalism in physical therapy. We became prouder of the profession with each of these interactions because of the level of thoughtfulness and commitment to the profession that we have encountered. The willingness of these numerous people to solve the problems they identified and to look at the long-term, big picture made us confident and excited about the future of our profession. xi Acknowledgments This text on professionalism in physical therapy would not have been possible with- out the efforts of a number of people. We are especially grateful to Marion Waldman, Jacqui Merrell, Marjory I. Fraser, Gail Michaels, and Cynthia Mondgock. Their thoughts, motivational communications, and efforts were always professional, and we thank them for their assistance in making this text a reality. Laura Lee Swisher Catherine G. Page xii PART I Historical Perspective and Professional Practice Issues 1 Introduction: The Physical Therapist as Professional As much as we would like to think so, physical therapy is not yet completely recognized as a profession. – Catherine Worthingham1 Before deciding on a definition of [physical therapy], physical therapists must decide whether they really want to be professional or just make believe they are by paying lip service to professionalism. – Mary E. Kolb2 As a profession, we have arrived. We have defined our scope of practice. We have developed a unique body of knowledge. We are documenting the effectiveness of our outcomes. We adhere to a code of ethics. And we take responsibility for the well-being of patients and clients. True autonomy is the destination. – Ben Massey, Jr.3 WHAT DOES PROFESSIONAL MEAN? As Catherine Worthingham1 observed in 1965, physical therapy has not always been considered a profession. In the 1966 Presidential Address to the American Physical Therapy Association (APTA), Mary Kolb described the definition of physical therapy in the Dictionary of Occupational Titles as narrow, technical, and obsolete; she called on physical therapists (PTs) to engage in a “reappraisal of the role of physical therapy and a more appropriate definition of the field.”2 Not until 35 years later could Massey3 state that physical therapy had arrived as a profession. Undoubtedly, most PTs currently in practice believe that they are professionals and would consider being called “unprofessional” an insult. However, even though most people use the term professional frequently in everyday conversation, its mean- ing may not be altogether clear or may differ among groups. For instance, athletes who are paid to compete are called “professionals” to distinguish them from am- ateur athletes. This use of the word clearly is in contrast to the ideas of Massey and Kolb. Indeed, the use of profession and professional varies so much that some have wondered aloud whether these words now mean anything at all.4 The concept of profession and professional has been the subject of vigorous scholarly debate spanning much of the twentieth century and continuing today. The rigor and 1 2 PART I Historical Perspective and Professional Practice Issues length of the debates reflect the ambiguity and multiple meanings of these terms and their importance as societal concepts embodying the legitimate expectations of the pub- lic for certain attitudes and behaviors exhibited by professionals. Consumers who feel that they received inadequate or impersonal physical therapy services, for example, may complain that the PT “was not professional.” Changes during the last 50 years in the way that professions are viewed have raised a number of important questions for professionals, scholars, and members of society. These questions include the following: Should an occupation be designated a profession on the basis of the possession of specific characteristics, the developmental process by which the profession as a whole has gained recognition and status by the public, or the power the profession is able to wield? Does being a professional still hold meaning? Have health care professionals been “deprofessionalized” by managed care and “deskilled” by bureaucratic control within organizations? Which is more important—the individual or the collective dimension of being a professional? Should medicine continue to be the paradigm for what it means to be a profession and a professional? Have professionals fulfilled their implied contract with society to be accountable and self-regulating? Given such questions, exploring the meanings of profession and professionals in some depth is appropriate. This chapter defines related terms, provides some back- ground on the concepts related to professionalism, discusses the evolution of PTs’ ideas about professionalism in the United States, addresses specific attributes important to being a professional, and reflects on current and future issues in phys- ical therapy professionalism. Preliminary Definitions of Profession and Professional The concept of profession is an ancient one that has roots in Greek and Roman times.5 The early origins of the word are reflected in its Latin precursor profiteor, which means “to profess a belief.” This root meaning suggests that professionals have historically been expected to have a sense of “calling,” or vocation.6 Although not everyone construes this calling as religious, society still expects professionals to exhibit dedication to their work and clients. The following preliminary definitions provide a starting point for discussion: A profession is an occupation that is viewed by society as a profession on the basis of it characteristics, development, or power. Professionalism is the internalized conceptualization of expected professional obligations, attributes, interactions, atti- tudes, values, and role behaviors in relation to individual patients and clients and society as a whole. Professionalism may be collective (practiced by the profession as a whole) or individual.7,8 Individual professionalism refers to the internalized beliefs of an individual member of a profession regarding professional obligations, attri- butes, interactions, attitudes, values, and role behaviors. Individual professionalism might also be called “professional role concept.” Sociological Perspective Much literature has been devoted to the discussion of what it means to be a profes- sion, especially in sociology. According to Ritzer,9 sociological literature about the Chapter 1 Introduction: The Physical Therapist as Professional 3 professions takes three approaches: structural, processual (or process), and power. mcq The structural approach focuses on the static characteristics that an occupation must possess to be considered a profession. The process approach focuses on either the stages and developmental periods that an occupation must pass through or activities that its members must perform to achieve recognition as a profession. Those advocating the power approach believe that a profession’s ability to obtain the political and social power to define its work is its most important characteristic. As Ritzer9 notes, these three approaches are not mutually exclusive. Indeed, when defining the term profession, most people blend these approaches. Structural Approach Although Emile Durkheim5 wrote about the positive functions of the professions as early as 1890, the structural approach to professions is most associated with Talcott Parsons,10 the founder of the structural-functionalist school of sociology. In translat- ing Max Weber’s11 work to English in the mid-1900s, Parsons became interested in the professions.10 Weber (1864-1920) had delineated the characteristics of priests, which formed a foundation for later definitions of professionals, and had also dis- cussed the link among professionalization, bureaucracy, and rationalization. Adherents of Parson’s perspective believed that existing social structures were the result of the positive function they served within society.10 The work of Parsons precipitated a tremendous amount of work in sociology during the 1950s and 1960s focusing on the professions. Much of this scholarship attempted to further refine the characteristics of the of true professions, in contrast to “semiprofessions” or nonprofessions.12 Although debate about the number and nature of these traits has been considerable, the classic definition of a profession includes at least four: a body of theoretical knowledge, some degree of professional autonomy, an ethic that the members enforce, and accountability to society (Box 1-1). Processual Approach The second sociological approach to professions places less emphasis on an abstract “ideal type” definition of characteristics of professions than on “professionaliza- tion”—the social processes or developmental stages through which occupations move to attain the power and status that professions have traditionally held in soci- ety.9,15-17 Central to this perspective is the recognition that an occupation can enhance its autonomy and professional status through social and political actions. For example, legislation requiring a license to engage in a particular occupation stage partly represents public acknowledgment of the professional status attained by that occupation. In a classic article, Wilensky wondered about the “professionaliza- tion of everyone.”18 Much of the sociological literature about professions has emphasized autonomy as the sine qua non of a profession. Those occupations with extensive autonomy in mcq their work are considered “true professions”; those with less autonomy are either “semiprofessions” or not professions at all.12 Moore19 and Pavalko20 built on the idea of autonomy as the defining attribute of professions in developing a continuum or hierarchy of professionalism. A hierarchical continuum of characteristics combines the structural and processual approaches to defining a profession.9 Pavalko’s continuum allows assessment of an occupation’s level or stage of professionaliza- tion (Figure 1-1). Use of the continuum requires placing a mark along the line between occupation and profession that best represents where an occupation is in  4 PART I Historical Perspective and Professional Practice Issues Box 1-1 CHARACTERISTICS OF PROFESSIONS CITED IN THE LITERATURE Knowledge Broad, theoretical, generalized, systematic knowledge13,14 Unique body of knowledge mcq “Formal” knowledge15—knowledge that is “embodied and applied in and through the professional”6 Autonomy in professional decisions Autonomy from client16,17 Autonomy from organizations or external parties16,17 Autonomy in selecting colleagues mcqAuthority Based on internal knowledge13 Granted by society15 Demonstrated by power and status in society Demonstrated by monetary and symbolic awards14 Education Extensive Skilled, technical, esoteric High standards for admission Responsibility, Accountability, and Ethics Service orientation14,15,19 Accountability and responsibility to society Formal code of ethics that members enforce Self-control of behavior through internalized professional ethic14 Belief in self-regulation16 Community interest more important than self-interest Fiduciary relationship and trustworthiness central6 Nature of work and decisions Important or essential to clients16 Complex14 Not routine13 Not programmed13 Role and Identity Internally based on a sense of calling6,13,17 Formed and driven by the professional group13,17 Extending beyond the specific work situation13 the process of professionalization. Writing in 1970, Pavalko20 described both phar- macy and occupational therapy as incompletely professionalized or “marginalized professions” at that time. Power Approach Although the earliest literature from the structural perspective emphasized the pos- itive functions of the professions, discussion began to shift to the negative aspects of  Chapter 1 Introduction: The Physical Therapist as Professional 5 Dimensions Occupation Profession 1. Theory, intellectual technique Absent Present 2. Relevance to social values Not relevant Relevant 3. Training period A Short Long B Non-specialized Specialized C Involves things Involves symbols D Subculture Subculture unimportant important 4. Motivation Self-interest Service 5. Autonomy Absent Present 6. Commitment Short term Long term 7. Sense of community Low High 8. Code of ethics Undeveloped Highly developed Figure 1-1. Pavalko’s occupation to profession continuum. (From Pavalko RM. Sociology of occupations and professions. Itaska, Ill, 1971, FE Peacock Publishers, p. 26.) professions by the 1960s and 1970s. This academic shift toward analysis of the use and abuse of power by the professions was accompanied by changes in public opin- ion regarding the professions. Scholars and members of the public criticized the professions for setting up economic monopolies, using political power for self- interest, and focusing on professional autonomy and self-governance without consideration of the public welfare.21 The requirement for licensure is one strategy for using political power to create an economic monopoly and decrease competition for members of a particular profession. AUTONOMY, SELF-REGULATION OF ETHICAL STANDARDS, AND ACCOUNTABILITY Whether a profession is defined by its characteristics, stage of evolution, or power, several qualities of professions have historically been held in high regard: autonomy, ethical standards, and accountability. Autonomy As the previous section suggests, autonomy in making professional judgments is a mcq “litmus test” for professions. Autonomy can be defined as the “extent to which [a profession] or an individual feels freedom and independence in his/her role.”22 Some writers clarify that this includes freedom from clients (those outside the profession) and the organization that employs the professional.16 Historically, those occupations whose members have had high autonomy in decision making and high degrees of control over their work have been considered true professions; 6 PART I Historical Perspective and Professional Practice Issues occupations whose members enjoyed less autonomy in decision making and less control over their work were relegated to being semiprofessions,12 paraprofessions, or nonprofessions. The shift toward managed care during the 1980s had a major impact on concepts of professions and professionalism. Managed care placed significant administrative restrictions on the decisions made by health care professionals. Many medical pro- fessionals perceived this loss of autonomy as a loss of professional status, or “depro- fessionalization,”23 because they were no longer able to freely make decisions based on their expertise and specialized training. As Reed and Evans described it, “Because of the crucial link between autonomy and professionalism, when consid- erable slippage in a profession’s autonomy occurs, as it has in medicine, the possi- bility of deprofessionalization becomes more tangible.”23 Despite these negative effects, these changes have also stimulated medical professionals to reexamine con- cepts of professionalism. Within medicine, Stevens called for “reinventing profes- sionalism”24 and Sullivan pointed to the need for “civic professionalism.”25 Whether PTs have enough autonomy in their work to be considered professionals has also been a subject of considerable discussion and debate. Until recently, the tendency has been to view physical therapy as an occupation in the process of pro- fessionalization but not yet fully recognized as a profession. However, many PTs have experienced significant increases in their autonomy over the last 20 years. One measure of professional autonomy is access to PTs without physician referral. In 1985, only 7 states allowed direct access of patients to PTs. By 2002, 35 states permit- ted direct access and 48 states allowed PTs to perform initial evaluations without referrals.26 The APTA has established the goal of “autonomous practice” as one of its priori- ties, delineated in its Vision 2020 statement: “Physical therapists will be practition- mcq ers of choice in clients’ health networks and will hold all privileges of autonomous practice.”27 This raises the question of what is meant by “autonomous practice.” The APTA Board of Directors has developed a position statement to define this term (Box 1-2).28 Use of APTA criteria to evaluate the level of autonomy exercised by PTs would undoubtedly result in enormous variation by state, practice, setting, and specific organization. Almost every PT exercises and acts on professional judgment, but few PTs have privileges to refer patients directly for diagnostic tests. At the same time, managed care and other third-party payers have imposed restrictions on most health care services, including physical therapy. Organizational constraints also may limit autonomy. For example, even in states that permit direct access, organizational poli- cies may require a referral for physical therapy services because many third-party payers require a referral for reimbursement. For much of physical therapy’s history, PTs have worked under the supervision of or through referral from physicians. Given the importance assigned to autonomy in the process of professionalization, only within the last several decades has physical therapy approached what some would define as full professional status. Ironically, PTs have attained increased legal autonomy through direct access in most states while simultaneously experiencing decreased autonomy through the administrative constraints of managed care. To many PTs the emphasis on autonomy seems out of touch with a health care environment that is characterized by interdisciplinary teamwork and collaboration. Jules Rothstein29,30 suggests that autonomy is a misnomer for the type of independ- ence that PTs desire29:  Chapter 1 Introduction: The Physical Therapist as Professional 7 Box 1-2 APTA BOARD OF DIRECTORS’ POSITION ON AUTONOMOUS PHYSICAL THERAPIST PRACTICE It is the position of the APTA Board of Directors that: Autonomous physical therapist practice is characterized by independent, self-determined profes- sional judgment and action. Physical therapists have the capability, ability and responsibility to exercise professional judgment within their scope of practice and to professionally act on that judg- ment. mcq Privileges of Autonomous Practice in 2020 Each of these elements includes two overarching concepts: recognition of and respect for physical therapists as the practitioners of choice, and recognition of and respect for the education, experi- ence, and expertise of physical therapists in their professional scope of practice. 1. Direct and unrestricted access: The physical therapist has the professional capability and ability to provide to all individuals the physical therapy services they choose without legal, regulatory, or payer restrictions. 2. Professional ability to refer to other health care providers: The physical therapist has the professional capability and ability to refer to others in the health care system for identified or possible medical needs beyond the scope of physical therapist practice. 3. Professional ability to refer to other professionals: The physical therapist has the professional capability and ability to refer to other professionals for identified patient/client needs beyond the score of physical therapist practice. 4. Professional ability to refer for diagnostic tests: The physical therapist has the professional capability and ability to refer for diagnostic tests that would clarify the patient/client situation and enhance the provision of physical therapy services. From the American Physical Therapy Association. Autonomous Physical Therapist Practice: Definitions and Privileges. (BOD 03-03-12-28.) Available at http://www.apta.org/Documents/Public/governance/bodPoliSec1.pdf. Accessed September 30, 2004. This material is copyrighted, and any further reproduction or distribution is prohibited. It’s not really autonomy that we as a profession seek.... We seek unfettered practice mcq that allows us to use our skills, knowledge, and compassion to our maximum potential. On behalf of patients and clients, we seek unfettered access to our services, free from unnecessarily restrictive laws and reimbursement policies. Like those we serve, we want to remove barriers. In Rothstein’s opinion, “interdependence is not a sign of weakness. Interdependence is a badge that civilized people wear to reaffirm their humanity, their capacity for kindness—and their competence.”29 He extended this line of thinking in a later editorial30: As I expressed in a previous Editor’s note... 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.... “Autonomy” conveys arrogance. Our profession has devel- oped a specialized definition of “autonomous” [see Box 1-2 of this chapter]—one that removes most of its noxious qualities and focuses instead on the attainment of profes- sionalism and professional recognition—but few outside our profession will have the ability or time to find that out. An implicit assumption in Rothstein’s writing is that the doctorate in physical therapy (DPT) will play a pivotal role in promoting autonomous practice of PTs. However, the expectation is that the DPT will better prepare PTs for autonomous 8 PART I Historical Perspective and Professional Practice Issues practice—the ability to make independent decisions—and the permission to exer- cise that decision making depends on direct access legislation and reimbursement policies. Meanwhile, several factors seem to negate the importance of autonomous practice even if all PTs achieve it. For instance, the vertical and horizontal integra- tion of health care systems most likely will limit the need for independent practi- tioners in all health professions. As a rule, PTs are employees (as are many physicians) rather than self-employed, the ideal status for autonomous practice. Third-party payers and providers more often negotiate decisions about where, when, and how often a person receives physical therapy than patients and physical thera- pists do. This has an impact on autonomous practice. PTs may not gain more auton- omy in decision making just because they have DPT degrees and patients have direct access to them. Health care systems must continue to control costs and man- age quality; the way PTs can practice autonomously while contributing to those goals in the health care systems that employ them is not clear. The obvious alternative for ensuring autonomy is for all PTs to be independent contractors, but whether health care systems are prepared to offer staff privileges to PTs remains to be seen. The managerial challenges of having individual PTs fol- lowing their patients through their health care experiences from acute care to out- patient to home care may be difficult to overcome in a health care system that is committed to providing all required services for patients admitted to their sys- tems. PTs employed by the health care system may have difficulty working along- side PTs who appear and disappear when patients from their autonomous practices are admitted and discharged from a hospital. Health care systems also may be reluctant for discharged patients needing outpatient physical therapy to receive that care in centers other than those of the health care system. Having consumers identify strongly with the services of a particular PT may also prove challenging unless they have chronic conditions that require services across years. However, PTs in their one-on-one relationships with patients have had variable degrees of autonomy in decisions about direct patient care. Particularly as the refer- ral relationship with physicians has moved from prescription to blanket referrals for evaluation and treatment, PTs have had a great deal of autonomy in establishing and modifying plans of care. PTs have gained the trust of physicians for autonomy at this level through the outcomes of care they have achieved and their interpersonal rela- tionship skills with individual referring physicians. Regardless of the academic degree PTs hold and limits of the law, these skills likely will remain the key to autonomous practice and its concomitant independent, self-determined judgment and action. Self-Regulation of Ethical Standards A second important characteristic of professionals is ethical conduct and self- regulation. This includes the possession of a code of ethics and mechanisms that ensure members abide by the code’s principles. The American Physiotherapy Association, the forerunner of the APTA, adopted its first code of ethics in 1935.31 mcq mcq The first code identified four major ethics violations: making a diagnosis, offering a prognosis, advertising for patients, and criticizing the doctor or other co-workers.31 Although development of a code of ethics can be one sign of movement toward pro- fessionalization, Purtilo notes that this first attempt was not necessarily a success in this regard32: Chapter 1 Introduction: The Physical Therapist as Professional 9 Declaring a document a code of ethics does not in itself assume that one has a code of ethics! Elsewhere I have shown that the early attempts of the American Physical Therapy Association to design a code of ethics was gallant in its intent though unsuc- cessful in its outcome: one can hardly judge this document’s set of rules designed solely to show devotion and complete deference to the physician as being grounded in any specifically ethical standards, even in the 1930s. While serving as a guide for good etiquette befitting the young ladies of the time, and while serving some other impor- tant ends, nonetheless, it did not serve as an ethical guide (Purtilo, 1977). Clearly more than good intent is required in the development of a code of ethics. From this perspective, a true code of ethics articulates some professional consensus about the ethical standards that should guide practice and serves as the collective ethical wisdom of the profession, a map on the road to high ethical standards. Other writers emphasize that a code of ethics is meaningless unless its members live by its ideals and enforce its provisions. The obligation to enforce a code of ethics mcq is also called self-regulation and is frequently framed in terms of an implied social contract. By this logic, professionals have a great deal of autonomy and freedom that enables them to serve the interests of their clients. In return for this freedom, soci- ety expects responsible behavior and action in the public interest. For example, society expects professionals to take action against incompetent colleagues and pro- vide pro bono care for those who cannot afford professional services. Unfortunately, many professionals fail to live up to the high standards espoused by professional codes of ethics, and few professions have been successful in policing their own ranks for ethical breaches. Most state chapter ethics committees for physical therapy receive few ethical complaints and refer even fewer to the Ethics and Judicial Committee of the APTA. Accountability of Professionals The third important attribute of professionals is responsibility and accountability. Taken together, these terms mean that professionals have obligations and must “account” to the public for the discharge of these duties. Emanuel and Emanuel mcq define accountability as “the process by which a party justifies its actions and poli- cies”33 and delineate three separate models of accountability: professional, political, mcq and economic.34 Each model of accountability has different domains, components, content areas, and procedures. Although the ethical standards for most health care professionals focus on accountability to patients inherent in the fiduciary relationship,34 PTs and other mcq health care providers are actually accountable to many different parties: the patient, the health care organization, other professionals, the government, and third-party payers (Figure 1-2). PTs have particularly felt the pull of competing accountabilities under managed care. Morreim35 has described these competing accountabilities as a “balancing act” in which health care providers must balance the patient’s interests with fiscal accountability for the public good. In addition, the financial incentives for cost containment in managed care create inherent conflicts of interest between the interests of the patient and the provider. According to Emanuel and Emanuel,34 medicine has traditionally used a profes- sional accountability model in which health care professionals establish and enforce standards of accountability through professional organizations. In their opinion, the professional model is outdated and inadequate for the managed care context  10 PART I Historical Perspective and Professional Practice Issues Government Patient Private All six domains payers (including community benefit) Professional competence Professional competence Legal and ethical conduct Adequacy of access Financial performance Employers Professional competence Lawyers Professional competence Financial performance and Legal and ethical conduct Physical therapists courts and other Adequacy of access health care providers Financial performance Professional competence Investors Legal and ethical conduct Adequacy of access Public health promotion Professional competence Legal and ethical conduct Professional competence Financial performance Professional Legal and ethical conduct associations− Financial performance APTA Managed care plans Hospitals Figure 1-2. Accountability of physical therapists. (Modified from Emanuel EJ, Emanual LL. What is accountability in health care? Ann Intern Med 1996;124:229-239, p. 229.) because it poorly addresses control of health care spending, one of the major goals of managed care. The difficulties of the professional model of accountability are fur- ther compounded by the decreasing numbers of PTs who actually belong to the pro- fessional association and the relative lack of success of all professions in self-regulation. The views of Morreim and the Emanuels imply that different notions of profes- sions and professional status may also have ramifications for the relationship between the physical therapy professional and the client. Ozar36,37 developed three different models of professionalism to describe medicine and dentistry: commer- cial, guild, and interactive. These models of professionalism are also applicable to the work of the PT. mcqIn the commercial model, professionalism is a commercial interchange in which physical therapy is a product or commodity and the therapist must compete with the patient and other professionals to sell services and maximize profit. Any duties of the therapist toward the patient are based on contractual agreements. In this model, pro- fessional associations exist to promote common business interests (Table 1-1). mcqIn the guild model, the profession is the transmitter of expertise, competence, and moral standards. The PT functions in a paternalistic role, providing services to a patient who is the uninformed, passive recipient of professional expertise.  Chapter 1 Introduction: The Physical Therapist as Professional 11 Table 1-1 Ozar’s Models of Professionalism as Applied to Physical Therapy Commercial Guild Interactive (Ideal) Dominant concern Maximizing Advancing the Shared decision making profits profession as a service by moral equals to benefit patients Nature of PT’s Commercial Privilege Expertise brought to services enterprise, interaction of moral commodity equals mcq Role of PT Salesperson Expert, a representative Moral equal, partner of the profession in decision-making mcq Role of client Consumer Passive recipient of Moral equal, partner expert knowledge in decision-making PT-client Competitors in Paternalism Mutual dialog in relationship self-interest demonstrated toward partnership of moral client, which may equals, each with compromise client’s different functions; autonomy autonomy of client valued highly Criteria for Services client Needs of client as Needs of client as determining can afford and determined by expert determined through PT intervention client’s desires judgment of PT dialog Relationship with Competitors Colleagues Interaction of equals other PTs Nature of Political action, Guardians of Partnerships of equals professional public relations, knowledge and skills in dialog with the associations and lobbying on community, (e.g., APTA) behalf of shared attempting to business interests improve care of members Derivation of Contractual Membership in the Relationship with obligations agreements profession, which community, which between client includes obligations to bestows standing and therapist clients and colleagues; as a professional focus is on needs of client Role of Marketplace for Transformation of Provision of knowledge, professional selling student into an expert, although the education knowledge initiation into the guild community bestows professional status Developed by LL Swisher from ideas of Ozar DT, Patient’s autonomy: Three models of the professional-lay relation- ship in medicine. Theor Med 1984;5(1):61-68; and Ozar DT, Three models of professionalism and professional obligation in dentistry. J Am Dent Assoc 1985; 110:173-177. PT, Physical therapist; APTA, American Physical Therapy Association. mcq Ozar believes that a third model, the interactive model, is the ideal model of the professional relationship. This model avoids the negative aspects of both the com- mercial and guild models, with therapists and patients interacting as moral equals in a relationship in which each person has a different function. Because the com- munity has given professional status, the PT is obligated to care for the patient in 12 PART I Historical Perspective and Professional Practice Issues need. The context for professional activity is construed as one of interaction between the PT and the community.36,37 Bellner has argued that the interactive model of professionalism is most appropriate for occupational therapists and PTs because of its emphasis on “enhancing and supporting the patient’s capacity to make choices.”38 Although the meaning of the terms profession and professionalism continue to be subject to debate—with no general agreement among scholars, professionals, or the public as to whether a profession should be defined on the basis of its charac- teristics, the process of professionalization, or its power—the concept of the profes- sion continues to hold some importance among members of society who expect professionals to provide professional expertise, have the freedom to act on their clients’ behalf, be guided by ethical principles, and to demonstrate accountability in their actions. The various models provide opportunities to advance discussion of this important topic by clarifying which perspective of “profession” is the most critical. PHYSICAL THERAPY AND CONCEPTS OF PROFESSIONALISM Generally speaking, since its early years physical therapy’s efforts to professionalize have concentrated on gaining increased autonomy, building a case for its expertise through improving education and scholarship, gaining public recognition, and enhancing political power through lobbying efforts. Especially from 1960 to 1990, PTs wondered whether physical therapy was a profession and were concerned with the public image of physical therapy (Box 1-3). During this same period, physical therapy was especially concerned with the appropriate degree to offer, evidenced by several decades of debate about the move from the baccalaureate degree to the master’s degree, followed by additional debate about the shift to the DPT degree. By the time the Commission on Accreditation established the master’s degree as mandatory for all educational programs during the 1990s, most therapists realized that the DPT would eventually supersede this requirement. The following quotation from the APTA website illustrates how the physical therapy profession in the United States is working to accomplish further professionalization45: The rationale for awarding the DPT is based on at least four factors, among oth- ers: (1) the level of practice inherent to the patient/client management model in the Guide to Physical Therapist Practice requires considerable breadth and depth in educa- tional preparation, a breadth and depth not easily acquired within the time con- straints of the typical MPT [Master’s in Physical Therapy] program; (2) societal expectations that the fully autonomous healthcare practitioner with a scope of prac- tice consistent with the Guide to Physical Therapist Practice be a clinical doctor; (3) the realization of the profession’s goals in the coming decades, including direct access, “physician status” for reimbursement purposes, and clinical competence consistent with the preferred outcomes of evidence-based practice, will require that practition- ers possess the clinical doctorate (consistent with medicine, osteopathy, dentistry, veterinary medicine, optometry, and podiatry); and (4) many existing professional (entry-level) MPT programs already meet the requirements for the clinical doctorate; in such cases, the graduate of a professional (entry-level) MPT program is denied the degree most appropriate to the program of study. Chapter 1 Introduction: The Physical Therapist as Professional 13 Box 1-3 PROFESSIONALISM AS DESCRIBED IN THE PHYSICAL THERAPY LITERATURE: 1935 TO 1986 Miles-Tapping (1986)39 Medical dominance through subordination, limitation, and exclusion is rooted in the medical model of health care that allows physicians to define what counts as evidence and knowledge. “As long as physiotherapists base their understanding of disease and therapy on a medical model, cooperating and coordinating with doctors in their work, their profession will remain a dominated paramedical profession.”39 Luna-Massey and Professionalism equals “strong motivation, established representative Smyle (1984)40 organization, a specialized body of knowledge, evaluative skills, and autonomy of judgment.”40 These criteria, established by Moore,19 are listed in ascending order of importance. When California consumers used the criteria as a basis for evaluation, they found no significant difference in professional image between PTs and physicians. Silva, Clark, and Using Moore’s five criteria,19 California physicians rated PTs lower Raymond (1980)41 on evaluative skills and autonomy than on other criteria. Family physicians rated PTs higher on professional image than did neurosurgeons or orthopedists. Schlink, Kling, and California PTs’ higher internal image conflicted with lower external Shepard (1978)42 professional image thought by PTs to be held by physicians and the public. Dunkel (1974)43 Professionalism equals competence, concern, and a sense of responsibility. Physician’s attitudes toward professional performance of PTs in Arkansas were rated. Senters (1972)44 Professionalization equals “process of development toward an ideal type, the profession.”44 Physical therapy is “moderately professionalized.” Kolb (1960)2 Professionalism equals service orientation, theoretical knowledge, and autonomy. “Before deciding on a definition of [physical therapy], physical therapists must decide whether they really want to be professional or just make believe they are by paying lip service to professionalism.”2 APTA (1935)31 In the first published code of ethics, professionalism is defined as etiquette and appropriate deference to authorities. PT, Physical therapist; APTA, American Physical Therapy Association. As indicated by this statement, the DPT degree links various aspects of professional- ization: autonomy, attainment of adequate power, and status. The perception is that the DPT will enhance professionalization, enabling physical therapy to enjoy the professional status and power of other professions. From 1990 to 2003, physical therapy scholars appeared to move away from the more general concepts of profession in an attempt to define the important attributes and behaviors of professionalism unique to physical therapy (Box 1-4). This coin- cided with a renewal in interest in professionalism in medicine stimulated in part by the perceived deprofessionalization resulting from managed care and increasingly negative societal views about professionals. 14 PART I Historical Perspective and Professional Practice Issues Box 1-4 PROFESSIONALISM AS DESCRIBED IN THE PHYSICAL THERAPY LITERATURE: 1990 TO 2003 Swisher, Beckstead, and Professionalism is a blend of autonomy, authority, agency, and Bebeau (2004)46 responsibility. Factor analysis of results of the Professional Role Orientation Inventory. APTA (2003)47 The seven core values of professionalism are defined as accountability, altruism, compassion/caring, excellence, integrity, professional duty, and social responsibility. Jette and Portney (2003)48 Construct validation of the generic abilities cited by May et al.53 identifies seven factors: professionalism, critical thinking, professional development, communication management, personal balance, interpersonal skills, and working relationships. MacDonald et al. (2001)49 Consensus is found among students (n = 4), clinical instructors (n =3), and faculty (n = 2) on key professional behaviors: communication, adherence to legal and ethical codes of practice, respect, sensitive practice, lifelong learning, evidence-based practice, client-centered practice, critical thinking, accountability, and professional image. Bellner (1999)38 Responsibility, an inherently relational concept, is posited as a central feature of professionalism. Bellner recommends that therapists embrace the interactive model. Lopopolo (1999, 2001)50,51 Acute care clinical managers report that physical therapists’ level of professionalism increased during hospital restructuring; fewer than one fourth report that it decreased. Threlkeld, Jensen, and These researchers use the grounded theory model of Royeen (1999)52 professions, to analyze the DPT degree. The DPT is framed as the vehicle by which PTs attain appropriate professional status, identity, and outcomes. May et al. (1995)53 Professionalism is included as one of 10 generic abilities: commitment to learning, interpersonal skills, communication skills, effective use of time and resources, use of constructive feedback, problem solving, professionalism, responsibility, critical thinking, and stress management. Professionalism is defined as “the ability to exhibit appropriate professional conduct and to represent the profession effectively.”53 Hart et al. (1990)54 Professionalism equals esoteric knowledge, a service ethic, and autonomy in performing tasks. Physical therapy is in the process of professionalization. Level of professional involvement does not depend on the use of complex procedures, but PTs who are more professionally involved are more likely to receive referrals that require such complex procedures. APTA, American Physical Therapy Association; DPT, Doctor of Physical Therapy; PT, physical therapist. Chapter 1 Introduction: The Physical Therapist as Professional 15 The scholarship on professionalism and the political actions of the APTA are con- sistent with the developmental stages identified as crucial to the professionalization of an occupation. Perhaps, physical therapy is taking its last steps toward profession- alization. INDIVIDUAL PROFESSIONALISM—PROFESSIONALISM WITHOUT PROFESSIONS? Thus far, this discussion has focused primarily on collective professionalism. Given the level of disagreement about the importance of professions and concerns about whether professionals are living up to professional ideals, reflection on the personal meaning of professionalism is crucial for every professional. Society and individual patients will continue to have high expectations for professionals. Kultgen has pro- posed that society stop making distinctions between occupations and focus more on desirable attributes in individual workers, creating a situation that he calls “profes- sionalism without professions.”5 This proposal would, he argues, preserve the posi- tive aspects of professionalism without carrying forward its negative aspects. Regardless of whether Kultgen’s proposal is accepted, each professional frames professionalism uniquely because of differing emphases on each of the many dimensions of professionalism (authority, autonomy, responsibility, expert judg- ment, accountability, and ethical ideal). Relative emphasis on these dimensions brings some PTs closer to the commercial model, whereas others are closer to the guild or interactive model of professionalism. Some within medicine have called for a renewal of “civic professionalism”25 as yet another model. Such an undertaking would require PTs to examine their implicit contract with society, collectively as a profession and individually as professionals. Writing an individual or a collective oath can be a vehicle for reflection on a per- sonal model of individual professionalism. The issue of whether PTs should take an oath similar to the Hippocratic Oath for physicians has been brought before the House of Delegates on several occasions. To date, PTs are not required to take an oath. Denise Wise55 has researched proposals for an oath in physical therapy and summarized the history of these efforts in physical therapy: History of an oath in PT: The concept of an oath was first introduced to the House of Delegates in 1997 or 1998. In 2000, the position Oath for Physical Therapists (HOD 06-00- 21-12) was passed. This position states: It is the position of the APTA that: The American Physical Therapy Association supports the use of an oath for physical therapists as part of a student’s education and graduation from an accredited physical therapist education pro- gram or as an affirming statement for use by all physical therapists. In 1994, Dr. Donna El- Din56 wrote the following in a guest editorial “Learning is an active process. The spoken word has power. Perhaps the learner rightly begins the process of validation in the profes- sional commitment with the sound of the spoken word. Perhaps with... an oath.” Denise Wise55 further stated the following: In 2000, it was decided to separate this position from a second RC that year that was ultimately withdrawn. This withdrawn RC was a model oath. Problems at that time included: not being clear it was a model oath and... a voluntary process. While there was support, there was also opposition. Since that time, several programs have continued to have an oath or affirming statement, with the knowledge that RC 06-00- 21-12 was passed. 16 PART I Historical Perspective and Professional Practice Issues However, the process of formulating or revising an oath can be helpful in concep- tualizing the obligations and commitments that a person or group believe are involved in professional life (Box 1-5). FURTHER THOUGHTS Neither individual nor collective professionalism is a static concept. History demon- strates that these concepts change and evolve in relation to societal need and opin- ions. Although professions and professionals no longer occupy a societal pedestal, members of the public continue to respect the judgments made by professionals and expect professionals to maintain high ethical standards. Some believe that soci- ety should abandon rigid distinctions between groups believed to be worthy of pro- fessional status and those that are not. In an environment of multiple meanings of the terms profession and professional, individual reflection on the personal meaning of these terms is especially important. QUESTIONS FOR REFLECTION 1. Using Pavalko’s continuum, how would you evaluate physical therapy’s level of professionalization? 2. Using Pavalko’s continuum, how would you evaluate your personal level of professionalism? 3. One criticism of professional codes of ethics is that society has no role in help- ing to write them.5 What difference would it make if physical therapy involved the public in writing the Code of Ethics? As a member of the public, what changes would you recommend to the Guide for Professional Conduct? 4. Professions have also been criticized because of their lack of self-regulation, with few professionals being disciplined by the professional association. Members who are in danger of being disciplined can drop their membership, and the association has no authority to discipline nonmembers. Some states require all licensed PTs to abide by the code of ethics and ethical standards of the professional association. Do you support this action? Is this a type of self- regulation or is it public acknowledgment of lack of self-regulation? 5. Jules Rothstein29-30 has suggested that physical therapy has placed too much emphasis on professional autonomy and that physical therapy should empha- size professionalism and interdependence. Do you agree? Why or why not? 6. Use Ozar’s three models of professionalism (commercial, guild, interactive) to classify the model of professionalism used by some of the PTs in your com- munity. How would clients and other colleagues classify these PTs’ models of professionalism? 7. Bellner38 suggests that the interactive model is the most appropriate model of professionalism for PTs. Do you agree with Bellner that the interactive model is most appropriate for physical therapy? 8. Ozar is candid in saying that he exaggerates the differences among his models to provide a clear distinction. As a result, both the commercial and guild mod- els appear unattractive. Are realistic portrayals of the commercial and guild models acceptable for physical therapy? 9. Should PTs take an oath to demonstrate their commitment to professionalism?  Box 1-5 FOUR OATHS* FOR PHYSICAL THERAPISTS CORRELATED WITH PRINCIPLES OF THE CODE OF ETHICS University of Southern Wayne State New York University of California† University‡ University§ South Florida (2003)⎥⎥ I pledge to hold faithful to my I solemnly and willingly state that I In the presence of my colleagues, friends, As a physical therapy professional, I embrace my responsibility as a physical therapist; dedicate myself to the following: families, and faculty, and in view of the responsibility and accountability to the individuals To use the highest science and skills of my I will practice physical therapy with honored profession into which I am I serve, the community as a whole, and my profession at all times; (5, 6, 8)¶ compassion and patience. (1, 2, 10) entering, I solemnly and willingly profession. I believe that physical therapy is a To exercise judgment to the highest degree I will preserve and value the dignity of dedicated myself to the following: calling to help the whole person—body, mind, and of which I am capable when determining those who seek my care and will I will ethically practice physical therapy soul. As a physical therapist, I will strive not only to the treatment to be offered; (1, 2, 4, 6) respect them, the choices they make, with compassion and patience, resolve movement disorders but prevent them, To refrain from treatment when it will not and the confidential nature of our recognizing the potential vulnerabilities while inspiring others to reach beyond barriers and benefit the patient; (2-4, 6, 8, 9, 11) relationship. (2, 3) in my patients and clients, and will limitations. I commit myself to the following To always place the welfare of my I will do no harm to another. (2-6, 8, 9, 11) preserve their dignity and promote professional obligations and values: patients above my own self-interest. (5-7) I will promote health and well-being their health and well-being at all I will strive to approach each patient with compassion, I pledge to uphold and preserve the through the alleviation and prevention times. (1, 2, 10) encouragement, respect, and empathy. (1, 2, 11) 17 rights and esteem of every person of impairments, functional limitations I will value the lives of those I serve I will strive to provide an environment where patients placed in my care; (2) and disabilities due to illness or through my concern and with respect can feel comfortable and accomplish the goals they To hold all confidences in trust; (2, 3) injury. (1, 2, 4, 6, 10) for them and the confidential nature of set for themselves. (1-6, 10, 11) To exercise all aspects of my calling with I dedicate myself to lifelong learning to our relationship. (2) I will strive to be a lifelong learner, seeking to dignity and honor. (1, 11) augment and expand my knowledge and I will be humble. (2, 7) advance my own knowledge as well as that of I commit myself to the highest ideal of the profession through consultation, I will recognize my limitations. (2, 4-6, 9, 11) current and future colleagues. (4-6) service, learning, and the pursuit of education, and research. (5) I will continue to consult with my I will strive to achieve excellence in the practice of knowledge. (3-6, 8, 9, 11) I accept responsibility to assure those who colleagues with which I may better serve physical therapy. (1-11) These things I do swear. seek physical therapy receive services my patients and clients and for the I will strive to relate to other professionals with that are proper, ethical, and just. (9) inspiration to expand and augment my respect and integrity in order to promote the best I will not allow my judgment to be education. (3-5, 11) interests of the patient. I will uphold the highest influenced by greed or unethical I will share my knowledge freely with my ethical stands set forth by the profession. (1-6, 9) behavior. (7) colleagues and with those I serve. I will respect diverse values, beliefs, and cultures. (11) I expect the same from my colleagues. (1, 2, 6, 8) I make these promises solemnly, freely, and upon my (6, 8, 9) I will strive for an improved quality of life personal and professional honor. Thus, with this oath, I freely accept the for all my patients and clients. (1, 2) obligations and reward which accompany I will work to improve the practice of the practice of physical therapy. physical therapy so that all who seek Continued  Box 1-5 FOUR OATHS* FOR PHYSICAL THERAPISTS CORRELATED WITH PRINCIPLES OF THE CODE OF ETHICS—CONT’D University of Southern Wayne State New York University of California† University‡ University§ South Florida (2003)⎥⎥ physical therapy services will receive those which are proper, ethical, and just. (6, 8, 9) I will not allow my judgment regarding the practice of my profession to be influenced by greed or unethical behavior. (7) I will respect the rights of all persons. (1, 11) Thus, with this oath, I freely accept all of the obligations and the many rewards which will accompany my practice of physical therapy. Modified from Wise D. Oath compilation summary. Unpublished manuscript distributed by electronic mail, October 28, 2003. 18 * Those who submitted oaths were not always certain of their origin. Several of these oaths were thought to be based in part on an oath developed by Helen Hislop. † Used with permission of James Gordon, PT, EdD. ‡ Used with permission of Susan Ann Talley, PT, MA. § Used with permission of Marilyn Moffat, PT, PhD, FAPTA. ⎥⎥ Used with permission of Laura Lee Swisher, PT, PhD. ¶ Numbers in parenthesis correspond to the following principles in the Code of Ethics established by the American Physical Therapy Association: Principle 1: A physical therapist shall respect the rights and dignity of all individuals and shall provide compassionate care. Principle 2: A physical therapist shall act in a trustworthy manner towards patients/clients, and in all other aspects of physical therapy practice. Principle 3: A physical therapist shall comply with laws and regulations governing physical therapy and shall strive to effect changes that benefit patients/clients. Principle 4: A physical therapist shall exercise sound professional judgment. Principle 5: A physical therapist shall achieve and maintain professional competence. Principle 6: A physical therapist shall maintain and promote high standards for physical therapy practice, education, and research. Principle 7: A physical therapist shall seek only such remuneration as is deserved and reasonable for physical therapy services. Principle 8: A physical therapist shall provide and make available accurate and relevant information to patients/clients about their care and to the public about physical therapy services. Principle 9: A physical therapist shall protect the public and profession from unethical, incompetent, and illegal acts. Principle 10: A physical therapist shall endeavor to address the health needs of society. Principle 11: A physical therapist shall respect the rights, knowledge, and skills of colleagues and other health care professionals. Chapter 1 Introduction: The Physical Therapist as Professional 19 10. How would you describe your own model of professionalism? 11. What effect will awarding the DPT have on the professionalism of PTs? REFERENCES 1. Worthingham CA. Second Mary McMillan Lecture: Complementary functions and responsibilities in an emerging profession. Phys Ther 1965;45:935-939. 2. Kolb ME. 1966 APTA presidential address: The challenge of success. Phys Ther 1966;46:1157-1164. 3. Massey BF Jr. 2001 APTA presidential address: We have arrived! Phys Ther 2001;81:1830-3. 4. Larson MS. Professionalism: Rise and fall. Int J Health Serv 1979;9(04):607-627. 5. Kultgen J. Ethics and professionalism. Philadelphia: University of Pennsylvania Press; 1988. 6. Sokolowski R. The fiduciary relationship and the nature of the professions. In: Pellegrino ED, Veatch RM, Langan JP, editors. Ethics, trust, and professions. Washington, DC: Georgetown University Press; 1991. pp. 23-29. 7. Connelly JE. The other side of professionalism: Doctor-to-doctor. Camb Q Healthc Ethics 2003; 12(2): 178-183. 8. Swick HM. Toward a normative definition of medical professionalism. Acad Med 2000;75(6):612-616. 9. Ritzer G. Professionalization, bureaucratization and rationalization: The views of Max Weber. Social Forces 1975;53(4):627-634. 10. Latham SR. Medical professionalism: A Parsonian view. Mt Sinai J Med 2002;69(6):363-369. 11. Weber M. Economy and society: An outline of interpretive sociology. Roth G, Wittich C, editors; Fischoff E et al., translators. Berkeley: University of California Press; 1978. 12. Etzioni A, editor. The semi-professions and their organization: Teachers, nurses, social workers. New York: Free Press; 1969. 13. Elliott P. The Sociology of the professions. New York: Herdman and Herdman;1972. 14. Barber B. Some problems in the sociology of professions. In: Lynn KS, editor. The Sociology of the Professions in America. Boston: Houghton Mifflin; 1965. 15. Freidson E. Professional powers: A study of the institutionalization of formal knowledge. Chicago: University of Chicago Press; 1986. 16. Forsyth BF, Danisiewicz TJ. Toward a theory of professionalization. Work Occupations 1985;12(1): 59-76. 17. Hall RH. Professionalization and bureaucratization. Am Sociol Rev 1968;33(1):92-104. 18. Wilensky HL. The professionalization of everyone? Am J Sociol 1964;70(2):137-158. 19. Moore WE. The professions: Roles and rules. New York: Russell Sage Foundation; 1970. 20. Pavalko RM. Sociology of occupations and professions. Itaska, Ill: F.E. Peacock Publishers; 1971. 21. Freidson E. The theory of the professions: State of the art. In: Dingwall R, Lewis P, editors. The sociology of the professions: Lawyers, doctors, and others. New York: St. Martin’s Press; 1983. 22. Bebeau MJ, Born DO, Ozar DT. The development of a professional role orientation inventory. J Am Coll Dentists 1993;60(2):27-33. 23. Reed RR, Evans D. The deprofessionalization of medicine. JAMA 1987;258(22):3279-3282. 24. Stevens RA. Themes in the history of medical professionalism. Mt Sinai J Med 2002;69(6):357-362. 25. Sullivan WM. What is left of professionalism after managed care? Hastings Cent Rep 1999;29(12):7-8. 26. Massey BF Jr. 2002 APTA presidential address: What’s all the fuss about direct access? Phys Ther 2002;82:1120-1123. 27. American Physical Therapy Association. APTA vision sentence and vision statement for physical therapy 2020 [HOD 06-00-24-35]. Retrieved December 8, 2004 at http://www.apta.org/About/ aptamissiongoals/visionstatement 28. American Physical Therapy Association. Autonomous Physical Therapist Practice: Definitions and Privileges. (BOD 03-03-12-28) Available at www.apta.org/Documents/Public/governance/ bodPoliSec1.pdf. Accessed September 30, 2004. 20 PART I Historical Perspective and Professional Practice Issues 29. Rothstein JM. Autonomy and dependency. Phys Ther 2002;82(8):750-751. 30. Rothstein JM. Autonomy or professionalism? Phys Ther 2003;83(3):206-207. 31. Purtilo RB. The American Physical Therapy Association’s code of ethics: Its historical foundations. Phys Ther 1977;57:1001-1006. 32. Purtilo RB. Codes of ethics in physiotherapy: A retrospective view and look ahead. Physiother Pract 1987;3(1):28-34. 33. Emanuel EJ, Emanuel LL. Preserving community in health care. J Health Polit Policy Law 1997;22(1):147-184. 34. Emmanuel EJ, Emmanuel LL. What is accountability in health care? Ann Int Med 1996;124: 229-239. 35. Morreim EH. Balancing act: The new medical ethics of medicine’s new economics. Washington, DC: Georgetown University Press; 1995. 36. Ozar DT. Patient’s autonomy: Three models of the professional-lay relationship in medicine. Theor Med 1984;5(1):61-68. 37. Ozar DT. Three models of professionalism and professional obligation in dentistry. J Am Dental Assoc 1985;110:173-177. 38. Bellner AL. Senses of responsibility. A challenge for occupational and physical therapists in the con- text of ongoing professionalization. Scand J Caring Sci 1999;13(1):55-62. 39. Miles-Tapping C. Physiotherapy and medicine: Dominance and control? Physiother Canada 1986;37(5):290-293. 40. Luna-Massey P, Smyle L. Attitudes of consumers of physical therapy in California toward the profes- sional image of physical therapists. Phys Ther 1982;62(3):309-314. 41. Silva DM, Clark SD, Raymond G. California physician’s professional image of therapists. Phys Ther 1981;61(8):1152-1157. 42. Schlink M, Kling R, Shepard K. An attitudinal assessment of the professional image of California physical therapists [master’s thesis]. Stanford, Calif: Stanford University; 1978. 43. Dunkel RH. Survey of attitudes of Arkansas physicians and physical therapists toward the profes- sional capacity of the physical therapist. Phys Ther 1974;54(6):584-587. 44. Senters JM. Professionalization in a health occupation: Physical therapy. Phys Ther 1972;52(4): 385-392. 45. Website of the American Physical Therapy Association. Accessed Nov 10, 2003. Available at: http://www.apta.org/Education/dpt/dpt_faq#BM6. 46. Swisher LL, Beckstead JW, Bebeau MJ. Factor analysis as a tool for survey analysis using professional role orientation inventory as an example. Phys Ther 2004;84:784-799. 47. Professionalism in physical therapy. Consensus document of the American Physical Therapy Association. Alexandria, Va: American Physical Therapy Association; 2003. 48. Jette DU, Portney LG. Construct validation of a model for professional behavior in physical therapist students. Phys Ther 2003:83:432-443. 49. MacDonald CA, Houghton P, Cox PD, et al. Consensus on physical therapy professional behaviors. Physiother Canada 2001;53:212-218, 222. 50. Lopopolo RB. Development of the professional role behaviors survey (PROBES). Phys Ther 2001; 81(7):1317-1327. 51. Lopopolo RB. Hospital restructuring and the changing nature of the physical therapist’s role. Phys Ther 1999;79(2):171-185. 52. Threlkeld AJ, Jensen GM, Royeen CB. The clinical doctorate: A framework for analysis in physical therapist education. Phys Ther 1999;79(6):567-581. 53. May WW, Morgan BJ, Lemke JC, et al. Model for ability-based assessment in physical therapy educa- tion. J Phys Ther Educ 1995;9(1):3-6. Chapter 1 Introduction: The Physical Therapist as Professional 21 54. Hart E, Pinkston D, Ritchey FJ, et al. Relationship of professional involvement to clinical behaviors of physical therapists. Phys Ther 1990;70(13):179-187. 55. Wise D. Oath compilation summary. Unpublished manuscript distributed via electronic mail, 10/28/2003. Used with permission of the author. 56. El-Din, D. Teaching diagnosis. J Physical Ther Educ 1995;2:34.  2 The History of a Profession SHARED HISTORY AS A KEY TO PROFESSIONALIZATION A look at professional organizations in general provides the foundation for an understanding of the role of the American Physical Therapy Association (APTA) in the development and history of the physical therapy profession. A professional organization fulfills a number of functions for its members and the profession as a whole and establishes a framework for meeting these responsibilities. The following are functions of a professional organization1: Advancing the economic and social welfare of the practitioners in a profession Consolidating practitioners into a single organization Providing social and moral support to help members perform their duties Reinforcing the strongest members rather than catering to the weakest Enabling practitioners to perform their professional duties more easily so as to further benefit patients Helping to prepare practitioners for their professional roles and advance their education Promoting legal and professional standards of competence Developing social and moral ties among members for a community of purpose The following are the obligations of a professional organization1: Setting standards for practice and research in the profession Helping to ensure the qualification of those recruited into the profession Maintaining the profession’s traditions Anticipating the future of the profession and continually raising the bar of expectations Advancing well-founded research and establishing journals for reporting that research Justifying the (frequently expanding) scope of the profession Developing a consensus so that the organization can speak authoritatively on behalf of the profession, yet at the same time encouraging different viewpoints Providing opportunities for communication of members’ interests and concerns through democratically elected representatives 23 24 PART I Historical Perspective and Professional Practice Issues Associations provide the social bonds that allow their practitioners to act as a sin- gle body. Each association serves as a mediator for the profession in many interac- tions, including those involving practitioners themselves, the organizations in which they practice, third-party payers, other professional associations, universities, and the government.1 Few would deny that the APTA has more than met the chal- lenge of serving as a strong professional association for the specialty of physical therapy, and the history of the organization reflects the development of the disci- pline. As Terlouw2 points out, a shared history is one of the strongest bonds of any social group. A group’s history is one of the keys to professionalization, because this history is the means by which the group defines itself and determines its mission and goals. To forge a collective identity, therefore, physical therapists (PTs) must build on their shared knowledge of the past. Studying the development of physical therapy as a profession reminds members of their achievements, alerts them to cur- rent possibilities, and projects the future of their profession. The history can also help answer these questions2: What binds the members of the profession into a unified group? What professional relationships exist between PTs and other health care specialists? How did these relationships evolve? Why were laws enacted to regulate the practice of physical therapy? Do the reasons for enacting these laws still apply? What makes the practice of physical therapy different from country to country? What new problems does the profession face? What old problems persist? What values do PTs consider important? How has the perception of the PT’s role changed—both within the profession and without? In general, PTs have an undeveloped historical consciousness of their profession and undervalue its history, in part because professional historians have made few attempts to develop a history of the profession. Terlouw2 points out that this results in a “collective amnesia” about the specialty. The United States, Australia, Norway, the United Kingdom, and the Netherlands have made the most progress in ar- chiving historical documents about physical therapy.2 This chapter provides a synopsis of the history of physical therapy in the United States within a broader social context and explores key events in the creation and development of the APTA, the professional voice of PTs in the United States. EVOLUTION OF PHYSICAL THERAPY Social History Wars, epidemics, accidents, the needs of the physically handicapped, and an increased social demand for integration of people with disabilities into society have all shaped the development of physical therapy as an essential component of health care.3 Federal legislation and medical advances also have contributed to the evolu- tion of the profession. The first decades of the twentieth century were exciting times in the development of physical therapy, with many firsts occurring: Pennsylvania became the first state to license PTs; the first physical therapy textbook and the first journal devoted to physical therapy were published; and the first baccalaureate program for PTs was established (Table 2-1). The creation of the American Women’s Physical Therapeutic  Chapter 2 Table 2-1 Important Events in the History of Physical Therapy: 1910-1939 1910-1919 1920-1929 1930-1939 Major social events 1903: Wright brothers initiate era of 1920: Women win right to vote 1932: Atom is split. flight. (Nineteenth Amendment). 1937: National Foundation for Infantile 1911: Structure of the atom is 1925: Scopes “monkey trial” tests Paralysis is created. discovered. theory of evolution. 1939: Helicopter is invented. 1912: Titanic sinks.