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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,
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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
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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.
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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
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Foreword
Professionalism in Physical Therapy: History, Practice, & Developmentis 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-
sionand 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
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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
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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.
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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
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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
W D P M ?
HAT OES ROFESSIONAL EAN
As Catherine Worthingham1observed 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 Titlesas 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
Massey3state 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 professionalfrequently in everyday conversation, its mean-
ing may not be altogether clear or may differ among groups. Forinstance, 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 professionand professionalvaries so much that some have
wondered aloud whether these words now mean anything at all.4
The concept of professionand professionalhas been the subject of vigorous scholarly
debate spanning much of the twentieth century and continuing today. The rigor and
1
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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 professionalsin
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.6Although
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:
Aprofession 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.7,8Individual professionalismrefers 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,9sociological literature about the
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Chapter 1 Introduction: The Physical Therapist as Professional 3
professions takes three approaches: structural, processual (or process), and power.
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 Durkheim5wrote about the positive functions of the professions as
early as 1890, the structural approach to professions is most associated with Talcott
Parsons,10the founder of the structural-functionalist school of sociology. In translat-
ing Max Weber’s11work to English in the mid-1900s, Parsons became interested in
the professions.10Weber (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
scholarshipattempted to further refine the characteristics of the of true professions,
in contrast to “semiprofessions” or nonprofessions.12 Although debate about the
number andnature 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 nonof a profession. Those occupations with extensive autonomy in
their work are considered “true professions”; those with less autonomy are either
“semiprofessions” or not professions at all.12Moore19and Pavalko20built 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
