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Editor's Notes |
Here I am, minding my own business, working quietly in my office, when Immelmann comes in. Immelmann is my imaginary friend. He has been visiting me a lot lately.
It may sound a bit bizarre, but there is no better check on reality than discussing things with imaginary friends. These figments have no personal agendas, and they never walk out in the middle of an argument. Immelmann always wants to discuss issues vital to physical therapy, even when I don't. But as we talk, all he does is mutter, "It is not logical." He's like Mr Spock, relentlessly arguing with Bones and Captain Kirk. Apparently Vulcans and imaginary friends have a lot in common.
Now, before you become alarmed at the prospect of an editor conversing with imaginary friends, keep in mind that Hillary Clinton allegedly sought the advice of Eleanor Roosevelt, and Richard Nixon apparently had lengthy discussions with the portraits in the White House. And here in Chicago, almost every elected official has an imaginary friend or two. (Occasionally, we find these friends on the city or state payroll—that is, until some zealous prosecutor argues that imaginary friends are not real and therefore should not be paid a salary. In Cook County, we even let imaginary friends vote, sometimes more than once!)
Chicago also had Mike Royko, who filled his newspaper column with imaginary characters, some of whom hailed from Eastern Europe. Similarly, the great African-American poet Langston Hughes often called on his imaginary friends to discuss important issues of the day. Several generations of children have had the good fortune to know about Mr Snuffleupagus, Big Bird's quintessential imaginary friend. According to the Children's Television Workshop Web site, Mr Snuffleupagus likes games, cabbage, and spaghetti, but he doesn't like "when nobody believes he exists." I agree. If you don't want to hear from my imaginary friend, you can stop reading now, but if you choose to read on, be forewarned that Immelmann speaks his mind and can be brutally honest.
My friend Immelmann is well informed about the state of physical therapy. He was shocked and saddened to hear that in America we care so little about people who are sick and disabled that we cut expenditures for their benefit under the guise of balancing the budget. He was even more shocked to learn about how HMOs, once considered to be the progressive solution to health care delivery problems, now are valued for their profits rather than for their services. He remembers how their original focus was supposed to be on cutting costs through active prevention and health promotion and is dismayed to find this activism replaced by a reactive system that focuses on limiting costs and not on maximizing health. The idea of managed care and prospective payments was always attractive to him—until he saw that what is widely being called managed care is in reality managed costs with chaotic care.
My friend "comforts" me with remarks such as, "You therapists used to be the good guys, and you still do the same wonderful stuff. But I hear a lot about you folks being greedy. It's a shame." He asks me what we could do to ensure that patients receive care and to reverse the downturn in the job market. Without missing a beat, I answer, "Demonstrate a need." I explain that if we could undeniably demonstrate the benefits of our services in terms of quality of care, outcomes, and costs, people would listen. We would then be in the best possible position to argue for expanded use of our services and for the elimination of arbitrary caps.
Immelmann begins to peruse a pile of publications on the table next to my desk. Occasionally he exclaims, "Wow!" or "Fantastic!"
"So what's so fantastic?" I ask him.
He flips to the advertisements for continuing education. "The problem is solved!" he says gleefully. "Look at all of these people teaching about all sorts of conditions and sharing their strategies for patient management. These folks must have evidence; after all, most of them have been teaching these kinds of courses for years."
"But those courses are not based on data," I explain. "They almost exclusively consist of people expressing their opinions about care after they have laid some groundwork for their beliefs."
"You're kidding, aren't you?"
I assure him I am not.
"What about all of these APTA chapters and sections?" he asks. "Certainly when they sponsor a course they check whether there are data. Certainly they check whether the speaker has evidence. Don't they look up what the presenters have published in peer-reviewed journals?"
"Almost never," I have to admit.
"Well, at least they make it clear in these courses that there is no evidence, don't they?
"No!" I said, driving him further into depression.
"Let me get this straight. Everyone seems to agree that your profession is facing some hard times, and so are your patients and clients. A lot of this has to do with people refusing to pay for existing services, which means that either you cannot provide certain interventions or you cannot provide interventions in a manner that you currently believe your patients need. Despite this, however, some of your colleagues want to teach you about more treatments. That is not logical, nor is it ethical or moral. People are complaining that they don't have the time and support to give existing treatments, but they go to courses to learn about more treatments—treatments that may be worse than what they already provide! Learning about treatments that are not supported by evidence does not make sense."
"So what would be logical, ethical, and moral?"
"To deprive people of high-quality care is clearly unethical. Therefore, if you really believe you can help people with new methods, your responsibility doesn't end with earning money on the continuing education circuit. In today's world, believing that something is best for patients is insufficient. You need to teach more than techniques and philosophy in continuing education. You need to give people evidence so that they will be allowed to use these supposedly wonderful new treatments. A failure to collect evidence is the same as keeping an effective treatment secret or covering up news that a treatment is dangerous. Those who believe that they have better techniques and strategies should stay home and collect evidence. Once they have it, then they can give courses. And I don't mean that they should give talks about research in progress, because that is not evidence. Many of us would never live to see that so-called evidence in a peer-reviewed publication."
Although many of us have been frustrated about the continuing education merchants and even those promoters who work within educational environments, Immelmann thinks we need to go a step further. He never actually uses this word but it seems that he wants us to shun people who don't meet their responsibility to collect evidence. He believes that our current crisis will show who really cares about the profession and our patients and who is in it only for the money and the ego enhancement.
But what do imaginary friends know? Can we really expect physical therapists and physical therapist assistants to boycott courses that are not evidenced based? Can we expect chapters, sections, and APTA's programming committee to invite only those speakers who have fulfilled their responsibility of critically evaluating, through research, the ideas that they promote? Can we really expect the gurus—the self-promoters and the self-anointed experts—to admit to themselves that the time has come for a moratorium on the promotion of untested ideas and treatments? Do we dare say to the promoters that, if you love this profession, you will do the right thing by collecting evidence before you promote? Or do we let them continue to promulgate their messages, providing further ammunition to those who argue that we as a profession are not trustworthy and that our profession lacks a credible basis for its actions and interventions?
Immelmann assumes too much. That's the trouble with imaginary friends. He assumes logical behavior. He assumes that those who willingly take money for their courses love our profession enough to do the right thing. He does, however, promise to attend some of those courses and meetings in the coming year. How will you know that the person sitting next to you is my imaginary friend? He will be the one who stands up and asks, "Do you have any evidence for this treatment? How do you know it works? And if you have no evidence, why are you here?"
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  J. Schreiber, P. Stern, G. Marchetti, and I. Provident Strategies to Promote Evidence-Based Practice in Pediatric Physical Therapy: A Formative Evaluation Pilot Project Physical Therapy, September 1, 2009; 89(9): 918 - 933. [Abstract] [Full Text] [PDF]
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