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Editor's Notes |
jules-rothstein@attbi.com
A television commercial proclaims that if you call a certain insurance company, you will be told not only their price but also the prices of some of their competitors. (The concept seems to be too good to be true, but I have never tested the veracity of their claim.) This is one commercial that actually gives me a warm feeling, as it reminds me of the scene in Miracle on 34th Street when the Macy's Santa sends mothers to competitors to find the toys their children covet.
In that same spirit, I remind you that this Journal offers you only one portion of the evidence and information that physical therapists need for practice and education. I urge you to check out what some might call "our competition."
No single Journal—not even a collection of professional journals in a given field—can provide all the information needed for contemporary practice and education. Parochial views of the literature have to give way to an eclectic approach that maximizes resources. If Physical Therapy is the only journal you read, you are not sufficiently prepared for practice.
This month, Miller and her colleagues (pages 123–131) report on their examination of the quality and type of research articles that have appeared in this and 3 other national physical therapy journals. As with most such analyses, the results can be judged only in the context of expectations. Of greatest concern is their analysis regarding both the rigor and applicability of the studies published. Neither the amount of rigor nor the level of applicability is adequate to fuel a growing profession.
As Miller and colleagues acknowledge, because only 6 issues of each Journal were examined (and those were from a couple of years ago), their study, like all studies, has limitations. In addition, not all of us would share the authors' view that measurement studies are not directly applicable to patient care, especially when those studies might focus on measurements used to guide interventions or assess outcomes. Despite what might be viewed as limitations in the study, there is a very compelling underlying theme: One of the great achievements of the physical therapy profession is that physical therapists are no longer ignored.
Research by physical therapists now appears in all sorts of journals, and clinically relevant research in physical therapy often is conducted by non–physical therapists. If you have any doubts, consider APTA's creation of a clinician-friendly, outcome-oriented database called "Hooked on Evidence." Begun in the summer of 2002, the database now contains extracts of 425 articles from 132 different journals. I would describe the use of 132 journals as very eclectic—and that number is going to grow dramatically as more articles are added. In any given year, dozens of studies relevant to physical therapy are published in journals throughout the world, including some of the most prestigious biomedical journals.
As an Editor, I might be tempted to view this widespread dissemination as a failure of our Journal to provide an adequate home for studies written by physical therapists and others. I take a broader view, however—one that is shared to some extent by Miller and her colleagues, who write that "physical therapists should attempt to access other sources of information to find additional high-quality evidence." Just as members of other professions fail their patients if they do not consider what our Journal publishes, we too fail in our professional responsibilities if we do not use modern electronic resources to find out what is available to help us practice and educate. Given the use of 132 journals this early in the development of the Hooked on Evidence project, the wisdom of providing practitioners with such a database should be evident.
We often can best serve our patients when we share articles from this Journal with colleagues who might otherwise not see a given paper. This kind of interaction is a longstanding tradition and has become a habit among many health care practitioners during their training. And what they share is evidence—not just the views of gurus or the behaviors that are born of tradition. This morning, for example, I sent an e-mail copy of an article to the physician caring for my mother because I knew the physician would be unlikely to see something from our Journal in a timely fashion.
Miller and colleagues contend that we might have to look beyond national professional journals for information on practice. I believe that we also need to develop a culture that cares about the literature and uses it. For too long, practice has been based on unpublished dogmas and the admonitions of the continuing education gurus who fail to test their ideas or even explicate them through peer-reviewed publication. With APTA's Hooked on Evidence project and other initiatives, the excuses of those who rely on dubious justifications for questionable practices are becoming less and less acceptable. Additional evidence on physical therapy interventions is still needed—but such articles will be of little value unless readers apply them to their practice.
In commenting on the paper by Miller and her colleagues, Jette (pages 131–132) suggests that one reason why there may be so little applicable research in some physical therapy journals is because there has been too little clinical research. He notes that, within the United States, there has been a disconnect between the research of academically based physical therapists and the practice of physical therapy. He shares my belief that APTA's Clinical Research Agenda for Physical Therapy1 is a bold effort to call for a new direction among researchers, with the focus placed on clinically relevant issues and outcomes. In Jette's view, there has to be a further nurturing of relationships between university faculty members and clinicians—especially clinical specialists—in order to realize this agenda.
Although I believe that Jette's suggestion is unassailable, its importance is arguable. Yes, faculty members should work more closely with the clinicians who educate their students, and certainly the greatest benefit might be expected from those who carry the credentials of clinical specialists. The great impediment to developing a more robust, clinically relevant research literature, however, is not just the disconnect between research and practice. It's also the disconnect between the academic environment and practice.
Jette notes that he sees the "university operating in isolation from the clinical setting." He is correct. Our education programs in academic health centers may share an address with the centers' clinical programs, but they have a hodgepodge of relationships with the clinics. In only a handful of cases are the physical therapist education programs tied to the clinicians in academic health centers in a manner similar to that seen in medicine or nursing. Until we insist on stronger ties between clinical practice and academic centers and on greater research productivity by faculties, the paucity of relevant research noted by Jette is unlikely to change.
In responding to Jette's comments, Miller and Haynes (page 133) state that their research dealt with what studies are published, not with what research is produced. They, too, endorse partnerships between clinicians and researchers. They give as an example a consortium of clinicians created to further a research agenda. Unfortunately, as desirable as such consortia might be, they are few and far between.
Miller and Haynes also note in their response to Jette's commentary that research is often published where it affects the largest audience. For example, our Journal is often the choice of non–physical therapists who would like to influence physical therapist practice—physicians, motor control experts, biomechanists. Likewise, physical therapists publish elsewhere as they try to reach other professionals, especially, as Miller and Haynes note, when there is interdisciplinary research. We would be dishonest not to recognize the importance of authors publishing their work where it can best be viewed by the most applicable audience. This may mean publishing an article about an arthritis intervention in a journal where physicians who are most likely to treat patients with this pathology can see it.
Our Journal might be Macy's, but sometimes you have to go to the "competition," because we cannot be all things to all readers.
Regardless of what research is published and where, there is still too little of it! Because it is disseminated widely across a number of journals, the "best" physical therapists will be those who know how to access the literature in a rapid manner and how to apply it most appropriately. These skills can be learned (the Journal's "Evidence in Practice" series is just one of the available learning aids). Perhaps someday soon we will be able to declare with pride that we truly are a profession that is "hooked on evidence"—but it will take some effort from all of us.
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