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  • 2018 NEXT: McMillan Lecture: Wisdom and Courage Exemplify the Best of Our Profession

    McMillan Lecturer: Laurita Hack

    Both wisdom and courage are needed to effect positive change. Laurita M. (Laurie) Hack, PT, DPT, PhD, MBA, FAPTA, opened her delivery of the 49th Mary McMillan Lecture with these thoughts and with her insights into gaining more of the wisdom and courage that will move the profession forward. Hack addressed a capacity crowd on June 28 during APTA's NEXT Conference and Exposition. Beginning with a discussion of wisdom, Hack observed that it starts with knowledge but also must include good judgment to apply that knowledge. Best judgment doesn't always occur, she said, because of the way clinicians may frame or process information, especially in situations of uncertainty. But because judgment is paired with action, best judgment is imperative. "We have patients in front of us," Hack noted, "and we need to do something."

    How, then, do we improve our decision making? Hack said the literature on evidence provides a framework, reminding the audience of the 3 aspects of evidence-based practice (EBP): appraisal of the literature, decision making, and consideration of the patient's preferences.

    As for appraising the literature, Hack outlined 3 steps. First, she said "we need research we can trust." To maintain strong standards of publication, scholarly journals need the freedom to publish based on unbiased peer review, "not limited by inadequate resources or constrained by political influences." Hack suggested collaboration among journals—such as the 12 peer-reviewed journals published by APTA and its components—to combine financial and contributor resources to produce models for publication that reduce inefficiencies. Second, she said "we need research we can use," as patient care can't be suspended to wait on years-long research agendas. Hack suggested more emphasis on translational research and more access to research sources such as APTA's PTNow online clinician portal. Third, she said "we need to know how to use the research." For PTs, this doesn't mean PTs must understand research design and statistical analysis, she said. Instead, returning to reliable research, she said, "teaching clinicians how to recognize journals that can be trusted is more important than remembering which t-test should be used." When clinicians can trust in the literature they're reading, they can and should instead "focus on determining the generalizability of work to their patients." In discussing the second aspect of EBP—decision making—Hack identified biases that interfere with good decisions, such as outcome bias, selective recall, and selective exposure. Outcome bias is the assumption that when an outcome is negative, the process was poor; and when an outcome is positive, the process was good. Such bias "denies reality," she said, "since most biological events have some level of uncertainty." Selective recall is the tendency to unconsciously remember only certain information because it's perhaps more recent, more dramatic, or more personal—or confirms what someone already believes. Hack gave an example of a PT favoring a certain technique and being susceptible to recalling cases in which it decreased pain more often than recalling cases in which it didn't.

    Finally, selective exposure, Hack explained, describes tendencies to seek out people and resources that mirror one's own opinions and thus don't provide other perspectives, such as discussing a potential intervention with only like-minded clinicians or reviewing only research from journals and authors known to support a particular approach.

    To counterbalance biases, Hack suggested that clinicians seek a variety of viewpoints and resources, and "bring good data into our practices." One way to accomplish this, she continued, is to use evidence-based algorithms, which "consistently outperform human decision making." However, Hack noted that clinicians may be right to have reservations about embracing algorithms, given that so many clinical practice guidelines state that their evidence is poor or weak. "We need more and better data about lots more patients," she said. Fortunately, Hack said there is potential to accumulate this type of data through APTA's Physical Therapy Outcomes Registry, which will make data available for detailed analysis to describe patterns of practice, variations of those patterns, and associated outcomes. Hack noted that the Registry can move the profession past thinking about 1 patient at a time toward thinking about populations, which she called an essential move to "ensuring the role of physical therapy in the future and one that allows us to meet our vision of transforming society."

    McMillan Lecturer: Laurita Hack

    In discussing the third aspect of EBP—patient values—Hack cited the Code of Ethics for the Physical Therapist and the Vision Statement for the Profession as "powerful guides" to the standards clinicians must uphold in interactions with patients, clients, and colleagues.

    "Meeting these standards may take courage," she said, moving to her second exemplar of the profession. Hack borrowed from Glaser's 3 ethical realms to frame her thoughts on courage: individual, institutional, and societal. As individuals, excellent PTs exhibit courage when they use good evidence to make changes in practice, even when colleagues around them do not. It takes courage to resist temptations "to do things faster…to do more of the things that generate more income whether they are needed or not, to do…whatever seems more economically advantageous," she said.

    At the institutional level, lines between for-profit and not-for-profit facilities are blurring—as is the potential for profit from referral as the need for referral has disappeared. "We need to think differently about institutions," Hack said. Instead of categorizing institutions, we should be identifying the features necessary to ensure that clinicians provide appropriate care, such as the ability to make decisions without undue influence, collaborative leadership to enable all to contribute to decisions, and increased interprofessional practice.

    Turning finally to society, Hack noted that it is prominent in the APTA Vision for the Profession, "but we're slow to recognize that helping each person is excellent but not sufficient." To fulfill the vision promise of transforming society, Hack offered several recommendations:

    • Addressing social determinants of health
    • Engaging in social issues that reduce health inequities
    • Building a diverse workforce
    • Collaborating with patients, clients, colleagues, and communities
    • Empowering APTA to define the profession's moral agency beyond the patient level

    On the last point, Hack was optimistic. "We recently have seen willingness to show courage to act as moral agents on behalf of society," she said. One indication is a shift from "groupthink"—with its negative connotation of allowing biases to take hold that result in poor decisions—with "the wisdom of crowds" that uses "collaborative leadership and distributed power to collect broad and diverse input that instead can reduce the likelihood of these biases."



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    2018 NEXT: Making the Case for the PT and PTA Role in Disaster and Emergency Responses

    A panel of 4 physical therapists (PTs) with firsthand experience in responding to Hurricane Harvey, the Orlando Pulse mass shooting, the Great White concert fire, and other emergencies agree: PTs and physical therapist assistants (PTAs) have an important role to play in responding to these situations. The problem, they say, is that not everyone fully understands that role—including many PTs and PTAs.

    The panelists shared their perspectives at the APTA NEXT Conference and Exposition in Orlando, Florida, during a session that allowed each to tell their own story and share lessons learned. Though the details and circumstances differed, what emerged was a consensus thatfacilities and programs responding to emergencies often aren't prepared to put PTs and PTAs to best use, leaving therapists little choice but to take the reins wherever they can.

    Jessica West, PT, DPT, was thrust into emergency response when Hurricane Harvey devastated the Houston area in 2017. Just 2 years out of PT school, "I was truly going off my education," she said.

    She felt prepared to help, but unfortunately many in charge of the emergency response weren't prepared for her offer. "It was frustrating—they were relocating people to a conference center designed to hold 5,000 that was now holding 10,000 people," West said. "At the same time they were turning away therapists [who wanted to help]."

    When West was finally able to join providers onsite, she found a host of situations that were suited to responses from a PT—wound care, functional needs, basic screenings, and more. In her particular situation, West found that an obvious role for a PT would be to help temporary shelters better understand how to set up beds and other components in ways that account for the varying mobility needs of those being sheltered. "They should've had someone like me, like you, telling them how to set up a facility," West said.

    Erin Jones, PT, DPT, encountered a different situation when her hospital found itself taking in victims of the Pulse nightclub shooting that took place in Orlando in 2016. Although she didn't have much training in emergency management, she had experience in critical care—and, thankfully, her hospital had just finished a "massive" multifacility drill that tested responses to a campus shooter scenario.

    As did other panelists, Jones stressed the importance of drills of all kinds. "Prepare to know your role," Jones advised, adding that the preparation should include more than just a solid understanding of duties. Providers also need to prepare emotionally, particularly for the sudden, unexpected emergencies such as mass shootings. "These events can be emotionally draining," Jones said.

    As a PT with experience working with the Red Cross in Arizona, Gail Zitterkopf, PT, DPT, felt fairly well-versed in the workings of emergency response efforts. What she wasn't prepared for, after she moved to Texas, was being told when she showed up to join response efforts for Harvey to "go open up the Houston Astrodome" as a temporary shelter.

    Like West, Zitterkopf sees PTs and PTAs as eminently valuable components of an emergency response team. One example: the PT's understanding of the relationship between fatigue, body mechanics, and the potential for injuries. Victims of disaster need to be evaluated for their risk of experiencing further injury due to the impact of fatigue on their mobility, and that could be a crucial role for the PT, she said.

    Zitterkopf also echoed West's opinion that her PT training "well-prepared" her for a role in emergency response efforts. The problem is that the response system itself can be hamstrung by its own logistical inefficiencies—lack of coordination among multiple agencies, technical shortcomings, and provider transportation plans that don't always connect the provider with the closest facility. Then, of course, there are the even-more-basic things: "Often, volunteer registration websites do not provide PT or PTA options among its list of providers," she said.

    Jamie Dyson, PT, DPT, president of the APTA Florida Chapter, added to the discussion by describing his involvement in responding to natural disasters and other emergencies. Over the course of these events—not only responses to Florida hurricanes but also to victims of the Great White concert fire at a Rhode Island nightclub in 2003—Dyson said he has learned that "we have a lot of education that we need to do, both inward and outward."

    The challenge, according the Dyson, isn't just making the case to those in charge of emergency response programs—it's also about informing those within the physical therapy profession that they have a role to play and then getting them to take action.

    "Let's say someone wants to contact PTs to help in response to a disaster. That's great! But who do you call? We are not organized," Dyson said. "If we want to sit at the big table with health care, we have to put our big boy pants on and show what we can do."

    Panelists agreed that a directive adopted by the APTA House of Delegates just a day before their presentation could make a difference. The charge directs the association to work with other organizations and stakeholders to better define the role of PTs and PTAs in disaster relief and recovery, and to promote this role throughout the profession. "There's so much to learn about, and I'm really excited about what APTA will be able to do," West said.

    However, he added, with more disasters in the near future a near certainty, PTs and PTAs shouldn't wait for instructions from the association. "I want to encourage everyone to get out there and try," she said.

    2018 NEXT: 'You're Changing People's Lives' NEXT 2018 Attendees Told

    Professional beach volleyball player Gabrielle (Gabby) Reece told attendees at the opening event of NEXT 2018: "To serve others and help other people is a really important thing. You're changing people's lives."

    2018 - 06 - 28 - Gabby NEXT

    Although she didn't take up volleyball until 11th grade, Reece won an athletic scholarship to Florida State University, where she majored in communications and played volleyball. While there, she says, she developed sciatica. "They said I needed back surgery. That was a pretty serious situation. I went instead to a therapist and was able to play again" she said, explaining her growing appreciation of physical therapy. From that point, she continues, "I'd go to a physician and ask for physical therapy. That kept me going. Even then, I knew what a tool your craft is."

    Reece thanked her physical therapists (PTs) for the quality of attention and care she received. "I was always looked at as an individual person, not treated with a ‘cookie cutter' approach," she said. "In return, I was a very compliant patient because I knew their advice was designed specifically for me."

    As a professional volleyball player, Reece and her 4-person team took first place at the first-ever Beach Volleyball World Championships. She also competed domestically in the 1999-2000 Olympic Challenge Series. Reece was a contributing editor for Yahoo Health and has hosted "Insider Training" on the Fit TV/Discovery channel.

    A recent experience led her to offer the NEXT 2018 attendees another suggestion: "Two years ago, I finally had a knee replacement. I knew I had a lot of life left, so I was compliant. I forced the change, invited the change. You don't realize how powerful it is telling patients, ‘You'll get there.' That alone is powerful. Therapy got me back to my previous level."

    One action she didn't take, however, was using opioids for the pain. In addition to the danger of opioid medication, Reece explained, "I knew it would delay my recovery. The pain is there for a reason. The body is ready to figure out a way to health, and physical therapists help with that."

    2018 - 06 - 28 - Opening Sharon

    She also spoke about the importance of good nutrition and exercise, and offered this suggestion to people who might not regularly exercise or eat good food. "It's a lifestyle. I've created a system in which I can be successful. It's not about wanting to exercise every day," she said. Earlier in the evening, APTA President Sharon Dunn, PT, PhD, had spoken on the importance of building communities. Reece echoed this point when discussing a lifestyle to stay healthy, saying the key is "about finding your community."

    She concluded, "I'm inspired by you and take my hat off to you. It's a really honorable profession."

    Dunn, in her earlier remarks, also addressed the subject of change. She said, "There are so many opportunities in change…and I'm so excited where physical therapy fits in. It's the answer to a broken health care system. We're at a very pivotal point. We're thrilled with the alignment [of the many health care issues]. It's fun to be here right now."