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."
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."