Abstract
Keywords
Two years ago when we met in Orlando, I introduced the concept of occupational therapy in high definition—OT in HD (Clark, 2010).
Florence Clark, PhD, OTR/L, FAOTA
Compared with a standard-resolution screen, HD upgrades a blurry, narrow, unsaturated picture into a crisp, widescreen, vibrant one. In the same way, the metaphor of occupational therapy in HD upgrades the picture of our profession to the 21st century. OT in HD communicates what occupational therapy is with clarity and confidence. It knows that occupational therapy’s wide-ranging work settings and patient populations show the fundamental essence of everyday activity. It celebrates the ways people’s lives are truly transformed as a result of occupational therapy.
Do you remember me telling you about the research I did while developing the HD analogy? I brought home electronics magazines and sales circulars to learn all the features and jargon. And just when I got up to speed, what happened? The technology changed! Now many televisions offer HD in 3D—high definition in three dimensions! With the right programming and wearing the special glasses, the picture jumps off the screen and into your lap!
Today’s 3D craze is another example of what’s old becoming new again. I vividly remember going to see the horror movie House of Wax in 3D in 1953 (Foy & De Toth, 1953). I was 7 years old! House of Wax generated buzz as the first 3D release from a major motion picture studio. One of the legends of horror, Vincent Price, was the lead actor. He played a serial killer who encases his victims in wax and displays them in his wax museum, unbeknownst to the museum patrons. To say the least, it was a pretty gruesome movie. I’m not sure what my parents were thinking, taking a 7-year-old to see the film. But the characters and the story felt all the more real coming right at me off the screen in 3D. It scared me half to death, and the experience still lingers in my mind today!
While the technology is not necessarily new, this latest generation of 3D looks more real than ever, thanks to HD technology. Last year alone, there were more than three dozen theatrical releases in 3D. This summer, moviegoers will see The Avengers (Feige & Whedon, 2012), Men in Black 3 (Parkes, MacDonald, & Sonnenfeld, 2012), Prometheus (Giler, Hill, Scott, & Scott, 2011), and the Amazing Spider-Man (Ziskin, Arad, Tolmach, & Webb, 2012) coming off their local megaplex screen. I’m probably most excited for the adaptation of F. Scott Fitzgerald’s classic The Great Gatsby (Fisher et al., 2012), coming in 3-D at the end of this year. But eye-popping effects alone don’t make a quality film. Great movies are appealing primarily because their themes, stories, and characters resonate within us.
A Hero’s Journey
In his book The Hero With a Thousand Faces, Joseph Campbell (2008) examined classical myths from across world cultures and historical periods. Campbell was an expert on the role of mythology in societies, and he studied the Greek and Roman mythologies, folklore from antiquity, and stories at the heart of world religions.
The word myth is sometimes used to mean “fabrication” or “exaggeration,” but that’s a modern usage—I’m talking about myth in the sense of culturally rich stories that teach larger, philosophical or spiritual lessons. Think of Homer’s Iliad and Odyssey, for example.
Campbell (2008) showed that many myths, even across cultures and throughout history, share a common storyline—the hero’s journey. In fact, this storyline is so pervasive Campbell believed it to be central to all human social experience. He called it the monomyth, translated literally as “the one story” shared by all humankind. The monomyth—the hero’s journey—goes something like this: First, the departure—An unsuspecting everyman is called to depart the known world, leaving behind the comfort and familiarity of normal life; second, the tests—The protagonist enters an alternate reality, encounters sequentially greater tests, grows in strength and character, and ultimately conquers a supreme challenge; last, the return—Our victorious hero returns home transformed by the experience, and life will never be the same again. How many versions of this basic storyline exist in pop culture? Think of your favorite movie, and I guarantee you can identify elements of the hero’s journey. In fact, the medley of soundtracks that was playing when you entered this room draws from movies based heavily on the monomyth.
When we adopted the Centennial Vision 7 years ago (American Occupational Therapy Association [AOTA], 2007), occupational therapy set sail on its own hero’s journey. Of course, the Centennial Vision envisions that by 2017, occupational therapy will be a “powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society’s occupational needs” (p. 613).
In 2003, AOTA President Barbara Kornblau first called us to leave behind life as we knew it by pursuing a Centennial Vision (Kornblau, 2004). In 2005, when Carolyn Baum was president of AOTA, we began the first phase of our journey by officially adopting the Centennial Vision (Baum, 2006). Dr. Baum scouted the trail ahead, asking us to harness opportunities to control our future and achieve our potential. She is especially credited for leading the effort for our career scientists to access the National Institutes of Health (NIH) funding mechanisms.
In the second phase of our journey, AOTA President Penny Moyers Cleveland asked us to push beyond our comfort zones to expand our influence, visibility, and power (Moyers Cleveland, 2008). In 2008, she told us to be unreasonable, to knock on big doors, and to knock loudly! No doubt we have faced trials and tribulations along the way—encroachment by licensed and nonlicensed professions; cuts to publicly financed programs and reimbursement payments; adapting to the uncertainties of health care reform. But as with Odysseus in Homer’s Odyssey or, as I discussed at last year’s conference in Philadelphia, Rocky Balboa in Rocky (Chartoff, Winkler, & Avildsen, 1976), Indiana Jones in Raiders of the Lost Ark (Marshall & Spielberg, 1981), or Dorothy in The Wizard of Oz (LeRoy & Fleming, 1939), we emerge from each challenge stronger, wiser, and better prepared for what lies ahead.
In 2010, we entered the third phase of our Centennial Vision journey when I stated that broadcasting occupational therapy in HD would be the overarching goal of my term as AOTA president (Clark, 2010). OT in HD sprang from my desire to challenge the fuzzy definitions of our profession held by clients, coworkers, and consumers.
I wanted all of us to speak what we have always known but may have been reluctant to say out loud: that occupational therapy is an invaluable profession with unparalleled vibrancy, distinction, and detail. I wanted us to be proud of our diversity, breadth, and complexity, knowing that it mirrors that of everyday human experience. I wanted the entire world to recognize that occupational therapy professionals, more than those in any other discipline today, have the singular expertise to ensure people can live life to its fullest.
Two years into this third phase, we are well on our way to accomplishing these objectives. Consider a few of our recent victories: Occupational therapist Tim Kennedy challenged a 28-year incumbent in the New York State Senate and was elected by a nearly 40-point margin! Senator Kennedy is the occupational therapist holding the highest public office in the entire country! Occupational therapy practitioners and academic programs made it into the pages of the Boston Globe, Time, Inc., cnn.com, atlanticmonthly.com, and the Huffington Post. In 2003, AOTA had 5,600 student members, but thanks to your personal recruitment efforts, last year we crossed the 17,000 student member mark—that’s more than 300% growth in less than a decade! Speaking of membership, 2011 was AOTA’s 7th consecutive year of membership growth, and today we number over 43,000 members strong!
At the 2011 AOTA–National Board for Certification in Occupational Therapy Student Conclave in Providence, Rhode Island, more than 400 students took the Centennial Commitment Pledge, which challenges students to stay with AOTA through 2017. If all of today’s student members maintained their AOTA membership through 2017, the size and therefore the resources of AOTA would literally double—let me say that again, literally double! Let’s hear it for the thousands of students who have since taken the Centennial Commitment Pledge, and I ask that by the end of this week another thousand join them!
Thanks to our grassroots advocacy, we successfully extended the Medicare therapy cap exceptions process, reversing a 27% scheduled payment reduction! In true David-and-Goliath fashion, occupational therapy educator Samia Rafeedie approached the Intercollegiate Bureau of Academic Costume, and for the first time, occupational therapy now has its very own academic regalia color, slate blue, which our students can wear with pride at commencement exercises.
And Ken Ottenbacher was the first occupational therapist to lead an Infrastructure Grant from the NIH National Center for Medical Rehabilitation Research, receiving more than $4 million in federal research funding. Let’s hear it for these gladiators in the ring, successfully fighting for occupational therapy! The significance of the hero’s journey lies not in the victory, but in the personal, spiritual, and moral transformation that happens along the way. In Philosophy of Freedom, Rudolf Steiner (1894/1964) asserted, “There is given to the human being the possibility of transforming himself just as within the seed there lies the possibility to become a whole plant” (p. 142). There is no doubt that with each year we come closer to meeting the Centennial Vision—and 2012 will be no different; OT in HD is accelerating our own transformation. It’s triggering a change in our own self-concept and identity; in the ways we are competing in the wider arena of health care; in the ways we are redefining what it means to be a complete occupational therapy practitioner, educator, advocate, scholar, or scientist. In so many respects, we, too, have been transformed during this journey, and our professional life will never be the same. Take comfort in the fact that transformation is fundamentally a process of refinement, not replacement. The soul of occupational therapy remains steady.
Our everyday pursuits are more than worthy. We still work to ease human suffering and optimize participation in the activities that make life worth living. We conduct scientific research to develop effective interventions and discover new knowledge. We mentor students who will grow into the next generation of leaders. Students, you hone your personal excellence through dedication to your studies. What valuable and admirable tasks! Diligence, compassion, and integrity are essential to the soul of our profession and to the spirit of all who make occupational therapy their career.
Evolution of Occupational Therapy
This is a brave new world, and for occupational therapy to not simply survive but thrive, we must continue to evolve. The information revolution is changing the whole world—what are the implications for how decisions are made in a world overwhelmed by raw data? Is it any surprise when policymakers demand data—also known as evidence—for occupational therapy’s effectiveness?
Information is also more portable, accessible, and interactive than ever before. How will we use mobile devices and applications to enhance occupational therapy practice? How will we ensure that electronic medical records capture our full scope and effectiveness? Care and reimbursement systems are riddled with complexity, and politics will continue to carve the landscape of health care. How will we maintain and expand occupational therapy’s political clout? Today’s most prevalent long-term health threats are chronic conditions—obesity, heart disease, diabetes—hastened by contemporary lifestyles. How will we strategically position occupational therapy at the forefront of health promotion and chronic care management?
Ironically, the nature of modern warfare combined with advances in trauma medicine have rendered once-fatal combat injuries survivable. How will occupational therapy continue to develop innovative interventions that best serve America’s wounded warriors? How will we position occupational therapy as a cutting-edge profession not only for disease or care or educational management, but for life management—making a difference for real people in their real-world circumstances, to ensure they can live life to its fullest? By seeing ourselves as heroes on a journey to 2017, we capture the attitude of occupational therapy in high definition.
At its core, that’s what OT in HD has emphasized—attitude—or maybe more accurately, an attitude adjustment. Too often the phrase attitude adjustment is used negatively. I believe the attitude adjustment of OT in HD will be beneficial for us, our profession, and the consumers we serve. This attitude adjustment says an aura of confidence is critical to securing leadership positions in health care systems. It believes that, as I discussed at last year’s Conference, playing nice need not be mistaken for playing dead. Rather, it embraces a healthy spirit of competition to hone personal excellence—what the ancient Greeks called arete.
This attitude adjustment says that power is not a dirty word. OT in HD has been a call for you to recognize the transformational power in your own self and in the work you perform every single day. Each of you are individual, vibrant pixels, and together we shimmer in the widescreen, crystal-clear, high-resolution picture of occupational therapy in the 21st century.
Occupational Therapy in Three-Dimensional HD
However, achieving the Centennial Vision’s promise to meet society’s occupational needs will require more than an internal attitude adjustment. That’s why the next phase of our journey to the Centennial Vision must focus on becoming more engaged with science and immersed in evidence. This is why I am so excited to build on OT in HD by unveiling a vision for occupational therapy in three-dimensional HD—OT in HD–3D.
For the past 2 years, OT in HD has focused on cultivating the attitude necessary for empowering our profession. OT in HD–3D goes a step further by aligning this empowered attitude with the rigor and credibility of science. If OT in HD was all about attitude, OT in HD–3D is about attitude plus evidence. Together, attitude with evidence—OT in HD–3D—will accelerate our journey toward the Centennial Vision.
Allow me to further explain the concept of HD–3D. In terms of video screens, HD–3D has both high definition and a three-dimensional display. The methods used to create the 3D experience mimic the biological hard-wiring of our visual system. Just as our two eyes provide us with a sense of depth perception, traditional 3D projects two images that are perceived by the brain as one. In the same way, OT in HD–3D merges two separate perspectives—attitude and evidence—into one cohesive picture. As with 3D video, which converges images creating an experience that is more than the sum of its parts, the synergy between attitude and evidence is greater than either one alone. This double vision—attitude with evidence—will bring occupational therapy out of the two-dimensional flat screen and display the depth and substance we bring into the three-dimensional realities of our patients’ lives.
Of course, you already know why occupational therapy must continue to build its scientific knowledge base and why practice must become increasingly evidence based. For one, policy decisions concerning coverage and funding will continue to be built around scientific evidence. Policymakers will see that every drop of value is squeezed out of every dollar spent. Last year, the first baby boomers turned 65, and the Administration on Aging has estimated that by the year 2030, the number of Americans entering retirement age will double (Federal Interagency Forum on Aging-Related Statistics, 2010). Demographics alone, without even mentioning the politics or economics, are just one reason why public resources will continue to feel the pressure of a tighter belt. On the policy front, science and evidence will be absolutely critical to the future of occupational therapy on our Centennial Vision journey.
Using Attitude With Evidence
And I’m not simply speculating about the two-pronged value of attitude with evidence. Here’s a concrete case: Last December, the North Dakota Occupational Therapy Association notified the AOTA policy team that Blue Cross Blue Shield of North Dakota was accepting public comments on its Draft Medical Policy for Sensory Integration Therapy. Insurance providers develop medical policies such as this one to serve as guidelines for coverage and reimbursement decisions. To our shock, Blue Cross Blue Shield of North Dakota reached the conclusion that sensory integration [SI] is considered investigational. However, AOTA realized that this conclusion was based on incomplete and outdated information.
AOTA had to act, and it had to act fast. At stake was the future of North Dakotans’ access to SI services as a function of their insurance coverage. We were disappointed that the draft medical policy did not include significant research findings regarding occupational therapy and sensory integration, and we said so.
We offered examples of current scientific evidence demonstrating SI’s effectiveness, such as randomized controlled trials conducted by Beth Pfeiffer, Kristie Koenig, Moya Kinneally, Megan Sheppard, and Lorrie Henderson (2011) and by Yesim Fazlioglu and Gulen Baran (2008). We urged dialogue among the North Dakota Occupational Therapy Association, AOTA, and our global community of experts. Practitioners in North Dakota submitted case scenarios to Blue Cross Blue Shield that reflected the evidence provided by AOTA. Parents provided invaluable examples of functional improvements resulting from the therapy their children received. And guess what?
After a bit of back-and-forth, Blue Cross Blue Shield of North Dakota decided to put their medical policy decision on indefinite hold. Bravo to Sarah Nielsen and members of the North Dakota Occupational Therapy Association’s Legislation and Practice Committee for a hard-fought victory! Even though the battle is not yet over, this North Dakota case is a picture-perfect example of how, together, attitude with evidence are critical to realizing the Centennial Vision:
Attitude: The North Dakota Occupational Therapy Association went on high alert knowing consumer access was on the line; AOTA took a cordial but firm tack and pursued negotiations with a sense of confidence, power, and justice.
Evidence: We accessed our best research studies, marshaled our experts on insurance policy and sensory integration, and stood tall on the foundation of scientific credibility and substance.
Look at what we can do by using attitude with evidence!
This past year, the linkage among evidence, policy, and clinical care was dramatically visible in other ways. As states have begun to implement insurance exchanges, AOTA has used research on maintenance and habilitation to shape its advocacy efforts so that patients enrolled in these new organizations will receive these critical components of comprehensive care.
During a call for public comment on the Autism Best Practice Guidelines that were being drafted by the California Department of Developmental Services, AOTA forwarded evidence on the effectiveness of sensory integration therapy to ensure it received due consideration. By leveraging evidence of occupational therapy’s effectiveness, we also successfully advocated for fair payment for occupational therapy services, extending the therapy cap exceptions process and reversing the payment reduction under the fee schedule. Armed with evidence of occupational therapy’s role in the public primary education system, AOTA worked to protect the primary role for occupational therapy as an early intervention service under the Individuals With Disabilities Education Act of 1990 (Pub. L. 101–476).
A Path Forward
The value of OT in HD–3D, however, is not limited only to policy and politics. Attitude with evidence can propel researchers, educators, and clinicians forward. Susan Murphy provides an outstanding example of a way to bring OT in HD–3D to life. Murphy, a research health science specialist and occupational therapist, leads the PORT program at the VA Ann Arbor Health Care System in Michigan. PORT is the acronym for practice-oriented research training, and through it clinicians receive mentoring and training in research fundamentals and learn the steps to develop their own clinical trials. In the next phase of our journey, let’s continue to find innovative ways, as does the PORT program, to narrow the gap between research and practice.
I want to take a moment to talk to our seasoned veterans who, like me, remember a time before all the fuss about evidence. I want to qualify the role that science and evidence plays in our clinical practices today. Do not misunderstand: I am not suggesting that everybody must be conducting clinical trials or publishing papers in peer-reviewed journals. But what I am saying is that we must absolutely not be intimidated by the idea of research and evidence. We must not cower when other professions appeal to their own evidence in an attempt to undermine occupational therapy. We must not assume that only randomized controlled trials and meta-analyses render a specific practice area scientific.
We must realize that across disciplines, the criteria to establish an intervention as evidence based are being fiercely debated. For example, in one set of reviews on autism intervention effectiveness, five single-subject design studies are considered adequate, but in another, such studies are deemed not sufficiently rigorous to even warrant inclusion in the review. Medical directors of insurance companies are skeptical that the findings of even the most tightly designed randomized controlled trial can be reproduced in their settings with their practitioners and with their clients. What is being realized is that when it comes to research methodology and the criteria for what counts as evidence based, one size does not fit all. Interventions must be individually tailored to, and adapted for, local contexts. Evidence is not a goal unto itself. Rather, blending evidence into your practice should feel more like a continuous process that ultimately enhances the quality of your outcomes in your local situation.
OT in HD–3D is about attitude with evidence, but as a corollary, let’s also have the right attitude about evidence as our journey moves forward. What counts most is that you demonstrate, at a local level, that what you do works with your patients in your setting. Go for it!
Mindlines
Let’s also be candid about the ways evidence-based practice is idealized in much of the literature versus its actual application in real-world settings. Social scientists John Gabbay and Andre le May (2011) studied the ways in which expert primary care physicians used evidence in their everyday practices—in the trenches, so to speak. They found, not surprisingly, that practitioners account for many different factors when making clinical decisions and play multiple roles beyond provision of treatment, for example, when consoling a bereaved spouse. They discovered that evidence—that is, evidence in its narrowest definition of peer-reviewed academic sources—played a really small part in most care decisions, even when it was readily available. It turns out that the bulk of clinical decisions are set against real-life backdrops that are complex, subjective, intuitive, and even conflicting.
Think of the way in which financial circumstances complicate best practices that otherwise seem cut and dried on paper. Gabbay and le May recognized that practitioners operate according to what they called mindlines, defined as clinicians’ “internalized … and often tacit guidelines that are informed by clinicians’ training, by their own and each other’s experience … by their understanding of local circumstances and systems, and by a host of other sources” (Gabbay & le May, 2004, cited in Gabbay & le May, 2011, p. 44). Mindlines are only partially woven from textbooks and academic journals. Media, colleagues, industry reps, patient views, opinion leaders, and experience also inform clinical practice (Figure 1).
“Mindlines.” From Gabbay, J., & le May, A. (2011). Practice-Based Evidence for Healthcare: Clinical Mindlines, p. 46, by J. Gabbay and A. le May, 1991, Abington, England: Routledge. Copyright © 2011 by Routledge. Adapted with permission.
Unlike research that cannot logistically account for every possible set of clinical circumstances, mindlines are malleable and responsive enough to guide practitioners through real-world contingencies. We all know tacit reasoning has an impact on the quality of our care just as much as external evidence does, even if it does not always receive equal time and attention. We know evidence doesn’t exist in a vacuum. We know clinical decisions are not made using a step-by-step checklist but instead flow from the confluence of mindlines, context, and client. And now we know that we must develop a mindline dedicated specifically to the relevant scientific evidence. Being fluent in the evidence must be part and parcel of our professional identity.
And although not everyone will do the science, we must all have a working knowledge of the most important evidence-based studies in our respective areas of practice. Not everyone will present research papers, but we must all learn to concisely and incisively communicate relevant evidence within our work settings. Not everyone will be inclined to critically evaluate each and every new study, but we must all know how to access vetted and respected evidence-based reviews. Not everyone will possess mindlines filled to the brim with scientific details, but we must all have at least one mindline dedicated to scientific evidence pertinent to our practice. Not every student will have a passion for the sciences, but every educational program’s curricula must groom evidence-based practitioners.
When you return home after this Conference, how will you strengthen your scientific evidence mindline?
How will you better weave it into your own practice?
How will your curriculum enhance its evidence-based focus?
Students, how will you better integrate evidence into your education?
How will all of you transform yourself, if you have not already, into a clinician who sees himself or herself as evidence based?
The good news is that AOTA is providing resources to support your own transformation:
Interdisciplinary literature reviews
Practice Guidelines
The AOTA Web site’s Evidence-Based Practice pages
Publications such as OT Practice and the American Journal of Occupational Therapy
The newly launched Evidence Exchange repository.
Access these tools!
Realizing the Centennial Vision
The attitude of empowerment—the HD—will be fueled by the 3D—our ability to generate research of consequence, secure NIH funding, integrate evidence into everyday practice, and internalize our identities as evidence-based practitioners.
With one eye on attitude and the other on evidence, OT in HD–3D creates a cohesive picture of high-powered, scientifically credible occupational therapy in the 21st century. My great hope is that you leave this Conference with a three-dimensional view of yourself as both an empowered and an evidence-based occupational therapy practitioner, ready to meet every challenge on your journey to 2017.
When we launched the Centennial Vision 7 years ago, our profession set out on its hero quest. We departed from our customary ways of being, thinking, and doing. We have been charged to tap into a new attitude and, now, to capitalize on and strengthen our scientific evidence base.
There have been challenges that tested us, and make no mistake, more lie ahead. But heroes are not simply born: They are forged through every test they face. Every individual and collective victory transforms us into who we were meant to become. When we reach 2017 and can reflect on these 12 years of dedication to the Centennial Vision, we will have the satisfaction of knowing that our journey in these years of service to our profession and to our consumers has indeed been heroic.
I know that discussing the structure of myths and the hero’s journey may seem at odds with my call for OT in HD–3D, which emphasizes a commitment to scientific research and evidence-based practice. The arts and humanities traditionally sit at the polar opposite of the natural sciences. But no profession embraces both the sciences and the arts quite like occupational therapy. If our own hero’s journey was adapted for the screen, it would certainly be playing in high-definition three dimensions. The scenes in which we perform—research laboratories, administrative suites, the hospital or clinic room, school playgrounds, nursing facilities, out in the community, in classrooms and in lecture halls—would certainly be jumping off the screen in three dimensions.
Our journey to the Centennial Vision concludes in 5 short years. In the shrinking window between now and 2017, putting OT in HD–3D will help us sustain and increase the momentum we have gained so far. Occupational therapy in high-definition three dimensions recognizes that our radiance, clarity, and complexity are only as good as the authority that comes from a solid grounding in scientific evidence.
We must continue to generate the data-based knowledge that demonstrates our efficacy and effectiveness. And we must continue to implement that knowledge in practice for the benefit of our patients and clients, the ones for whom occupational therapy matters most.
In many ways, we have come so far in our journey, and in other ways there are challenges that lie on the horizon. Putting occupational therapy in high-definition three dimensions will help us pursue and achieve professional victories in these years. Let’s stand firm, stay united with passion, and harness the attitude of empowerment with the credibility of scientific evidence, and together we will heroically reach our 2017 destiny. Thank you.