CHARLES MAGISTRO, B.S. President, American Physical Therapy Association
Exactly twenty-five years ago, just a few miles from this city of Anaheim, California, I began my career as a physical therapist. This day, therefore, has special significance for me since it represents the culmination of twentyfive years of continuous involvement in the practice of physical therapy and with the American Physical Therapy Association. I will always be grateful for both of these oppor tunities since I view this parallel involvement as equal and necessary means to achieve a full measure of personal and professional satisfac tion and service. It is highly rewarding to me personally, as it must be to you, to witness the phenomenal growth of physical therapy as a profession. This
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progress has been especially dramatic these past twenty-five years. When I search for compari sons of things as they were twenty-five years ago and as they are today, it becomes evident that little remains the same. This is especially true of the physical changes which surround our lives and which oftentimes occur with little or no influence on our part. These changes are usually easily recognized. If someone were to suggest that I have the same physical appear ance I had twenty-five years ago, I would be alarmed about his powers of clinical observa tion. Yes, much has changed in the past quarter century. But my intent is not to dwell on the subject of physical change. Rather, I would like to address myself to those elements of change which have occurred in our thinking, in our attitudes, and in our behavior as physical therapists and to what degree we have been successful in modifying the thinking of others whose influence affects our professional growth and development. I would like to call to your attention three critical issues which have acted as roadblocks to an even more rapid development of our profession. Our inability to influence the rigid attitudes and opinions of those who wish to assume control of our professional destiny has been and continues to be a source of serious concern to us. This fact has been recognized and spoken to by recent Association presidents in similar addresses and by other esteemed leaders in our profession. 1 ' 2 My fear is that those who follow me may still have to speak to the same issues. That should concern all of us. Ruby Decker, in 1199
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The 1975 Presidential Address
profession.
her 1966 Mary McMillan Lecture, said: "Wait ing with a purpose is patience. It is dawdling when there is no evidence of fulfillment of purpose, and we have waited too long." 3 We have been dawdling, and no purpose will be served in waiting any longer for the changes we deem necessary to ensure our continued growth as a profession. The changes we seek will only happen if we make them happen. To achieve our goals, we must consider realistic alternatives in our approaches for new solu tions. I refer specifically to three major concerns: first, we have not yet gained approval from the American Medical Association of our "Essentials of an Accredited Educational Pro gram for the Physical Therapist"; second, we have been unable to influence the Joint Commission on Accreditation of Hospitals in the development of physical therapy standards which realistically reflect the mainstream of physical therapy services in our nation's hos pitals, and finally, we have not stopped the escalating encroachment of government into the practice of physical therapy. As we search for reasons for our apparent failures in prevailing in these three areas, we must first examine critically our own attitudes and behaviors. In my opinion, we must accept some of the blame for our inability to influence the bureaucracies concerned with these matters. We have not always demonstrated the courage of our convictions in defending those tenets we deem essential to our development as a profession. Neither have we truly recognized the important role we have played and will continue to play in the total scheme of health care. Consequently, we have not consistently negotiated with others from a standpoint of strength. In the past twenty-five years, I can recall only a few actions on our part that have
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demonstrated with finality that we were willing to go to the wall on an issue. Among these was our formal withdrawal from the American Registry of Physical Therapists in 1961. As we look at ourselves as a profession, we must ask if we are a truly unified group. Or are we a group of individuals only concerned with issues which affect our own individual spheres of interest and professional involvement? Evi dence suggests that we are a somewhat frag mented group. We seem to have great difficulty in recognizing that any issue which affects one special interest group has a potential impact on all our members. But the source of many of our problems is not totally related to our own shortcomings. Forces outside this Association have had a restraining influence upon us. Some have suggested that "organized medicine" is respon sible for many of our problems. One would have difficulty in describing just what organized medicine means in this country. At one time the term was synonymous with the American Medical Association; such is not the case today. For at least five years the AMA has represented less than 50 percent of this nation's medical doctors. 4 That there is political unrest within this organization and increasing dissatisfaction among its membership is public knowledge. This situation is unfortunate indeed since I sincerely believe that the AMA should represent the majority of physicians in this country. Of particular concern to APTA, however, is whether an organization which evidently is not being responsive to its own members' needs can be responsive to ours. To my knowledge, only a small fraction of the medical community has been guilty of suggesting that physical therapy is opposed to medicine and that medicine is opposed to physical therapy. The circumstances which
We have not always demon strated the courage of our convic tions in defending those tenets we deem essential to our develop ment as a profession. PHYSICAL THERAPY
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No purpose will be served in waiting any longer for the changes we deem necessary to ensure our continued growth as a
surround this issue are so bewildering that they seem unreal. Without medicine there can be no physical therapy. To oppose medicine would be to oppose physical therapy. Our unwillingness to identify openly and confront directly the elements of one medical specialty group which has opposed the advancement of physical therapy education and practice has to a great degree delayed the solutions to many of our problems. It is neither my purpose nor within my purview to speak against the concept of Physical Medicine and Rehabilitation as a medical specialty or to speak against any other of the many specialties in medicine. Each has a specific purpose in the total scheme of health care as we know it today. The degree to which medical specialties are successful will be greatly dependent upon the need for their services as well as on the quality of those services. These factors can be judged by other referring physicians and by patients who use these services. When I speak in opposition to certain actions taken by those in the specialty of Physical Medicine and Rehabilitation, there fore, I do so only within the context of that specialty's attempt to exert control over our profession. I am certain that the majority of physical therapists in this country enjoy excellent professional relationships with physicians, and I am equally certain that many physical thera pists have similar relationships with physiatrists. I fear, however, that some physiatrists have created considerable confusion about the re spective roles they and we should assume in the delivery of physical therapy services. To suggest that some 320,000 physicians in this country share the same concerns about the roles and functions of physical therapists as those expressed by some physiatrists is a distortion of the truth. The majority of
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physicians we serve in this country are pri marily interested in our ability to provide ethical and effective physical therapy services to their patients. Some members of this specialty feel threatened by certain actions of our profession and respond in an unconstructive and repressive manner. They overreact to those things we are doing in education and practice or to those things we wish to do. In so doing, they make every conceivable effort to convince their medical colleagues that physical therapists wish to practice or are practicing medicine. Nothing incurs the wrath of physi cians more than the suggestion that a nonphysician is attempting to practice medicine. The fact that our practice is subjected to stringent controls as delineated in our Code of Ethics, our Guide for Professional Conduct, 5 and various state licensing laws, and that we abide by these rules is somehow brushed aside. Even more unfortunate is the fact that leader ship in medicine has failed to properly investi gate these baseless accusations and to dispose of them. This failure will continue to cause serious problems for both of our professions in several areas. ACCREDITATION OF PHYSICAL THERAPY EDUCATIONAL PROGRAMS
First, let me cite the effects on physical therapy education. The events which have occurred in the accreditation of our basic educational programs are well documented in the archives of this Association. We started, in 1926, with full responsibility for the accredita tion of our educational programs. We suc cumbed to a combination of financial and certain physician pressures, however, and re linquished this important professional responsi-
Our firm belief is that physical therapy educational programs must be administered by physi cal therapists who are expert in the field of education. 1201
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The collaborative accreditation process has presented numerous problems for our Association since its inception.
I am confident that physical therapists will continue to be edu cated in this country by physical therapists in a manner which best meets the demands required of them in practice. 1202
Accrediting in 1968 for recognition as the official accrediting agency for physical therapy education. Action on this petition was deferred pending the outcome of conferences between the Council on Medical Education and our Association. The petition was further delayed until completion of the "Study of Accredita tion of Selected Health Educational Programs." The proposals of this commission were rejected by the AMA's Board of Trustees. Our petition was never acted upon by the National Commis sion on Accrediting because it appeared that progress was being made in our negotiations with the AMA. In 1972, the United States Commissioner of Education notified AMA's Council on Medical Education of deficiencies in compliance with the United States Office of Education's "Crite ria for Nationally Recognized Accrediting Agencies and Associations." The commissioner granted renewal of recognition for one year, even though the maximum period could have been four years. Discussions between the Council on Medical Education and the APTA ensued to identify areas of mutual concern. One of the primary concerns was the fact that the Essentials had not been revised since 1955. Our Association made every attempt to pre serve and build upon elements in the existing accreditation process to the end that collabora tion would be mutually acceptable to both the AMA and APTA. In 1973, our Board of Directors outlined various proposals which represented a realistic alternative to the still pending request to the National Commission on Accrediting to be recognized as the sole accrediting agency for physical therapy educa tion. 8 These conditions were accepted by AMA's Council on Medical Education, and our "Standards for Basic Education in Physical Therapy [Essentials]" were adopted by our House of Delegates in June 1973. These standards were then submitted to AMA's Council on Medical Education for its review. The Council sent the proposed revised stand ards back to us with suggestions from its Advisory Committee on Education for the Allied Health Professions and Services. Our Association willingly agreed to the suggested changes and once again (June 1964) our House of Delegates approved the Essentials PHYSICAL THERAPY
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bility to the AMA's Council on Medical Education in 1936. In a review of the historical events which have occurred in this process, a statement written in 1955 is significant: "After four years of intensive study and discussion by the Council on Medical Education, the AMA's Council on Physical Medicine and Rehabilita tion, the American Physical Therapy Associa tion, and the Council of Physical Therapy School Directors, a compromise revision of the 'Essentials of an Acceptable School of Physical Therapy' was adopted by the American Medical Association's House of Delegates." 6 I will use the term Essentials frequently in this portion of my address and I wish to make it clear that the Essentials are minimum standards for approval of our educational programs by the AMA in collaboration with the APT A. 7 In 1960, we embarked on a collaborative process of accreditation with AMA's Council on Medical Education. This arrangement exists today. The collaborative accreditation process has presented numerous problems for our Association since its inception. What should be significant to us is the fact that the AMA does not accredit the educational programs of all allied health professions. Ex cluded are such professions as nursing, phar macy, speech and hearing, dietetics, and social work. For the most part, these professions are accredited by their own peers and recognized by the United States Office of Education and the National Commission on Accrediting. After years of disappointment with the collaborative accreditation process, our Associa tion petitioned the National Commission on
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The cornerstone of any profes sion must be firmly established on a sound foundation of theoretical knowledge. Any attempt to un dermine or weaken that founda tion is unacceptable to our pro fession.
state licensing boards of medicine and allied health fields. This resolution was significantly modified by the AMA's Reference Committee. The net effect of this change was that the responsibility for persons who should perform electromyographic examination rests within the jurisdiction of each State Board of Medical Examiners. 11 Even though these arguments failed to demonstrate to us any substantial reasons for rejecting the Essentials, subsequent negotiations were held with the Council on Medical Educa tion and various Section Council representa tives. The purpose of these meetings was to attempt to resolve our differences before the next House of Delegates meeting of the AMA which was to be held in early December 1974. The items discussed and their relevancy to the Essentials are too numerous to list; in my opinion, they represented nothing more than stalling tactics spearheaded by the Section Council on Physical Medicine and Rehabilita tion and they were reminiscent of our 1955 negotiations. Further concessions were made by our Association. At AMA's House of Delegates meeting in early December 1974, our revised Essentials were once again submitted for ap proval. The AMA's Reference Committee held open hearings on them, and all interested parties except one spoke in favor of approval. The dissenting voice came from one representa tive from the Section Council on Physical Medicine and Rehabilitation who raised certain legal questions about our Essentials. The Refer ence Committee had no other recourse but to seek legal advice, and the Essentials were 1203
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as revised. The same document was approved by the Council on Medical Education of the AMA and submitted to AMA's House of Delegates in June 1974. The document, how ever, was rejected once again. I would like to comment on some of the reasons given for the defeat of the Essentials. The proposed revisions, it was claimed, repre sented a major departure from the previous Essentials—those in effect since 1955—and the revisions had not received widespread circula tion. 9 The first portion of the contention is accurate and it should be evident to all concerned with this process that much has changed in physical therapy education in the past twenty years. A statement from the Journal of the American Medical Association in the "Allied Medical Education—1973 Report" reads as follows: "One of the primary responsi bilities of the Committee on Standards is to ensure that the 'Essentials' reflect the needs of a changing society." 7 Our standards as pro posed reflected that kind of change. Another expressed concern was that the proposed Essentials did not require physician guidance and direction of the program. 9 Our firm belief, and a belief we can defend, is that the directorship of physical therapy educational programs must be administered by physical therapists who are expert in the field of education. A third contention was that no mention was made in the Essentials regarding the limitations in the practice of physical therapy. 9 This contention has no basis since the limitations in the practice of physical therapy are regulated by individual state licensing laws and should not be identified with our Essentials. The last major reason for denying approval had to do with the fact that some of our curricula include instruction in electromyo graphic testing procedures. 9 Curiously enough, this technique is not even mentioned in the revised Essentials. In 1973, the Section Council on Physical Medicine and Rehabilitation pre sented a resolution to AMA's Reference Com mittee on this subject. 10 The resolution in its original form prohibited the performance of electromyographic examinations by nonphysicians and specified that the resolution should be distributed by the AMA to all third party providers of health care as well as individual
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The Standards for Accredita tion of Hospitals do not reflect the manner in which physical therapy services are delivered in our na tion 3 s hospitals.
cooperative and helpful to our Association in this endeavor. Perhaps some of you will feel that I have dwelled on the subject of education too long. May I assure you my reasons are valid. The cornerstone of any profession must be firmly established on a sound foundation of theo retical knowledge. Any attempt to undermine or weaken that foundation is unacceptable to our profession. STANDARDS FOR ACCREDITATION OF HOSPITALS
Those in the practice of physical therapy also face other serious problems. The second area to which I now turn could have a scenario as long and labored as the one just described, but time does not permit me to go into great detail. I am sure you will recognize that only the stage is different; the players are the same. One of the critical concerns of physical therapy practice that I would like to discuss is the Standards for Accreditation of Hospitals as developed by the Joint Commission on Accredi tation of Hospitals. 1 3 These standards affect all hospital-based physical therapists. I urge you to review the position paper adopted by our House of Delegates in 1972 pertaining to these standards and the events which have occurred in our negotiations with the Joint Commission on Accreditation of Hospitals. 14 The Joint Commission uses various advisory committees to assist in the development of standards for a variety of hospital-based services and functions. Our particular interest, obvi ously, is with the Physical Medicine Services Advisory Committee. In 1972, this committee of forty-one members comprised twenty-nine physiatrists, eight other physicians, primarily orthopedists, three physical therapists, and one PHYSICAL THERAPY
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referred again to the Council on Medical Education. Some of the comments expressed by individ ual delegates during the discussion on the motion to refer the Essentials back to the Council of Medical Education should be of interest to you. I have no direct knowledge of who made these statements but will leave that to your imagination. One delegate encouraged rejection and cautioned that if the Essentials were to be adopted, they would condone the independent practice of medicine by physical therapists without physician direction and control. 12 Another delegate encouraged refer ral because one Section Council still objected to the proposal, and approval in its present form would probably create the chiropractors of the future. 12 Fortunately, I am coming to the end of a long story. It had to be related to you in some detail in order for you to gain a proper perspective of precisely what the real problems are in this one important area. Representatives from your Association have had further meet ings with instructions from your Board of Directors not to compromise our position further. The proposed Essentials are being reconsidered this week by AMA's House of Delegates. If I were to speculate on the outcome, I would wager that the revised Essentials will be referred back again, or if they are approved, it will be with certain conditions unacceptable to us. If this occurs, I am certain that all negotia tions with the AMA pertaining to our Essentials will cease and that we will actively seek alternative methods for the accreditation of our educational programs. I am confident that physical therapists will continue to be educated in this country by physical therapists in a manner which best meets the demands required of them in practice. I further believe that our educational programs will be accredited by a responsible accrediting agency. I wish to thank all those in our Association who have worked so diligently and so long to develop revised standards for judging the quality of our educational programs. An enor mous task has been completed and will make subsequent revisions of these standards a much easier process. I must also acknowledge those in the AMA who have made every effort to be
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accomplishment and with the impression that after almost twenty years of fruitless negotia tions, we were on the threshold of achieving our objectives. I was obviously lulled into a false sense of security, for subsequent draft documents of proposed revised standards re flected no substantive change in the areas of critical concern to us. I am firmly convinced that until such time that our profession has a determining voice in the development of these standards, nothing will occur to improve our current position. Your Board of Directors has viewed this issue as one of highest priority because the facts of the situation do not support the standards in their current form. Here are some of the facts for you and others to consider. In 1973, there were 7,123 hospitals registered by the American Hospital Associa tion. 15 Of these hospitals, 6,549 reported their statistical data in 1973, and 69.8 percent indicated that they had established physical therapy departments. In round numbers, ap proximately 4,500 departments of physical therapy exist in our nation's hospitals. The development of physical therapy programs has increased dramatically in the past twenty-five years and has more than doubled in community hospitals during this same period. 15 Who has been responsible for providing these physical therapy services? Who will be respon sible for providing the future manpower needs? One must examine critically the source of this manpower. In 1964, we had 1,631 students enrolled in approved educational programs for physical therapists and, in 1973, 4,061 students were similarly enrolled. It is projected that we will have 8,000 students enrolled in approved educational programs by 1980. 6 In contrast, the number of residency programs in physical medicine and rehabilitation in 1964 was 86, with 192 physicians enrolled, and in 1973 the number of programs decreased to 69, and although 478 positions were offered only 368 were filled. Currently, approximately 875 physiatrists are certified by the American Academy of Physical Medicine and Rehabilitation. Various conclusions and interpretations can be drawn from these statistics. The most obvious is that in addition to providing the manpower, our profession is also providing the direction for most of our nation's hospital physical therapy departments. Another obvious 1205
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occupational therapist. It is important for all of you to know that the APTA has never had any official representatives on this advisory com mittee. Since 1955, our Association has attempted to effect change in these standards as they relate to physical therapy services. We have contended that the standards do not reflect the manner in which physical therapy services are delivered in our nation's hospitals. Further more, the standards are not in compliance with existing APTA standards of physical therapy practice. Following the dissemination of our position paper, members of our Association were invited to attend a Physical Medicine Services Advisory Committee meeting to discuss our position. Those who attended this meeting were not there in any official capacity. The bases for our objections to the existing standards were expressed by your representa tives and were no different from those enun ciated previously by our Association. We objected to physical therapy services being re ferred to as physical medicine services. Physical medicine is a medical specialty and to include the services we render under that heading means, by inference, that physical therapy services are subsumed by one medical specialty group. In actual practice, our referrals emanate predominately from physicians who are not specialists in physical medicine and rehabilita tion. We further objected to any standard which interposes a secondary physician be tween the referring practitioner and the phys ical therapy service. At the conclusion of this meeting, there appeared to be general agreement that our conditions would be met. Truthfully, I came away from that meeting with a feeling of
RELATIONS WITH GOVERNMENT
The third and last issue which I will touch on only briefly concerns our relationships with government. This problem will not be a simple one to resolve since some rather fundamental issues are at stake. No one can deny that government has a justifiable interest in how funds are expended to support governmental programs, nor should we be willing to support imprudent use of our tax dollars. Evidence to support the fact that government has been rather inconsistent in its concerns for spending our taxes wisely is abundant. 16 When government became aware of abuses in the Medicare program, Congressional investiga tions followed. One needs only to read the testimony before investigating committees to
The
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The time has long since passed for this Association to avoid con fronting some of the unpleasant realities which surround us.
recognize that to some degree all facets of the health care industry were implicated. 1 7 We, as other professions, had a few unscrupulous practitioners. The actions taken by government to remedy the identified abuses of health care services in the Medicare Program were not uniformly nor consistently applied to all con cerned. Instead, the services of some allied health professions, namely physical therapy when provided under arrangement, were singled out and disproportionate and punitive correc tive actions were taken against these individ uals. When one considers that less than 1 percent of the total program costs for Medicare are attributable to physical therapy services, the action is difficult to explain, especially if the government's only purpose was cost contain ment. Even though elements of our profession have been waging a fierce battle to combat this issue, we appear to be losing. This is indeed regret table, for with this loss we shall lose a measure of professional respect and our rights to self-determination. The concepts embodied in Public Law 92-603, Section 251(c), of the Social Security Amendments of 1972 are totally contradictory to the freedoms we in America have enjoyed. Your Association's legal counsel contends that the regulations, as written, violate the equal protection guarantee of the Fifth Amendment of our Constitution. Forces at work in this country pressing for social reform in health care obviously do not agree with this contention. This difference of opinion, I am positive, will ultimately be decided by the highest court of the land. I have truthfully searched for reasons why these discriminatory actions were taken against one segment of our profession. I suspect, even though I have no tangible evidence to support PHYSICAL THERAPY
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conclusion, I would say, is that the majority of hospitals accredited by the Joint Commission are not in compliance with their existing Physical Medicine Services Standards. Why, then, does the Joint Commission persist in clinging to unrealistic standards for hospitalbased physical therapy services? The answer is clear. It is because we have been denied a representative voice in the development of accurate standards and criteria to judge the services we render. Your Executive Committee is now in the process of exploring new approaches to remedy this long-standing problem. Fundamental to any approach will be the necessity to convince the Joint Commission that physical therapists must be assured of meaningful input into the process of developing standards which involve our services. This will require strong and decisive actions on our part because much is at stake for our profession.
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It is high time that practition ers concern themselves with issues involving the education of physi cal therapists and that educators become involved with those issues facing practice. THE CHALLENGE
In discussing some of our present concerns, I have attempted to relate the facts as I know them to be in simple direct terms lest there be any misunderstanding of what I have said. The time has long since passed for this Association to avoid confronting some of the unpleasant realities which surround us. From its beginning, this profession has faced numerous adversities and crises. I believe, and I think you would agree, that we have earned our rights to self-determination. We must not despair or become apathetic during these difficult times. I know we all truly believe that physical therapy is a most necessary and worthwhile profession. We must now demon strate to all concerned that we will make every effort to defend this belief. Even though we are an Association of almost 25 thousand members, we cannot afford to dilute the full impact of our efforts in resolving the issues which confront us. It is high time that practitioners concern themselves with issues involving the education of physical therapists and that educators become involved with those issues facing practice. Without each other we cannot exist; therefore, I urge that we all work together for the common cause of physical therapy. These efforts will require courageous and loyal support of every member of this Association because, to some degree, the professional future of each of us hangs in the balance. It is my firm belief that we in this Association have the ability to find solutions to what have appeared to be insoluble problems. It is urgent that all of us unify as never before since our profession will only be what we will it to be. 1207
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this supposition, that the long-range plan conceived by certain government bureaucracies is to place ceilings on the earning power of all health professionals. Nevertheless, I can posi tively identify for you two actions which might have influenced the existing legislation. In June 1968, AMA's House of Delegates adopted a resolution calling attention to the dangers of any contractual agreements which removed the services of paramedical personnel from the supervision of the physician. 18 Following the adoption of this resolution, the Board of Governors of the Academy of Physical Medi cine and Rehabilitation issued a statement supposedly in support of this resolution but directed at physical therapists working in contractual relationships with health care pro viders. In substance this statement warned of the various evils of such arrangements, and members of the academy were urged to use their influence in obtaining legislation to counteract such paramedical arrangements. As I indicated earlier, the solutions to counteract government's discriminatory actions against a segment of our profession will not be achieved easily. A single association of our size will have a difficult time mustering the neces sary resources to resolve these issues. Since government seems to be testing some of its theories and focusing its interest in the area of allied health professions, these professions could reasonably unite in an attempt to overcome these constraining influences. Our Association is, in fact, a member of the Coalition of Independent Health Professions. This organization is currently composed of eleven health professions and includes such groups as nursing, medical technology, die tetics, optometry, occupational therapy, speech and hearing, and social work. The coalition represents almost one-half million health pro fessionals. Coincidentally, our own executive director is the current chairman of this group. This organization, properly directed, appears to possess the resources and influence to see that allied health professionals receive fair represen tation in the areas of health education and practice. A coalition, such as this, could serve as a vehicle to work effectively with government and others involved in health care decision making.
1. Kolb ME: The challenge of success. Phys Ther 46:1157-1164, 1966 2. Michels E: The 1969 presidential address. Phys Ther 49:1191-1200, 1969 3. Decker R: A hard look. Phys Ther 46:1165-1171, 1966 4. Los Angeles Times. April 27, 1975, p 9 5. American Physical Therapy Association: Code of Ethics and Guide for Professional Conduct. Washington, American Physical Therapy Associa tion, 1973 6. American Physical Therapy Association: Division of Educational Affairs. Washington, American Physical Therapy Association 7. Allied medical education—1973 annual report. JAMA 226:966-67, 1971 8. American Physical Therapy Association: Board of Directors Minutes. Washington, American Physical Therapy Association, February 1973, pp 5-6 9. American Medical Association: House of Dele gates. Chicago, American Medical Association, June 1974 10. American Medical Association: Clinical Electroneuromyographic Examinations—Resolution 52, House of Delegates. Chicago, American Medical Association, 1973
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11. American Medical Association: Clinical Electroneuromyographic Examinations—Resolution 52 as amended, House of Delegates. Chicago, American Medical Association, 1973 12. American Medical Association: House of Dele gates. Chicago, American Medical Association, December 1974 13. Joint Commission on Accreditation of Hospitals: Standards for Accreditation of Hospitals. Chicago, Joint Commission on Accreditation of Hospitals, October 1969, pp 98-100 14. American Physical Therapy Association: APTA Position Paper on JCAH Standards. Progress Report, July 1972 15. American Hospital Association: Hospital Statis tics. Chicago, American Hospital Association, 1974 16. Los Angeles Times. December 26, 1974, p 1 17. Hearings, Subcommittee on Medicare-Medicaid of the Committee on Finance. United States Senate, Ninety-First Congress, Second Session, Part 2 of 2 parts, April, May, June 1970 18. American Medical Association: Utilization of Paramedical Personnel by Physicians: Resolution, House of Delegates. Chicago, American Medical Association, June 1968
PHYSICAL THERAPY
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REFERENCES
Exactly twenty-five years ago, just a few miles from this city of Anaheim, California, I began my career as a physical therapist. This day, therefore, has special significance for me since it represents the culmination of twentyfive years of continuous involvement in the practice of physical therapy and with the American Physical Therapy Association. I will always be grateful for both of these oppor tunities since I view this parallel involvement as equal and necessary means to achieve a full measure of personal and professional satisfac tion and service. It is highly rewarding to me personally, as it must be to you, to witness the phenomenal growth of physical therapy as a profession. This
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progress has been especially dramatic these past twenty-five years. When I search for compari sons of things as they were twenty-five years ago and as they are today, it becomes evident that little remains the same. This is especially true of the physical changes which surround our lives and which oftentimes occur with little or no influence on our part. These changes are usually easily recognized. If someone were to suggest that I have the same physical appear ance I had twenty-five years ago, I would be alarmed about his powers of clinical observa tion. Yes, much has changed in the past quarter century. But my intent is not to dwell on the subject of physical change. Rather, I would like to address myself to those elements of change which have occurred in our thinking, in our attitudes, and in our behavior as physical therapists and to what degree we have been successful in modifying the thinking of others whose influence affects our professional growth and development. I would like to call to your attention three critical issues which have acted as roadblocks to an even more rapid development of our profession. Our inability to influence the rigid attitudes and opinions of those who wish to assume control of our professional destiny has been and continues to be a source of serious concern to us. This fact has been recognized and spoken to by recent Association presidents in similar addresses and by other esteemed leaders in our profession. 1 ' 2 My fear is that those who follow me may still have to speak to the same issues. That should concern all of us. Ruby Decker, in 1199
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The 1975 Presidential Address
profession.
her 1966 Mary McMillan Lecture, said: "Wait ing with a purpose is patience. It is dawdling when there is no evidence of fulfillment of purpose, and we have waited too long." 3 We have been dawdling, and no purpose will be served in waiting any longer for the changes we deem necessary to ensure our continued growth as a profession. The changes we seek will only happen if we make them happen. To achieve our goals, we must consider realistic alternatives in our approaches for new solu tions. I refer specifically to three major concerns: first, we have not yet gained approval from the American Medical Association of our "Essentials of an Accredited Educational Pro gram for the Physical Therapist"; second, we have been unable to influence the Joint Commission on Accreditation of Hospitals in the development of physical therapy standards which realistically reflect the mainstream of physical therapy services in our nation's hos pitals, and finally, we have not stopped the escalating encroachment of government into the practice of physical therapy. As we search for reasons for our apparent failures in prevailing in these three areas, we must first examine critically our own attitudes and behaviors. In my opinion, we must accept some of the blame for our inability to influence the bureaucracies concerned with these matters. We have not always demonstrated the courage of our convictions in defending those tenets we deem essential to our development as a profession. Neither have we truly recognized the important role we have played and will continue to play in the total scheme of health care. Consequently, we have not consistently negotiated with others from a standpoint of strength. In the past twenty-five years, I can recall only a few actions on our part that have
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demonstrated with finality that we were willing to go to the wall on an issue. Among these was our formal withdrawal from the American Registry of Physical Therapists in 1961. As we look at ourselves as a profession, we must ask if we are a truly unified group. Or are we a group of individuals only concerned with issues which affect our own individual spheres of interest and professional involvement? Evi dence suggests that we are a somewhat frag mented group. We seem to have great difficulty in recognizing that any issue which affects one special interest group has a potential impact on all our members. But the source of many of our problems is not totally related to our own shortcomings. Forces outside this Association have had a restraining influence upon us. Some have suggested that "organized medicine" is respon sible for many of our problems. One would have difficulty in describing just what organized medicine means in this country. At one time the term was synonymous with the American Medical Association; such is not the case today. For at least five years the AMA has represented less than 50 percent of this nation's medical doctors. 4 That there is political unrest within this organization and increasing dissatisfaction among its membership is public knowledge. This situation is unfortunate indeed since I sincerely believe that the AMA should represent the majority of physicians in this country. Of particular concern to APTA, however, is whether an organization which evidently is not being responsive to its own members' needs can be responsive to ours. To my knowledge, only a small fraction of the medical community has been guilty of suggesting that physical therapy is opposed to medicine and that medicine is opposed to physical therapy. The circumstances which
We have not always demon strated the courage of our convic tions in defending those tenets we deem essential to our develop ment as a profession. PHYSICAL THERAPY
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No purpose will be served in waiting any longer for the changes we deem necessary to ensure our continued growth as a
surround this issue are so bewildering that they seem unreal. Without medicine there can be no physical therapy. To oppose medicine would be to oppose physical therapy. Our unwillingness to identify openly and confront directly the elements of one medical specialty group which has opposed the advancement of physical therapy education and practice has to a great degree delayed the solutions to many of our problems. It is neither my purpose nor within my purview to speak against the concept of Physical Medicine and Rehabilitation as a medical specialty or to speak against any other of the many specialties in medicine. Each has a specific purpose in the total scheme of health care as we know it today. The degree to which medical specialties are successful will be greatly dependent upon the need for their services as well as on the quality of those services. These factors can be judged by other referring physicians and by patients who use these services. When I speak in opposition to certain actions taken by those in the specialty of Physical Medicine and Rehabilitation, there fore, I do so only within the context of that specialty's attempt to exert control over our profession. I am certain that the majority of physical therapists in this country enjoy excellent professional relationships with physicians, and I am equally certain that many physical thera pists have similar relationships with physiatrists. I fear, however, that some physiatrists have created considerable confusion about the re spective roles they and we should assume in the delivery of physical therapy services. To suggest that some 320,000 physicians in this country share the same concerns about the roles and functions of physical therapists as those expressed by some physiatrists is a distortion of the truth. The majority of
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physicians we serve in this country are pri marily interested in our ability to provide ethical and effective physical therapy services to their patients. Some members of this specialty feel threatened by certain actions of our profession and respond in an unconstructive and repressive manner. They overreact to those things we are doing in education and practice or to those things we wish to do. In so doing, they make every conceivable effort to convince their medical colleagues that physical therapists wish to practice or are practicing medicine. Nothing incurs the wrath of physi cians more than the suggestion that a nonphysician is attempting to practice medicine. The fact that our practice is subjected to stringent controls as delineated in our Code of Ethics, our Guide for Professional Conduct, 5 and various state licensing laws, and that we abide by these rules is somehow brushed aside. Even more unfortunate is the fact that leader ship in medicine has failed to properly investi gate these baseless accusations and to dispose of them. This failure will continue to cause serious problems for both of our professions in several areas. ACCREDITATION OF PHYSICAL THERAPY EDUCATIONAL PROGRAMS
First, let me cite the effects on physical therapy education. The events which have occurred in the accreditation of our basic educational programs are well documented in the archives of this Association. We started, in 1926, with full responsibility for the accredita tion of our educational programs. We suc cumbed to a combination of financial and certain physician pressures, however, and re linquished this important professional responsi-
Our firm belief is that physical therapy educational programs must be administered by physi cal therapists who are expert in the field of education. 1201
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The collaborative accreditation process has presented numerous problems for our Association since its inception.
I am confident that physical therapists will continue to be edu cated in this country by physical therapists in a manner which best meets the demands required of them in practice. 1202
Accrediting in 1968 for recognition as the official accrediting agency for physical therapy education. Action on this petition was deferred pending the outcome of conferences between the Council on Medical Education and our Association. The petition was further delayed until completion of the "Study of Accredita tion of Selected Health Educational Programs." The proposals of this commission were rejected by the AMA's Board of Trustees. Our petition was never acted upon by the National Commis sion on Accrediting because it appeared that progress was being made in our negotiations with the AMA. In 1972, the United States Commissioner of Education notified AMA's Council on Medical Education of deficiencies in compliance with the United States Office of Education's "Crite ria for Nationally Recognized Accrediting Agencies and Associations." The commissioner granted renewal of recognition for one year, even though the maximum period could have been four years. Discussions between the Council on Medical Education and the APTA ensued to identify areas of mutual concern. One of the primary concerns was the fact that the Essentials had not been revised since 1955. Our Association made every attempt to pre serve and build upon elements in the existing accreditation process to the end that collabora tion would be mutually acceptable to both the AMA and APTA. In 1973, our Board of Directors outlined various proposals which represented a realistic alternative to the still pending request to the National Commission on Accrediting to be recognized as the sole accrediting agency for physical therapy educa tion. 8 These conditions were accepted by AMA's Council on Medical Education, and our "Standards for Basic Education in Physical Therapy [Essentials]" were adopted by our House of Delegates in June 1973. These standards were then submitted to AMA's Council on Medical Education for its review. The Council sent the proposed revised stand ards back to us with suggestions from its Advisory Committee on Education for the Allied Health Professions and Services. Our Association willingly agreed to the suggested changes and once again (June 1964) our House of Delegates approved the Essentials PHYSICAL THERAPY
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bility to the AMA's Council on Medical Education in 1936. In a review of the historical events which have occurred in this process, a statement written in 1955 is significant: "After four years of intensive study and discussion by the Council on Medical Education, the AMA's Council on Physical Medicine and Rehabilita tion, the American Physical Therapy Associa tion, and the Council of Physical Therapy School Directors, a compromise revision of the 'Essentials of an Acceptable School of Physical Therapy' was adopted by the American Medical Association's House of Delegates." 6 I will use the term Essentials frequently in this portion of my address and I wish to make it clear that the Essentials are minimum standards for approval of our educational programs by the AMA in collaboration with the APT A. 7 In 1960, we embarked on a collaborative process of accreditation with AMA's Council on Medical Education. This arrangement exists today. The collaborative accreditation process has presented numerous problems for our Association since its inception. What should be significant to us is the fact that the AMA does not accredit the educational programs of all allied health professions. Ex cluded are such professions as nursing, phar macy, speech and hearing, dietetics, and social work. For the most part, these professions are accredited by their own peers and recognized by the United States Office of Education and the National Commission on Accrediting. After years of disappointment with the collaborative accreditation process, our Associa tion petitioned the National Commission on
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The cornerstone of any profes sion must be firmly established on a sound foundation of theoretical knowledge. Any attempt to un dermine or weaken that founda tion is unacceptable to our pro fession.
state licensing boards of medicine and allied health fields. This resolution was significantly modified by the AMA's Reference Committee. The net effect of this change was that the responsibility for persons who should perform electromyographic examination rests within the jurisdiction of each State Board of Medical Examiners. 11 Even though these arguments failed to demonstrate to us any substantial reasons for rejecting the Essentials, subsequent negotiations were held with the Council on Medical Educa tion and various Section Council representa tives. The purpose of these meetings was to attempt to resolve our differences before the next House of Delegates meeting of the AMA which was to be held in early December 1974. The items discussed and their relevancy to the Essentials are too numerous to list; in my opinion, they represented nothing more than stalling tactics spearheaded by the Section Council on Physical Medicine and Rehabilita tion and they were reminiscent of our 1955 negotiations. Further concessions were made by our Association. At AMA's House of Delegates meeting in early December 1974, our revised Essentials were once again submitted for ap proval. The AMA's Reference Committee held open hearings on them, and all interested parties except one spoke in favor of approval. The dissenting voice came from one representa tive from the Section Council on Physical Medicine and Rehabilitation who raised certain legal questions about our Essentials. The Refer ence Committee had no other recourse but to seek legal advice, and the Essentials were 1203
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as revised. The same document was approved by the Council on Medical Education of the AMA and submitted to AMA's House of Delegates in June 1974. The document, how ever, was rejected once again. I would like to comment on some of the reasons given for the defeat of the Essentials. The proposed revisions, it was claimed, repre sented a major departure from the previous Essentials—those in effect since 1955—and the revisions had not received widespread circula tion. 9 The first portion of the contention is accurate and it should be evident to all concerned with this process that much has changed in physical therapy education in the past twenty years. A statement from the Journal of the American Medical Association in the "Allied Medical Education—1973 Report" reads as follows: "One of the primary responsi bilities of the Committee on Standards is to ensure that the 'Essentials' reflect the needs of a changing society." 7 Our standards as pro posed reflected that kind of change. Another expressed concern was that the proposed Essentials did not require physician guidance and direction of the program. 9 Our firm belief, and a belief we can defend, is that the directorship of physical therapy educational programs must be administered by physical therapists who are expert in the field of education. A third contention was that no mention was made in the Essentials regarding the limitations in the practice of physical therapy. 9 This contention has no basis since the limitations in the practice of physical therapy are regulated by individual state licensing laws and should not be identified with our Essentials. The last major reason for denying approval had to do with the fact that some of our curricula include instruction in electromyo graphic testing procedures. 9 Curiously enough, this technique is not even mentioned in the revised Essentials. In 1973, the Section Council on Physical Medicine and Rehabilitation pre sented a resolution to AMA's Reference Com mittee on this subject. 10 The resolution in its original form prohibited the performance of electromyographic examinations by nonphysicians and specified that the resolution should be distributed by the AMA to all third party providers of health care as well as individual
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The Standards for Accredita tion of Hospitals do not reflect the manner in which physical therapy services are delivered in our na tion 3 s hospitals.
cooperative and helpful to our Association in this endeavor. Perhaps some of you will feel that I have dwelled on the subject of education too long. May I assure you my reasons are valid. The cornerstone of any profession must be firmly established on a sound foundation of theo retical knowledge. Any attempt to undermine or weaken that foundation is unacceptable to our profession. STANDARDS FOR ACCREDITATION OF HOSPITALS
Those in the practice of physical therapy also face other serious problems. The second area to which I now turn could have a scenario as long and labored as the one just described, but time does not permit me to go into great detail. I am sure you will recognize that only the stage is different; the players are the same. One of the critical concerns of physical therapy practice that I would like to discuss is the Standards for Accreditation of Hospitals as developed by the Joint Commission on Accredi tation of Hospitals. 1 3 These standards affect all hospital-based physical therapists. I urge you to review the position paper adopted by our House of Delegates in 1972 pertaining to these standards and the events which have occurred in our negotiations with the Joint Commission on Accreditation of Hospitals. 14 The Joint Commission uses various advisory committees to assist in the development of standards for a variety of hospital-based services and functions. Our particular interest, obvi ously, is with the Physical Medicine Services Advisory Committee. In 1972, this committee of forty-one members comprised twenty-nine physiatrists, eight other physicians, primarily orthopedists, three physical therapists, and one PHYSICAL THERAPY
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referred again to the Council on Medical Education. Some of the comments expressed by individ ual delegates during the discussion on the motion to refer the Essentials back to the Council of Medical Education should be of interest to you. I have no direct knowledge of who made these statements but will leave that to your imagination. One delegate encouraged rejection and cautioned that if the Essentials were to be adopted, they would condone the independent practice of medicine by physical therapists without physician direction and control. 12 Another delegate encouraged refer ral because one Section Council still objected to the proposal, and approval in its present form would probably create the chiropractors of the future. 12 Fortunately, I am coming to the end of a long story. It had to be related to you in some detail in order for you to gain a proper perspective of precisely what the real problems are in this one important area. Representatives from your Association have had further meet ings with instructions from your Board of Directors not to compromise our position further. The proposed Essentials are being reconsidered this week by AMA's House of Delegates. If I were to speculate on the outcome, I would wager that the revised Essentials will be referred back again, or if they are approved, it will be with certain conditions unacceptable to us. If this occurs, I am certain that all negotia tions with the AMA pertaining to our Essentials will cease and that we will actively seek alternative methods for the accreditation of our educational programs. I am confident that physical therapists will continue to be educated in this country by physical therapists in a manner which best meets the demands required of them in practice. I further believe that our educational programs will be accredited by a responsible accrediting agency. I wish to thank all those in our Association who have worked so diligently and so long to develop revised standards for judging the quality of our educational programs. An enor mous task has been completed and will make subsequent revisions of these standards a much easier process. I must also acknowledge those in the AMA who have made every effort to be
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accomplishment and with the impression that after almost twenty years of fruitless negotia tions, we were on the threshold of achieving our objectives. I was obviously lulled into a false sense of security, for subsequent draft documents of proposed revised standards re flected no substantive change in the areas of critical concern to us. I am firmly convinced that until such time that our profession has a determining voice in the development of these standards, nothing will occur to improve our current position. Your Board of Directors has viewed this issue as one of highest priority because the facts of the situation do not support the standards in their current form. Here are some of the facts for you and others to consider. In 1973, there were 7,123 hospitals registered by the American Hospital Associa tion. 15 Of these hospitals, 6,549 reported their statistical data in 1973, and 69.8 percent indicated that they had established physical therapy departments. In round numbers, ap proximately 4,500 departments of physical therapy exist in our nation's hospitals. The development of physical therapy programs has increased dramatically in the past twenty-five years and has more than doubled in community hospitals during this same period. 15 Who has been responsible for providing these physical therapy services? Who will be respon sible for providing the future manpower needs? One must examine critically the source of this manpower. In 1964, we had 1,631 students enrolled in approved educational programs for physical therapists and, in 1973, 4,061 students were similarly enrolled. It is projected that we will have 8,000 students enrolled in approved educational programs by 1980. 6 In contrast, the number of residency programs in physical medicine and rehabilitation in 1964 was 86, with 192 physicians enrolled, and in 1973 the number of programs decreased to 69, and although 478 positions were offered only 368 were filled. Currently, approximately 875 physiatrists are certified by the American Academy of Physical Medicine and Rehabilitation. Various conclusions and interpretations can be drawn from these statistics. The most obvious is that in addition to providing the manpower, our profession is also providing the direction for most of our nation's hospital physical therapy departments. Another obvious 1205
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occupational therapist. It is important for all of you to know that the APTA has never had any official representatives on this advisory com mittee. Since 1955, our Association has attempted to effect change in these standards as they relate to physical therapy services. We have contended that the standards do not reflect the manner in which physical therapy services are delivered in our nation's hospitals. Further more, the standards are not in compliance with existing APTA standards of physical therapy practice. Following the dissemination of our position paper, members of our Association were invited to attend a Physical Medicine Services Advisory Committee meeting to discuss our position. Those who attended this meeting were not there in any official capacity. The bases for our objections to the existing standards were expressed by your representa tives and were no different from those enun ciated previously by our Association. We objected to physical therapy services being re ferred to as physical medicine services. Physical medicine is a medical specialty and to include the services we render under that heading means, by inference, that physical therapy services are subsumed by one medical specialty group. In actual practice, our referrals emanate predominately from physicians who are not specialists in physical medicine and rehabilita tion. We further objected to any standard which interposes a secondary physician be tween the referring practitioner and the phys ical therapy service. At the conclusion of this meeting, there appeared to be general agreement that our conditions would be met. Truthfully, I came away from that meeting with a feeling of
RELATIONS WITH GOVERNMENT
The third and last issue which I will touch on only briefly concerns our relationships with government. This problem will not be a simple one to resolve since some rather fundamental issues are at stake. No one can deny that government has a justifiable interest in how funds are expended to support governmental programs, nor should we be willing to support imprudent use of our tax dollars. Evidence to support the fact that government has been rather inconsistent in its concerns for spending our taxes wisely is abundant. 16 When government became aware of abuses in the Medicare program, Congressional investiga tions followed. One needs only to read the testimony before investigating committees to
The
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The time has long since passed for this Association to avoid con fronting some of the unpleasant realities which surround us.
recognize that to some degree all facets of the health care industry were implicated. 1 7 We, as other professions, had a few unscrupulous practitioners. The actions taken by government to remedy the identified abuses of health care services in the Medicare Program were not uniformly nor consistently applied to all con cerned. Instead, the services of some allied health professions, namely physical therapy when provided under arrangement, were singled out and disproportionate and punitive correc tive actions were taken against these individ uals. When one considers that less than 1 percent of the total program costs for Medicare are attributable to physical therapy services, the action is difficult to explain, especially if the government's only purpose was cost contain ment. Even though elements of our profession have been waging a fierce battle to combat this issue, we appear to be losing. This is indeed regret table, for with this loss we shall lose a measure of professional respect and our rights to self-determination. The concepts embodied in Public Law 92-603, Section 251(c), of the Social Security Amendments of 1972 are totally contradictory to the freedoms we in America have enjoyed. Your Association's legal counsel contends that the regulations, as written, violate the equal protection guarantee of the Fifth Amendment of our Constitution. Forces at work in this country pressing for social reform in health care obviously do not agree with this contention. This difference of opinion, I am positive, will ultimately be decided by the highest court of the land. I have truthfully searched for reasons why these discriminatory actions were taken against one segment of our profession. I suspect, even though I have no tangible evidence to support PHYSICAL THERAPY
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conclusion, I would say, is that the majority of hospitals accredited by the Joint Commission are not in compliance with their existing Physical Medicine Services Standards. Why, then, does the Joint Commission persist in clinging to unrealistic standards for hospitalbased physical therapy services? The answer is clear. It is because we have been denied a representative voice in the development of accurate standards and criteria to judge the services we render. Your Executive Committee is now in the process of exploring new approaches to remedy this long-standing problem. Fundamental to any approach will be the necessity to convince the Joint Commission that physical therapists must be assured of meaningful input into the process of developing standards which involve our services. This will require strong and decisive actions on our part because much is at stake for our profession.
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It is high time that practition ers concern themselves with issues involving the education of physi cal therapists and that educators become involved with those issues facing practice. THE CHALLENGE
In discussing some of our present concerns, I have attempted to relate the facts as I know them to be in simple direct terms lest there be any misunderstanding of what I have said. The time has long since passed for this Association to avoid confronting some of the unpleasant realities which surround us. From its beginning, this profession has faced numerous adversities and crises. I believe, and I think you would agree, that we have earned our rights to self-determination. We must not despair or become apathetic during these difficult times. I know we all truly believe that physical therapy is a most necessary and worthwhile profession. We must now demon strate to all concerned that we will make every effort to defend this belief. Even though we are an Association of almost 25 thousand members, we cannot afford to dilute the full impact of our efforts in resolving the issues which confront us. It is high time that practitioners concern themselves with issues involving the education of physical therapists and that educators become involved with those issues facing practice. Without each other we cannot exist; therefore, I urge that we all work together for the common cause of physical therapy. These efforts will require courageous and loyal support of every member of this Association because, to some degree, the professional future of each of us hangs in the balance. It is my firm belief that we in this Association have the ability to find solutions to what have appeared to be insoluble problems. It is urgent that all of us unify as never before since our profession will only be what we will it to be. 1207
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this supposition, that the long-range plan conceived by certain government bureaucracies is to place ceilings on the earning power of all health professionals. Nevertheless, I can posi tively identify for you two actions which might have influenced the existing legislation. In June 1968, AMA's House of Delegates adopted a resolution calling attention to the dangers of any contractual agreements which removed the services of paramedical personnel from the supervision of the physician. 18 Following the adoption of this resolution, the Board of Governors of the Academy of Physical Medi cine and Rehabilitation issued a statement supposedly in support of this resolution but directed at physical therapists working in contractual relationships with health care pro viders. In substance this statement warned of the various evils of such arrangements, and members of the academy were urged to use their influence in obtaining legislation to counteract such paramedical arrangements. As I indicated earlier, the solutions to counteract government's discriminatory actions against a segment of our profession will not be achieved easily. A single association of our size will have a difficult time mustering the neces sary resources to resolve these issues. Since government seems to be testing some of its theories and focusing its interest in the area of allied health professions, these professions could reasonably unite in an attempt to overcome these constraining influences. Our Association is, in fact, a member of the Coalition of Independent Health Professions. This organization is currently composed of eleven health professions and includes such groups as nursing, medical technology, die tetics, optometry, occupational therapy, speech and hearing, and social work. The coalition represents almost one-half million health pro fessionals. Coincidentally, our own executive director is the current chairman of this group. This organization, properly directed, appears to possess the resources and influence to see that allied health professionals receive fair represen tation in the areas of health education and practice. A coalition, such as this, could serve as a vehicle to work effectively with government and others involved in health care decision making.
1. Kolb ME: The challenge of success. Phys Ther 46:1157-1164, 1966 2. Michels E: The 1969 presidential address. Phys Ther 49:1191-1200, 1969 3. Decker R: A hard look. Phys Ther 46:1165-1171, 1966 4. Los Angeles Times. April 27, 1975, p 9 5. American Physical Therapy Association: Code of Ethics and Guide for Professional Conduct. Washington, American Physical Therapy Associa tion, 1973 6. American Physical Therapy Association: Division of Educational Affairs. Washington, American Physical Therapy Association 7. Allied medical education—1973 annual report. JAMA 226:966-67, 1971 8. American Physical Therapy Association: Board of Directors Minutes. Washington, American Physical Therapy Association, February 1973, pp 5-6 9. American Medical Association: House of Dele gates. Chicago, American Medical Association, June 1974 10. American Medical Association: Clinical Electroneuromyographic Examinations—Resolution 52, House of Delegates. Chicago, American Medical Association, 1973
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11. American Medical Association: Clinical Electroneuromyographic Examinations—Resolution 52 as amended, House of Delegates. Chicago, American Medical Association, 1973 12. American Medical Association: House of Dele gates. Chicago, American Medical Association, December 1974 13. Joint Commission on Accreditation of Hospitals: Standards for Accreditation of Hospitals. Chicago, Joint Commission on Accreditation of Hospitals, October 1969, pp 98-100 14. American Physical Therapy Association: APTA Position Paper on JCAH Standards. Progress Report, July 1972 15. American Hospital Association: Hospital Statis tics. Chicago, American Hospital Association, 1974 16. Los Angeles Times. December 26, 1974, p 1 17. Hearings, Subcommittee on Medicare-Medicaid of the Committee on Finance. United States Senate, Ninety-First Congress, Second Session, Part 2 of 2 parts, April, May, June 1970 18. American Medical Association: Utilization of Paramedical Personnel by Physicians: Resolution, House of Delegates. Chicago, American Medical Association, June 1968
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REFERENCES
