Tuesday, February 24, 2015

Can occupational therapists predict the future?

There is ongoing debate on the AOTA forums about move to an entry level doctorate.  Within that debate there is repeated discussion about the 'future.'  I am very interested in the concept that occupational therapists should attempt to 'focus more on what COULD and SHOULD be different for practitioners graduating in the future.'

Prognostication is an interesting endeavor, and I am wondering if this is something that most occupational therapists really have the skill set to accomplish.  I don't believe that there is evidence to support OTs having these skills.

R. Buckmister Fuller, who in my opinion was a tremendously gifted anticipatory design scientist, felt that he had an ability to prognosticate based on his model of integrative systems thinking and on his naval training in navigation and ballistics.  
In his book 'Operating Manual for Spaceship Earth' he explained how some people felt that he was 1000 years ahead of his time, which puzzled him because he did not understand how others thought they could understand events 1000 years into the future when he only felt confident about analyzing 25 year scientific, industrial, and innovation cycles.  As he got older, some people said that he was 'behind the times.'  An analysis of these varying assessments of his ability seems to be a good example that most people have absolutely no ability to prognosticate reliably or to assign time values to future events.

Nonetheless, this does not seem to stop people from thinking that they have the ability to prognosticate.

I thought it would be interesting to look at the accuracy of occupational therapy prognostications - so I would like to refer everyone to the special meeting of the Representative Assembly in 1978 that was held on 11/8 through 11/12 in Scottsdale Arizona.  The purpose of the meeting was to direct the course of the profession for the coming decades and to hear the thoughts of leaders of the profession at that time.  The thoughts of these leaders is encapsulated in a series of lectures that were published under the title Occupational Therapy: 2001 AD.

Several of the authors were so mired down in 1978 concerns that they could not really offer much specificity about the future.  At the time of the conference Wilma West and Alice Jantzen were talking about whether we would be a professional or a technical vocation.  This ended up being such an esoteric concern that by the time 2001 rolled around no one was really discussing it any longer.  

Nedra Gillette suggested that we would require post professional training in order to achieve 'professional' status, but it seems that professional status was conferred more by a robust certification process and state licensing than by conversion to graduate education, which didn't end up happening until 2007.  

Ruth Weimer thought we should develop knowledge in economics so that we could convince others of our value.  I don't know that we accomplished that; today OT persists in many environments by legal mandate and not because it is a 'valued service.'  Jerry Johnson focused mostly on the present failings of the Association and difficulties in responding to member needs.  

Elizabeth Yerxa focused on socialization requirements between what made for a caring and empathetic OT vs. what would be required to seize power and exert control in a professional context.  I think she failed to understand that the future would create a context whereby if someone raised this issue today that they would be accused of genderism.  Gail Fidler took Yerxa's comments and overtly discussed her perspectives on the fact that OT is a female dominated profession.  I can state with confidence that these kinds of conversations would not be openly appreciated in 2001.

Florence Cromwell believed that the proper place for OT would be in helping people with chronic illness.  It seems that she did not see the trends of OTs abandoning mental health, adults with developmental disabilities, and other populations of people with chronic health problems.

Mae Hightower-Vandamm's presentation stood out in that she took very bold positions on what she thought the future would hold.  She thought that AOTA would have 80,000 members in 2001.  She also thought that cities would not be able to handle conferences so there would be regional conference centers where there were no hotels but just modest rooming for attendees and that food would be available in a concentrated capsule form designed to be ingested with a liquid nutrient.  She actually wrote that.

She also believed that OTs would be integral to the unemployment system.  OTs would be available 24 hours a day, in shifts.  She was kind of repeatedly interested in closed circuit TV, thinking that it would be used for education as well as for certification.  Kind of like the Internet, I guess.  She was close on this one.

She thought that OT Aides in hospitals would be 'Quasar Men' and they would be programmed to do all craft preparation, monitor the clinic for safety, clean up, and transportation.


There is not much evidence to consider in analyzing OTs ability to predict future events.  In 1978 there was a concerted effort to plan for 2001, and important leaders at that time were overwhelmed with 1978 issues as opposed to what would be needed in order to move forward.  The primary issues at that time were concerns with professional vs. vocational training, inability to precisely articulate a scope of practice, and other sundry issues such as career laddering for OTAs, dominance of women within the profession, generalist v. specialty practice, and inefficiencies in professional training and in the Association itself.  Most of the OT leaders at that time were skilled in discussing present day concerns.  Most of those concerns were interesting, but few if any of them have ever been fully resolved.  Most of the OT leaders kind of avoided discussing the future even though that was the point of the conference.  Those who did discuss the future were generally off target.

Watching the current AOTA leadership seems similar.  They seem aware of problems (like the structure of the Association) but are not able to mobilize resources to change much.  They seem to be aware of the Affordable Care Act, but focus on primary care models that don't reflect any current realities of practice on a large scale.  They seem to value evidence based models, but can't grasp the reality that pediatric practice is rife with snake oil.  They understand that OTs abandoned mental health, but it is all a little johnny-come-lately.  They understand that there are opportunities for OTs in new areas of practice, but we have an academic faculty that is largely divorced from the clinics.  In sum there is a big focus on articulating current problems, but the solutions constantly fall short of fixing anything.  OTs seem to have skill in articulating present day problems.  OTs just are not skilled in prognosticating the future.

I believe that the status of the profession in 2014 is the same as it was in 1978 - the only difference being that there are different present day concerns on the table.  The French have a saying for this: Plus ca change; plus c'est la meme chose.  Translated, the more things change, the more they stay the same.

I am concerned that we are asking members to plan for the future.  Leaders don't seem to have good ability to plan for the future.  As an example, we are told that we need an entry level doctorate as a single point of entry for the profession.  A lot of ancillary issues about current problems are discussed, but there is no real evidence to support the recommendation.  I previously mentioned that OTs are skilled in chasing trends but not so much in leading change themselves.

For this reason I will place the prediction of this 'need' for entry level doctorates in the same category as the Quasar Man.  It is an interesting idea, loosely sensible on a superficial level, but lacking in any real substance of justification and practicality that is necessary to support its existence.

AOTA (1979). Occupational Therapy: 2001 AD. Papers presented at the special session of the Representative Assembly, November, 1978.  Rockville, MD: AOTA.

Fuller, R.B. (1968). Operating manual for Spaceship Earth, Carbondale: Southern Illinois University Press.

1 comment:

lej said...

Thanks for the history lesson and deep thoughts, Dr. Alterio! It is an interesting idea that our leadership has, about mandating a professional doctorate, and it's even more interesting/saddening to see so many high-quality programs pre-emptively making this change without considering the ramifications on future clients or potential OT students.

Additionally, I feel that it is somewhat ridiculous to ask people to back the idea of a professional doctorate for a profession that continues to be misunderstood, undervalued, and still working to solidify its professional evidence base. I hope the entry-level OTD doesn't come to fruition, but only time will tell!

(Also, I hope that you will write something about the future of OT soon, so we can see how your predictions hold up; I'd love to know just where you think our leadership's current choices are taking us!)