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Keep Your Hands

Image Courtesy: https://www.flickr.com/photos/xlordashx/
Image Courtesy: https://www.flickr.com/photos/xlordashx/

A Hand Raised in Concern

At the 2014 APTA Combined Sections Meeting in Las Vegas, during the Orthopaedic Section membership meeting, Dr. Catherine Patla stood up and expressed a notion to the Section’s Board of Directors. She was concerned physical therapists were giving away their hands (she also expressed a similar concern to the AAOMPT Executive at AAOMPT 2014). After over a year of consideration and contemplation, I have to agree. We are in the midst of a silent crisis of physical therapy scope of practice!

Motivated by Dr. Patla’s observations and concerns, I began keeping unofficial (and admittedly unscientific score) of students in my musculoskeletal programs and how their clinicals handled, well, the hand. Conservatively, about 50% of the students reports that they were expressly forbidden by clinic policy to treat hands, elbows, and to a lesser degree, shoulders. Concernedly, the distal upper extremity appears to be the land of the OT.

This is a complicated situation.

A Handsomely Negative Impact

From a profession-wide perspective, there’s not much that can easily be done to counteract clinic-level policies. Certainly, both Occupational Therapy and Physical Therapy are qualified to perform rehabilitation to distal upper extremity injuries. Furthermore, I think the ultimate care pathway, for many injuries common to the area, involves both professions. I’ve not actually met a member of either profession who thinks differently (or at least admitted as such), yet the policies exist.

This trend has potential long-term, and wide implications. From my perspective as Director of the Kaiser Hayward Physical Therapy Fellowship in Advanced Manual Therapy, this increases the challenge to train fellows, who by decree, must have experience treating and managing patients with distal upper extremity diagnoses. Outside of residency/fellowship training, new professionals may exist without ever getting to see a hand patient in some clinics/regions! Over time, the collective knowledge of physical therapists will be diluted and will atrophy. Soon no one will be left to TEACH the hand. At my previous University, it was common practice for the senior orthopaedic PT faculty to contract an OT to come in and teach the hand to DPT students. This was a constant and disappointing source of stress for me. What message does this send! We could literally be voluntarily cleaving off an important scope of our practice! The irony is, it’s the body region most important to how we treat! It’s decidedly more difficult to be a PT if you don’t have hands.

The Hand Rehabilitation Section

I don’t know any more than a couple people in the Hand Rehab Section of the APTA. Perhaps that’s my issue. Perhaps it’s because the Section itself is a bit of an anomaly. Of the 18 Sections within the APTA, it’s the only one designated by an anatomical focus. The other sections are delineated by practice areas like Orthopaedic or Neurologic, settings like Home Health, Acute Care, or Aquatics, or related professional activities like Research, Education, and Federal Advocacy. Arguably, the Women’s Health section is anatomically focused, but in fact it’s not, since Women’s Health is more broad than a pelvic floor and I think “The Vagina Section” would offer some terribly difficult search engine optimization challenges! I do not know the history of how the Hand was excised from the rest of the Orthopaedic Section and would love to learn.

All that criticism on name/organization aspects aside, you have to also argue that the Hand Section is doing the best it can with the membership audience it has (~472 members and 36 Facebook likes). It offered an outstanding selection of programming at this years CSM Meeting in Indianapolis. Everything from a high-profile lecture including ESPN’s Stephania Bell, to a comprehensive clinical reasoning model for TFCC management by Brenda Boucher and Pieter Kroon was offered. Notably, the Hand Rehab Section also offered two pre-conference courses and presented the results for projects for 3 different clinical practice guidelines: carpal tunnel, distal radius fractures, and lateral epicondyalgia. Yet, while all this is taking place, other PT’s seem more than happy to give up the hand and let someone else manage it. Let some other PROFESSION manage it.

Hands are for Holding

To me, this boils down to a grassroots effort, and is an issue of personal responsibility as a professional. You cannot in good conscious, let your clinic enforce and carry out a policy that prohibits, or through practice, eliminates the opportunity to treat any body region, especially the hand. We all know the outcry when outside professions claim a technique is only their purview, and attempts are made to remove that from our practice. Physical therapists rise up in a collaborative rage and claim it back. Yet, I see malaise and laziness, and an acceptance of insufficient knowledge as a behavior pattern among physical therapists in these clinics. That may seem harsh, but I can’t see it any other way.

My one caveat, and an important one at that, is that some hand injuries do require a very experienced hand specialist. Hand tendon surgical repairs quickly surpass entry-level practice. There is an insufficient numbers of physical therapists trained Certified Hand Therapists. In fact, I have only encountered one PT who holds the dual acclaim of Fellow of the Academy of Orthopaedic Manual Physical Therapists AND is a Certified Hand Therapist: the aforementioned, Dr. Boucher, who hails from Texas State University and teaches as part of the Manual Therapy Institute’s manual therapy fellowship program.

There are pathways, and opportunities that can happen, and I’ll outline my suggestions in just a moment, but this boils down to each and every physical therapy professional deciding to hold onto hands. It’s up to YOU!

Getting a Grip on this Problem

By all means, this is just a suggestion, but we need to start somewhere and why not now? Please comment, edit, innovate, or ACT on this:

  • Hand Rehab education should be led by physical therapists as often as possible in DPT programs.
  • Individual PT’s in clinics with hand-prohibitive policies should challenge these, and reach out to professional advocates like those in the Hand Rehab Section for assistance if needed.
  • Consideration of upper extremity policies in DPT Clinical Education should occur.
  • Joint clinical practice guidelines should be developed by OT’s and PT’s collaborating as authors.
  • Increased visibility and ultimately membership in the Hand Rehab Section. 36 Facebook likes is not going to cut it. 472 members is difficult to defend.
  • Development of post-professional pathways for Hand/Wrist/Elbow instruction including residencies, fellowships, and some stake in the Certified Hand Therapist credential.
  • Consideration of how the Hand Section can further collaborate with the Orthopaedic Section (absorbed by the Ortho Section?) and AAOMPT to further their collective mission.
  • Wide APTA support for these endeavors, including resources for training training, pathways for expertise, research, and advocacy.

Thanks for listening. Thanks for thinking. Thanks in advance for taking the challenge to not let this problem get any worse!

 

 

 

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#DPTStudent Chat January 28th at 9PM EST: Choosing the Right PT School & Welcoming @MarkyKev!

It’s about that time when acceptances are coming in for DPT-to-be’s across the country! If you’re lucky enough to have garnered multiple acceptances, you’re probably working hard to figure out what school is right for you. How much should location matter? Is a higher cost ever justified and in what situations? How do different programs set up their clinical affiliations? Do different programs focus more heavily on different settings?

We’ll discuss these questions and more on Wednesday, January 28, 2015 at 9PM EST! If you’re a current #DPTstudent please join us & add input about why you chose your program! Follow & use the #DPTStudent hashtag to participate.

In other news, we are sad to announce that Laura Webb (@lauralwebb) has finished her time as a moderator of the #DPTstudent chat. She is onto bigger & better things as she nears graduation and we are grateful for her enormous contributions to our team! The good news is we are happy to announce that Mark Kev (@MarkyKev) has agreed to join the team. He is an integral part of the #DPTstudent community and we are excited to have him on board.

More about Mark:

“Greetings everyone, my name is Mark; almost everyone calls me Mark Kev. I’m a second year physical therapy student at The Richard Stockton College of New Jersey (which will soon become a university sometime soon I believe), a Certified Strength and Conditioning Specialist (CSCS) through the National Strength and Conditioning Association (NSCA) and also a Level 1 Sports Performance Coach through USA Weightlifting (USAW-1). I’m a baseball lover, bourbon aficionado #BourbonPT and a lifter of all things heavy. My endeavor into the #DPTstudent world on Twitter just so happened by chance. At the time, I was applying to schools and connected with prospective/current students which lead me to stumble upon the chat. I’ve been hooked ever since participating in my first chat. I’ve been fortunate enough network with some amazing people, both students and professionals alike and even had the opportunity to meet some of them in person – one of my goals is to meet and hang out with all you cool people! I’m excited to be part of the #DPTstudent moderator team and I look forward to all great adventures to come. “

As a reminder, you can request that we cover certain topics by emailed DPTchat@gmail.com!

Jocelyn Wallace, SPT (@Jocelyn_SPT)
Tyler Tracy, SPT (@TylerTracy10)
#DPTStudent Chat Moderators

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#DPTstudent chat for January 14, 2015

Hello and happy New Year, #DPTstudent chatters!

As the spring semester begins, we’re addressing practice-relevant topics you will need to know once your start your clinical rotations and begin interviewing for PT jobs!

To get things started, we’ll be talking with Mark Dwyer (@MarkDwyer87), for some quick tips on administrative aspects of PT practice.

This discussion will teach you how to:
–Spot fraud and abuse
–Appropriately bill for Medicare patients
–Clarify an organization’s labor practices in job interviews (productivity, use of techs, etc.)
–Choose the best CPT codes for your interventions
…and much more!

Do you have questions related to PT billing, administration, etc? This is your chance to ask an expert! Tweet us your questions using #DPTstudent, then tune in at 8pm CST on Wednesday January 14 to hear your answers LIVE during our YouTube broadcast.

See you then!
#DPTstudent
@LauraLWebb, @Jocelyn_SPT, @TylerTracy10

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Better: Performance and Change Through Positive Deviance

Atul Gawande, MD, MPH is a surgeon, writer, and researcher who provides genuine insights into the challenging complexities of medicine. But, he also creates novel solutions like check lists in operating rooms. Dr. Gawande connects reflection on personal experience, processes from other fields, and scientific research into insightful narratives that outline the rationale and concrete action needed for improvement. He contends problems in healthcare are not necessarily conceptual, but rather stem from poor processes. There is a lack of knowledge translation and application. In his book Better: A surgeon’s notes on performance, he explores the science of performance and specific high performing individuals.  At the end, he outlines general advice for improvement. Atul Gawande’s suggestions for becoming a positive deviant:

1. Ask an unscripted question

Ours is a job of talking to strangers. Why not learn something about them? On the surface, this seems easy enough. Then your new patient arrives. You still have three others to see…But consider, at an appropriate point, taking a moment with your patient. Make yourself ask an unscripted question. So ask a random question of the medical assistant…a nurse you into on rounds…you start to remember the people you see, instead of letting them all blur together. And sometimes you discover the unexpected. If you ask a question, the machine begins to feel less like a machine.

2. Don’t complain

We all know what it feels like to be tired and beaten down. Yet nothing in medicine is more dispiriting than hearing doctors complain. Medicine is a trying profession, but less because of the difficulties of disease than because of the difficulties of having to work with other human beings under circumstances only partly in one’s control…You don’t have to be sunny about everything. Just be prepared with something else to discuss: an idea you read about, an interesting problem…

3. Count something

Regardless of what one ultimately does in medicine–or outside medicine, for that matter–one should be a scientist in this world. In the simplest terms, this means on should count something.

4. Write something

It makes no difference whether you write five paragraphs for a blog, a paper for a professional journal, or a poem for a reading group. Just write. What you write need not achieve perfection. It need only add some small observation about your world. You should not underestimate the effect of your contribution, however modest.

5. Change

Look for the opportunity to change. I am not saying you should embrace every new trend that comes along. But be willing to recognize the inadequacies in what you do and to seek out solutions. As successful as medicine is, it remains replete with uncertainties and failure

Simple, applicable, and needed suggestions.

To be sure, we need innovations to expand our knowledge and therapies, whether for CF [Cystic Fibrosis] or childhood lymphoma or heart disease or any of the other countless way sin which the human body fails. but we have not effectively used the abilities science has already given us. And we have not made remotely adequate efforts to change that. When we’ve made a science of performance, however–as we’ve seen with hand washing, wounded soldiers, child delivery–thousands of lives have been saved. Indeed, the scientific effort to improve performance in medicine–an effort that at present gets only a miniscule portion of scientific budgets–can arguably save more lives in the next decade than bench science, more lives than research on the genome, stem cell therapy, cancer vaccines, and all the other laboratory work we hear about in the news. The stakes could not be higher.

More specifically to physical therapy within the realm of healthcare, two of the most profound, if not obvious, examples are the “treatment” of musculoskeletal conditions (pain) and the mobilization of hospitalized adults. The knowledge is present to dramatically improve both. Societally, there is dire need for more movement, whether activity or exercise, in healthy individuals as well as older adults, those with chronic medical conditions, and cardiac & pulmonary disease. Again, the knowledge is there. But, are the processes and incentives for performance available? How can physical therapy as a profession and each of us as individuals move forward to enact meaningful change? Atul comments:

True success in medicine is not easy. It requires will, attention to detail, and creativity. But the lesson I took from India was that it is possible anywhere and by anyone. I can imagine few places with more difficult conditions. Yet astonishing successes could be found. And each one began, I noticed, remarkably simply: with a readiness to recognize problems and a determination to remedy them.

Arriving at meaningful solutions is an inevitably slow and difficult process. Nonetheless, what I saw was: better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.

Ask questions. Sideline complaints without solutions. Count things. Write. Change.

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Assessing and Integrating the Evidence

Are we teaching it backwards? Without understanding premise or argument validity in relation to research, an individual article analyses may be useless. A study may be flawed on premise alone even with strong methodology and statistically significant results. A valid argument is false. And, inappropriate conclusions will be drawn. Likely, this will lead to misguided justifications and explanations. Such errors can affect clinical practice, education, and future research.

Plenty of systems and check lists exists for systematically evaluating the quality of an individual study including it’s design and methodology. The PEDro scale  (PEDro Website), The Consort Statement, 25 Item Checklist, Checklist for Qualitative Analysis, PRISMA for Systematic Reviews and Meta-analyses, and other Critical Appraisal Checklists all guide and contribute to appropriate analysis. But, a critical review should not only critique the rigor of the inquiry and accuracy of the conclusions, but also, and maybe more importantly, assess the study’s plausibility in context of the whole of current scientific understanding.

What does this tell us? What can it tell us given the design? What doesn’t it tell us? Too often scientific research, clinical and otherwise, is interpreted too broadly and thus inaccurately. It’s one of the major flaws of popular “pop” science journalism: over reaching conclusions. The sensational headlines touting miracle cures and “bad” foods that cause cancer. But, even a narrow lens of assessment focused only the specific study may lead to improper understanding. Outside of a purely methodological critique, an article analysis can not, must not, be done in isolation.  The current state of the literature on the topic specifically, in conjunction with basic science generally, must be taken into account.

Is this plausible?

Plausibility must not only take into account previous clinical research and outcomes studies (efficacy and effectiveness), but also basic science and current mechanistic research. Such an approach prevents reinforcing an unlikely or inaccurate explanatory model despite positive outcomes. Unfortunately, physical therapy is likely plagued by positive outcome studies misinterpreted, and thus explicitly or implicitly, supporting a theoretical construct that is (may be) invalid. One example, more specifically, is the variance in explanatory models of manual therapy effect.

What are my beliefs? Biases? Preferred treatment constructs and approaches?

An overlooked area of assessment is ourselves. The person doing the analyzing. It’s imperative that the critical lens of analysis be pointed back upon its user. Rarely will an orthopedic manual physical therapist postulate that manual therapy does not work.  The very best may ponder if the mechanisms are completely outside the current understanding. A physical therapist practicing in an ICU rarely questions the effectiveness of movement and mobility. But, clinicians and researchers should strive to rigorously falsify via the scientific method in order to focus accuracy and understanding over time. Physical therapists are inherently, and understandably, focused on the specifics of treatment that appear most important. What exercise? What technique? What works? Yet, the scientific rigor, and uncomfortable thought, of attempting to prove physical therapy does not work will lead to more specific knowledge on why it does work and the potential attainable outcomes. Seems contradictory, but falsifiability is the basic tenant of hypothesis testing in science. So, ask yourself: what would it take to change my mind? It’s time for some serious critical thinking.

Points to Ponder

  • Hypothesis & Null Hypothesis
  • Plausibility of Hypothesis based on previous research and overall knowledge
  • Methods Critique (utilize checklists)
  • Efficacy vs. Effectiveness Design
  • What is the comparison or control group?
  • Are these groups similar in abstract variables such as frequency, duration, and one on one time?
  • Believability of the comparison or placebo by patient?
  • What the results can tell us given study design
  • What the results can NOT tell us given the study design
  • Plausibility of results from author’s interpretation
  • Plausibility of theoretical model presented or utilized
  • Plausibility of the discussion & conclusion  in relation to understanding on the topic specifically
  • Plausibility based on basic science, physics, mechanics, including tissue mechanics, physiology, psychology
  • How else could the results be explained? Placebo? Regression to the mean? Different mechanisms?
  • Did the authors make the appropriate conclusion?
  • What’s YOUR conclusion and understanding?
  • Overall summary and critique
  • How and why to integrate?

What is the take away?

“That’s valid,” you say, but what do you mean by that? A single statement can be valid by itself if it is a previously proven “truth”, but what about an argument? You remember arguments, right? Premise, premise, therefore conclusion? Funny thing about valid arguments, they have nothing to do directly with truth. Arguments can be valid and false at the same time, just as they can be invalid and true at the same time. What?

Since deductive arguments are the basis of all research, you need to understand this concept. I have quoted before on a podcast, “A flawed study is still a flawed study regardless of p-value or level of evidence. – Erik Meira, When a valid argument can be false

The complications continue. Concepts such as placebo, non-specific effects, nocebo, incentives, behavioral psychology, decision making, logical fallacies, cognitive biases, and epidemiology all play vital roles in not only which treatments we (should) utilize, but how they (may) work. In addition to clinical and scientific research, the understanding of the how’s and why’s of decisions in clinical practice rest upon these concepts (by jennifer). Given where trials of physical therapy interventions are published it’s imperative to read outside the physical therapy specific literature. Research in psychology and behavior assists in a deeper understanding of the importance of the entire treatment encounter in addition to how clinicians make decisions within a treatment encounter.

It is reflective and complex decision-making that integrates all sources of evidence that we should be having serious conversations about, and its that thoughtfulness [PDF] that is required of a doctoring profession – not the myopic and obtuse yes or no to the question: “Are you evidence based?” – Jason Silvernail, DPT, DSc

So, stop volleying RCTs back and forth in an evidence ping pong match, and begin integrating knowledge. The information from seemingly unrelated fields contain insights that can result in true evolution in our understanding of clinical practice. Surprisingly, even many of the randomized control trials of physical therapy interventions are not published in physical therapy specific journals. Ponder how  the “evidence base” should be selected.

We rarely believe we are ignorant, but could we be wrong?

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Should we all do the same thing? Perceivable vs. Conceptual Practice Variation

Conceptual variation is more damaging, and a bigger issue, than perceivable, apparent practice variation. Because of the multi-faceted nature of the mechanisms of effect in physical therapy treatments, especially for pain, striving for observable decreases in “practice variation” may not actually solve many of the issues within the profession. The real problem is conceptual differences. The stark contrast between explanatory models, and stories told, results in significant variance in explanation and education received by patients. Patients are still routinely told they have “bad” posture, an SI joint that is “out” and weakness causing their painful problems. Such unhelpful and debunked ideas are the unnecessary imaging of our profession.

Words matter. The stories we tell patients, and those we tell ourselves. It appears that in medicine generally, and orthopedics specifically, the language utilized by clinicians affect not only patient’s understanding, but perceptions including pain, disability, function, and quality of life. Beliefs are powerful. So, why do we keep beating around the bush? There is a remarkable range in treatment paradigms, potential mechanisms, and explanations on why things (appear to) “work.”

Now, to be fair, striving for a decrease in practice variation within physical therapy is a worthwhile endeavor. However, I am not convinced current conceptualizations are the appropriate approach. Assessing variation in medical treatments and practice is likely easier than in physical therapy practice. Why? It’s more concrete. Medical treatment relies heavily on the appropriate diagnosis of essential, or substantial diagnoses. Treatment follows, and is mostly dependent on proper diagnosis. Thus, analysis of timely proper diagnosis, matching of treatment and diagnosis, and actual treatment content is more concrete to study. For physical therapy, a different construct is required. The complexities of the clinical encounter and individual nature of the therapeutic process in conjunction with the many potential and identified mechanisms of treatment effect complicate the study of variance. Striving for utilization of the exact same interventions is likely to be a surface level success. It appears like progress. Therapists are dealing with many nominal diagnoses and messy concepts such as unexplained symptoms, function, and behavior change. (note: medical diagnosis is still very complex and full of challenges)

Specificity should be sought after, but not assumed. As more is understood about the effects of interventions it is becoming apparent that techniques, exercises, and interventions themselves are not as specific as originally assumed. If observably clinicians appear to have no practice variation, but utilize different conceptual frameworks and tell the patient in front of them different stories, gross variation is actually still present. Utilization of similar constructs may result in similar “outcomes,” but with significantly different “interventions.” So, what are the common factors?

Regardless of setting, physical therapists should strive for the most accurate deep models of practice, validated and efficient processes in conjunction with an individualized, assessment based, response dependent approach. The best clinical research evidence should be incorporated. This will lead to less practice variation, you just might not be able to see it. Observational variation in interventions may not actually represent difference in concepts. Conversely, two clinicians may perform exactly the same “interventions” with marked disagreements in conceptual framework, reasoning, patient interaction, and patient education. Maybe the method is not the trick? Maybe the process is as important as the product? It’s high time for the accountable practitioner. That means metacognition, critical thinking, and science based practice. Simple…now only if it were easy.

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It’s all in the incentives

An incentive is something that motivates an individual to perform an action.

And, that something could be anything. Meet the omnipresent influencer of behavior. Frequently, incentive is understood to be associated with some form of monetary compensation for specific behavior. But, incentives are not merely monetary. And, they exhibit influence. Yes. Always. 100% of the time. In any environment, any scenario, any interaction, and every decision including clinical encounters. Incentives can be viewed as any tangible or intangible reinforcement, and thus influencer, of behavior. Theses “rewards” range from monetary to personal, concrete to cognitive-emotional. And interestingly, incentives still affect behavior even when individuals consciously identify and recognize their presence. They are social, contextual, or even cultural. And, they impact decisions and performance.

Incentives are present in a variety of forms and contexts. Most generally, incentives can be assessed via a variety of binary comparisons including: Explicit verses Implicit, Reward verses Punishment, Short verses Long Term, and Immediate verses Delayed. Yet, the content of incentives range from monetary to verbal, and in contexts of private and public. The environment, including people, specific location, and context of the situation, in conjunction with broader constructs such as expectation and culture also matter.

Physician’s prescribing habits are affected by pharmaceutical marketing. Prescribing is affected by the gifts, no matter how menial, of pharmaceutical companies. This effect is observed even if physicians believe the gifts have no bearing on their prescription decisions. The data and incentives lead the Office of the Inspector General to research gifts and payments that promote prescription drugs. In this instance, physicians are Prescribing Under the Influence:

This kind of advertising is crucial to sales. A doctor is not going to prescribe something he or she has never heard of, and it’s the drug representative’s job to get the products’ names in front of the physicians. Maybe the drug representative does that while the resident is slathering cream cheese on a bagel; maybe it’s while the intern is saying, “Oh, what’s this cute little stuffed bear?” Either way, the doctor stops and spends a moment.
In private practice, the little gifts are often even more important. If you’re a drug representative, physicians are usually not interested in talking to you unless you have something to catch their attention. Then you can get your three sentences in: “We’ve got such and such on the hospital’s formulary now.” Or “The new form of this drug can be given once a day instead of four times a day. The patients will love it.” It’s a way to get in the door so that your information rather than somebody else’s reaches the doctor’s brain.

Self-referral, or referral for profit, is associated with increased utilization of lab tests, imaging, and physical therapy. A meta-analysis revealed a 2.48 combined relative increased frequency of referral in refer for profit scenarios. In most cases, I truly believe physicians are not sitting in front of patients actively scheming on how to justify an imaging procedure, lab test, or referral to physical therapy in order to maximize profit. On the whole, I don’t assume the physicians in these scenarios are unethical and overtly over prescribing. But, the incentive is present, and thus behavior is altered. The evidence shows that self-referral invariably leads to higher utilization and higher costs.

What are specific incentives within the profession of physical therapy? What should be modified? Everyday outcome measures are handed to patients, clinical measurements made, and assessments written. What are patients and incentivized to say and do? Or, believe? Administrators, managers, and clinic directors in hospitals and private clinics present data to their staff. Specific metrics are identified and goals are constructed.

Recognizing the development of interaction between personal and environmental (including social, societal, cultural) influences on behavior illustrates the complexity of how, when, and why we behave in certain ways. In healthcare, the layers of systems and hierarchy of influence is complicated. Our decisions and behavior are not nearly as rationale, nor conscious, as they feel to us personally. The interplay of personal, inter-personal, and environmental influences coupled with tangible or perceived rewards influences how people act. In conjunction with individual motivation, incentives, both seen and unseen, are determinants of who will thrive in certain educational and clinical contexts. One such example is the difference between extrinsic and intrinsic motivation. What people do is just as complex as why people think they do it. And, there is a disconnect, a blind spot, between our perception of bias in ourselves verses others.

Unfortunately, incentives have unintended consequences. The cobra effect is an illustration that “incentives don’t always work out the way we expect them to.” Beyond identifying a target metric and outcome, it’s imperative to identify the actual behaviors that are desired. Sometimes a change in a specific measurement (productivity, patient report outcomes, etc) do not necessarily reflect the desired behavior changes. In particular, research investigating payment incentives and subsequent clinician behavior within healthcare illustrate tangible manifestations of “unintended consequences.”

How is the outpatient therapist incentivized if measured and assessed primarily via patient report questionnaires? How are we changing behavior in the acute care therapist by assessing them based on the number of “units” they “bill?” What about the outpatient therapist who receives a bonus based upon units billed? What if changes in the metrics we are utilizing don’t truly illustrate significant change, don’t result in the best care, and don’t reinforce ideal behavior? A health services research article on medicare payment comments:

While some payment methods may lead to excessive utilization, other payment methods may put too much pressure on cost containment and potentially lead to underprovision of resident care (Coburn et al. 1993; Cohen and Spector 1996; Murtaugh et al. 1988)

In addition to tracking specific measures, ideal behaviors need to be identified. To account for unintended consequences broadly identify various behaviors likely to lead to the measured goals. Sometimes behaviors that are actually not desired can cause significant desirable change in target measures. Undesirable action for desired outcome. So, what behaviors can cause a change in the metric? And, what contributes to encouraging such behaviors? But, also, what incentivizes behaviors that change the metric, but may also cause unintended consequences?

If a clinic, hospital, profession, or health care system seeks to fundamentally alter care delivery robust assessment of the current incentives within healthcare, including conflicts of interest is mandatory. Then change the incentives to affect and encourage ideal clinician behavior. A successful approach likely involves a combination of incentivizing important outcomes as well as specific behaviors. Changing the single data point does not necessarily reflect the desired overall change in other measurements or behavior. The depth of affect of incentives in conjunction with unintended consequences illustrate the difficulty in controlling change. A seemingly brilliant idea such as “pay for performance” or outcomes based payment is fatally flawed without a conscientious focus on the many potential behaviors that may result in the specific outcome. Might it even be chaos?

What are the incentives? Identify the answers and then target behaviors requiring alteration. Shift behaviors towards ideal processes. Ideal behaviors will likely have positive unintended consequences. A myopic focus on only the desired numeric change will produce a myriad of potentially paths to “success.” Some of these paths were never the intended action of success. And in fact, may be the opposite of the incentive’s initial philosophical goal.

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The Right Call. APTA Public Relations Removes Questionable Podcast

A few days ago Move Forward, the APTA’s consumer targeted website, posted a podcast. The premise was inaccurate, and the conclusions appeared potentially damaging for patients and the general public. I posted a link to the original Facebook post with a brief statement of my disagreement. Via Twitter and Facebook other physical therapists expressed their disappointment with podcast.

@SandyHiltonPT expresses her disagreement
@SandyHiltonPT expresses her disagreement

 

Historically, Move Forward has published accurate and useful information for patients and consumers including a podcast with Joe Brence and John Ware on Understanding Pain, a post 9 Things You Should Know About Pain, and publicity regarding Choosing Wisely: 5 Things PT’s and Patients Should Question. Yesterday afternoon, Jason Bellamy APTA’s director of web and new media, removed the podcast from the Move Forward website as well as deleted all related Facebook posts.

 

APTA_Remove

I commend the decisive action by Jason and the APTA. I agree with decision. And further, I’m encouraged by their ability to respond to informal feedback via the conversations occurring on social media. Personally, I participated in a panel at #CSM2014 The Value of Using Twitter for Branding Yourself and the Profession, and was highly impressed with Jason’s commitment to engagement. Jason stressed that he and others at the APTA are “listening” to the conversations, discussions, and informal feedback ocurring in the realm of social medical (even if just lurking). But, he also encouraged members to actively contact the APTA with suggestions, feedback, and insight. They want to hear from concerned members. And, apparently, they are willing to act on those intentions.

The APTA listens, so speak up. Becoming a member is a start. Using your voice is next. What do you have to say?

Feedback? E-mail consumer@apta.org
Feedback? E-mail consumer@apta.org
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#DPTstudent chat for Wednesday, December 3: Rehab during the Holidays

Now that the holiday season is in full swing, we may notice our patients experiencing holiday-related stress and busier schedules that compromise their ability to stay committed to healthy lifestyles. How do you address this in your clinic to keep patients moving towards their goals? What fun promotions or #bizPT specials do you offer patients during the holidays? How do you address holiday employee scheduling? We’ll discuss these topics and more during our next #DPTstudent chat on Wednesday, December 3rd at 8pm EST! See you there.

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Do you need to care to be caring? Sympathy, Empathy, Compassion, and Caring in Healthcare

What I couldn’t say – but wanted to – was the truth: I don’t care.

Seriously. I don’t. I can’t.

Keith P states “I don’t care.” And, I think he’s right. A certain type of detachment from the potential suffering and emotional struggles of patients is vital for a clinician. The ability to assess, analyze, and make proper decisions may be clouded if those treating are overly emotionally involved in the circumstances of those they treat. Further, shouldering the burden of the many unfortunate clinical, emotional, and social situations encountered within healthcare can easily leave one with a sense of hopelessness. It’s quite easy to succumb to pessimism and apathy when the grand scale of suffering, inequality, and just plain bad luck occupy the beds and treatment tables daily. But, is this ideal for patient interaction? What do patients prefer? Establishing and enhancing alliance, rapport, and an environment of care is necessary. An explicit connection with the patient is a precursor to, or maybe even the foundation of, the therapeutic process. Too far to one extreme and the risk is burnout. Too far to the other and the risk is a cold, distant clinician (and still burnout). As in anything, explicitly defining terms and concepts is helpful.

Definitions and Terms

Sympathy, empathy, compassion, and caring are connected concepts, but have differing definitions. And, specifically within healthcare these concepts require more specific exploration. While various, and vague, characterizations of sympathy exist within and outside of healthcare, for the sake of clarity sympathy generally centers around an emotional state of feeling. It can manifest as pity or sorrow for another, a common feeling, or a relationship in which that which affects one mutually affects the other. The simplest definition is entering into or sharing the feelings of another. Empathy, by contrast, is characterized by identification and understanding. But, empathy has been sub-characterized into two, or even three, separate conceptualizations: emotional (or affective), cognitive, and compassionate empathy. To complicate matters, compassion itself is an awareness of suffering of another and a desire to act in order to relieve it. Therefore, compassion is best understood as an action, or potential action. This desire and subsequent action may stem from both rationale and emotional sources.

Healthcare & Empathy: Emotional vs. Cognitive vs. Compassionate

Daneil Goleman briefly outlines and discusses the three (potentially) separate kinds of empathy. Empathy is founded upon understanding and identification which may include projecting ourselves (hypothetically) into another’s situations. And, it can happen emotionally and/or cognitively. Emotional empathy is the ability of a person to feel a similar emotion as another (which confusingly can be accomplished cognitively). Although this appears to mirror sympathy, sympathy is a sharing of emotion, or emotional state, feeling along with another. In contrast, cognitive empathy relates to recognizing, understanding, or even appreciating a person’s feelings. To be fair, the definitions of sympathy and empathy as well as cognitive verses emotional empathy appear to overlap. It seems they are, at times, used interchangeably. Specifically to healthcare, empathy is “a cognitive attribute that involves the ability to understand the patient’s inner experiences and perspective and a capability to communicate this understanding,” Many in healthcare education recognize IQ and didactic skill are only a portion of the ideal clinician equation. The ability to understand and perform within the above constructs relates to emotional intelligence. And, “…empathy, as defined here, must be included in the curriculum. It is a powerful communication tool that enables a clinician to clearly express his or her understanding of another’s suffering while protecting his or her own psychological integrity.”

Do you have to care to be caring in your practice?

A major issue in health care professions generally, but therapy specifically, is mistaking the necessity of cognitive empathy for a requirement to sympathize and feel with patients. Front line clinician burn out is in part due to an understandable inability to sympathize with every patient, and the resulting cold, concrete distance that can result in situations when sympathy is not feasible. Whether clinician fatigue, a need for emotional distance, or carryover from the patient before feeling the emotions, sympathizing, and providing pity to every patient is likely not possible. And, probably not effective. The issue is likely further clouded by a lack of understanding regarding the differences of sympathy and empathy. I don’t ever remember learning about this stuff. But, it’s vital. The concept of objective empathy grossly changed how I approach patient interactions. Patients and practitioners report “compassionate care” is important to successful medical treatment. So, what’s to be done?

The role of the clinical instructor is paramount in helping students to become aware of behaviors that can block empathy. We can no longer simply hope that our students will become mature professionals with compassion and empathy for patients. We must create experiences to develop these attributes, and we must take responsibility for modeling these behaviors and reflecting on them with students, to raise their consciousness about the nature of a mature healing presence.” The art of healing is, in part, made up of a therapeutic use of oneself or a therapeutic presence for patients. This presence is more than knowledge and skill alone; it is also composed of a compassionate understanding of the patient and a communication that the therapist is worthy of the trust that the patient has bestowed. Empathy enhances the therapist’s therapeutic presence and deepens the patient practitioner interactions without fear of losing one’s self in the process. This shared meaning seems to enhance the patient’s process of healing.  Carol Davis, Can Empathy be taugh? PTJ, 1990

To the observer I’m sure it appears I do care, and care deeply. But, in the end Keith, you’re right. I don’t care. And, I don’t need to. Does that mean I never engage with patients on an emotional level? That patient’s circumstances never affect me? That I never feel a connection, or shared emotional states with a patient? Or, a powerful emotional response during the course of treatment? Of course not. It happens. And, that’s OK. But, we don’t need to strive for it. Someone inquired to Keith “I wonder if being detached from our patient makes for a better clinician… Any thoughts?” He responded:

A therapist needs an appropriate amount of attachment for success, but that attachment, I reason, needs to be to a high professional standard of care, not the patient’s outcomes themselves.

You don’t need to sympathize to provide appropriate empathy. You don’t need to care to be caring. You don’t need to feel the emotions of your patients to address the emotions they feel.

When I freed myself from the responsibility for the “outcome” of the clinical encounter, something interesting happened. I freed my patients from blame, also. –Jason Silvernail

It’s important to care, but maybe not in the assumed emotional involved ways. And, I think we should not apologize for claiming not to care. I’m still, I think, a caring clinician. I just don’t make a point of feeling pity for the suffering I encounter. I am passionate, empathetic, and hopefully a thoughtful interactor.

 …an older relative of mine who has cancer is going back and forth to hospitals and rehabilitation centers. I’ve watched him interact with doctors and learned what he thinks of them. He values doctors who take the time to listen to him and develop an understanding of his situation; he benefits from this sort of cognitive empathy. But emotional empathy is more complicated. He gets the most from doctors who don’t feel as he does, who are calm when he is anxious, confident when he is uncertain. And he particularly appreciates certain virtues that have little directly to do with empathy, virtues such as competence, honesty, professionalism, and respect. –Paul Bloom, Against Empathy

We need to be able to treat our patients, all of them, and still function in our own lives. If not, we risk riding the roller coaster of sympathy and pity in clinic at the potential expense of engaging emotionally in our personal lives. It’s a bad outcome all around. Our patients need us to understand, interact, and guide them along the best possible course of recovery. So, whatever we call it, put your pity aside. I’m not sure our patients want it anyway. Be resilient. You don’t need to care to provide compassionate care. Our patients need us to listen, but also to initiate difficult, honest conversations.