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When to throw in the towel
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When to throw in the towel - April 8, 2004 11:34:00 AM
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MPT
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Joined: April 4, 2004
From: Syracuse, New York
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"Insanity: doing the same thing over and over again and expecting different results"
Albert Einstein-
As a student I remember thinking that many of my clinical instructors were insane based on Einstein's definition. They would do the same treatments over and over on a patient without any results. Or the pt would finally get better but it had been 2-3 months. They probably would have gotten better in three months on their own!
When I finished school I vowed never to do that! The problem I have is knowing when I have given a treatment enough of a try.
I usually feel that if in 3 wks I have not made any significant change then I better change my approach or send the pt along.
Unfortunately, even when I send pts back to their MD's with a note saying (I have done all I can) the MD often sends them back for more! How frustrating
I know it will vary based on chronicity of the condition but any thoughts on how long is too long to try a tx without any results?
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Re: When to throw in the towel - April 8, 2004 12:29:00 PM
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ONDC
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From: canada
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Boy - does this ever ring true! For example, I've been treating (along with a PT from another facility by the way) a nurse with diabetic shoulder for approx 3 months and while we certainly have decreased the discomfort she is in, as well as improved her level of functioning, the three of us agree that it is no where near where we would like her to be, and yet, her MD's advice is to continue treatment. Maybe its my inexperience (2 years), but I get very frustrated when I don't see some kind of change withen a short period of time. It would be interesting to see what some of the more experienced professional have to say.
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Re: When to throw in the towel - April 8, 2004 1:00:00 PM
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Dr.Wagner
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From: Indianapolis
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In cases like this, it is helpful to either 1. have a sub acute exercise/wellness program developed by PT's but executed by ATC's or exercise physiologist 2. if this is not available, dictate a note immediately find out when the patient has an appointment fax it to the physicians office the day of the appointment or have the patient hand deliver the note expressing your plateau in therapy. 3. even better, go to med school and attempt to make a direct change and difference...I felt very frustrated too, so I went back to school to better understand both views, and then make a difference.
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Re: When to throw in the towel - April 8, 2004 10:50:00 PM
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nari
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From: Australia
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It is indeed frustrating, but an opportunity to educate the doctors who keep sending them back; explain the lack of significant outcome/s and end it there by discharging the patient.
I find that many doctors are at a dead end too, and sometimes think of physiotherapy as the last and only resort, in the hope that something, sometime will improve.
We have time limits and work pressures, just as they do, and perhaps they need to understand that better. Sometimes I suggest options, and occasionally that works.
We have to stand by our principles of efficient and valid practice.
Nari
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Re: When to throw in the towel - April 9, 2004 4:37:00 AM
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PTupdate.com
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From: Pittsburgh, PA USA
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No doubt a problem every PT has to deal with. More chronic problems seem to take longer until something kicks in, and I had found in the past that if I really felt I had a grasp on their problem and my program was right, sticking with it usually worked. When HMO's came around, I found I had to speed things up, and with that process came some increased symptoms from throwing too much into the program too soon. But, 10 visits per calendar year is 10 visits, so I better make the most of my time.
I think the only time we ever really see patients getting turfed back to us even when we have indicated "no progress" is when we are dealing with either workers comp or auto claims. They don't get better because there usually isn't anything wrong with them in the first place. The physician wants to keep out of the legal loop by showing he did all he could to help the patient.
Getting to know your physicians one on one helps, because then you can call them to discuss the situation, as opposed to formally writing things down, where you may get held to your words. Remember, as a PT, you don't really have to treat a patient that is not benefiting from the program. After all, it will be you that has to explain to a reviewer why you continued when no gains were being made.
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: When to throw in the towel - April 9, 2004 7:24:00 AM
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IN-PT
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I agree with Duffy that the telephone works well to convey your point without being held to courtroom accountability. Also, if you explain to the patient and/or physician that you believe the maximum therapeutic benefit has been achieved...and you cannot financially justify billing for further skilled intervention - they generally understand they are putting you in a tough position (and if they want to continue treatment - they have the option of paying out-of-pocket...you'll see then if they truly think they've plateaued or not).
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Re: When to throw in the towel - April 9, 2004 9:05:00 AM
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MPT
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From: Syracuse, New York
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[Dr. Wagner] No thanks, I don't want to be an MD. I want to see my pts getting the best and most efficient care. I think MDs (may just be the system) do not always allow me to do that!
I do send my pts to the MD with a note and I often call the MD. Some don't seem open to being educated by a PT (especially a young one)
The option of discharging the pt anyways is always available however; with declining referral sources (mostly due to POPs) I don't want to piss off any of our referral sources!
How long should we treat a pt (without any sig improvement) before we finally say (I can't help you anymore)?
[This message has been edited by MPT (edited April 09, 2004).]
[This message has been edited by MPT (edited April 09, 2004).]
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Re: When to throw in the towel - April 9, 2004 5:49:00 PM
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nari
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From: Australia
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How long should we treat a patient without significant improvement?
I think it rather depends on the patient. If they are keen and motivated, I will persevere for quite a long time, perhaps up to several months, with sessions about 1-2x fortnight. If there is no motivation or compliance, no more than 5-6 sessions.
If education in the first 2-3 sessions fails, then I warn them the next session will be the last.
In the free system, where I work, we are very strict re outcomes, in order to keep the waiting list down. In the private system, patients often come 1-2/week for years.
Even if there are short-term gains (eg just symptomatic pain relief for a few days), I tend to discharge after 6 sessions. We as physios are not, I think, in the business of providing nothing more than temporary relief.
Nari
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Re: When to throw in the towel - April 16, 2004 5:14:00 AM
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Ron
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It is interesting that no one has mentioned the reason for this "common problem"
IMHO I believe it is caused by the fact that all too often we see patients after "everyone and everything" has been done. All of us would be wise to work with the referral source to get the patients to us in an expedient manner. Unfortunately this is not an easy task. I think this is where we need to spend our energy and the reason direct access makes a lot of sense.
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Re: When to throw in the towel - April 16, 2004 7:36:00 AM
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Yogi
Posts: 403
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From: San Antonio, Tx., USA
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I agree with Nari we are or shouldn't be in the business of palliative treatment (the old money cow, hot pack, e-stim, us, ma.). Duffy, you seem rather cynical, no doubt for good reason, but if you don't mind advice, not getting better is sometimes because the etiology is not what it is guessed to be. I worked in a whiplash attorney referred clinic once, we found that lingering back pain meant an untreated SI lesion, and I estimated that to be 20 to 30 percent of the time. Back when Medicare started denying hot packs and whirlpool as solitary treatments, business offices started having pt.'s sign the form saying if payment was denied by medicare, they would pay, that form scared alot of inappropriate therapy referrals off. My hospital wouldn't implement that form because they didn't want to irritate pt.'s and Drs., so I had to ask the Docs to please not send palliative pts. over, unless they just really needed to get them out of their office and hair, and then as a courtesy we'd give them some of the chronic condition therapy. I'm seeing this money cow mentality in home health again, like no one remembers 1998. Anyway, as I was advised during the time I couldn't weed out pts./referrals, and medicare seemed to think my name was Deny, if you're in an untenable situation, get out. You may be in a frustrating position (that goes with the therapy territory), or in untenable one, that's for you to figure out. Not very helpful, is this? It's only to let you know you're not alone.
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Re: When to throw in the towel - April 16, 2004 8:43:00 AM
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Ron
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Yogi, who guessed wrong? The PT or MD, obviously in this case much time is wasted on inappropriate care.
In your example of the "whiplash clinic".
Where these patients seen acutely , or after the MD's and Lawyers "had their way"?
Yes I am a bit testy over this issue, but after 2 nearly 3 decades of practice I continue to see our profession suffer because too many referring entities are too arrogant to refer to those that CAN make a difference.
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Re: When to throw in the towel - April 16, 2004 6:36:00 PM
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nari
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From: Australia
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Ron, I totally agree; we see these patients who have complex problems that could have been prevented, in many cases, if we had seen them earlier.
Far too many doctors see us as 'palliative' after the drugs, resting and referral to surgeons etc has not helped.
But I also say that far too many of us accept the situation. In a private setting, I appreciate that goodwill with doctors is very important; nevertheless, I have seen in these posts over the months, there are PTs who actively educate doctors and at the same time preserve that 'teamwork'goodwill.
It is partly arrogance, and partly ignorance of the phsyiotherapist's role.
The ball is in our court, I believe, for that hurdle.
Nari
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Re: When to throw in the towel - April 20, 2004 7:09:00 AM
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Yogi
Posts: 403
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From: San Antonio, Tx., USA
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MPT, you should be getting alot of knowledge from these great posts. There is just no cookbook answer, but everyone has given you some ingredients to try to mix. Some Drs. are open, some are not, some realize we can help them, some do not. I think the best we can do is to maintain some humility, (PT's can be know-it-alls just like anyone else) and be as competent as we can be, and report what we know or don't know, as well as possible to the referral source and the pt., but with tact, and even tactful can piss some people off. We really do best as a team with physicians (that's for Dr. Wagner), because if we do our job properly, a high percentage (in my opinion) need further medical workup or treatment. That's why direct access actually scares me. I think only an experienced PT with a Clinical Doctorate should have direct access, and hopefully they would have more experience and knowledge to be able to judge, "when to hold'em and when to fold'em" (treat or refer). Ron, yeah it was a hired ex-prison Doc working for a businessman owned clinc marketed to lawyers. And I risked my job sometimes by doing things like telling a pt. "It's not this Dr.'s knee, or your lawyers knee, it's your knee and you need to see an orthopedist". I can be as cynical as anyone due to past experiences, but I always remember that I can not "walk a mile in some one else's moccasins" and the SI illustration was just to show we don't always know it all, because at that time SI Muscle energy was not well-known, so there's always more to learn. Great dialog and comments, I know you've all worked hard and put out effort above and beyond, congratulations SJBird5 on your good physician relations, I know I enjoy it when I have it.
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Re: When to throw in the towel - April 20, 2004 11:34:00 PM
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nari
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From: Australia
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SJBird5
I regret that my statement in my last post was ambiguous - I meant to say that doctors tend to be arrogant with their knowledge and are ignorant about the physiotherapist's role with a patient's condition. Looking back at the sentence, I can see how it could be misconstrued. Nothing could be further from the truth re education of doctors - I am a fervent supporter of the maxim that we can effect a change in medical attitudes by education, and it is something all PTs should be involved with, as many are.
Nari
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Re: When to throw in the towel - April 21, 2004 10:01:00 AM
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Dr.Wagner
Posts: 1242
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From: Indianapolis
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Once again I have to say this...take an active role in the education of Physicians to what PT's know. A PT should go and observe surgeries, stand up to the pimp questions, and then ask informed questions regarding the surgery. Invite the Physician to an open house. Write letters to the Doctor regarding recent continuing education courses. Have PT students demonstrate a case study with a treatment plan to a surgeon over lunch.
Instead of "bitching", actively take part. The problem with PT and MD relationships is that they are very separate, very little communication on either end. Furthermore, there is a huge difference in what a patient tells a therapist and what they tell their doctor. I have seen it on both sides of the fence. I have heard patients bad mouth physical therapy and their therapist when I KNOW they don't do that to the PT in face to face. It is amazing how many patients say "that crap never helped, I could do it at home"...but they never would let the PT know about it...then the Doctor gets a soured opinion of the PT...Unless they know you because you actively take part.
I know you guys are frustrated.
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