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One expert will lead to better care
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One expert will lead to better care - June 22, 2008 9:12:14 PM
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proud
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Bonez`implied in another thread that all this slamming going on here is an indication that we must not have "patient care" in mind.
false.
The current set up of conservative NMSK management is ineffective. Have a look at the statistics involving healthcare extenditure involving this. We have not gotten better at it, we've gotten worse. Chiropractic in my mind, is a poorly regulated crew. PT's are better but require much better self regulation as well( hello all you craniosacral therapists out there).
No other area of healthcare has multiple providers plying to be the primary provider. Dentists, Pharmacists, optomitrists etc.
Why?
Regulation. It's easier to maintain a high professional standard when the public simply knows who is who when it comes to their healthcare needs. As it stands now, it's a free-for-all market with wack jobs and snake-oil salesmen/women convicing the public that they need their sutures mobilized, their innate energy released, or their "knots" rubbed out. All bunk....yet there it is..due to poor regulation.
One expert. It's better for healthcare...it's better for patients.
< Message edited by proud -- June 22, 2008 9:21:37 PM >
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RE: One expert will lead to better care - June 23, 2008 6:49:18 AM
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SJBird55
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Regulation isn't going to solve the problem. We're over-regulated as it is. We don't market ourselves in a manner that is conducive to communicating our strengths.
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RE: One expert will lead to better care - June 23, 2008 9:07:18 AM
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proud
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quote:
ORIGINAL: SJBird55
Regulation isn't going to solve the problem. We're over-regulated as it is. We don't market ourselves in a manner that is conducive to communicating our strengths.
And why do we not market our stengths?
Ask yourself SJ....out of 10 PT's....how many actually practice in a manner consistent with say Sackett's definition of EBM? I'll start....4.
So it's pretty hard to market our strengths when perhaps 60% of the profession is out there zapping people with electrodes, rubbing gel all over a back, mobilizing sutures, and releasing the myofasia.
I jump all over chiropractors for silly practice building techniques that lend itself to increasing levels of disability, yet Physiotherapists are not much better( at least that is my experience in my area).
We have the research available to guide practice effectively. There is no excuse for PT's out there that fail to remain curent and demonstrate a commitment to EBM. That can and should be a regulated aspect of our profession. The college of Physicians and surgeons do it....why are we any different?
I do agree, we have to market our research. That is truly our stength. But it's hard to market that when such a large proportion of Physiotherapists don't even know about CPR's....( it's true, here in canada, I asked a recent grad about them and she had no clue. asked her classmates...no clue.). And I KNOW that most private practices in my area....are simply clueless.
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RE: One expert will lead to better care - June 23, 2008 10:50:27 AM
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SJBird55
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Here in the States, you can't really answer your EBM question. Even if we had access to all the claims for services provided. The code for manual interventions covers both evidence based interventions and non-evidence based interventions. Patients are also not classified and the ICD-9 codes that are used are up for interpretation AND used based on payable services/medically necessary. We do not have a PT classification system to more clearly define the patient in front of us. I have no idea how many therapist follow evidence. I tend to associate with those that practice better than myself or at least communicate with that caliber of a physical therapisti. You are correct that most that I associate with and enjoy emailing and speaking with definitely aren't in my area. Sad, but true.
Maybe if we marketed ourselves in a way that also had pre-defined expectations (don't ask me how), maybe consumers would reduce their expectations of passive care? Maybe patients would become more demanding and desiring the EBM approaches? I don't know.
There isn't an easy way to monitor the minute details of how a licensed physical therapist practices. I don't think there is a regulatory way to monitor behaviors. There could be competency requirements.
The only way for physical therapists to become more homogeneous is for their performance expectations to be monitored and the bar raised for the performance expectations. If they are held accountable to their performance, behaviors might change. I don't believe increasing regulations is the best answer to the problem.
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RE: One expert will lead to better care - June 23, 2008 10:57:11 AM
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proud
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quote:
The only way for physical therapists to become more homogeneous is for their performance expectations to be monitored and the bar raised for the performance expectations. If they are held accountable to their performance, behaviors might change. I don't believe increasing regulations is the best answer to the problem.
Is that not a "form" of regulation?
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RE: One expert will lead to better care - June 23, 2008 11:48:31 AM
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SJBird55
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Not really... could be a measure for quality control done at a departmental level. Regulations are mandatory, auditable and enforceable. I think it would just be better to begin to measure behaviors that matter that translate into better outcomes.
Just to give you something to think about. Last year I implemented a change in processes at my clinic. After every initial evaluation, I wanted a letter mailed WITH the evaluation and plan of care. I decided that the one page "letter" would provide insight into my clinical decision-making by providing just a few research articles to support the anticipated interventions/clinical thoughts. I just analyzed how that process is going. 53.85% of the time I actually have a letter going to the referring physician. That means that 46.15% of the time, I can't easily, readily or succinctly communicate the basis for my clinical decisions. Yes, there are times that I have referrals for unusual diagnoses or multiple co-morbidities OR multiple body parts to be treated (there is no easy way to convey treatment rationale with supporting literature with those situations). 46.15% of the time I don't have solid ground using direct evidence that is easily related to the patient in front of me. I don't know about you, but that means that you could basically flip a coin to determine if there is evidence existing for the patient coming to you. This also means that there is a reasonable percentage of patients that won't be treated with evidence because evidence may not exist.
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RE: One expert will lead to better care - June 23, 2008 12:21:23 PM
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proud
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quote:
46.15% of the time I don't have solid ground using direct evidence that is easily related to the patient in front of me. I don't know about you, but that means that you could basically flip a coin to determine if there is evidence existing for the patient coming to you. This also means that there is a reasonable percentage of patients that won't be treated with evidence because evidence may not exist.
Which would be in tune with the most accepted definition of EBM( in the absence of....clinical expertise).
So I see a world where where our regulatory bodies randomly require said reports you alluded to for a 3-4 month period. They are cross referenced for the norm of an evidence based practioner. If it appears suspect...a site visit is performed.
By the way, I did the same thing you did and found that about 60% of what I do can be directly supported by the evidence.
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RE: One expert will lead to better care - June 23, 2008 12:28:59 PM
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proud
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quote:
46.15% of the time I don't have solid ground using direct evidence that is easily related to the patient in front of me. I don't know about you, but that means that you could basically flip a coin to determine if there is evidence existing for the patient coming to you. This also means that there is a reasonable percentage of patients that won't be treated with evidence because evidence may not exist.
Which would be in tune with the most accepted definition of EBM( in the absence of....clinical expertise).
So I see a world where where our regulatory bodies randomly require said reports you alluded to for a 3-4 month period. They are cross referenced for the norm of an evidence based practioner. If it appears suspect...a site visit is performed.
In other words, if a patient shows up with LBP, onset less that 16 days, No symptoms distal to the knee, FABQ score work subscale less than 19 etc etc( yes...the CPR), and the clinic is mobilizing cranial bones....it's time for a site visit.
What's so hard about that?
By the way, I did the same thing you did and found that about 60% of what I do can be directly supported by the evidence.
< Message edited by proud -- June 23, 2008 12:33:33 PM >
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RE: One expert will lead to better care - June 23, 2008 12:42:29 PM
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TexasOrtho
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Who is paying the person performing the site visit?
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: One expert will lead to better care - June 23, 2008 12:59:24 PM
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proud
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In Canada, each province has a college. We pay an annual fee to that colllege. My proposal would add a salary to the equation. Which would translate to an increased annual liscensing fee. Perhaps an extra $150 per member depending on the province and number of members.
Does it make sense? I think so. It would usher in an era of weeding out the rats( old school shake and bake clinics that are damaging our image).
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RE: One expert will lead to better care - June 23, 2008 1:07:10 PM
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rwillcott
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Great discussion. TexasOrtho is right since no one works for free. In Canada I think it would be in the best interest of the insurance companies to request a treatment plan and have it analzed by a third party PT with a certain level of training. It would have to be someone that is not in direct competition with that clinic of course. Maybe some PT graduate students that have access to the research and need extra money for tuition.
As it stands now insurance companies request initial assessment letters with a detailed treatment plan and timeframe. I don't think they're too particular about the evidence based treatment though. If they do it I can't see why Blue Cross and others wouldn't do the same.
As it stands now Blue Cross has non-PT's working for them in their "rehab" departments determining what they will cover. At one time they decided to remove non-evidence based techniques such as CST in the province I live in. A group of PT's that perform CST got together and compiled 'evidence' for Blue Cross supporting CST. They argued it's manual therapy. Because of that Blue Cross continues to pay for CST as a form of manual therapy performed by a PT. So their 'research' is simply based on who cries the loudest.
As an aside, I saw in the local paper today an article about a massage therapist that now provides teeth whitening through the use of some machine she bought. So you can get a massage and then get your teeth whitened. And they want to be consisdered health professionals!
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RE: One expert will lead to better care - June 23, 2008 1:08:31 PM
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rwillcott
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The insurance companies that request the treatment plans are only for MVA patients. Just thought I'd correct that.
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RE: One expert will lead to better care - June 23, 2008 9:13:45 PM
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bonez
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When you communicate your tx plan to the refering provider have you actually followed up to see how many of the refers actually read your corespondence and how many stuff it back in the file only to look at it if the patient asks them about it.
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RE: One expert will lead to better care - June 23, 2008 9:57:27 PM
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TexasOrtho
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quote:
ORIGINAL: bonez
When you communicate your tx plan to the refering provider have you actually followed up to see how many of the refers actually read your corespondence and how many stuff it back in the file only to look at it if the patient asks them about it.
I have...pretty disappointing. Few docs read or care about what we send. In their defense, I have seen some of the things we send to referring providers: Handrwritten notes with tons of superfluous information. I doubt I'd read it after a while.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: One expert will lead to better care - June 24, 2008 1:21:26 AM
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bonez
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quote:
ORIGINAL: proud
Bonez`implied in another thread that all this slamming going on here is an indication that we must not have "patient care" in mind.
false. ( maybe)
The current set up of conservative NMSK management is ineffective. Have a look at the statistics involving healthcare extenditure involving this. We have not gotten better at it, we've gotten worse. Chiropractic in my mind, is a poorly regulated crew. PT's are better but require much better self regulation as well( hello all you craniosacral therapists out there).
No other area of healthcare has multiple providers plying to be the primary provider. Dentists, Pharmacists, optomitrists etc.
Why?
Regulation. It's easier to maintain a high professional standard when the public simply knows who is who when it comes to their healthcare needs. As it stands now, it's a free-for-all market with wack jobs and snake-oil salesmen/women convicing the public that they need their sutures mobilized, their innate energy released, or their "knots" rubbed out. All bunk....yet there it is..due to poor regulation.
One expert. It's better for healthcare...it's better for patients.
While this is true for you proud you may not have the patient's thoughts behind you. There is importance to you and I that research backs up what we do and we are the best at it. But trust me the patient could give a squat. The system also does not weight MSK treatment with the importance that you do either because it is by far a quality of life issue not a quantity of life issue.
If you review it from the patient's point of view they think like this.... Can you get me better, do I have to come very much, what is it going to cost, why do I have to do all the forms, will this affect my work (appointments and missing work) will you touch me and do I have to work around others???
What they won't tell you that they might be thinking is ...Am I comfortable with this guy, how does his personality fit with mine, he sure seems to hate/ talk about other professions should I trust him???
Have you ever been asked what you got in your anatomy class or what the course you just took last weekend was about that caused me to miss my appointment?
Now the third party payors they care but the errosion that is occuring in Canadian healthcare will see that more non life threatening treatment is not covered by what ever plan and the patient will be the payor. So as you design your new model be aware ,who you are designing it for and who you are preaching to.
By far and large the average patient just wants you to have a licence and that you can get the job done. They are not really concerned how you police your self until they have a problem. they also don't really track whether you read the recent article on tendonosis and as such this is likely why those members of your profession that are busy compared to you but don't practise by your standards have figured "it" out as they are thinking from the patients view.
< Message edited by bonez -- June 24, 2008 1:26:19 AM >
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RE: One expert will lead to better care - June 24, 2008 6:29:34 AM
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SJBird55
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proud - patient mix of diagnoses and age of patient mix would probably be the determining factor for the frequency in which evidence can directly be applied. If all one treated was acute low back pain, one could feasibly have 80-90% of care evidence based. If one has a higher population mix of 65+ aged patients, the percentage will substantially decrease.
bonez... with regard to the patient's perspective... <edit here... this goofy thing cut me off and posted!!! I have no clue what button I hit!>
Can you get me better? What do we have out there either as individuals, as departments or as a profession that truly answers that question for consumers?
What is it going to cost? Again, do we as individuals, departments or as a profession truly answer that question. I currently have data combined with outcomes that addresses this for my patients. I know if someone comes in for PT for low back pain the cost is on average around $550 and the average cost for the same diagnostic category if treated by my Michigan peers is around $1,200.
Let's not be silly here... of course patients don't like filling out forms and I agree it is always redundant AND until we have some intercommunicating system in place OR every patient has some google health account deal, life will be full of completing forms. I haven't had to respond to patients questioning the forms in quite a while. My response though is generally somewhat of a joke with an added comment that indicates to better serve them I need to know that information. In fact, there has been a complete reversal of attitude with patients where they actually voice appreciating the thoroughness.
I will disagree with your point that patients don't care or track whether I read or don't read recent articles. They care more than you can imagine. I am actually thanked on a regular basis for doing just that. I have an example just from yesterday... 63 year old female referred for bilateral knee pain with post op history of arthroscopy in October 2007. Seems pretty straight forward, right? 3 physicians (PCP and ortho and cardio) were completely missing the boat! She had recently been hospitalized for 11 days in mid to late April secondary to kidney stones removed but then had a complicating factor of sepsis. PCP had no idea why she had knee pain... referred her to ortho.... cardio had concerns about her endurance and advised doing upper extremity strengthing exercises and told her hospitalization had weakened her... ortho referred her to me. Further questioning... bilateral knee pain and bilateral shoulder pain. Shoulder pain began back in May around the 15th after attempting gentle strengthening exercises twice AND pain hasn't subsided. Hmmm... questioning on meds... 750 mg levoquin for 30 days and 500 mg cipro for 23 days. 63 year old... multiple joint pain... tendon pain... high dose of antibiotic... the conversation came to a grinding halt... I told her that I had read more and more in the last year on joint pain from antibiotics but couldn't remember the meds and told her I'd do a quick search on meds. Yep... her meds had a side effect/risk for tendon rupture. She was still taking her precribed cipro. Someone made a mistake and didn't communicate to her. Her knee symptoms began 3 weeks after initiating levoquin. You can bet that she definitely appreciated that I do read all sorts of articles - might not remember everything perfectly BUT can find what I need to know rather quickly! When situations like that occur, there is often another question that comes out of their mouths... if I went to another physical therapist, would that therapist know what you know? How do you answer a loaded question like that? I'd like to smile and say sure.... I don't though, because I know that overall individuals in our profession are complacent.
< Message edited by SJBird55 -- June 24, 2008 7:08:01 AM >
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RE: One expert will lead to better care - June 24, 2008 6:34:35 AM
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Sebastian Asselbergs
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From: Barrie, Canada
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You make very good points, bonez.
In addition to those, I just saw an article that quoted research that 1/3 of north Americans (don't know if it is the States only) state that they have witnessed or experienced divine healing of an illness or an injury. This is fertile ground for ANY practitioner, and does not bode well for the general population's reliance on and trust in things scientific as far as healing is concerned.
I keep thinking about the "one expert" issue. I can't help but think of the three orthopods - all excellent spinal surgeons with great outcomes, working in the same hospital corporation with 2 excellent neurosurgeons, who are also very good at spinal surgery. Also, a very well known general surgeon specialised in arthroscopies - so much that he was considered better than most orthopods.
Take myself - no Masters, no PhD, no DipGradManip, like a quite few here in town, yet I am considered an expert?
I suggest that "one expert" makes sense from a professional perspective, but does not address the vagaries of the popular needs and trend, and does not take into account the personality and people skills of the practitioner; and those WILL influence the "market" significantly.
_____________________________
Mundi vult decipi
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RE: One expert will lead to better care - June 24, 2008 8:42:07 AM
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proud
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Bonez,
let's be serious. I'll take you on a trip. Imagine a world with no expert in say.....dental care. say there were 5 different people claiming to know how best to treat tooth pain( not a cavity, just tooth pain). One uses acupuncture, one uses a special tooth rubbing technique, one uses a machine developed by NASA, one is a dentist with expert training in differential diagnosis( yet all "claim" to be skilled at differential diagnosis) etc etc.
A patient, not knowing anything about dental care, is going to almost randomly select one of those providers. Let's suppose they select the NASA machine because it just sounds new age and the provider( read: salseman) provided an excellent explaination for the tooth pain and how the NASA machine would fix it.
Now....due to patient expectation, placebo type effects, etc etc...the tooth pain starts to feel better. They tell two friends who then tell two more friends and on and on.
6 months to a year latter the tooth pain returns....this time the NASA machine does not work. So the ill-informed patient goes in search of a new treatment. This time, by luck...they land at the dentist. The dentist looks and indicates that they had been developing root disease for quite some time and unfortunately, the nerve root had died resulting in significant bone loss. The only treatment option now is removal of the tooth and a dental implant( very costly). If they had recieved early and appropriate treatment, they may have simply required a small filling......
End of the story. You can apply LBP and all the "red flags" for progression towards disability that should be screened for in an initial evaluation to the above. It's unlikely that the operator of the NASA machine is going to have the knowledge required to understand the science of impairment and disability that a Physiotherapist will have. The NASA machine may work short term, but that patient will trend towards impairment/disability if they have those red flags....that should have been evaluated and cared for in the first place....
You simply cannot rely on consumers to deciede who to go to for their healthcare needs. They are not equiped to do it. Governments need to provide the public with an understanding of where they SHOULD be going. If a patient choses to go elsewhere...it's at own risk and....cost.
Seb,
See above....
< Message edited by proud -- June 24, 2008 9:00:15 AM >
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RE: One expert will lead to better care - June 24, 2008 9:13:05 AM
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TexasOrtho
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quote:
ORIGINAL: proud
You simply cannot rely on consumers to deciede who to go to for their healthcare needs. They are not equiped to do it. Governments need to provide the public with an understanding of where they SHOULD be going. If a patient choses to go elsewhere...it's at own risk and....cost.
Proud you are off the deep end here. Government involvement should be minimal. For better or worse, consumers need to be left to make their own decisions. It is up to US to win their hearts and minds.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: One expert will lead to better care - June 24, 2008 10:27:39 AM
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Sebastian Asselbergs
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From: Barrie, Canada
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Proud, I never implied that the situation is GOOD with regards to the patient expectations and such. I am saying it IS a reality that is unlikely to change - the more government regulates the choices of individuals, the more they will resist. You should know by now that I abhor some of the tripe that patients ask for as `therapy` - but limiting their choice for above is not the answer.
I agree 100% with Rod here: we have to educate each and every patient with our professionalism, our education and our effectiveness - without having to rely on a big brother. And without having to denigrate another PT or professional.
_____________________________
Mundi vult decipi
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