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Reflecting on 2009 and Moving to 2010

As 2009 comes to an end, it's probably the perfect time to kick back and reflect on the year, what you've learned throughout the year and even more importantly how you grew and implemented what you learned into practice.  I would tag Dr. Gail Jensen as the queen of knowing how experts practice.  If you want to be an expert physical therapist, you need to self-reflect.

So... back pain... the majority of patients treated in outpatient settings are going to have back pain.  For the patients you treated with persistent, non-specific low back pain, did you incorporate motor control exercises?  Did you stay away from the feel good short term modalities.  You know what I'm talking about... did you avoid ultrasound, hot packs, massage and electrical stimulation?

How about this... did you attend a continuing education course?  Did you become more effective in treating those specific patients?  Literature seems to indicate continuing education alone doesn't improve physical therapist effectiveness in treating neck pain.  What does seem to improve effectiveness are episodic reminders or pushed information on what was learned.  If you attended a continuing education course, did you incorporate some mechanism to keep you mentally alert throughout the year about the topic you learned?

Clinical prediction rules... where are you on that topic?  Have you mentally battled your thoughts on those?  Have you looked at both sides of the debate?  Would you be able to debate about the value or lack of value at a higher level than "cookbook" philosophy?

What about incorporating standardized outcome measures into practice?  Have you done this yet?  How are you capturing change that does or does not occur with physical therapy intervention?  How are you learning of your clinical experience to know how you practice and know your level of effectiveness?

Have you thought about the logistics within the setting in which you practice?  Are you shying away from using physical therapist assistants or are you taking a bit more control in the delegating process?  Have you measured to learn if outcomes changed?

Did you know that there were 3.7 million single falls and 3.1 million recurrent falls in 2002 in adults 65 years of age and older?  Of those falls, 2.2 million resulted in a medically injurious fall.  Only 48% of fallers reported falling to a health care provider.  Of those that did report a fall, only 60% received any fall prevention information.  How did you practice in 2009?  Did you address falls?

Oh, and what about adhesive capsulitis?  Uh, huh... after learning that the likelihood of improvement is reduced by 19-32% if iontophoresis, phonophoresis, ultrasound or massage were included in treatment plans, did you step away from the passive interventions?  Did you change your plan of care to focus on interventions that would move the patient forward and get them back to life?

Have you begun taking steps to screen for psychosocial factors that affect physical therapy treatment sessions (i.e. fear or depression)?  Do you just go through the motions of screening or do you step up to the plate and use the information gained from the screening process to alter your treatment sessions?

The new news... single level microdiskectomies... do you treat those patients as being frail or are you progressively strengthening their back extensors working up to 80% of 1 repetition maximum?

Are there any topics I missed that would be great for self-reflection?  Do you have any method for self-reflection?  What method do you use to ensure you are an expert?

photo by irargerich via flickr

~Selena

Thunder from Down Under Coming to OU!

     Once again, Peter Gibbons and Philip Tehan of Melbourne, Australia are making a trip across the pond to and will be teaching the Seventh Annual Spinal Manipulation Update program. It is scheduled for March 4-5, 2010 (course 2) and March 6-7, 2010 (course 3). at the University of Oklahoma this spring. Peter and Phil are 1975 graduates of the British School of Osteopathy. Tehan also is a physiotherapist, and Gibbons also is a medical doctor.

     It is primarily a technique/skill focused offering, but having previously taught as faculty in this course, I can tell you that there is an appreciation for the EBP approach and the techniques are simply very user friendly and easy to incorporate into your clinical skill-set. Both Peter and Phil are superb teachers as well as master clinicians who, because of their respective backgrounds, bring a unique perspective. You can preview some of the material they will be presenting which is directly from their text "Manipulation of the Spine, Thorax, and Pelvis: an Osteopathic Perspective"

 The other real treat while at this course is the presentation made by Dr. Bill Kinsinger on the state of Chiropractic. Dr. Kinsinger is an anesthesiologist practicing in Oklahoma City who has investigated and documented the particulars of the Chiropractic profession extensively. You can view the "Kinsinger Report on Chiropractic" presentation by clicking the link below. Dr. Kinsinger will delivering a live presentation during the March program. You can get more information and additional details about the program by clicking here.

Cheers!

Rob

Happy Thanksgiving!

As is the case with many of you, I am reminded on this day that I am simply blessed and overwhelmed with things for which to give thanks. 

This Thanksgiving, EIM would like to pause and thank all of you who have worked and interacted with us personally and professionally over these last several years and given us the opportunity to impact and contribute to our profession; it is indeed a privilege.   Most of all, we are thankful for the wonderful new relationships we have made with many of you as well as the strengthening and maturing of bonds we have had with long-time friends.  We do count all of you as part of our professional family.

 

  We all have special reflections of Thanksgiving.......food, family, football.....of course!.....and special people and events for which we are thankful. And yes, we are extremely thankful for a profession that allows us to do what we love, make a living while doing it, and changing peoples lives. With that in mind on this special and uniquely American Holiday, please take a  moment to share with us what you are most thankful for this season. We would love to hear what makes your heart sing and what you are thankful for on this special day: add your comments and may they flow freely !!

 

 

From Rob, Tim, Larry and John as well as the entire EIM Team, Happy Thanksgiving to you and yours!

Friday Private Practice Physical Musings

On wayto PPS National Meeting for a presentation tomorrow entitled Charity Good For Business? I am gong to have participants text or twitter me questions and feedback during the presentation.  We shall see how it goes.

Online access courtesy of Delta airlines for $12.95.  Data shows that few people actually pay this-similar to the phones that used to be in airplanes. My guess is airlines will all go this route anyway-similar to PT practices that get a biodex, BTE, or any capital intensive piece of equipment just because their competor has obtained it.

Enjoyed reading this article in NEJM about controlling US Healthcare spending.  They looked at 12 policy options and the ability (or lack thereof) in decreasing cost.  Other than bundled payment, the savings are marginal at best, are not real likely to occur, and would result in a loss of income to someone along the chain.  We already have addressed why bundling won’t work. Looks like we are headed to more of the same from my standpoint.

Was reading in WSJ about a proposed plan to put medicare tax on capital gains for healthcare reform.  This is very confusing to me as I thought healthcare reform and any potential publich options was not about medicare.  Perhaps they will rename it healthcare reform tax. Maybe they are just running out of names for taxes.

Read an equally confusing CMS release about shelving Medical Home Demonstration project.  This is one that I substantially agree with.  Perhaps CMS is reading this blog and my contention about them from last April?

Cheers!

Larry@physicaltherapist.com

OCS Exam 2010: How Are you Preparing and How Do You Know You Are You Ready?

 

I remember back to 1994 when I was preparing to take the OCS board exam. I had to deal with the universal question everyone asks who decides to take it: “how in the heck do I prepare for this?!” I ended up spending hours putting together a static homemade study guide (the only option then as the internet wasn’t widely accessible). I have fielded the same question from many therapists over the years, thinking eventually I might be able to recommend to them an excellent resource dedicated for the one purpose of preparing them to take the exam. Unfortunately, none ever materialized....not just a resource that I could recommend, but none period!! As the song says, “times are a changing” and indeed they have changed.

EIM has just released the EIM OCS Prep Course. While clinical experience and self-directed reading are useful, there are few practice settings where the broad scope of knowledge captured by the term ‘orthopedic physical therapy’ is utilized on a day to day basis… and how much of your orthopedic academic knowledge have you reviewed lately? The EIM OCS Prep Course in an interactive and dynamic tool that will help you sort through the challenges of studying for the OCS Exam.

The added bonus of the EIM OCS Prep Course is that not only will you BE prepared to take and pass the exam, but you will FEEL prepared – so that you can be truly confident walking into the exam.

This course is a great resource for anyone who wants to prepare to take and pass the OCS exam. You can get more information and how to sign-up for the course on EIM’s website now. Click here for more details.

 

Rob

Physical Therapy and Spinal Cord Injury

The choices people make and why they make them captivates me.  For a couple of days, I've been thinking about how to convey, in a kind way, something I read.  The mom's choices and actions didn't bother me - she's really doing what any good mom would do.  What bothered me, "I would call physical therapy places... they either didn't have the equipment, or the manpower or they didn't take my insurance." So, the daughter is now 2 years or so post spinal cord injury and this is what she states about the recovery center her family owns, "There's no other type of therapy place that offers hope like we do. I get to work with them and we get to reach our goals together," says Amanda.

My curiosity always takes me through some cognitive journey.  I wondered what was available in Florida for people with a spinal cord injury.  The first thing that came into my head was the Miami Project.  They have made a huge dent in understanding spinal cord injury.  I didn't easily see information on becoming a patient, but with a bit more searching, I found the University of Miami does have a Department of Rehabilitation.  Amanda's mom didn't indicate anything that occurred in the initial stages of rehabilitation or where rehabilitation occurred.  Somehow she found Project Walk.  Project Walk hinges its whole entity on the Dardzinski Method and the Five Phases of Recovery.  Interestingly, as I tried to learn more about the supporting evidence of the theory, I was led to a neat paper written by Professor Mary Galea who shared on page 8 of that document her thoughts on Project Walk. Galea also included a reference on intense exercise and spinal cord injury by ET Harness. 

Stories sell.  All the stories seem to revolve around hope.  The clients are more than willing to pay $100 or more an hour out of pocket for sessions 3 times a week.  I didn't see a single claim of actually walking independently again.  I wonder how the physical therapy sessions ended?  I mean, the mom could have continued paying for services out of pocket... the physical therapist could have continued to work with the daughter providing intense exercise.

If a patient believes the relationship with us is coming to an end too abruptly and would like more services, how do we handle the whole end of insurance benefits for the condition?  Are we a factor that propels people to pay for unproven methods and potential false hope?  Is it wrong to continue a working relationship if deep down we believe no substantial progress will occur?  Is it wrong to attempt to help a patient to learn to accept and cope?  Why do some patients view this as giving up?

~Selena

EIM 2nd Annual Elevator Pitch Contest Deadline!!

Don’t forget that EIM’s 30 Second Elevator Pitches on why physical therapy is the Best First ChoiceTM in musculoskeletal care are due on November 30th.

Top prize is $1000, second is $500, and third is $250!
Check out Elevator Pitch info on Wikipedia or see last year’s winners… first, second, and third places.

Video and Audio submissions are taken via email @ elevatorpitch@evidenceinmotion.com

Rules:
• MUST answer “Why Physical Therapy is the Best First ChoiceTM for musculoskeletal care?”
• 25-30 Seconds (no longer, no shorter)
• Individuals Only
• Must be a PT Student or practicing PT
• No Entry Fee
• Submit via email @ ElevatorPitch@EvidenceInMotion.com
• Include name, email address, school or place of work, phone number, and age with submission
• Must be in the form of video or audio files
• Submissions are due no later than 11:59pm, November 30, 2009
• Winners will be announced on Facebook, My PT Space, and YouTube on December 15, 2009 at 4pm
• First place will receive $1000, second gets $500, & third gets $250 (winners contacted via phone & email)
• All submissions and their content will become the property of Evidence In Motion, LLC
• Email ElevatorPitch@EvidenceInMotion.com with questions and visit EIM’s website for more info

Spending Money to Save Money-Innovation vs. Marketing

I recently had a sandwich prepared with white wheat bread.  It is essentially whole wheat bread “disguised” as traditional white bread.  The intent I guess is to provide for me a healthier option without me really knowing it.  Not sure this qualifies as innovation or marketing.

The same is true of for IBM’s decision as reported in Oct 29th WSJ article regarding dropping co-pays for primary care visits.  IBM is one of largest employers in the US and spends about $1.3 Billion on healthcare.  Because they are self-insured, they carefully watch every dollar spent in the medical system.  It is their belief that they can save significant money by incentivizing folks to use primary care physicians by eliminating co-pays so they can get earlier diagnoses that can save more expensive visits to ER’s and specialists.  I will let you decide whether this is innovation or marketing.

Contrast this to the incentive system in Massachusetts “global payment” system which creates tremendous incentives to render as little care as possible.  If your care costs less than an annual allotment, then they (medical providers or a hospital) keep the unused amount.  While the pendulum on too much care in the US is undeniable, its compete counter of too little is equally as bad.

My post last week on “bundling” creates a financial incentive for a patient to choose a provider within a set system-the patient essentially gets a cash rebate under that demonstration project (side note:  this worked real well in the auto industry).

I seriously doubt IBM will save money under their initiative since primary care docs are in a shortage and patients will simply get frustrated and pay the co-pay to see a specialist. All IBM needs to do is look at Massachusetts primary care waiting in their system which is 2–3x national average!However, I do think that all of these marketing tactics can be replaced by real innovation- which would take into account best current evidence, utilization data analysis, and some element of financial incentives to drive patient choices.

Here is a start of a list for PT that tries to couple this concept:

1. Pay patients $20 rebate for seeing a PT for musculoskeletal cervical or lumbar pain.  They first follow a simple online or iphone/blackberry app that largely eliminates the major red flags that would guide them to a more appropriate provider.  The $20 would be well spent.  Savings on imaging and drugs would be astronomical.

2. Any service done thru physician self-referral has an additional $200 co-pay.  Routine lab and X-ray would not be included.

3. Patients have zero co-pay if they pro-actively pick their personal family physical therapist who is board certified or resident trained and who actively participates in 3^rd party outcomes.  Their personal PT also agrees to answer emails/texts/phone calls about routine musculoskeletal complaints and provide a free fall balance screen once the patient turns 60.

Combining evidence and incentives vs. marketing. That just might get us to some real answers.

Thoughts?

larry@physicaltherapist.com

Wait & See, Neck Collar Or Physical Therapy for Cervical Radiculopathy?

What to do for neck and arm pain that started within the last 30 days?  Drum roll... which will it be the a) just wait and see what happens, b) the semi-hard collar (Cerviflex S, Bauerfeind)  which has 6 sizes to snuggly fit necks of all sizes, or c) physical therapy?  The winner is.... the Cerviflex S semi-hard collar!

In this century of effectiveness and effectiveness studies.... What a spectacular day for people who have cervical radiculopathy - just strap on a snug fitting semi-soft neck collar and life will be fabulous within 6 weeks!

I was fearful of these types of studies because the devil is in the details and as a whole, we are lazy.  Which is more realistic?  Read an abstract and believe the conclusion OR read the full study and reflect and think?  I'm betting most will read the abstract and believe the conclusion.

I liked that the subjects seemed to be a homogeneous group.  I like the fact that the same collar was consistently used.  I don't like not knowing psychosocial factors.  I really don't like the description of what physical therapy intervention was provided.  "Physiotherapy with a focus on mobilising and stabilising the cervical spine was given twice a week for six weeks, by certified physiotherapists who participated in the study. The standardised sessions were "hands off" and consisted of graded activity exercises to strengthen the superficial and deep neck muscles."  

Current literature indicates that manual intervention and exercise are key components for a successful outcome with various types of patient complaints.  Standardized sessions that are hands off do not meet the requirements of evidence.  The design of the study capturing the interventions provided by physical therapists really wasn't up to speed on the existing evidence on how physical therapists treat patients with cervical radiculopathy. 

It's a sad, sad day when the physical therapist involved in the design of the physical therapy intervention wing of a study didn't incorporate evidence into the treatment protocol.  I really have a problem with the design of the standardized physical therapy sessions!  Where was the evidence for the protocol?

So, the big question... which payer will see the abstract... which payer will deny payment for physical therapy services because physical therapy services are not cost effective and a neck collar will "effectively" take care of the patient's cervical radiculopathy?

~Selena

Halloween and the Bundling Flaw

Larry gave me the most excellent idea.  Bundling the Cost of Care got me thinking about the future.

Last night was my initiation as a physical therapist gone negotiator!  I was 100% successful in acquiring THE largest pieces of chocolate candy (or whatever choice I wanted) out of the bucket!  In some cases, the whole bucket of candy was just handed to me!  (I was polite every time and smiled and said, "thank you.")

I am so ready to be at the service of any physical therapist that has to negotiate with some large hospital system for the payment of physical therapy services provided by an independent physical therapist.  Trust me, as your negotiator, I know how to walk quietly and carry a big stick.  Your company will survive this change; you and your family will survive this change.  I know you have to put food on the table and eat.  Call me and make my day... I am so ready to negotiate for you!

Physical therapists in independent practice really can't negotiate AND treat patients.  Consumers really should have quick access to physical therapists no matter where they practice; consumers should have the freedom to choose their physical therapist.  Seriously now... Larry didn't get any responses.  My humor won't solve the issue.  Really though, will the next growing field in the future be physical therapist gone negotiator? 

photo by dunechaser via Flick

~Selena