Re: Protecting the Public?!?!?!? You kidding me?!?!?

[Guest guest]

In a message dated 12/1/99 6:01:12 PM Eastern Standard Time,

drewpt@... writes:

> II think our energies are inexplicably misdirected.

>

>

> Quit misdirecting your energies with whining and do something that

> actually makes a difference for our profession . . . RESEARCH!

This much is true, we will not survive without good, solid evidence...and

some good solid marketing of our results, to boot! Something that the

McKenzie Institute and Wayne Rath (of the Duffy-Rath system) understood early

on.

By the way,when I say marketing, I mean marketing to the public as well as

doctors and insurance companies...just like the chiros, acupressurists,

massage therapists, and others to whom the public go...just because they at

least " know " what they " do " .

Murray-, PT

[Guest guest]

Drew,

Can you provide references to substantiate your contention that ATC's

are.. " just as effective as PT's in treating the orthopedic sports population "

? Also, please further define what conditions you are referring to.

Thanks!

Pat Walaszek,PT

[Guest guest]

In a message dated 12/1/99 7:28:47 PM Eastern Standard Time,

PWalaszek@... writes:

> Drew,

> Can you provide references to substantiate your contention that ATC's

> are.. " just as effective as PT's in treating the orthopedic sports

population "

>

> ? Also, please further define what conditions you are referring to.

> Thanks!

> Pat Walaszek,PT

>

Dear List,

Please note that my prior response was not meant to substantiate the original

claims that Drew made, just that I agree that research and marketing are

indeed necessary.

Murray-, PT

[Guest guest]

Folks.

A REQUESTED RESOURCE IS PROVIDED AT END THIS POSTING...AFTER MY

EDITORIAL RANTING.

Funny how whenever the issue of efficacy and outcomes comes up, the

typical PT's reply is " I'll show you yours if you show you mine. " This

misses the point. When it comes to $$$ however, the practicing

provider is guilty until proven innocent in terms of patient

effectiveness. Decisions of healthcare economics are not based upon PT

vs ATC vs DC vs exercise phys research . . . they are based upon the

LACK THEREOF in most cases . . . leaving it up to the profession in

question to demonstrate their own self worth.

Don't shoot at the bringer of bad news folks, I'm sickened at the

present state of physical therapy outcome research, and I have a hard

time listening to the realities of the editorials that I write. The

state of PT outcomes research leaves those of us with an eye toward

policy with precious little ammo in the political arena however. We

seem to achieve progress (e.g. $1500 cap repeal, HCFA repeal) by

pointing out the systems errors of the policy (e.g. typo error of " , "

instead of " ; " regarding BBS legislation; difficulty in training

students to meet next generation of healthcare needs regarding HCFA),

we do not " do battle " on the basis of our effectiveness.

Appropriate I suppose, if you have a cavity, for example, and go to the

DDS, you feel better the day of your filling. This is unlike PT.

There is no fumbling. There is no latent timing, and no " well, let's

try heat . . . didn't work so let's try cold . . . didn't work so let's

try US . . . didn't work so let's try E-stim . . . and oh, yeah, a few

exercises too " mentality. If we KNOW what works for a specific

diagnosis (and I suggest that we can do better with diagnostic

classification of functional movement and painful disorders . . . eg.

not all LBP is the same, not every stroke, not every child with autism

.. . . but there are clearly distinct sub-classifications within each,

and some consistently respond better, or worse, to specific

treatments), then the " fumbling " that some PT's do would never be

tolerated. Though I do not personally know of any PT's that " fumble " ,

patients (friends of mine) typically describe this as their treatment

course. I'm not an ortho PT, so I've got to ask, What's up with that?

The problem is that this manner of treatment leads to the general

population feeling that they could get just as good outcomes from

another type of provider. Those people include the healthcare

executives who control the flow of dollars. Right or wrong.

____________________________________________________________

RESOURCES:

Anyway, for those of you who would like a resource regarding

inter-discipline effectiveness, a particular favorite of mine (but by

no means the only one), which wakes me up in the middle of the night

screaming and in a cold sweat, is a study that examines PT, DC and an

education booklet in the treatment of patients with low back pain. The

point of an ATC is not of particular relevance if you believe (as I do)

that there is something inherently beneficial to human contact . . .

and that ATC should yield better results than a booklet.

The study is

Cherkin, DC et al, " A COMPARISON OF PHYSICAL THERAPY, CHIROPRACTIC

MANIPULATION, AND PROVISION OF AN EDUCATIONAL BOOKLET FOR THE TREATMENT

OF PATIENTS WITH LOW BACK PAIN. " N Engl J Med, 1998 Oct 8;

339(15):1021-9

Let me break it down for ya . . . (Gimme a little bass)

Randomly assigned 321 adults with LBP that persisted for seven days to

McKenzie PT, Chiropractic Manipulation, or provision of an educational

booklet. PT or DC provided for 1 month. RESULTS: Both the

chiropractic group and McKenzie PT group had less severe symptoms than

the booklet group. Differences in the extent of dysfunction among the

groups were small and approached (but did not reach) statistical

significance at one year (yes, the booklet group faired poorest).

HERE'S THE IMPORTANT POINT . . . over a 2-year period, the mean costs

of care were about $425 for DC or PT care, and $150 for the booklet.

(That's seen as $275 that could be cost-shifted toward the pre-natal

care of your baby, or over the course of a lifetime . . . a

considerable portion of the funds necessary to operate on your father

to fix his ailing heart, and . . . with no appreciable difference in

the health of this population of individuals with LBP). CONCLUSIONS:

For patients with low back pain, the McKenzie method of PT and DC had

similar effects and costs, and pts. receiving these treatments had only

marginally (and statistically insignificant) better outcomes than those

receiving the booklet. WHETHER THE LIMITED BENEFITS OF THESE

TREATMENTS ARE WORH THE ADDITIONAL COSTS IS OPEN TO QUESTION.

___________________________________________________________

Yes this study has a few flaws, for example, would the results be

different if 321 people with chronic (more than 1 year) occupational

LBP been studied (I believe that it may). If you read the study

carefully, you will find other flaws in the research, but this is not

the point. The point is that these are the types of studies that

heatlhcare executives read and base reimbursement policy upon. They

don't care about the flaws; they leave it up to the practitioner to

identify the flaws, and conduct their own studies to contradict the

original published study with outcome studies. We don't tend to do

that, we can't. I believe this has something to do with my original

ranting about a good diagnostic classification system of movement

disorders BEFORE research is conducted. The Guide makes a good start

in this direction, much as DSM did for psych. I don't see many PT's

embracing the Guide in clinical practice though, but then again, DSM

did not enjoy widespread use until it's 3rd edition or so. If psych

could do it 20 years ago with something as abstract as human behavior,

why has it taken us so long to move in that direction in the

classification of things that by and large, we can see?

Food for thought

Drew

[Guest guest]

Drew--I can assure you those of us " quietly lurking without comment " are

learning, some of us just don't have the time (or the desire) to sit down and

respond with a one or two page response to every subject that is brought

forth. You seem to be generally saying basically the sme thing in each

response. It is entertaining and enlightening but, i will choose to continue

to " qiutely lurk " and hopefully learn something in the process!

[Guest guest]

Drew:

The purpose of licensure and regulation is to protect the public. In

health care, licensure and regulation is/should be aimed at ensuring

that those individuals who are licensed have meet minimal educational

and competency standards to practice. Licensure is also there to ensure

that those licensed individuals practice within their respective scope

of education and competency. Licensure has nothing to do with who can do it better or cheaper. That

is the role of a free marketplace. Health care is not a free market.

Implicit in its nature healthcare cannot be left to the market place.

The public does not have the knowledge or education to make an informed

decision as to whether the "product" they are buying is of quality,

safe and fairly priced. When the public cannot be an informed consumer

the government assumes that role. As a profession and as professionals we have a duty to the public to

help protect it from unqualified individuals, licensed or not, that are

holding themselves out as providing health care. Because we have

knowledge that the lay public does not have about the minimal

educational qualifications necessary to safely practice certain aspects

of medicine we have a duty to advocate and inform the legislature and

the public when we feel individuals may put the public at risk by not

having sufficient education to do what they would like. When the state licenses a profession it confers special privileges on

the profession. In addition to those privileges come limitations and

duties. If we think that licensure, accredited education and minimal

competency are important principles of PT practice to ensure that the

public receives quality and safe services then we should have the

greater responsibility to society to advocate those princibles to

health care in general. That is what it is to be a Professional.

"andrew m. ball, ms, pt (mba/phd candidat"

wrote: original article:/group/ptmanager/?start=8884

> "Protecting the Public?!?!?" You've got to be kidding me.

> > I love my profession, don't get me wrong, but I'm not disillusioned

> enough to think that PT's are somehow magical in their ability to

> provide intervention for a given problem. Other professionals provide

> less expensive service with identical outcomes for specific

> sub-populations of our clients. Turf-wars are arrogant, and a

> self-destructive aspect of our profession. We cannot control this. We

> will never control this. We rather waste valuable time and energy

> bitching and complaining instead of going back to school for an

> advanced degree and PROVING that PT has some efficacy, or linking up

> with a University directed clinical research project.

> > ATC's, FOR EXAMPLE, COST LESS TO UTILIZE AND ARE USUALLY JUST AS

> EFFECTIVE IN TREATING THE VAST MAJORITY OF THE SPORTS ORTHOPEDIC

> POPULATION. As a PT, our reaction to this makes me want to puke. Stop

> whining that we "know more and are more effective in treating these

> patients," and mindless chanting that the "public must be protected"

> we're not more effective, we just have an overinflated professional

ego

> and tend to whine a lot. > > As an MBA/PhD student of healtcare management however, the choice is

> simple. If you can get equal outcomes for less money to the healthcare

> sector . . . well that's basic health economics. If we could prove our

> effectiveness over ATC's then this would not be an issue. The

> population would flock to us instead of ATC's, instead of

> Quack-o-practors (I mean Chiro-Shamans, I mean chiropractors). They

> don't. This is the core issue, not billing an ATC or Ex. phys. as

PT. > WAKE UP!!

> > II think our energies are inexplicably misdirected. > > Hope I've pissed off enough of the ever complaining, never researching

> antiquated clinicians to finally GET OFF YOUR COLLECTIVE ASS and prove

> something that we do is effective. ANYTHING. EACH AND EVERY ONE OF

YOU.

> There is no excuse for doing otherwise. If you can't hack the new

needs

> of the profession, then get out.

> > Quit misdirecting your energies with whining and do something that

> actually makes a difference for our profession . . . RESEARCH!

> > Drew

>

[Guest guest]

Doug,

I agree with your conclusions regarding the purpose of licensure, but I feel that several of you underlying premises are grossly incorrect. I emphatically disagree that "Health care is not a free market. Implicit in its nature healthcare cannot be left to the market place." This may be the way that the market has been held out to be today, but I suggest that you read some of the newer models of healthcare delivery proposed by experts published in the Journal of Cost and Quality, the Journal of Health Affairs, or the Journal of the Healthcare Executive proposed to replace Managed Care after its inevitable death. A quasi-moderated free market with peppering from the Oregon Project, Minnesota Gang of Seven, Chaffee tax-free Medisave, and Century Projects's variable co-payment scale is consistent in all of the newer models. E-mail me if you'd like more specific references, I'm not ill prepared in making the above statement.

I agree that physical therapists have a duty to protect the public from those that are unsafe, inefficient, antiquated, etc. But you make a tremendous, and in my opinion erroneous jump in your assumption that other disciplines are somehow unsafe because they have slightly different training than we do. Is it possible that some of our roles overlap??? PT's do hand therapy, chest percussion, some in the recent past did suction, some work with augmentative communication / environmental control systems and feeding . . . roles traditionally allocated to OT's, SLP's, RT's etc. Using your philosophy, I assume that your position is that these issues are out of the scope of physical therapist practice and does not include these procedures. That PT's are somehow dangerous to the public because they don't have the same training as these other professionals. This may be true, but that doesn't make them unsafe. Sometimes a different perspective is just what the patient needs. I suggest you seriously review your position. It opens a tremendous Pandora's box that cannot be easily closed. We cannot have both freedom for ourselves and restrict the scope of practice of others, for it will eventually come back to bite us in the tushy. (Hope that's not offensive to anyone, but I've been trying to work the word "tushy" into a posting for several weeks now).

I suggest that we take a cold, hard, objective look at our own profession before we begin casting stones. SW diathermy was promoted as a save and effective treatment technique back when I was in school . . . but now electromagnetic fields (especially from cellular phones) are blamed for everything from malignant growth to in-utero genetic mutations. I enjoy the way our unconscious violation of the Hippocratic Oath to do no harm was quietly overlooked for decades, and now simply swept under the carpet in today's discussions. How about the physical therapists who were involved in the facilitated communication efforts of the 1970's??? As I've stated in a previous posting, innocent people's went to jail and had their lives destroyed on the basis of statements made by individuals (speech therapists, and physical therapists alike) claiming to facilitate communication of previously non-communicative individuals with autism or sever mental retardation. Upon further research which I referenced earlier, the communication was found to be no more than an amplifier of the facilitator's unconscious mind . . . and not of patient origin. Again, we overlook this violation of the Hippocratic Oath. Are you seriously telling be that PT's are safe and do no harm? Are you honestly trying to tell me that the profession of physical therapy is "safer" to the public than that of occupational therapy, athletic training, massage therapy, or chiropractic??? Do you honestly believe that we do not hold ourselves out to provide outcomes that are no better than natural history (please refer to my previous posting regarding DC vs PT vs educational booklet). Even if you do, do you honestly believe that it is our profession that should be the "police." I can't believe that you're serious.

Drew,

P.S. Doug, I'd really like to hear a response from you in particular. Though we clearly disagree on this issue, I admire the passion with which you write. Please understand that depite the confrontational tone of this posting, I hold you in the upmost respect. I hope from this dialoge, something positive will be gleened for each of us (and hopefully others quietly lurking without comment).