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REP 7 - Incentives and murky waters: the prescription of orthotics

Anonymous

During my Master’s of physiotherapy degree, custom orthotics were not an integral part of our curriculum for entry-level practice. 

However, shortly after passing my national exam, I began working at a private practice facility that encouraged us to prescribe custom orthotics. 

The ask

I remember feeling surprised when my then-boss, who was not a health care professional, told me that they had booked an appointment for their father to see me. I recognized that this was a potential conflict of interest.

If I assessed the patient’s need for custom orthotics and was unsure of their appropriateness, my boss could possibly be angry if I did not recommend them. Further, I saw in the online patient booking system that the following day’s 40-minute appointment for my boss’ father was described as “for custom orthotics.” This kind of wording puts pressure on physiotherapists.

Instead of booking an initial foot assessment, it was fairly clear that my boss wanted me to prescribe custom orthotics. I cannot recall all of the assessment details with my boss’ father. 

In hindsight, prior to the assessment, I should have said something like “I will only prescribe custom orthotics if my assessment points to their appropriateness for the patient.” 

In fact, I do recall that my physiotherapist colleague (also a new grad), spoke up to say “I do not feel that I have the necessary education and training to prescribe custom made orthotics”. I was impressed by their ethical backbone and communication skills. But, even though I agreed, I stayed silent for fear of job security. 

Using my professional judgment, I concluded that the ideal scenario would be to prescribe a tailored home exercise program to stretch the foot and surrounding tight musculature.  If exercises did not alleviate symptoms within three weeks, then I might explore the appropriateness of custom orthotics. 

I did prescribe stretches, but I also went ahead and mailed the foam cast and submitted the gait scan results for their custom orthotics. 

In other words, I softened my ethical backbone, mostly out of fear of backlash from my boss.

 

The incentive lurks

At another clinic I worked at, there were financial incentives for the physiotherapists to prescribe custom orthotics to their patients. I do not recall the bonus amount, but employees were asked to indicate how many custom orthotics they prescribed biweekly. That number of bonuses would appear on the next paycheck. 

This incentive may increase temptation to inappropriately prescribe custom orthotics for financial gain.

 

Murky waters

The CPA’s position statement on Physiotherapists and Orthoses states that physiotherapists “are qualified to assess dysfunction, injury or pain related to foot biomechanics. The assessment, prescription (depending on provincial jurisdiction) and dispensing of foot orthoses are included under the scope of practice for physiotherapists in Canada for the treatment of clients’ foot dysfunction, injury or pain.” 

However, as we all know, if our competence with a particular treatment is lacking, we cannot apply it to a patient. 

The ability to reflect on whether we personally are competent is a key skill, and physiotherapists need to have the communication skills and ethical backbone to communicate otherwise. 

 

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Comments

A very timely post. I see a lot of physio marketing plans that include orthotics. This at a time when most research questions their efficacy. 

Hi there, not an easy story to share, so first of all -- thank you for your reflective sharing, that's an act of courage in my books! 

I'm a physio for 25+ years in public, private and throughout continuum of care and have come across many awesome but also some unfortuante situations which at times made me question whether I should continue as a PT myself.  I think that's part of the discovery process and mapping out a careeer journey that honors your interests, ethics and wellbeing.

As I re-enter private practice under my a solo-umbrella -- I am floored by the diversity of the "marketplace" since I last worked in this area (15 years ago).  There are so many more players, diverse interests, potential for conflict of interest etc all admist a sea of fast-paced information overload.  How is one to navigate safely?

By doing what you did.

You did the best you could in the given moment, you spoke to others, , you did seek guidelines/guidance, you reflected on your actions, you identified areas for improvement, you made a plan for next time and then you went a step futher them most people by completing the loop by sharing with us all.  Thankfully 30 reps has given you place to do that (sidebar comment: I have been following the posts this month, I hope the association will be able to create a space where this type of communication can continue to occur).

Back to example - if experience is a good teacher, I would have approached the situation by acknowledging the owner's needs but not making any committment.  You couldn't know the outcome without assessing the indivduals. Also it turnsout you need to do some of your own assessment of the owner's needs in this situaiton. For example did the request come from clinical need/determination on his part, from a desire to control your behavior or could it have been based on communication dynamics with the father (e.g. old school, old world, established culture where as a son it may be easier to give him what he needs then proceed with education and discussing options...which is where we pick up the ball).

In short good practice to be truthful, acknowledges any gaps in your information, creating space for your decision making and acknowledging the role that  fear or intimidation plays in the process.

Physiotherapists are human beings too.   thanks for posting.

;)

 

 

Thank you for your comments- we will be sure to pass them along to the author.

As for your side-bar comment- we are so pleased that you are enjoying this years #30Reps. We will need to look into ways to continue the conversation!

@CPA_Melissa

Thank you for your courage to speak up. The scenarios you listed are descriptive of a term in Health Economics called Moral Hazard. It hounds every health care profession and is not unique to physiotherapy at all. This ubiquitus fact, however, does not justify us rather it calls us to a higher standard of public accountability. 

We must remain aware and alert to this and other such compromising situations and actions that can tanish the reputation of our laudable profession and put our public perception at an unjust risk. 

I am with you on this matter.

We appreciate your comments, and will ensure that the author of this blog post sees them.

In preparing #30Reps, we spoke with many people involved in the delivery and regulation of physiotherapy.  One phrase that we kept hearing was that difficulty begins when "people put their needs ahead of their clients' needs." As a self-regulating profession, we need to strive for the 'higher standard of public accountability' and avoid the moral hazzards.

@CPA_Melissa

I can totally relate with that. A position I held was similar in that there was often pressure to prescribe orthotics and braces for even the smallest indications which I found wasn't necessary and I also didn't feel as though I was adequately trained to know when a patient may benefit/ how to fit it. I've since worked closely with both an Orthotist and a Podiatrist and found those are best left in their hands and that by working together and knowing our boundaries/ working within our comfort zone everyone benefits. 

Thank you for sharing your experiences. @CPA_Melissa

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