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