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REP 9 - Good practice: are you selling snake oil?

Leanne Loranger, PT, Practice Advisor

Every now and then the Physiotherapy Alberta offices are host to some hot debates - the kind that only happen when you put a few opinionated and passionate people around a lunch table. Recently, one of these debates erupted on the subject of accountability, and more particularly, what an individual practitioner’s responsibilities are when they are selling their treatments.

We all sell services in the context of physiotherapy practice, whether we are selling directly to patients, to third party payers, or to Alberta Health Services. If you are being paid to be a physiotherapist, you are selling your services.

Having sat on the Conduct Committee for a number of years, I have heard more than one complaint from a patient who paid for services and did not get better. They presented to the Committee with the belief that the physiotherapist’s practice must have been unskilled or they would have recovered. As difficult as it was to explain to these individuals that treatment doesn’t always work and there are no guarantees; that doesn’t make the treatment unskilled or inappropriate. But is that the whole story?

I don’t think it is.

Whether you are being paid an hourly wage to provide services in your local hospital, or charging for a series of private practice treatment sessions, you have a professional responsibility to sell treatment that works.

 

This responsibility is supported by the following requirements found in the Standards of Practice:

  1. Quality Improvement Standard of Practice: Gather and review information related to clinical outcome measures.
  2. Records-Clinical, Financial and Equipment Maintenance Standard of Practice: Document client outcomes, how outcomes were measured, amendments to treatment plans resulting from those outcomes, and reassessments or changes in client's condition.
  3. Advertising and Promotional Activities Standard of Practice: Ensure advertisements do not guarantee success of service(s) unless claims are supported by evidence available to the public.
  4. Client-centered Service Standard of Practice: Value the client’s best interest. Communicating effectively to ensure clients fully understand physiotherapy services offered and how those services will meet their needs.
  5. Conflict of Interest Standard of Practice: Not participating in any activity in which professional judgment could be compromised or is for the sole purpose of personal gain.

 

Recently, the Auditor General of Alberta presented a report on Chronic Disease Management (CDM) that included a report about the lack of accountability between family physicians and Alberta Health:

“Physicians are primarily accountable to their patients for the quality of their care. They are also accountable to the college for their professional conduct. The department receives billings from physicians indicating the patient, location and date of service, diagnoses and medical service provided. The department does not require any direct accountability from physicians for the quality of care they provide or the results they achieve for funds provided… Until CDM expectations are set, and systems are put in place to see they are met, the department’s vision for effective primary health care for every Albertan will not be realized.”

Physiotherapists are similarly accountable for the quality of care they offer to their patients and are accountable to Physiotherapy Alberta for their professional conduct. It would be nice to believe that a lack of accountability to payers wasn’t leading to inefficiencies and substandard outcomes in our own profession for the patients we serve both with chronic diseases and otherwise, but that simply isn’t the case.

 

In an annual analysis of health benefits spending, Green Shield Insurance reported a rapid rise in use of paramedical services such as physiotherapy, massage, and chiropractic services. Usage data seems to indicate that some services are being used not as a health care service but as part of a patient’s lifestyle. Another disturbing trend is the increased incidence of individuals using all three services in tandem. As the report states:
“There are situations where this traveling in threes is medically warranted, but the large usage of this combination of benefits suggests that using all three may represent a savvy business model of cross-referrals more than evidence-based health care. It appears that good old-fashioned marketing is increasingly offering these services as a package deal.”

Again, that doesn’t match with the concepts of professionalism or accountability. It certainly doesn’t match the requirements to value the client’s best interest or avoid activities in which professional judgment could be compromised or is for the sole purpose of personal gain.

Let me ask you this: are you selling expensive treatments that have little to no evidence to support their use? Are you selling effective treatments, but not providing them in an adequate dose to be effective? Are you working for a business that places priority on revenue generation over clinical considerations?

 

I can hear the arguments already. How can you have valid evidence about what will work for a 67 year old, female, eastern European immigrant who has spent her whole life working as a housekeeper for a hotel chain? She is too individual to have a study that tells me how to manage her back pain. And, what about my clinical experience? I know what works.

You’re right. Your clinical experience does count for something, and client-centered service does require that we tailor our treatment to our patient’s needs.

However, the Standards of Practice I cited earlier clearly tell us that we are expected to track our outcomes and demonstrate the effect of our treatments, both for our individual patients over time and for larger patient groups (such as the patients in your practice who have back pain, or all your total hip replacement patients).

 

Scotty Butcher’s contribution to the CPA’s ‘30 Reps’ campaign, Mark Rippetoe asks are Physical Therapists Really Frauds, provided a strong reminder about how selling under-dosed exercise in physiotherapy practice is no better than selling extended courses of expensive treatment modalities that aren’t working. If we are selling something that isn’t designed to work in the long term, we run the risk of being called frauds. Worse, we run the risk of deserving the title.

When a patient comes to the college disgruntled that they spent hundreds of dollars on a treatment that was ultimately ineffective and has been told “it works in 80% of patients, too bad you’re part of the 20%” something seems a bit off to me. My question for the physiotherapist is: If the treatment wasn’t working, why did you keep going? Were you just lining your pockets? Did you evaluate the impact that your treatment plan was having? Neither behaviour meets the Standards of Practice.

What about the multidisciplinary business that gathers information about a patient’s extended health benefit coverage and then intentionally sets out to use up all of that coverage, physiotherapy and otherwise, regardless of the patient’s actual needs? If you think that as an employee you aren’t responsible to say something about that practice, you are wrong.

 

These types of behaviours do not exemplify accountability in action. Physiotherapy Alberta requires that you, the regulated member, ensure that your practice of physiotherapy meets the Standards of Practice and Code of Ethics of the college, and when the actions of your employer contravene these standards, you work with your employer to correct the situation. You are also required to practice evidence-based practice and when research evidence is lacking for the treatments you are using, to collect and evaluate your own clinical data to have some evidence upon which to base your treatment decisions.

Physiotherapists enjoy the privilege of self-regulation and a high level of public trust and respect. Let’s make sure that through our actions as professionals and our accountability to those we serve, we continue to deserve this trust and respect.

 

By Leanne Loranger, PT, Practice Advisor, @PTAlberta

 

This post was originally published on April 30, 2015, and can be accessed here http://collegept.org/Resources/Perspectives/PhysiotherapyAlberta201506  Opens in a new window. Content is republished with permission from Physiotherapy Alberta.

 

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Comments

My first thought when I read through this piece is that nothing much has changed in the 31 years since I graduated as a PT.

We have once again, one sector of the profession criticizing another sector for something the entire profession (i.e., clinicians, academics, researchers, private practice owners (corporate and small shops), hospital administrators and department heads, funding agencies, the regulatory and professional associations including, Branches, Divisions and their sub-units) are actually responsible for (and that is support for and funding for research).

Research to support what we do clinically regardless of the practice area.

My own experiences, now as a near (let's hope! says my supervisor) completed PhD student, specializing in MSK research, with a two phase project examining non-specific low back pain usng MRI has influenced how I might have responded to this discussion before I became an apprentice clinician-scientist.

The issue isn't just that there are snake oil carrying clinicians but few others who are willing to change the snake oil into something more substantive for clinicians to use.  As I search for a post-doc position somewhere in the world, because I do not apparently have enough academic training after five university degrees, what I can report is that there are few academic centres anywhere offering research funding to support the type of long term research into what we do as clinicians.  There are of course pockets of research being conducted and, many more PT's who have moved into the academic realm to do research but it is hardly what would be considered a critical mass to really make a diffference.  Snake oil changing requires a critical mass.

I have been told that most acute low back pain gets better anyways so why fund research into it.  That there are too many researchers splitting too little funding.  That MSK problems are not necessarily life threatening so funds go to more important research.  Your research is too "esoteric".  There is a litany of reasons you can choose from to explain why there is so little research going on to help clinicians.  Pick your poison or your snake oil formula.  

Like the Leadership Forum coming up in Ottawa in November this year let's organize a Snake Oil Forum but call it, "Moving From Questions To Answers" How to Work Together to Improve Research Into What We Do.  

I echo what Italian PT, Alberto Cairo, said, Physical rehabilitation is a priority.  Dignity cannot wait for better times. (see his talk here - https://www.youtube.com/watch?v=1QX7aoxSTAQ)

 

Joe Putos, PT

PhD Canadidate

Faculty of Health Sciences

Western University

London, ON

 

Thank you Joe for your comments and for directing my attention to Alberto Cairo's TED talk. 

I would just like to comment on patients use of combinations of multiple practices to maximize use of their benefits.  I work in a multidisciplinary clinic, and it is not uncommon for patients to see a variety of providers at their own discretion (not a product of cross referrals), but also for patients to wish to maximize the use of benefits that they are paying for when they exhaust their physiotherapy (or chiropractic, or massage, osteo, etc.) benefits.  In these instances, care is transferred to a different service professional in order to allow the patient to continue to recieve treatment for their condition, often with a recommendation as to which colleague may be best able to assist the patient based on the issue at hand.  I consider this to be good patient care (continuing to recieve treatment vs not), and not as an abuse of insurance benefits.

Thanks for your comments, Joe.

As always, you give us lots to think about!

@CPA_Melissa

P.S.- I love Alberto Cairo's TED talk- should be required viewing for everyone in the rehabilitation field.

Thank-you Joe so much for your comments.  I finally just finished watching the Alberto Cairo ted talk perhaps a must see talk for all physiotherapists. and in particular students.   Yes Joe I have to agree on the dearth of clinically relevant research out there.  Please keep chipping away at this problem and yes keep being a "rule breaker" Hmmm, So what is the "snake oil" when the latest American recommendations lay NO mention of the use the "usual modalities" other than a hot pack  in the treatment of either acute low back pain or chronic back pain?

I haven't seen those recommendations yet so will refrain from commenting.  Modalities may be useful as they can offer temporary relief of symptoms.  And that temporary relief is really important as anyone who has experienced pain can attest to.  But that is not the end point.

Wwe are as a profession, called to higher things.  Including...asking and pursuing questions such as, "where is the pain coming from and how can we affect it so the person experiencing it can function and then flourish."

My experiences as a peer reviewer and assesor for the College of PT over the past 10 years has imprinted on me that there are many, many PT's who are asking the same questions and who are looking for help from their research colleagues.

That's why funding for research is so important.  I cannot recall how many times I have heard someone tell me in the last 4.5 years as a PhD student, yes that is important but there is no funding for it.  Well, let's change that.  Let's start by organinzing a Research Forum for PT's.

 

 

 

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