The Best You Can Be
I am writing to comment on the article titled “The Best You Can Be,” which appeared in the January 2015 edition of Impact.
The article is written by a Private Practice Section (PPS) board director and highlights his experience in receiving physical therapy treatment for a herniated disc. I have to say, I cannot recall a single article evoking so many different emotions in me.
The first question that came to mind is whether there is any consideration for evidence-based practice? First, the author states they had a “herniated disc” in the lower back. Now I do not know if they had any imaging studies, but given the diagnosis I assume so. If that is the case, why not self-refer to physical therapy first? Assuming imaging was done, it did nothing more than increase the cost for his episode of care as there is in fact evidence showing limited benefit in performing imaging studies routinely; unless of course there are severe, progressing neurologic deficits that were not mentioned. My other thoughts about evidence-based practice relate to the comments the author made that he went daily, each session lasted at a minimum of two hours and the longest three hours, and that he “walked, stretched, suffered, strengthened, trained, laughed, was poked, pushed, and manipulated (physically, mentally, and emotionally), heated, iced, lasered, and stimmed.” Wow, what happened to the kitchen sink, did they just forget to throw it in the mix? Where is the evidence to support all this time and stuff the author had done to him? I am glad he got better, but how long did it take? What really helped him and where is the evidence?
That is not what I am most disheartened about in this column, however. What concerned me, and upset me the most, is the author’s comment that he wanted to remind us all of the incredible impact that more appointments and more interventions provided by a large team of providers can have on outcomes. We do not know what helped him get better, but because he got better he is advocating that more is the reason and advocating for us to take that approach. Do we really want that to be our message? It is for exactly this reason that our profession is where it is at today with all of the utilization management companies scrutinizing us. This is why we now have the Care Core’s, Orthonet’s and OptumHealth’s of the world limiting what we can do. Our profession and association have put in a tremendous amount of resources to provide us with evidence and to overcome this perception of physical therapy just wanting to do more and more. I fear this article has the potential to set us back decades.
The final concern I will address about the article is that it appears in a section called “Board Member Report.” So now the perception will not only be that this is what private practitioners are advocating, but it is what the section and PPS Board of Directors are advocating as well.
Tom DiAngelis, PT, DPT
Managing Member at OrthoSport Physical Therapy
Thank you for the opportunity to respond to the comments from Tom DiAngelis about my article in the January 2015 issue. Being limited to 800 words and wanting to inspire the masses has obviously left some readers confused and full of emotion.
I will attempt to address the confusion in the order that the questions were asked:
Diagnosis: The diagnosis of “herniated disc” was a self-diagnosis. I employed all of my education, training, and experience to synthesize the mechanism of injury, the signs, the symptoms, and response to movement to arrive at my diagnosis. I subsequently self-referred to my physical therapist. I am sure my physical therapist used a diagnosis code to describe my pain, although I cannot be sure of her documented diagnosis. We are blessed in Idaho to have unrestricted direct access, and, in fact, we were one of the first states to have unrestricted direct access. There were no upstream costs—no physician visits, no MRIs, no injections, and no prescriptions medications.
Evidence: Sackett et al defined evidence-based medicine some 15 years ago as the integration of best research evidence with clinical expertise and patient values. The goal of evidence-based practice is the integration of: (a) clinical expertise, (b) best current evidence, and (c) client values to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve. The experience I tried to share was to directly support the traditionally accepted definition of evidence-based medicine. My article was limited to 800 words and was not intended to be a scientific paper and therefore I did not feel the need to break down every element of treatment. My article was also written from my perspective, therefore I chose to write for more dramatic effect. My physical therapist, applied her expertise as well as the best current evidence to solve my problem. Where my perspective becomes more interesting is in the comments about forgetting to throw in the kitchen sink! This was exactly the point that I hoped my article would drive home. This is in direct reference to possibly the most forgotten and most important part of evidence-based practice: patient-client interest, values, needs, and choices. I wanted to drive home the reminder that the goal of evidence–based practice is to provide high quality service that reflects the interests, values, needs, and choices of the individuals we serve. The intent of my article was to share my story, a story that was reflective of my interests, values, needs, and choices.
I did not want to engage upstream costs as I am very aware of current evidence and best practice with regards to low back pain. Additionally, I desperately wanted to avoid all prescription medications and injections. Therefore, I wanted more physical therapy, more movement, more passive modalities more of everything possible to help me avoid prescription medications and other potential procedures.
My intent was not to advocate that every patient you see should have more appointments and more interventions. My desire was to simply describe my case and remind everyone of the impact that we can have when we are providing services that reflect the interests, values, needs, and choices of our patients. I know exactly what helped me get better. My physical therapist and my time in physical therapy treatments solved my problem. My physical therapist and my physical therapy care were the answer to my avoidance of physicians, MRIs, injections, medications, and surgery. I would add that given our push for direct access and our association advertising that a physical therapist can help patients avoid medications, surgeries, MRIs, and to support our claims we must do everything we can during our time with our patients to control pain and to control symptoms. Severe pain and debilitating symptoms cannot always be controlled with a manipulation twice per week and a prescription of home exercises.
My point is we should not forget the wants and needs of our patients. In an era in which we are working hard as a profession to demonstrate the value of physical therapy, providing care that is consistent with the interests, values, needs, and choices of our patients will drive value in the eyes of our patients. When our patients perceive and trust that we are a critical part of their health care team, those same patients will demand that we are a paid service of their insurance carrier.
CareCore, Orthonet, and Optumhealth are not limiting what we can do. Payers may limit how much they are willing to pay for our services, but they do not define physical therapist practice. In my perspective, the third party payers are not limiting payment due to an excess of physical therapy appointments / interventions, they are limiting payment due to a lack of trust and demonstrated value.
The case I presented was an attempt to define how we provide value, both to our patients and third party payers. In the case presented, upstream costs were avoided, and the only episodic costs were physical therapy costs. The downstream costs have been nullified secondary to excellent outcomes from physical therapy intervention—an ideal scenario in my perspective. We must drive our value through the perception of our patients. And our patients will not perceive value unless we provide care that is truly evidence-based medicine.
And to address the final concern that my article appeared in a section called “Board Member Report.” I will be clear that this article is the perspective of this board member. I did not consult my fellow board colleagues. I did, however, submit this article with the intended audience in mind. My intent was to inspire physical therapist-owned businesses to remember to treat their patients like they themselves would want to be treated. And please forgive me if my perspective, as a patient, has set the profession back. My intent is to remind physical therapists to prescribe care with the fullness of evidence-based practice and to work hard to drive the perception of great value into the experiences of our patients.
Thanks Tom for the opportunity to expound my original article.
Sackett D et al. Evidence-Based Medicine: How to Practice and Teach EBM, 2nd edition. Churchill Livingstone, Edinburgh, 2000, p.1
Kevin Hulsey, PT, DPT, is a PPS director and the founder and chief executive officer of RehabAuthority, LLC. He can be reached at firstname.lastname@example.org.