I was recently reading through an online thread regarding the best management of complex regional pain syndrome. In this thread, a bunch of students and clinicians gave their recommendations for the treatment of this disorder. While some of these recommendations had some evidence to support, many did not (note: a great full text on evidence behind the management of this disorder here). One similarity I saw in many of the responses, which is common in many of these threads, was the number of variables the participants wanted the poster to consider. Modalities, exercises, manual techniques, sensory treatments, etc. “You should try X, Y, and Z and if Y doesn’t work try N.”
So what has lead us to recommend so much and is it all necessary?
I suspect our current modes of thinking, in regards to treatment, is likely influenced to some degree on the current reimbursement structure. It is well-known that in the Outpatient setting, the more treatments you deliver, and the more units the bill, the more you can be paid (its quite ridiculous when you think about it). I know some payers have limited the max units to be billed, but does this structure of payment influence what that patient really needs (or are we influenced to add fluff to reach our productivity standards)? Do these practices influence the future clinical decision making processes of our student physical therapists (they learn that the patient needs X,Y and Z and maybe N for the treatment of a disorder)? Heres a secret: Things are changing (like very soon—). As the payment model drastically shifts, I suspect panic will occur, and then a shift in practice patterns.
Clinical Certainty with Protocols(maybe Uncertainty is Better?)
I was recently talking to an academician regarding his knee pain. He stated his physical therapist has “the” recipe for treating knee pain — ice, ultrasound and closed-chain activity. Now put aside your beliefs of those activities and let’s consider this statement: “the” recipe for treating knee pain. This “certainty” regarding a treatment protocol for a condition concerns me a bit. Its not patient centered…at all. It has nothing to do with altering behavior…or introducing context…or graded exposure…or _______. Its patho-anatomically driven which is actually more of a physicians domain than ours (and they can have it). When we approach a patient with knee pain, we should approach them with a hint of uncertainty of what to do. When we provide too many “inputs”, we make the equation of treatment much more complex. I would recommend trying something—reassessing the patients response—decide if we should try something else (ie. Input –> Reassess the Output –> Input (Maybe same or new). We don’t know how a patient’s nervous system will respond. It’s ok that what we do is a bit of trial and error. We work with humans.
I once worked for a corporation that awarded and bonused clinicians. These awards ranged vacations, to Kindles, etc. These awards weren’t based upon clinical outcomes (ie. The winner wasn’t receiving an award based upon having the lowest visits per new patient ratio with supported outcome scores). The clinicians were awarded and bonused based upon revenue growth (with a stipulation that your average units per patient could not drop > 5%). Enough said.
As I stated above, clinical education may influence this concept. Students expect to learn about true clinical practice from their instructors. Unfortunately, there is not a lot of internal control over what that clinician does clinically (I find it odd that the instructor is the only one completing a CPI—who mentors, or grades, the mentor? This concept has been noted and is tightly controlled by ABPTRFE in post-graduate education). So with all of the variance in not only practice patterns, but reimbursement, culture and certainty, we must understand that students may suspect they truly need to deliver X, Y and Z, when coming back from clinical education.
How do we change?
Short answer: We begin to manipulate the potential variables that led us to provide a lot of variables. As I linked above, we will soon be paid different. As this payment model shifts, practice culture will shift. As practice culture shifts, clinical certainty will shift to uncertainty. As this happens, I suspect we will revert to a better understanding clinical decision making processes.
– Joe B
PS: At the Nxt Gen Institute, we have developed a clinical decision making algorithm which we call “M.I.P”. I recently presented this out at the San Diego Pain Summit wearing a “GoPro”. While the video may make you a bit queasy, give it a go for better understanding what we think needs to be in place for helping patients to move.