Pot-Pourri from a PT

[Matthew Rupiper, PT]

As a physical therapist, I'm confronted with daily questions. Many of these are of my own doing and curiosity about things. A number of years ago I wrote them down (under an alias) with many other rehab professionals around the world taking part. I plan to do something similar here...

For anyone interested. Maybe it will stir up questions.

https://www.somasimple.com/forums/fo...376-pot-pourri

Views are my own and do not reflect those of my employer

[Matthew Rupiper, PT]

I'm confronted with a difficult question:

What factors or variables determine if you're a "good PT?" The topic of pay for performance is occasionally put out there. What determines "performance" for a healthcare provider?

Is it outcomes? Should it be? How can you grade someone on the outcome of someone else?

Is it patient satisfaction? Should it be? How can you grade someone on how others "perceive" them?

Is it billed units? For those non-healthcare providers reading this...spoiler alert....there are companies/practices that emphasize and incentivize licensed healthcare providers for how much they bill YOU...not whether or not the services provided are considered best evidence or efficacious.

Views are my own and do not reflect those of my employer

[Matthew Rupiper, PT]

From 2013:

https://www.somasimple.com/forums/fo...f-manipulation

Views are my own and do not reflect those of my employer

[Matthew Rupiper, PT]

From 2009:

https://www.somasimple.com/forums/fo...d-start?t=7717

Views are my own and do not reflect those of my employer

[Matthew Rupiper, PT]

Views are my own and do not reflect those of my employer

Goal Writing in Healthcare

Take a stroll through the swamp of physical rehab-centric social media, forums or podcasts and you’ll invariably become a sideline observer to arguments, competition of who’s right, wrong, evidence or science-based. Citations and accusations will be made and taking offense will occur. No side will relent, both remaining stead-fast proclaiming victory. Each side will retreat to writing editorials in journals or on social media. The cycle soon repeats itself….

So what can we agree on? If critical thinking, reasoning, interpretation of science and evidence is so divided, where can this community of healthcare professionals come together?

My opinion: Goal Writing

No practicing clinicians enjoys documentation of services provided. None are satisfied with seeking “authorization” or “approval” of services. How many enjoy documenting “skilled services” (what does that even mean???) Clinical instructors and students spent HOURS on learning to document. They even teach how to document in a fashion that shows “skill.” In many cases it’s less about documentation and more about “creative writing.”

Of all the the precious minutes/hours/days spent documenting, a large portion comes by way of writing goals.Has it every been asked, why do rehab professionals even write goals? I have. And I have yet to get a clear answer why physical therapists (or OT’s/SLP’s) write goals. I’ve seen PCP’s, specialists, dentists, etc and not once was I asked “what are your goals?” Having read countless notes from all healthcare specialties I have yet to come across something like:


“Patient will floss upper and lower level canines daily and independently to improve dentition”
“Patient will consume metformin with 50% accuracy to improve fasting glucose levels by 5%”

Goal writing….like standing on wobbly devices, is a concept I still don’t understand after a decade of being a licensed healthcare provider…

Many hours are spent in school writing, submitting to professors and subsequently re-writing goals about another human. Many valuable minutes/hours are spent by clinical instructors and clinicians plugging these things in EMR (electronic medical records). Numerous resources are thrown at chart audits ensuring it’s SMART (Specific/Measurable/etc etc)

Writing a goal for another human. I still don’t understand.

In all things legal, what sense do goals make? I can get behind a solid subjective/patient history, objective measures (watts, pounds/kilos, ft/lbs, time, distance), vitals, assessment of response, maybe a self report outcome, but how/when/why did “goals” ever show up? I’ve yet to meet a provider that enjoys writing goals. If so, who are these people? Would rehab professionals lose sleep if one day they showed up to the clinic and were informed they could stop writing goals for other humans?

We already know the true goals:

I don’t want to feel the way I’m feeling.
I can’t do what I like to do the way I want to do it.
I want my headache/cancer/disease to go away.

So why continue the creative writing circus non-sense, when the goals are so crystal clear?

Who agrees? Everyone….based on my anecdotal surveys of everyone I’ve ever asked.
Who disagrees? I’d love to know and understand…

[Matthew Rupiper, PT]

I’ve heard it before. “He’s a great PT.” “My PT was the best.” “That PT didn’t know what he was talking about.” So what defines a “good physical therapist” or “master clinician.” Is there a standardized list of attributes? Does it depend on the lens you look through? Maybe it depends on the view you take. There may be a difference when looking through the lens of a student/mentee, colleague/co-worker, patient, manager/boss or insurance provider. In a decade of practice I’ve looked through each lens.

The Subordinate:

I’ve listened to, observed/shadowed and trained under multiple clinicians described as masters, gurus, or “leaders” in the field. They cited research, verbalized their thoughts and established rapport with most folks entering the clinic. Given these attributes, my opinion is they’d have been just as successful being a faith healer or scam artist. Some will come to their own defense citing the positive outcomes they achieve. Unfortunately this does little to support their standing as most outcomes are a product of the patient’s socio-economic status, pre-conceived belief systems, self perception or some other non-objective measure.


The Colleague:

This perspective will likely be driven by your own beliefs, bias, experience and/or opinions. Think of the colleague you’d trust with your most loved family member or friend? Why is that? Do you see this person as “working on” your loved one to provide the fix, cure or answer to their problem? Do they have a toolbox of “treatments” you feel may be necessary to manage your loved one? Or do you respect this person’s ability to listen, explain and lay out options, advise on positive life concepts while “doing” very little?


The Manager:

The managerial viewpoint is unlike the others. It views the clinician through many lenses: the patient satisfier, human resources, revenue generator and practice patterns to name a few. A clinician with high patient satisfaction may by proxy have positive revenue generation (low cancel/no show rate) but lack the awareness of positive interaction with co-workers. The revenue generating clinician may be an outdated practitioner, but effective biller of services provided. The co-worker everyone loves as a person may struggle with patient rapport and have lower revenue generating practices. The clinician using the “evidence” to drive practice may lack patient satisfaction due to differences in expectation.


The Insurance Provider:

The insurance provider appreciates cost-effectiveness. Does the cost of paying for physical therapy reduce the need for more costly downstream services. Or is the physical therapy service cheaper than something else. Many insurances will not authorize imaging or procedures until the patient has seen a physical therapist for a specific number of visits.


The Patient:

This may be the most difficult one to understand. Obviously the patient wants to see someone that can help them with their problem. Some patients may favor a specific personality characteristic (confidence, empathetic, funny, outgoing, etc, etc.). Some patients just want to feel heard or listened to. Some just want the nuts and bolts about their condition or situation. This is likely the most complex lens to look through and one researchers are still working to understand more fully.

Views are my own and do not reflect my employer

[Matthew Rupiper, PT]

A simple succinct article on achieving elite level performance

https://journals.humankinetics.com/v....2021-0541.xml

[mjwurtz]

Very succinct and true - listen teenagers!

[Matthew Rupiper, PT]

If you've ever watched the Dave Ramsay show you'll understand the difficulties encountered in physical therapy clinics everywhere.

A caller phones Dave seeking financial advice. He typically asks very simple questions about their finances; income, debts (mortgage, credit, student, car, etc), retirement savings, other savings, assets, etc. Based on the individuals question and their existing financial situation he makes a recommendation. In some cases the caller is in financial distress. Sometimes the response is simple: save more money, get another job, decrease living expenses, sell the stupid vehicle, etc. None of these options are viewed as solutions or fixes, but as something to move the needle in a positive direction. The call ends and we don't see or hear from them again.

I/we (physical therapists) see people daily seeking advice on their pain and/or function. We collect background information. Part of that consists of: physical activity/exercise, work, home life, social and behavioral factors etc. In many situations the patient's current state, pre-existing background and lifestyle leave us with no other recommendation beyond asking them to just do more activity. Go for a 1 minute walk. Stand for 5 minutes. None of these options are viewed as solutions or fixes, but as something to move the needle in a positive direction. The visit ends and we may not see or hear from them again.