Friday, November 7, 2008

Part 2: Are All Physical Therapists the Same

In the first post I made an argument that treatment variability was not necessarily a bad thing all of the time. The caveat is, I feel, that variation in clinical reasoning should not exist.

In the first post I discussed how many therapists differ in their explanations of WHY they do what they do. This is bad variation.

In this post I'll talk about the 2nd caveat for appropriate variation, which is that the therapist should always have the consent of the person they intend to treat. You should not only expect, but should require that the plan to address your predicament addresses your goals and has your approval. Additionally, the more you are involved in establishing the goals the better chance you'll have of a positive outcome. It is, after all, your predicament and you'll have to be the one to get out of it so it makes sense that your involvement in the solution is paramount.

It also makes sense that you should be the architect of what a positive outcome will look like. This will be a source of much variation from one person to the next. You may have the same exact pain description as another person, but may have entirely different needs based on your life and activities. It is likely that goals will be much different between a professional athlete, who may need to regain the ability to jump high, and a stay at home mother needing to be able to pick up and hold her child, for example. The treatment between individuals will be much varied despite the similarity of their pain.

Of course, it is also appropriate for you to expect your clinician to be able to assist you in the process of determining your goals. They should be able to give you ideas of realistic goals as well as time frames and expectations.

What they should also offer to you is a plan of treatment or action to achieve your goals, and this is also where much variation exists. It is completely appropriate for you to expect your clinician to explain to you why it is they are using a specific approach in a way that makes sense to you. If you are not comfortable with that reason and you don't agree with the course of treatment, you have the right to refuse the treatment.

Of course, the other side of this coin is that your clinician has the right to refuse your request for a specific treament as well. I'll give an example of a common treatment that will hopefully clarify both sides of this issue.

Therapuetic ultrasound is one of the most traditional treatments used by physical therapists. It has been a part of our treatments for many years and continues to be used very commonly. Indeed, when many think of What is Physical Therapy they often think of ultrasound and exercise (see the link for my thoughts on that). The problem is that ultrasound has been studied a hundred times in a hundred ways and all the evidence points to the same conclusion: it is of no benefit beyond placebo. Despite this, many therapists continue to use it for a number of reasons, such as tradition, demand for it by physicians, demand for it by patients, influence by poor quality research from the companies that build the machines, etc. You won't find one of these machines in my clinic.

Now, knowing what I've told you about your right to consent and the lack of support for ultrasound, you know that it would be completely appropriate for you to refuse it as a treatment. On the other hand, many patients feel that ultrasound has helped them in the past (and I won't deny that it feels good and that occasionally a person feels better after a treatment. But it is clear that this is not the result of a treatment effect from the ultrasound. I plan to talk more about how this apparent paradox might be in the future.) and demand that this be included in their treatment. As a responsible clinician, knowing that ultrasound is only as effective as placebo, I have the right to refuse to dispense this treatment. In the rare event that this confrontation happens, most people are grateful for the honesty and understand my reasons for not providing this treatment. For the rest, I will politely inform them that I am likely not the person that will meet their needs if this is a requirement on their part. Until all of my collegues begin to treat in a way that is consistent with the research on ultrasound, this will remain an example of what I consider to be innapropriate treatment variability.

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