LET ME USE MY JUDGMENT
I'm a big fan of talk radio. So when the topic is healthcare related my ears perk up. On a recent show the topics was a discussion about why Medicare is going broke. One of those reasons was the belief that everyone is entitled to any and all available medical care no matter what cost at all times. The show went on to explore the costs associated with that. The host took the position that just because a treatment is available, that doesn't mean the treatment should be used. Rather, he favored a system of limiting treatment to those that were feasible and cost effective.
I see this to a lesser extent in the world of therapy. In this case the issue isn't so much cost as utilization of services. There is a finite amount of therapy a department can provide. When demand for services exceeds that care suffers. The first line of defense is usually shortening treatments so that everyone gets a little something. The positive side is that more patients on case load receive therapy. The down is twofold. First, some therapy isn't necessarily the best therapy. Doing exercises with someone just so that someone can be said to have therapy isn't enough. Same for edge of bed exercises when the patient really needs to get into a chair but can't because of time restraints.
The second downside is more insidious. There are therapists who can't think outside the box. Its almost like they memorized for this diagnosis you do that treatment. I don't' think this is the best approach but it can be effective. The problem is when you take those therapists and tell them to do something different, for example see more patients by spending less time with each. I worked with someone like this. He couldn't do it. If anything fewer patients were actually seen because he wasted so much time explaining why he couldn't make those changes.
These aren't the problem. They are symptoms. The problem is therapy is being ordered for patients who aren't appropriate. The do everything available mentality has trickled down. Just because therapy is offered doesn't mean it is appropriate. I'm saying we should deny therapy. In theory everyone deserves that chance. If an order is written, a therapist responds. An evaluation is completed. Most facilities will follow patients on a trial basis. The problem is the stress these trial patients put on an already over worked staff. There is an assumption that if an order is written the patient will receive therapy when in reality all the order does is initiate an evaluation. We go to school to learn how to be therapists. We learn how to use clinical reasoning. If my clinical reasoning is good enough to develop treatment plans based on an evaluation it is also good enough to recognize someone won't benefit from therapy.
It's a shame we're not allowed to do that. I've tried. First of all let me say dependent isn't a bad word. It's a description of functional status. The same is true of being at baseline. If a person's status is the same after admission as before admission they are at baseline. The goal of therapy is to recover function. Baseline implies maximum functional level. That does not indicate therapy. A decline in functional status indicates therapy. This may seem obvious to you and I. It isn't to everyone else. Admission to a hospital isn't an automatic referral to therapy. If a patient doesn't want therapy I'm not accomplishing anything going back the next three or four days to be sure.
In case it isn't obvious, this is one of my pet peeves. Anyone that needs therapy should receive it. Anyone referred to therapy should be given a chance. The radio talk show host I mentioned earlier summed up the situation by saying over utilization is draining healthcare. The same is true of therapy. By relying on our clinical judgment all those who will benefit from therapy will receive it. Those who won't will come off case load. Controlling case load will result in better treatment because no one will be as rushed.