Over the holidays, we were sitting and whinging (English for complaining) over drinks about the demise of clinical and critical thinking in practice. In both the US and the UK, algorithms have been employed to standardize care in an attempt to assure everyone gets the same quality of treatment. As a public health advocate, I almost always advocate for something that reduces variations in care. Why should a patient have better treatment from practitioner A than practitioner B? Algorithms are an essential component to telemedicine and tele-physio. NICE (National Institute of Clinical Excellence) in the UK and the Milliman guidelines in the US provide those frameworks we need to work within in order to get paid.
That would work perfectly if every person with back pain presented in the same way, or with chest pain, or a hip fracture. When did you last see two of any presentations that were identical? For an algorithm to capture every possible presentation, it would most likely be unmanageable and of little practical use. Many professions are now being trained according to an algorithmic approach. At my last post in the US, we actually taught new employees about critical thinking because it was a skill lacking in so many newly hired people. Are we dumbing down the health professions in an effort to standardize care?
When I took a practical exam in PT school, many years ago, there would be wildcards in the patient's presentations. Our skills of thinking on the spot were harshly tested. I'm grateful for that now that I'm older and minutely wiser. I wrote about taking an OSCE (Objective Structured Clinical Examination) here in the UK when I first arrived. There was no thinking involved, simply a checklist to run through in 7 minutes. It wasn't easy, but it didn't prepare me for a real situation.
Are we risking our patients and our careers by trying to stay safe?
I mentioned in an earlier blog that physiotherapists in the UK will soon be able to prescribe medications independently from doctors. A clarifying statement has been issued by the Chartered Society of Physiotherapists:
"The physiotherapist independent prescriber may prescribe any licensed medicine from the British National Formulary, within national and local guidelines, for any condition within the practitioner's area of expertise and competence within the overarching framework of human movement, performance and function. They may also mix medicines prior to administration and may prescribe from a restricted list of controlled drugs as set out in Regulations."
That is a pretty impressive responsibility! Physios will be required to complete a course at a university and practice with a mentoring medical doctor before they can begin this activity. Currently, phyios can be supplementary prescribers. This is where they partner with doctors and prescribe under a clear remit. For instance, if they work in community respiratory care, they may begin antibiotics and or aerosols for chest infections with a medical doctor ultimately responsible for their decision-making. Independent prescribing takes the doctor out of the equation.
Would you feel confident enough in your own practice to have this ability? How will this impact on physios' liability (and the insurance)? Could this practice ever take hold in the US? Would you want it to?
So I've finished my induction and have been happily plugging along for almost two weeks now. One of my major tasks is to consult on patients living in care homes (senior housing with ADL assistance that may or may not have nursing included) who have fallen. I work fairly independently and get my referrals from a wide range of sources: Accident and Emergency, doctors, community nurses, the care homes themselves, or community rehab teams.
It's a pretty comprehensive assessment of environment, medications, medical history, vitals, gait and balance. You name it, I look at it. I provide the patient's GP with a letter detailing the actions I've taken, like issuing a walker with wheels, and my suggestions for him, such as a medication review for the person on 19 meds, nine of which are designated as culprit medications for falls. I like it.
The other major task will start becoming clearer shortly. The last time I worked here, I helped redesign an outpatient clinic for people who had fallen. Now the neighboring town wants me to do the same for them. It sounds great, except they don't have the funding the first place did. Instead of 2 FTE nurses and 1 FTE physio, I have 0.4 FTE physio and no nurses at all. This could be very challenging indeed!
I saw my old New York doctor today. He was the main focus in a New York Times article about providing healthcare in a cash-only model. I really should point out that when he was my PCP, he was still accepting insurance and I was not paying the $25,000 annual fee for his services.
Frank Bruni, of the New York Times editorial staff, points out this practice is rife with potential for abuse and ethical dilemma. When a patient is paying $25,000 a year and demands an antibiotic for his viral infection or he will take his business elsewhere, it could be tempting to simply give him the drug he doesn't need.
What about testing? If someone demands a test that isn't warranted, could a doctor be tempted to order it anyway? So for that amount of money, one can get his toe held during a procedure (really, you have to read this article), but is he getting better quality care? What about the wrath of someone who has paid that much but has a negative outcome anyway? That should make for an interesting court case!
I should also disclose that I had a private clientele for a few years that paid on a cash-only basis. It worked well in that I was able to focus on rehab, spend whatever necessary time was required with each one, and not have to waste time arguing with insurance companies. My reputation was good enough that I never had to advertise and had a steady word-of-mouth referral base.
That being said, I charged a market-rate, reasonable fee for a house call, not the humongous retainer fee described in this article. I left that model of practice for a number of reasons, but primarily because I got bored with very similar presentations of my clientele (golf injuries and treatments around resuming the game or improving their performance at it).
How about your practice? Do you take insurance, a mix of insurance and cash, or cash only? Do you find any ethical issues arising if you have a cash-only business? I think the model can work, if reasonable fees are charged. Once outlandish fees are charged, I think that's where the ethical issues arise.
You know what that means... orientation! I'll be attending four continuous days of induction, which will cover all of the statutory/mandatory modules for this NHS Trust. Very interesting to compare it to the orientations I've experienced in the USA. Today five members of the executive board arrived, on time, to introduce themselves and each in a different way voiced how employees fulfill the mission of this organization.
At my last post in the USA, the president insisted on being on the agenda, and then rarely showed up. When he did, he informed new employees that if they didn't make the grade or like the way things worked, they could leave. Today we had security and fire safety training. The security bit amounted to "If you see something, say something" but the fire safety bit was something I've never done in more than two decades as a PT. We put out fires (yep, real fires) with fire extinguishers.
The head of safety quite reasonably made the point that if he was going to teach us how to use them, then it should include a practical component. The same topic in New York? Well, I'll admit it is difficult to create a flaming toaster in midtown Manhattan, but that head of safety was a retired NYPD detective. Nobody knew security better than he did, or had more interesting stories to tell.
What is on the agenda for the rest of this week? Bullying and harassment policy (not even touched on in NYC), manual handling (body mechanics with a practical lab for moving patients and objects), information governance, safeguarding children and adults, risk management, infection control, conflict resolution, and CPR. How does this list compare with what you have gone through with your employers?
Also, I have finally heard back from that NHS Trust that I interviewed with in August and requested reimbursement for travel expenses. I've successfully argued my case and they are agreeing to refund the cost of the flight. This week has started off just about as well as I could have hoped.
As I mentioned in my last blog, I'll be starting my new job next Monday. That has left me with a lot of downtime. Some of it has been productive; some of it has been rejuvenating. I managed to watch all five seasons of "Breaking Bad," the highly popular show that finished its run this year. I had never seen it before. I was pleasantly surprised to see a character who has cerebral palsy. The actor, RJ Mitte, actually has CP, a milder version than the character he portrays, but it's nice to see actors like this actually working.
There's another character, played by Dean Norris, who sustains a gunshot (or rather a few gunshots) and must portray a man with a spinal injury who recovers over the remainder of the show. He does a fairly decent job of making the physicality of the character believable. Were either of the actors perfect in their portrayal of the physicality? No, and we shouldn't fault them for that.
Making a movie, TV show or play requires a big suspension of disbelief. If you've seen any play on stage, you've noticed all the furniture faces in one direction, which nobody really does in their own home. Likewise, actors and directors have to make choices to get the story told. I learned in theatre school (many of you probably didn't know that was my first degree) that foreign accents are rarely accurate. Not because the actors are lazy (except for Gwyneth Paltrow in "Sliding Doors"), but because the audience needs to understand what's being said. If you've ever seen the film "Billy Elliot," you'll understand. The father sounds like he is speaking in tongues to an American ear, but is actually from Northeast England and speaking in his usual voice.
More and more we're seeing people with different disabilities being portrayed in TV and movies. These include Kevin McHale, who plays Artie Abrams the wheelchair-bound paraplegic on "Glee," Jamie Brewer's numerous characters on "American Horror Story," and now Blair Underwood as "Ironside." All help to improve the visibility of people with disabilities and combat stereotypes. This is a good trend!
On September 26, I submitted my application for a job here in the UK. It was the first day the opening was announced. Job openings here are kept open and CVs are collected until a closing date, generally a week later, after which no further applications are accepted and a committee "short-lists" the candidates for interview.
I had my interview on October 24. It went well and three days later I was offered the post. Then I had to wait for a packet to arrive from human resources, after which I could schedule an appointment with them. This is the point where they look at one's original degrees and ID information. It's also when the form for a criminal background check is completed. It used to be called a CRB (criminal record background) but has now changed to a DBS (disclosure and barring service).
That gets sent away to a central office for processing. One may not start, even non-clinical work, until that certificate is received. Had it arrived on Friday, I could've started work this Monday. It arrived Saturday, which means I have to wait until the next induction session on December 2. I understand "The Hitchhikers Guide to the Galaxy" ever so much better now, especially the Vogons' bureaucracy.
I'm really ready to get to work. I've kept myself busy since I've been back; reading up on changes in the NHS, going to the gym four times a week, putting tile up in my kitchen and watching the first three seasons of "Breaking Bad." But really, enough is enough. Let's go to work!
Most of my career has been spent working with older adults. I've worked in acute-care hospitals and briefly in a skilled nursing facility, but the majority of the time I've worked in the community. I think one of the reasons working in the community has appealed to me is the level of preventative care that can be provided. Often we're treating someone for a sub-acute condition, but we can spot the things that could be troublesome down the road. The nearly empty refrigerator, the torn carpets and loose floorboards, the spouse who actually requires more care than the patient, the well-meaning family who brings high-carb-content foods to a diabetic, the stacks of unpaid bills on the kitchen table.
Yep, there is a little bit of dietician, nurse, social worker, GP, and physical therapist in any professional who makes house calls. Most patients and their families really appreciate this holistic approach and I believe it results in better long-term outcomes. Often, older adults are resistant to change. Frequently I'll hear, "I've gotten to X years old without your help before. I certainly don't need it now." I respect the truth in that statement, but I also recognize the educational opportunity to make someone aware that if they make some changes, often small, they'll make it to X + 10 and probably not need more of my help. Many times I hear older adults say, "I don't want to be a burden." That is understandable and one of the toughest battles to fight. How to get people to accept a small level of help to prevent becoming a major burden?
Last week the essay "A Very Ungrateful Old Lady" appeared in the New York Times. It is a story of a very angry lady in her mid-80s who resents the help her children are willing and trying to provide. She relishes her defiance and challenges the idea that she should ever bend to anyone's wishes. They have a saying here in the UK: "It'll all end in tears," to describe a disaster waiting to happen. This will most likely all end in tears for all involved.
In this woman's quest to not be a burden, she takes some dramatic health risks. One fall, a UTI, or medication mix up, and a hospitalization is pretty much guaranteed. She will then require lots of attention from her family, the healthcare system, and Medicare money, all of which could have been avoided. I doubt this person would ever listen to a PT, a doctor, or anyone. I've had a few patients like that over the years. I've never actually said, "I told you so," but I have been tempted.
I found out some interesting facts when I attended the Physiotherapy UK conference two weeks ago. One that surprised me was that physios have not required a medical referral to treat since 1978. Physiotherapy was recognized as an autonomous profession in 1977, which was required prior to a separate act the following year allowing treatment without referral. I found it interesting that in the US it has been such a struggle for so long.
I've said before, I don't believe that direct access is a matter of professional competency as much as financial tyranny. If doctors didn't have to see patients prior to our evaluations and treatments, they would lose money. Which is the more powerful lobby group, AMA or APTA?
Generally, we like to treat our patients with something other than a medication prescription. So third-party payers would rather send their members to doctors first as well. One visit and some muscle relaxers for that back pain are cheaper for the HMOs. Which is the more powerful lobby group, insurance companies or APTA?
The fear here in the UK is that as private insurers become more powerful, physios may loose the ability to evaluate and treat without a doctor's referral. The Chartered Society of Physiotherapy is all too aware of practice restrictions in the US and does not want that scenario here. If that happens, it would be a shame. It would also be empirical evidence that direct access is about dollars and pounds, not about competency.
One other interesting practice development I learned about at the conference -- physios will be independent prescribers this year. Meaning that after completing appropriate training, they'll be allowed to prescribe medications. That will be fascinating to watch as it develops!
There is a wonderful practice in the NHS of England called "Secondment." The Oxford Dictionary defines it as: A period of time when an employee is sent to work somewhere else temporarily, either to increase the number of workers there, to replace a worker, or to exchange experiences and skills
Essentially one gets to try out another job within an organization for a period of time. It allows people to expand their skill sets and experience whilst allowing management to more efficiently allocate staff and sometimes give a position a trial period to see if it's really needed. It is also a good way to tackle projects that have a limited duration.
This is a bit different from the practice of making someone the "acting _____," which I know from back in the States. Essentially I've experienced that as management's way of saying we need a new person in that job, but we can shove the work onto another without having to provide the appropriate pay and/or benefits. When one is seconded here, one gets the appropriate pay and title for that post.
Secondment is working out very well for me this week. I've just got a post filling in for someone who will be seconded for a year. Who knows what can happen in that time? That person may wind up moving permanently to the new job. With an expanded skill set and experience, that person may then move on to another post. I may be offered another post based on my performance in this role. Lots of possibilities exist! In the meantime, I'm the senior physiotherapist falls specialist for our NHS trust!
Over the years that I've been blogging about my findings whilst working here in the UK, I've had more than a few people state something like, "Well if the care is so good there, why do so many people come to the USA for the best treatment?"
Some people do travel for improved care, that is true. What many don't realize is that Americans also do a fair amount of traveling abroad for healthcare. I've blogged recently about people traveling to Belgium for elective hip replacements. They found markedly reduced costs and equivalent care. I did a little more digging. I found this report from Deloitte on the projections of Americans travelling abroad for their care.
In 2007, there were 750,000 Americans who went abroad for their care. According to Patients Beyond Borders, 900,000 Americans are estimated to seek out healthcare outside the US this year. The amount of information available with a simple Internet search was pretty surprising to me. That an investment company like Deloitte advises on this practice was really startling.
No matter which side of the Affordable Care Act barricades one stands on, it's becoming increasingly clear that the status quo is just not an option. Our system is losing revenue from people going abroad who can afford that option, while those who are too sick, too poor, or perhaps both, require the greatest amount of available resources. Meanwhile the population ages, resulting in fewer people paying into Medicare and more and more people needing the resources it provides. Costs continue to rise and those of middle class means are left to foot the bill.
A huge part of the Physiotherapy 2013 conference discussion here focused on trying to tackle this issue. It was made plain and clear that nobody in health will be able to practice as they have been. Innovation and dramatic change will be required to meet the challenges of the coming years. Does the UK have the answers? No. But they do recognize there will be difficult times ahead and are trying to position themselves as proactively as possible.
Don't like the ACA? OK. What is your better idea?
I've just returned from the Physiotherapy 2013 conference in Birmingham, England. I never thought I would say this, but it's probably the best thing I've done for my career in the past decade. The speakers were inspirational. One of the main themes was combining physiotherapy and public health. There's a real focus in the Chartered Society of Physiotherapists (CSP) on the role of physios in prevention. The CSP is also openly embracing change and innovation in ways of practicing. All in all, it's an exciting time to be a physio in the UK. A little excitement about my career is exactly what I needed!
I'm not ashamed to say, despite my years of ranting against tele-physio as being ineffective and perhaps dangerous, I've changed my mind. A speaker from one of the UK's largest private insurers gave an excellent discussion on proving value for money of physio services. They utilize tele-physio as a way of triaging patients into three different pathways.
The patients who present initially as lowest risk for complication or poor outcomes are given advice and education and then are called back for follow up after two days. If the symptoms haven't resolved or have gotten worse, they then get a face-to-face assessment. He demonstrated how this process has improved access and reduced expense on referrals to specialists and overall spending on treatment with excellent outcomes. Just goes to show that it's best to have an open mind when it comes to healthcare!
I also want to become more involved. I'm going to seek out committees needing assistance. I've made a few contacts this weekend and have sent out follow-up emails. I'm very hopeful for the future and that is priceless.
So I've been back in England a month now. It is good to be home. The work of looking for employment can be more exhausting than simply being an active physiotherapist! Recruitment agency interviews, collecting data on immunizations and titers and such, getting up-to-date CPR certification, and Internet searching... endless Internet searching. At the moment I feel like I should rename this blog "Unemployed PT."
Actually, having only been back a month, I do feel like I've made some real progress. I had an interview on Monday and was offered the post on Tuesday. With the economy being what it is, and the NHS reorganization in full swing, I was very tempted to take the job. There was one problem; I felt it wouldn't be a good fit. The post was work I was more than capable of doing. That made me concerned boredom would set in quickly.
The company has had a lot of bad press recently. I don't believe it's because of how the company operates. I believe it has more to do with the task the government has set out for them to do -- reassess every single person receiving disability benefits in the country to ensure they actually do qualify for benefits. The task alone is likely to generate lots of political controversy.
I've worked for a company that had developed a poor reputation before. We're often told that we're the face of a company and how we behave is a reflection on them. The flip side is also true. Companies that are on our CVs give people impressions about us as well. I thanked the interviewers, who were lovely, and the hard-working recruiter and decided to keep looking.
I have some other irons in the fire, which I won't jinx by going into depth this week. I have the national physiotherapy conference in Birmingham next week to do some more networking. I'll keep you up to date.
By the way, my initial request for reimbursement for travel expenses to the unfortunate interview in England back in August was denied. I've now filed a formal appeal. That may take a while.
I was riding the train to Edinburgh yesterday to visit friends. I picked up a copy of the English newspaper, The Independent, which had a very interesting article on childhood obesity. This topic has come up frequently in the ADVANCE blogosphere. We've discussed New York's Mayor Bloomberg and his "nanny state" tactic of limiting the size of soft drinks most recently. Well, this article from the place most Americans view as the grand-mama of nanny states thinks maybe this topic needs to be rethought.
The British Association of Sport and Exercise Sciences (BASES) supports the idea that fitness and weight are not necessarily dependent on one another. They have published the studies identified in the newspaper. The poor health of the young people today will become the public health problem of tomorrow... unless steps are taken to avert it. So far, it seems there has been little success in mitigating the lowered fitness of UK youth. The government is investing £300 million into primary education to focus on this topic.
Should the US follow suit? Would that investment be better spent in another way? Given today's propensity for seated electronic activity (you're sitting reading this now, aren't you?), will it even be possible to stem the tide of poor fitness?
Update on the complaint issue. The Trust has gotten back to me with an unacceptable response. I'm pursuing a hearing with the national ombudsman. Will tell more when I can.
An interesting discussion has arisen here in the UK regarding healthcare providers and the niqab (the full face veil some Muslim women wear) Prime Minister David Cameron stated that it should not be up to the government to decide what people can or cannot wear in a free society. Deftly dodged, David. He did support organizations, such as schools and others, having a dress code though.
There is no current national guidance on this issue and the debate goes on about it in the NHS. The doctor interviewed for the BBC article stated that she removes her niqab when treating patients, as it is "essential" to their care. Given how much we are taught about the impact of non-verbal communication, I think I agree with her. What about patients who read lips due to hearing impairment? What about security issues? How do I know if someone is really my doctor or nurse if I'm unable to view/recognize her face? I can't verify the face with the badge.
We have dress codes in all areas of healthcare. For example in the trust I worked in, we had to be "bare below the elbows," meaning no watches, jewelry or long sleeves. Even wedding rings with stones in them were prohibited. Plain wedding bands were the only exception allowed. This was to minimize risk of infection. We all had uniforms so that we could be easily identified in our role. We had to give up some personal identity in order to assure patient safety. In this light, I feel the niqab is inappropriate while working in a patient care environment.
What do you think?