"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Friday, November 26, 2010

Can You Put a Number on Physical Therapy?

One of the most popular Simpsons episodes ever - MoneyBART - succinctly describes the struggle between intuitive and algorithmic decision making in physical therapy.

(video length 2min 50sec.)

This struggle, catapulted to prominence in 2002 with the publication of Flynn's manipulation rule, is not unique to physical therapists.

Physicians, too, resist the influence of decision rules and adhere poorly to clinical practice guidelines.

Physical therapists share some commonalities with physicians in that we overestimate our ability to access medical knowledge relevant to the patient, to screen for low-frequency events and to apply effective treatments while mitigating the use of ineffective treatments.

MoneyBART captures what I think is one of the drivers for the low utilization of evidence-based decision rules (including treatment-based classification). This driver is captured in the struggle between Lisa and Bart.

Lisa argues for numbers and statistics - the "brains" of the algorithmic, "computer logic" behind treatment based classification - while Bart argues for his "gut" - the intuitive, naturalistic basis for pattern matching traditionally employed by physical therapists.

Plot synopsis: Lisa becomes the manager of Bart's Little League baseball team even though she doesn't know anything about baseball ("Go kick a field goal, Bart!").

To learn about baseball, Lisa turns to a team of statisticians who meet to discuss sabremetrics at Moe's Tavern. Using this brand of statistical baseball analysis, Lisa begins winning games and Bart complains that she has taken the fun out of the game. Bart gets kicked off the team after disobeying Lisa's instructions to walk off a pitch and hits a home run, winning the game.

Lisa eventually makes the city championship and she asks Bart to come back because she needs Bart to pinch run from first base. He agrees to help but again disobeys her management and tries to steal all the way home. As Bart makes his move, Lisa calculates the odds as being vastly against him but, instead of being mad, comes to love the thrill and excitement of the game. Bart is tagged out at home, losing the game and the championship, but Lisa thanks him for showing her how to love baseball as a game.

In fairness, I've made some simplifying assumptions that physicians and physical therapists resist clinical decision support (CDS) because of personal factors ("It takes the fun out of the game") when, in fact, clinicians are professionals who may resist the "top-down" management of complex doctor-patient interactions they perceive as limiting.

Physicians typically not trained, incented or supported for using evidence-based decision rules. The rational response, then, is not to use them.

But, we do have good evidence that safety and efficiency, from high-quality impact studies, are both improved when algorithmic decision making replaces intuition.

Does that take the "fun" out of the game?

Medicine isn't Little League so, if we're going to play, let's play to win.

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Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

"Make Decisions like Doctors"

Copyright 2007-2010 by Tim Richardson, PT.
No reproduction without authorization.

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