Are Physical Therapy Students Risk Averse?

Do physical therapy students always choose the safe alternative?

Does $100,000 in debt cause students to vote for the status quo?

Do physical therapists and students feel so much anxiety over health care reform that they prefer to vote for short-run self-interests over long-run investments?

Outcomes measurement linked to physical therapist reimbursement was the subject of the 2012 Oxford Debate at the Florida Physical Therapy Association Meeting (FPTA) in Daytona Beach. The students and physical therapists in the room - about 400 - mainly voted against using these measures for payment.

I question if students, in these changing times, are prepared to put the interests of their patients and their profession ahead of their own interests. I can't really blame them. I was a student once, too. The future is uncertain and scary.

This student-led decision was reminiscent of the American Physical Therapy Association's (APTA) 2011 Annual Conference in Washington DC when a student-dominated audience voted against Clinical Decision Rules.

Oxford Debates pit two teams arguing contrary positions. Each team "wins" by persuading the audience to cheer, make noise or physically move from one side of the room to the other. The side with the most supporters wins the debate. Most Oxford Debates handle serious topics in a fun environment. Drinks are usually served.

This convention was well-attended by students, many of them from the University of St. Augustine. The student-dominated audience split about 60/40 against using patient outcomes to reward physical therapists.

Inadequate risk adjustment seemed to be the main reason outcome measures should not be used, according to the speakers and the audience. In other words, the measure would ONLY capture the outcome of care which might depend on factors other than the therapists' effort and skill.

For instance, if the patient does not do their home exercise program they will tend to have worse outcomes than if they do their exercises. Older people with multiple diseases will usually have worse outcome scores at baseline and at follow-up than younger people without disease.

We've recently heard similar arguments in the Chicago teachers' strike when school teachers objected to being paid based on the standardized test scores (outcomes) of their students. The teachers argued that many factors that affect test scores are beyond their control. Paying teachers based on test scores was unfair since many of the determinants of teacher performance happened outside of the classroom.

A physical therapy student at the Oxford Debate noted that the most important determinants of health also occur outside the physical therapy clinic. These determinants are things like the following:

• family and social support 
• a positive outlook 
• educational level 
• addictive behaviors, such as cigarette smoking 
• level of activity

Young people are typically more tolerant of risk, according to standard economic thought. They have more years to make up any financial loss so they're supposed to be more willing to accept risk.

However, I think these students' behavior is rational.

Instead of pushing physical therapists and students to accept a reimbursement system that puts us at risk let's design a system that lets us think about patient care rather than worry about money.

What do you think?

"Stealing" Patients from Physicians, Part 1 of 3

Right now in America, most physical therapists accept referrals from physicians for conditions like simple ankle sprains and lower back injuries.

What if I told that soon, physical therapists will "steal" these patients from physicians' caseloads?

And, physicians will thank us for stealing their patients.

How can we do that?

How can physical therapists steal patients from physicians and get a big "Thank You" in return?

By following Clayton Christensens's "rules-based medicine".

Rules-based Medicine

"Rules-based" medicine is described in Harvard professor Clayton Christensen's Innovator's Prescription (2011)



Professor Christensen describes a clear process by which professions inevitably transform their bodies of knowledge upon which they are built from an art into a science.

Rules-based medicine is the "technological enabler" that physical therapists need to "steal" physician market share

"Work that was once intuitive and complex becomes routine, and specific rules are eventually developed to handle the steps in the process.  

Abilities that previously resided in the intuition of a select group of experts ultimately become so explicitly teachable that rules-based work can be performed by people with much less experience and training... 

The term "technology" that we use here refers to... mathematical equations (algorithms)...  

However, at the heart of this evolution of work is the conversion of complex, intuitive processes into simple rules-based work, and the handoff of this work from expensive, highly trained experts (physicians) to less costly providers (physical therapists, nurses, physician assistants, etc.)."

Clinical decision rules are available now which can help physical therapists diagnose the following patients BETTER than the unaided physician:

• acute stroke in dizzy patient
• foot fracture in trauma/sports patients
• ankle fracture in trauma/sports patients
• knee fracture in trauma/sport patients
• pneumonia in community-based patients
• spinal fracture in older patients with lower back pain
• cancer in patients with lower back pain

"Stealing" market share may be an uncomfortable concept for private practice physical therapists who have been accustomed to close, collaborative relationships with family physicians.

The primary argument against Direct Access legislation is that patient are not safe to see a physical therapist without a physician referral.

"Stealing" Patients from Physicians, Part 2 of 3 will discuss who is currently "stealing" market share from our physician colleagues.

They are getting GREAT outcomes and making money, too.

The Art and Science of Physical Therapy

The 2011 Oxford Debate at the APTA Annual Conference in Washington DC pitted clinical decision rules - algorithms - against clincial intuition. You can see some of the debaters coments here.

I wrote, at the time, that this was a false choice. Algorithms and intuition can BOTH be used by the physical therapist to improve patient outcomes and speed the clinical workflow.

It's not an either-or decision. The question is WHEN to use the algorithm and WHEN to use your intuition.

A recently published systematic review by Henschke to diagnose spinal fractures provides an example of HOW physical therapists can use algorithms and intuition together.

I included Henschke's original decision rule in my new book, Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting due out January 15th, 2012.

Henschke's new rule was also recently posted to PhysioPedia in a page titled Subjective Exam - Diagnostic Strength by Brian Duffy, Carleen Jogodka, Jeff Ryg, James White of the Evidence in Motion Fellowship program.

Henschke's New Rule to Diagnose Spinal Fractures

Henschke's rule to diagnose spinal fracture in a low risk setting provides physical therapists a unique opportunity to use their clinical intution.

Clinical Decision Rules are usually intended to provide probabilities confirming a diagnosis or predicting an outcome so the physical therapist can make clinical decisions with confidence.

Henschke's rule screens patients for vertebral fractures without the use of expensive and overly sensitive diagnostic imaging. This rule may be employed in two different settings: low risk primary care offices or high risk emergency rooms. The setting determines the pre-test probability, or prevalence.

Here is Henschke's new rule:

• History of major trauma
• Pain and tenderness
• Age < 50 years
• Female
• Corticosteroid use

The base rate of vertebral fractures in a population of 1,172 patients accessing primary care for treatment of lower back pain in Sydney, Australia was 0.5%. Primary care in Australia is defined as offices of physicians, physical therapists and chiropractors.

Low Risk Decision Rule
Screening Finding Present	Likelihood of the Diagnosis
1 present	1% chance of a spinal fracture
2 present	7% chance of a spinal fracture
3 or more present	52% chance of a spinal fracture

The base rate of vertebral fractures in patients accessing the emergency room and specialty physicians’ offices for treatment of lower back pain in Sydney, Australia was 3.0%.

High Risk Decision Rule
Screening Finding Present	Likelihood of the Diagnosis
1 present	5% chance of a spinal fracture
2 present	32% chance of a spinal fracture
3 or more present	87% chance of a spinal fracture

The predictive power of the decision rule varies with the setting in which the clinician sees the patient – high risk patients seen in specialty clinics had a higher prevalence of spinal fracture. The new rule is the same in both settings.

The physical therapist's intuition is especially important in the LOW RISK situation when three or more of the subjective variables were present. In this situation, the clinical decision rule returns a probability of 52% favoring the diagnosis of vertebral fracture. The rule, in this situation, barely performs better than chance.

A physical therapist flipping a coin could do just as well in predicting a spinal fracture (~50%).

In this situation, the physical therapist should rely on their clinical intuition. Intuiton might include additional data points from the physical therapy evaluation, including:

• the patient's history
• subjective pain complaints
• physical examination
• special tests 
• other pathology screening exams.

Also, a medication list, cognitive status and input from family members could add useful data points that might increase or decrease the probability of a fracture.

This example is meant to demonstrate WHY physical therapist intuition is still important, combined with first-pass screening algorithms that supplement human memory for low-frequency events. In these situations, the use of clinical intuition and experience supplements the algorithmic decision rule.

Henschke's rule to diagnose spinal fracture is a useful algorithm for screening high risk patients in the emergency room.

In the low risk setting, such as an ambulatory PT clinic, the rule requires that the physical therapist remain alert to subtle cues that might affect the diagnosis.

Henschke's rule demonstrates clearly how your diagnosis requires both the art and the science of physical therapy.