Physical Therapists and Bloom's Taxonomy

Teachers have used Bloom’s taxonomy since 1956 to organize their work and identify their activities.

Physical therapists teach or train our patients, based on the results of our examination and evaluation findings.

What, then do we teach our patients?

Do we teach them something we learned in school? Read in a book or a blog? Heard on the street? Do we teach something we learned at a weekend course?

Or, do we teach something new? Something we created or discovered?

Bloom’s taxonomy helps me understand my point. I’ll use Bloom’s to illustrate:

The pyramid shows the hierarchy of the cognitive domain (that is, mental skills) in Bloom’s taxonomy – the affective (feelings and emotions) and psychomotor (manual or physical skills) domain are not represented here although they are equally important to teachers.

Since I prefer to think of physical therapy decision making as the most important contribution that I can make to improve my patients’ lives then the cognitive domain is the one that best illustrates my point.

The Cognitive Domain of Bloom’s Taxonomy

Remembering, the earliest and broadest domain, must be mastered before any of the higher domains can be achieved. Examples of remembering are:

1. memorizing the origin and insertion of a muscle
2. stating the physiology of an electric modality
3. memorizing predictor variables for a treatment based classification
4. recall of Medicare minimal documentation standards for outpatient PT

Understanding is ownership of knowledge remembered. Examples of understanding are:

1. Recognizing a dysfunctional muscle or motor performance test.
2. Discussing the findings of a patient evaluation with the patient, PTA or physician.
3. Training a new clinician in your clinic’s Medicare compliance program.

Applying your understanding is the next step in learning. Examples of applying include:

1. Problem-solving the results of the physical therapy examination with yourself or with peers.
2. Choosing a treatment based on the examination results.
3. Writing the examination findings in a note.
4. Illustrate to a new grad PT the intent behind Medicare’s ‘medical necessity for physical therapy’ requirement for treatment.

Analysis is the next step in learning. Analysis looks at the underlying structure of an argument and examines motives for why an argument is proposed. Examples of analysis include:

1. Why are predictor variables useful for a lumbar spine examination?
2. What types of outcome measures can we use to show progress for specific physical therapy patients?
3. What are the pros and cons of treatment-based classification in physical therapy?
4. Questioning the ethical implications of Medicare’s exceptions process to the outpatient PT caps

Evaluating an argument requires the student to take a stand. Some examples are:

1. Defend the medical model of spinal dysfunction.
2. Defend the biopsychosocial model of spinal dysfunction.
3. Argue that the exceptions process to the PT caps create the perverse incentive for physical therapists to deny needed services to Medicare beneficiaries based on perceived audit risk.

Creating a product in physical, written or conceptual form is the final step in learning. Some examples include:

1. Peer-reviewed research reports, case studies, clinical commentary, letters-to-the-editor and book reviews, blog posts.
2. Bulletproof Physical Therapy Decisions website (soon to be a book).
3. PhysicalTherapyDiagnosis.com blog.

There's an old (and somewhat cynical) saying in physical therapy - there are therapists with twenty years experience and there are therapists with one year of experience - repeated twenty times.

Which one are you?

Patients learn what physical therapists learn about them.

Each day is a new discovery.

Every patient is a teacher.

What will tomorrow teach you?

Classifying Physical Therapy, Nuclear Submarines and Cardiac Care Beds

The United States Navy had a problem. It was the early 1970’s and the height of the Cold War.

US Navy submarines were playing cat-and-mouse submerged reconnaissance with Soviet submarines in every ocean around the world. Nuclear submarines ran quieter, faster and longer than older, diesel subs and could submerge to new, record-setting depths. US Navy submariners were among the best trained, most highly motivated military men in the world.

Submariners, however, still got chest pain at the same rate as ordinary civilians.

Navy doctors had to decide, based on clinical findings, if the submariner’s signs and symptoms were serious enough to consider aborting the mission and seeking a friendly port.(Blink - Malcolm Gladwell)

Underwater heart attacks didn’t fare well outside of a hospitals’ intensive care unit.

That’s where Dr. Lee Goldman came in. Dr. Goldman was studying statistical rules – algorithms – that predicted when people were having a heart attack. Dr. Goldman’s rules predicted the occurrence of a major cardiac event based on three predictor variables:

1. Is the patients’ pain unstable angina?
2. Do you hear rales above the base? (indicates fluid in the lungs)
3. Is the systolic blood pressure below 100mm Hg?

Combinations of these predictor variables indicated different treatment options:

1. surface and give away your submarine’s position to the enemy but save your submariner’s life
2. sit tight and monitor your submariner’s vital signs or
3. send your submariner back to work with a bottle of Pepto-Bismol.

Navy doctors studied these treatment algorithms and used them in the care of their sick submariners. At one point, military physical therapists led their civilian cousins using evidence-based medicine in decision making, ordering radiographs and making referrals to other health care professionals.

While the US military lead the way in the early 1970’s in using clinical prediction rules the American health care community responded to Dr. Goldman’s work with deafening silence. (Gladwell)

American Doctors Make a Decision

It wasn’t until 1995 that American doctors began to use decision rules to inform the care of their patients. The best example on record comes from Cook County Hospital in Chicago. (Gladwell)

This 700-bed urban teaching hospital is a century-old, publicly-funded institution that was seeing thirty new chest pain patients per day in its emergency room and 79% of them were getting a full work-up for chest pain.

Patients were admitted to one of two wards for hospitalized chest pain patients:
• eight coronary intensive care beds or
• twelve telemetry-monitored coronary beds.
The coronary intensive beds cost $2,000 per bed per day and the telemetry-monitored beds cost $1,000 per bed per day.

Ironically, only 5-10% of the patients admitted to the hospital suspected of having a heart attack progressed to a full-blown heart attack. The hospital’s problem was that they were spending expensive resources on patients who were not having a heart attack.

The hospital’s chairman of the Department of Medicine, Dr. Brendan Reilly, wasn’t worried about the quality of care – the quality was good. Dr. Reilly was worried about the cost of providing cardiac care to patients who weren’t having a heart attack. He began studying the decision-making processes used by the emergency room doctors caring for patients with chest pain.

Ironically, the initial response from the ER doctors was reluctance and resistance – how can Dr. Goldman’s algorithm allocate intensive care bed space better than ER doctors’ decisions? What about family history? What about weight, sex, race, smoking history, stress and many other factors considered important at the time in the diagnosis of heart attack?

What Dr. Reilly found out was that race, gender and lifestyle factors were less important than whether or not the doctors followed the algorithm. Not that these factors were unimportant in the overall care of the patient – just that the initial decision to allocate the expensive, intensive care bed was better made by adhering to the algorithm, not to the host of factors that, while important, were incidental to the initial decision.

Dr. Reilly studied the impact of using the Dr. Goldman’s CPR in the Cook County ER. He found that the efficiency, the rate at which patients not having a heart attack were sent to inexpensive observation or sent home, went from 21% to 36%. Dr. Reilly also found that safety, the rate at which patients having a heart attack were triaged to coronary intensive care, went from 89% to 94%.

Just as the submariner’s doctor had to make a quick, initial decision that balanced the risk of giving away the submarine’s position with the risk that the submariner would progress into a full-blown heart attack so too did the Cook County ER doctor have to make a decision that balanced the risk that Cook County would spend $2,000 per night for up to three nights on a patient with acid indigestion versus the risk that the patient was having a heart attack.

Classifying submariners was a clinical 'shortcut' that enabled the submarine to stay submerged in those cases that were not clearly a major event. Classifying chest pain patients in Cook County was a clinical 'shortcut' that prevented spending thousands of dollars on people with tummy gas.

Classification as a Resource Allocation Tool

Both the submarine and the cardiac beds examples treat classification as the solution to a resource allocation problem. Both scenarios were prompted by crises of scarcity. Dr. Reilly at Cook County finding fewer public funds to pay for critical care cardiac beds as emergency room admissions rose and the US Navy facing a trade-off between dying submariners and national security.

American health care is facing its own crisis of scarcity as rising rates of per-capita health care consumption, the tidal wave of aging baby boomers and budget constraints on increased health care spending impose resource allocation challenges on increasingly scarce physical therapy resources, like time and money.

Classification, however, is not the appropriate tool for every clinical decision faced by physical therapists. As noted, classification is probably appropriate only for the initial treatment assignment and may not describe the exact treatment to be used. For example, the spinal traction classification is useful in cases of non-centralizing leg pain of radicular origin but the decision rule does not give information as to the parameters of spinal traction: force, total time, ramp time, or patient position.

Classification is probably most useful when one or more discrete alternative treatment possibilities exist, eg: lumbar manipulation or stabilization. Presumably, not both. Classification is probably not helpful in straightforward PT decision-making such as an uncomplicated ankle sprain. There needs to be some risk that making the wrong choice will produce worse outcomes or a less efficient clinical process.

For example, if the Navy doctor incorrectly diagnoses a heart attack and the submarine captain decides to surface en route to a friendly seaport it reveals its position to enemy radar and US national security could be compromised.

The submarine and cardiac beds examples offer illustrations of risk that are far more clear-cut than physical therapists would typically encounter in the clinic. It seems obvious that clinical prediction rules developed by Dr. Goldman and others were utilized earlier in these environments because of increased risk and greater costs involved.

Classification as Diagnosis

The physical therapy profession is currently shifting towards Treatment Based Classification (TBC) using clinical prediction rules (CPR) for diagnostic and treatment decision-making.

Unlike the physician profession, the physical therapy community seems almost uniform in its acceptance and embrace of classification measures as an aid to clinical decision-making. (Gladwell, Groopman in How Doctors Think)

An understanding of probability is required to fully understand the use of statistically-derived predictor variables. For example, the Fear-Avoidance Beliefs Questionnaire (FABQ) is a predictor variable for the manipulation classification while plausible findings like pelvic landmarks and sacroiliac region pain are not predictor variables. How can this be?

The derivation studies that identified the original predictor variables tossed out biologically plausible tests and measures instead showing us the true predictors of patients likely to respond to lumbar spinal manipulation.

Not leg length inequality, not mechanism of onset, not MRI or x-ray findings, not pelvic landmarks or pelvic movement tests. Instead, some surprising findings turned out to show physical therapists who should be manipulated:
1. Time since onset (> 2 weeks)
2. Extent of distal leg pain (not past the knee)
3. Lumbar hypomobility
4. FABQ work sub-scale >19 points
5. No hip ROM asymmetry

If, on average, manipulating your patients is a coin flip (about 50% get better, 50% don’t get better), then application of the CPR improves your chances to 68% for patient who have any 3/5 of the predictor variables. Your chances improve to 95% if the patient has just one more of the predictor variables.

Classification as Probability

Probabilistic decision-making is consistent with the hypothetico-deductive model that is associated with physician decision-making, prescriptive medicine and the patient’s role emphasizing ‘compliance’ over ‘collaboration’. As such, classification seems to shift traditional physical therapist decision making way from its ‘collaborative’ roots.

Will this shift threaten the intimacy that physical therapists have come to treasure with our patients?

Is intimacy sacrificed when decisions are made quickly?

Will physical therapists continue to consider patient-centered factors such as culture, social class, age, experiences and goals when applying clinical prediction rules? Just like the Cook County ER doctors who felt that the chest pain CPR ignored too many important factors in the ongoing care of their patients so too can TBC ignore important aspects that impact the ultimate physical therapy outcome.

Will CPRs allow therapists to quickly deliver routine aspects of care that are best made by statistics, like initial group allocation? Then physical therapists can focus on face-to-face interactions that engage patients’ emotional involvement in their own care.

Classification Success

Nothing succeeds like success and classification has succeeded in capturing the imaginations of educators, researchers and clinicians within physical therapy because of clinical successes and because of several well-designed studies published in prestigious medical journals.

Classification of spinal pain patients has crystallized an incoherent field of data into five or fewer examination findings per group. Classification has revolutionized physical therapy education and empowered students and experienced clinicians to become better decision-makers.

Questions remain:
1. Can classification change physical therapist behavior?
2. Can classification change physical therapy outcomes?
3. Are classification groups mutually exclusive and exhaustive? 75
4. Are some manipulation patients also candidates for stabilization?
5. Can some findings be treated that are not measured by classification predictor variables?
6. Can one patient fit the criteria for more than one diagnostic label?

Is classification good for documentation?

Aside from the risk that classification will change the interaction of patient and physical therapist to a less intimate relationship that is more typical to that of patient and physician I have concerns that classification will be used as a panacea for documentation; the clinical ‘shortcut’ will become a note-writing shortcut that leaves the physical therapist exposed to a Medicare audit because she has not adequately expressed her skilled decision in writing at every follow-up visit.

Why 'Quality' Care is Inevitable

In "Why 'Quality' Care is Dangerous" Jerome Groopman, MD complains the definition of 'quality' is too narrow, eg: only 'quality' that conforms to consensus standards set by Medicare experts is of sufficient 'quality'.

Consensus means measurement of simple clinical procedures that fail to capture the complexity of medical decision-making, such as diabetic management.

But 'quality' in P4P is meant to capture under-treated aspects of big, high-cost drivers in medicine, like why do so many people suffer from lower back pain (LBP)?

For example, pain is the number one reason people go to see a doctor. A simple zero-to-ten pain scale is more sensitive to clinical change than a comprehensive pain questionnaire yet pain is assessed in less than 50% of the clinical encounters in America.

Why?

One P4P quality metric for physical therapists is pain assessment and implementing a plan of care to treat pain.

Lower back pain has passed cancer spending in research dollars and, prior to 2006, small-dollar, high-volume CPT codes for therapeutic spine treatments were growing at over 35% per year.

Another simple problem in medicine:

Why are so many Americans obese?

Obesity, not disease, is the primary driver of disability in America.

Another quality metric for physical therapists is assessment of body mass index.

While Dr. Groopman could, no doubt, cite examples of complexity in medical decision-making involving LBP and obesity the vast majority of these cases are simple diagnoses that relate to lifestyle factors, not exotic diseases.

There's that old saw in medicine: "When you hear hoof beats, think horses - not zebras"

Show Me the Money!

The biggest, costliest health problems in America are not rare diagnoses - the costliest problems are the result of daily choices we make about diet and exercise.

Dr. Groopman is right, P4P simplifies the collection of basic data which may interfere with complex physician and physical therapist decision-making.

But, it's not the complex decisions American doctors needs help with...

We need help with the simple decisions.

Do Physical Therapists Make Decisions Like Doctors?

Anchoring, Availability and Attribution.

One medical student calls these the "3-A Mistakes" so she wont forget how doctors make mistakes.

In How Doctors Think Jerome Groopman, MD describes common cognitive errors that busy doctors make in diagnosing their patients.

Do physical therapists make these same mistakes?

Perhaps I should be more circumspect but I'll follow Dr. Groopman's lead and share with you how at least one physical therapist committed cognitive errors in the diagnosis of a physical therapy patient.

I'm that physical therapist.

Definitions

First, I'll define the terms Anchoring, Availability and Attribution - types of cognitive errors made by all professional decision makers and not unique to medical doctors or physical therapists.

Anchoring - is seizing upon an initial presenting symptom and making a snap judgment about the diagnosis.

My patient was a middle-aged African-American female with leg pain radiating to, but not past, the knee. Many of my patients with radicular leg pain, past the knee, have been successfully treated with lumbar traction.

My anchoring error occurred when I lumped my poor patient into a traction classification based on what I thought was radicular leg pain which I did not investigate thoroughly enough to find that the radiation stopped just above her knee - referred, but not always radicular pain.

I 'anchored' my decision to use traction based on her leg pain, assigning a high probability that she would improve after the treatment,

Availability - is estimating the probability of a diagnosis based on how easily an example of a recent patient can be brought to mind.

As I've said, many of my patients got better with spinal traction - their successes were fresh in my mind. Many on my patients with referred leg pain had initially presented with pain all the way to the foot and, with treatment, their pain had worked its way back up the leg - occasionally presenting as 'leg pain to the knee'.

My cognitive error was simply because I had many other patients who responded well to traction that my poor patient would also respond well to traction.

Because my experiences were mentally 'available' I was able to quickly decide based on a vivid memory rather than actual statistical probability.

Attribution- is similar to Confirmation bias, where information that confirms one's beliefs is highlighted and information that contradicts prior beliefs is ignored.

Since my poor patient had a referral from her orthopedic surgeon that said 'consider traction for lumbar degenerative disc disease' I easily fell into the Attribution bias trap.

I didn't examine every patient characteristic that I normally do and I 'attributed' her leg pain to a pathologic diagnosis based on a reputable source.

I should have known better.

My Poor Patient

Needless to say, my poor patient didn't get better with lumbar spinal traction - she got worse. She could barely stand up when she got off of the table and it took her ten minutes to walk out of the traction room.

What did she have?

She was in a stabilization classification.

Upon further examination, my poor patient had a mild 'instability catch' and a positive prone instability test. See the full classification criteria here (Childs et al, JOSPT, 2007 June).

She is still seeing me and doing well with a stabilization program.

So, now you know my cognitive errors.

Anyone willing to share theirs?

Physical Therapy Diagnosis Redefined

In updating my Facebook page I've rewritten the mission statement for the Physical Therapy Diagnosis blog.

As my knowledge and commitment to my physical therapy patients and practice deepen and broaden through years of study so has my understanding of this blog: it's purpose and it's power to educate and inform go both ways.

Many thanks to those of you who have chosen to respond and comment to my posts - your voices have enlightened me.

Many thanks also to the readers (500 strong each week) who choose to read only - your surfing helps this blog rank well in physical therapy web searches.

Physical Therapy Diagnosis Redefined

Physical Therapy Diagnosis blog is a forum that speaks to the difficulty in doctor-level decision-making for physical therapists.

By 2020, the APTA Vision Statement calls for all physical therapists to be educated at the level of the doctor of physical therapy.

Physical Therapy Diagnosis blog does not assume that today's practicing physical therapists are making daily decisions of sufficient complexity and riskiness to qualify physical therapists for the title of doctor.

Therefore, the format, quality and tone of the content on this blog will be aimed at improving daily decision-making among physical therapists.

Together, let's help physical therapists improve the quality of their decision-making and assume the title of doctor.

Recently, I have been told that I do not have the credentials (eg: DPT,PhD, etc) to undertake such a mission.

That may be so. Please, say so in the comments if you like.

I have also been told that my content is valuable, spot-on and relevant in today's ever-changing health care market.

If you like the content please sign up for the free Bulletproof tutorial below.

If not, thanks for reading.

The Episode of Care that Cost More

Miss Edy still can't kneel down.

She told me today in physical therapy.

Miss Edy has been a physical therapy patient before for short courses of PT that have, thus far, ended with a surgical procedure.

She has, at various times, received therapy for her right hip, knee, low back and neck.

In that time span, she has had her right hip replaced and has had rods-and-screws implanted in her spine.

Her complaint was always right knee pain and an inability to kneel.

She never had hip pain.

She never had back pain.

She can kneel on her left.

Pathology Persuades

Miss Edy is convinced that her surgeons did a great job on her hip and back but she is perplexed why she cannot kneel on her right.

Kneeling is a skill.

Kneeling can be taught.

Physical therapists often need to ask their patients , specifically,

"Can you kneel?"

The OPTIMAL scale specifically asks patients, "Can you kneel?".

Did Physical Therapy Fail Miss Edy?

Why did each of Miss Edy's courses of PT end in surgery?

Did the surgeons, armed with her impressive MRIs, push the surgical option too hard?

In our fee-for-service system, they had every incentive to do so.

Did Miss Edy have too much faith in technology?

Did she have low self-efficacy?

In Search of a Better Model

I have taught students and new graduates the importance making decisions by the rehabilitative model instead of the medical model.

Sometimes I get blank looks.

Sometimes I get rolling eyes.

Sometimes I get "Tim, it's just too theoretical for daily decision-making!"

But, when I still hear physical therapists saying "We need to put a little ultrasound on your shoulder for the tendinitis", I know they have abdicated their diagnostic decision-making in favor of the physician's diagnosis.


Patients hear enough of that - they need to hear a unified message of hope from physical therapists.

"You can do it!"

An Epiphany

I was never taught a disablement model. I graduated from PT school in 1992 and I learned about Nagi in 2001 when the Guide to Physical Therapist Practice was delivered to my doorstep like an extra phone book.

I dutifully read it.

I learned about Nagi's framework which has since segued into the ICF framework seen above.

How do PT decisions relate to Miss Edy and the cost of her episode of care?

I wonder if the entire episode were managed with her chief complaint in mind?

"I can't kneel down."

How much would it cost?

Would she have been saved from two major surgeries?

This image shows the payment model that distinguishes between our current system and some alternatives:

• fee-for-service (yellow)
  
• episode of care
  
• Condition-specific capitation (aka: risk-adjusted global fees)

Get the Report here and view some physical therapists discussing the alternatives here.

$100,000 dollars later, Miss Edy still can't kneel down - but now we're working on it.

Do you make doctor-level decisions?

One of the missions of this blog is to help physical therapists make better decisions diagnosing and treating your patients.

Physical therapists aim to be doctor-level decision makers but what are the differences in how physicians and physical therapists decide?

Are there similarities, too?

What are they?

This chart shows the process physicians use to decide which Evaluation and Management (E/M) code to bill.

There are three components to the physician encounter used in decision-making:

1. History
   
2. Examination
   
3. Medical Decision Making

Note that physical therapists use this same process in the initial evaluation.

History is composed of...

1. History of Present Illness
• location
  
• severity
  
• timing
  
• et al...
  
2. Review of Systems
• constitutional
  
• musculoskeletal
  
• neurological
3. Past Medical, Family and Social History

Same old, same old

So far, you and I do this every day, right?

The Examination

The examination focuses on Body Areas and Organ Systems - the more the physician examines the higher she can code.

Physical therapists usually examine back (spine), extremities, neck, maybe the abdominal body areas.

We examine 'cardio', 'musculo', skin, 'neuro', 'resp' and constitutional organ systems.

Physicians examine more areas and systems than do physical therapists and can perform 'detailed' or 'comprehensive' examinations in this part of the process.

Medical Decision Making

Three 'grids'are presented:

1. Number of diagnoses or treatment options
   
2. Amount and/or complexity of data reviewed
   
3. Risk of complications and/or morbidity or mortality

Physical therapists consider many treatment options and possible diagnoses but our limited ability to order sensitive testing and further diagnostic procedures hampers our scores on these grids - in my opinion.

Show Time

I used a 'typical' physical therapy LBP patient and went through the process - answering the questions physicians have to answer for each new (or established) patient.

History	Detailed
Examination	Expanded, problem-focused
Medical Decision Making	Moderately complex

Additionally, 'face-to-face time' may be used to determine the level of service.

One-on-one anyone?

Take Home Message

Many physical therapy lumbar evaluations may qualify for a Level 3 or 4 E/M code, if physical therapists were allowed to bill like physicians.

Take a look for yourself - do you make doctor-level decisions?

'Fancy Theory' in Physical Therapy

Outpatient physical therapists don't often deal with life and death issues.

We may help patients with...

• back and neck pain
  
• walking difficulty
  
• stiffness
  
• sports injuries
  
• balance problems

...to name a few.

We make decisions, however, that affect patients' quality of life based on their self-reported activity limitations and their performance on standardized tests and measures.

That's why I was surprised day-before-yesterday (March 5th) when I gave a presentation to a class of Physical Therapist Assistant students and I mentioned the International Classification of Functioning (ICF).

I described the ICF disablement model as THE most important decision-making tool in my practice.



I got some blank stares.

I have heard other, experienced physical therapists describe disablement models as "too theoretical" for day-to-day decision-making.

Physical therapists' decisions are often made independent of the physicians' diagnosis and may not immediately impact a patients' pain.

This is where the ICF helps me.

Diagnosis and Prognosis

The physician may send the patient with a request for ultrasound (a technique).

The patient may show up in my office expecting a massage.

I may examine the patient and find the underlying cause of her dysfunction and decide that ultrasound and massage are irrelevant to the patient's long term goals.

For example, I examined a marathon runner this week with left lumbar and hip pain at rest and right knee pain while running. Previous treatments had focused palliative modalities on the left hip region. My examination found a stiff right hip (non-painful) and lumbar hypermobility.

I treated the right hip, explained to her why right knee ultrasound and lumbar massage would not be expected to help and asked her to return Friday.

She was quite a bit better and is running a 5k on Saturday.

My physical therapist assistant students listened intently to my story and jotted down the reference for review of the ICF.

Is it just me?

I came upon disablement models later in my career (2001) and I am still impressed with their elegance.

They have simplified my day-to-day decision-making and clarified my treatments.

My mission is to train PTs and PTAs to explicitly use the ICF to make decisions.

It's not just another fancy theory.

Hopefully new grads and students, with training that I never had, will segue into their careers using disablement models as a matter of course to improve patients quality of life.

It's not life or death but the ICF does make a difference.

Is Medicare compliance related to clinical competence?

Bulletproof Decision Making started out as my own professional exploration of Medicare chart compliance for my private practice physical therapy clinic.

(note: you can sign up for Bulletproof at the bottom of this page)

I wanted to make a better compliance plan for my Medicare charts and notes.

My starting assumption was that good clinical documentation is completely related to competent clinical decision-making.

It is not.

Good clinical documentation today (2009) is all about dotting your 'i' s and crossing your 't' s.

What I learned

In early 2009, I paid a Medicare auditor $1,000 to come in and examine my charts and comment upon my compliance program. As you might expect, the auditor was able to find many 'deficiencies' in my charts.

I realized then that, to be helpful to other private practice therapists, Bulletproof needed to be about physical therapists' decisions driving treatment, documentation and compliance.

Why do physical therapists' decisions matter to Medicare?

Within a few short years, physical therapists may track their patient outcomes using remote data-gathering technology such as e-mail, web-based forms and CAT testing.

Patients could enter their own data.

This should reduce the 'information asymmetry' that has led some insurers to refer to physical therapy as a 'black hole' into which money disappears.

Currently, 52% of physical therapists do not use outcome measures which means that payers have no information showing if their beneficiaries got better, or not.

Electronic, standardized outcome measures will provide information on patient functional progress as well as initial and ongoing medical necessity for physical therapy.

Who are the Doctors?

Expansion of physical therapists' ability to serve as front-line health care providers means that the complexity of physical therapists decisions will determine the extent and intensity to which those services can be billed.

Physical therapists will bill like physicians.

Currently, physicians use Evaluation and Management codes (E/M) , that one day I hope physical therapists will use.

Payment to physicians is based on the following:

• an extended patient history
  
• detailed, multi-systems exam
  
• number of diagnoses
  
• complexity of decision-making
  

How do compliance and competence relate to each other?

Bulletproof is a resource that prepares physical therapists for the day when our decisions drive practice: when the frequency, intensity and need for physical therapy are derived from our physical therapy diagnosis.

The duration of physical therapy will be derived from the physical therapy prognosis.

I eagerly await the day when a Medicare audit of my charts is based, not on my handwriting or my chart templates, but on my decisions and on my clinical competence.

Physical therapists still get to decide!

I want you to get the message from this new Medicare Transmittal 1678.

It came out February 13th, 2009.

Scroll to 'page 9' - find the new text (usually in red).

Here you will find the following:

"There are a number of sources that suggest the amount of certain services that may be typical, either per service, per episode, per condition, or per discipline."

The Transmittal references the Computer Sciences Corporation (CSC) Therapy Cap Report and the Edit Tables.

What are these reports?

CSC mines Medicare data to help government analysts understand their own data.

Then, since you and I pay for this data, they make it public.

Transmittal 1678 is the first time Medicare has specifically referenced these CSC reports to give physical therapists guidance on how much therapy to give our patients!

For example, this table (zipped file) says that, on average, Physical Therapists in Private Practice (PTPP) charge four (4) Therapeutic Exercises every session and that the range is 4-6 units.

How much Therapeutic Exercise do you do? More? Less?

Wait!

Shouldn't the physical therapist decide, based on findings from the evaluation, how much therapy the patient needs?

Why are governement bean counters in green eyeshades deciding for physical therapists how much therapy to provide?

Because we let them.

You decide.

If you go over (or under) the statistical ranges in the CSC reports you need to show why your patient needs more (or less) than the average amount of therapy.

Why are you different?

Are you better?

If you are then show it! Say it! Measure it!

Use new measurement tools to show Medicare the numbers - they love numbers!

Use validated outcome measures to show need and progress.

Who gets physical therapy?

Physical therapy happens between your patient and you - not in Washington DC!

I want you to get the message - you decide.

Motion

Motion.

The new brand statement of physical therapy.

The package is slick, comprehensive (tone?) and stylish.

I like it, but...

Is motion a technique?

Not a decision?

I prefer to think that my special skill is physical therapist decision-making.

Massage therapists and athletic trainers can provide motion techniques.

Still, we need to own a piece of the consumers' mind in this competitive market.

Motion is where the consumer already positions physical therapists.

So, let's run with it.

Do you like it?

The Audacity of SOAP

SOAP notes hinder good physical therapy documentation.

SOAP notes began in the 1950's as part of the Problem Oriented Medical Record (POMR) for physician decision-making.

SOAP has been implicated by many authorities as hazardous to physical therapist decision-making.

Imagine this scenario: 

A big, fat hospital chart with specialty information: 

• internal medicine
  
• orthopedics
  
• cardiology
  
• gasteroenterology
  
• physical therapy
  

...all represented in one chart.

Clipped to the front of the chart is a single sheet of paper with the (in)famous acronym: S.O.A.P.

The doctor, whatever her specialty, needs to see the patient and do the following:

• establish the reason for the visit (S)
  
• take measurements (O)
  
• arrive at a medical diagnosis (A) and
  
• establish the plan of care (P)

Do physical therapists need to make these decisions - each visit?

*****

Do physical therapists make the same decisions as medical doctors?

SOAP hinders physical therapy notes because physical therapists make different decisions than medical doctors.

Daily, physical therapists need to assess and measure patients' activity and participation levels and make decisions based on the measurements.

For example...

"Today, I can't walk as far as yesterday because the bad weather has swollen my knee and hip joints"

Because her medical diagnosis is chronic knee osteoarthritis you decide to measure her knees and you find increased swelling, due to the weather.

You decide to alter her plan of care - instead of exercise today you want to use modalities.

You decide to recommend a cane, during the period the knees are swollen - to prevent falls.

Will your SOAP note support your decision-making?

Many authorities don't think so.

Is it time to ditch SOAP?

Do physical therapists need a proprietary clinical note-writing format?

Can physical therapists diagnose depression?

Mary began crying in physical therapy the other day.

Tears streamed down her face as she told me the story of her automobile accident and her subsequent attempts at recovery.

She told me how difficult work and school had become - sitting and studying were too painful with whiplash and headaches.

Sleep was interrupted by pain and she got up every morning not rested, with dark, red circles under her eyes.

"I just can't go on like this", she said.

Physical therapists treat chronic pain patients whose somatic symptoms may contain an emotional component.

Physical therapists can consider the whole person when we assess the patient and we can screen for depression by asking two questions:

1. "During the past month, have you often been bothered by feeling down, depressed or hopeless?"


2. "During the past month, have you often been bothered by little interest or pleasure in doing things?"
   

These questions are taken from the Primary Care Evaluation of Mental Disorders Procedure (PRIME-MD) and are referenced in Physical Therapy Journal (December 2004 Haggman et al).

In The Cultural Context of Depression by Robert J. Hedaya, MD asserts:

"...depression is rapidly becoming the second leading cause of disability in the world."

Physical therapists treat disability using, primarily, physical interventions (eg: exercise, manual therapy, modalities, etc.).

If we try to treat problems that are emotional with physical interventions we risk making the conclusion that our interventions are ineffective.

It may be appropriate to refer our patient to a professional with training and credentials to treat depression if our screening tests are positive.

Mary answered yes to both of my evidence-based screening questions. I called her primary care physician who arranged for a referral to a physician specializing in depression.

Mary is continuing physical therapy with concurrent management of her depressive symptoms.

Does depression affect physical therapy outcomes?

I've not seen the literature that quantifies the effect of depression on physical therapy outcomes but the prudent clinician should bear the depressive diagnosis in mind when designing a restorative plan of care.

Physical therapists can diagnose the link between depression and Mary's activities:

• sitting
  
• studying
  
• sleeping

...by using a decision-making framework like the International Classification of Function (ICF) disablement model.

	ICF descriptor	ICF code
Body Functions
	Pain in Head and Neck	b28010
	Regulation of Emotion	b1521
	Psychomotor control (agitation)	b1470
Activities & Participation
	Maintaining a lying position	d4150
	Maintaining a sitting position	d4159

By studying the outcome of Mary's therapy health policy-makers will understand the impact of depression on physical therapy outcomes overall.

Adding depression to 'risk adjusted' outcome models prevents the mistaken belief that physical therapy treatments are ineffective for patients like Mary.

Adding depression to the model assumes physical therapists can assess the condition initially.

I think we can.

It all begins with your diagnosis.

Do You Understand Physical Therapy?

"Do you understand?"

"Does that make sense?"

You might think I'm asking you about Obama's new health care plan.

I'm really showing you how I speak to my physical therapy patients every day as I explain their diagnosis and ask for their 'buy-in' for their plan of care.

What I'm actually doing is asking many of my patients to make commitments to lifestyle changes that take their money, attention and time.

Patients with arthritis, hip replacement surgeries, sports injuries and car accident victims all depend on an accurate physical therapists' diagnosis.

Head nods are nice but I need commitment to get patients to adhere to their home exercises.

I'm asking my patients to commit to action-plans that I have made based on my decisions in my physical therapy diagnosis.


What's a Physical Therapy Diagnosis?

Doesn't the doctor do that?

The doctor makes the diagnosis, orders therapy and the therapist follows the orders, right?

Maybe.

What if the diagnosis is "Low Back Pain" (a symptom, not a diagosis) and the orders are "Evaluate and treat"?

Then the physical therapist needs to make a decision.

The physical therapist needs to make a diagnosis.


Different than the Doctor?

The physical therapist may arrive at her decision differently than the doctor.

Ian Edwards, an Australian physical therapist, studied clinical reasoning strategies in physical therapists.

Clinical reasoning strategies are...

"...a way of thinking and taking action within clinical practice."

Edwards was able to divide reasoning strategies into two groups:

1. Diagnosis


2. Management

Diagnosis was further divided into two groups:

1. Diagnostic reasoning - linking physical impairments to disability (see the ICF model)


2. Narrative reasoning - listening to patient 'stories', beliefs and cultures.

Management was divided into six groups:

1. Reasoning about procedure - selecting interventions.


2. Interactive reasoning - establishing patient-therapist rapport.


3. Collaborative reasoning - setting patient goals and progression of activities based on consensus.


4. Reasoning about teaching - assessing the patient's receptivity to and understanding of the therapist's findings.


5. Predictive reasoning - 'envisioning future scenarios with patients', eg: getting better.


6. Ethical reasoning - ethical and practical barriers to achieving all of the patient's goals.

What's the point?

Physical therapist decision-making can also be divided based on its intended purpose:

1. Treatment


2. Documentation

Physical therapists, I believe, treat their patients using the following of Edward's reasoning strategies:

• Narrative reasoning


• Interactive reasoning


• Collaborative reasoning


• Reasoning about teaching

Physical therapists document their findings and write their notes and charts using the following of Edward's reasoning strategies:

• Diagnostic reasoning


• Reasoning about procedure


• Predictive reasoning


• Ethical reasoning

The physical therapist's diagnosis is important for the patient's final outcome. Make the wrong diagnosis and the patient doesn't get better.

The physical therapist's notes and charts are important for legal and audit protection, accurate reimbursement, peer communication and patient progress.

Make the wrong decision while writing in the chart and the therapist doesn't get paid, or worse.

Do you understand?

Does that make sense?