delicate situation

[Guest guest]

This is a situation that frequently occurs in my area. Those of you who have

instantly answered correctly to stand firm and appear amazed that a therapist

would have difficulty with that concept, must have been blessed with an

abundance of refering physicians and surgeons who are reasonable, understanding

and collaborative. I can say most assuredly that in my area we are not. Drew

eloquently and pointedly maintains that we must only treat effectively with

" proven " effective and efficient approaches. Hear! Hear! Would you please come

down to the Chicago area and begin a carreer educating, training, forcing the

physicians and surgeons ( most notably the orthopods) to do exactly that? I

still see lateral releases performed regularly on teenagers with PFJD! With no

other intervention until failure of the " miracle surgery " which then gets blamed

on the Therapist because " the patient didn't have a 10 degree extension lag when

I saw her! " I see middle aged and seniors who have had multiple epidural

steroid injections for their diagnosed " radiculopathy " that turned out to be a

chronic hamstring tear. " See I told you that if you waited long enough the

injections would work, " are the words I hear when the patients return from their

md (lower case intended) appointment. The most incredulous thing is that these

patients have a long term relationship with these docs ( some social) and blind

themselves with the " truth " they choose to perceive. Now, if you think,

" Chicago is a large metropolitan area, surely Greg's experience is an anomolous

one, " let me say this. I have worked in 19 different hospitals in markedly

different geographical areas as a contract therapist, I have covered half the

city and suburbs in home health, I had a solo, albeit shortlived private

practice, I started one of the first " healthclub based " PT practices in the

early 80's, I have treated chiropractic physician referalls, I worked in sales

and managed a 5 state area selling a " modality " (horrors!). I have been to those

" sports medicine " seminars with World Famous Physicians and then treated their

16 y.o.patients in our clinic (with s/p lateral release). I feel I can say with

authority that while there are 'good' physicians, there are more than enough

truly horrible ones out there with huge practices and even bigger reputations (

not to mention egos) with unethical arrangements with " corporate " PT practices(

who by the way don't take medicare patients so we get them) and these 'horrible'

mds STILL have more perceived credibility than all of your MBA/PhD/MPT/MOUSE

card carrying APTA members put together. Why? Let me answer in the words of my

favorite general surgeon, who asked me this question when I offered to see a

patient of his, with quite possibly the most necrotic, arterially insufficient

wound I've ever seen, " DO YOU HAVE m. d. AFTER YOUR NAME?? " Don't get me

started.

Barrett's point is a good one and the approach we take here is not new (

Ilearned it in PT school in '79) We try to change those needy patients behavior,

gradually over time. Bouts of therapy get shorter, alternatives are gradually

introduced and patients are given permission to feel good in spite of their

malady. Sound like psychotherapy? Maybe, but I've held fast to the words of a

PT professor I had in school who said, " remember talking can be therapeutic

too. "

The newly educated therapist has trouble with this concept. They don't see their

patients as people. They see them as problems because that's what PT school

inadvertantly teaches them to do. Is it fradulent to rub an ultrasound head that

has been disconnected from the running device on a patient that has had 50

previous treatments in another clinic if you don't bill for it?? Maybe, but that

may get you an opportunity to discuss prevention of a return in their pain and

independence in managing their condition so that they can live a more full life!

A martial arts instructor once told me " you can be right or you can helpful,

seldom can you be both. "

Sorry for the run-ons I still have Christmas shopping to do, and I'm on call for

y2k.

Happy Holidays everyone

Greg Znajda PT

[Guest guest]

I have a question for the group. I am a surgeon here in Anytown USA. I recently had a patient come to me seeking to have his appendix removed. I took a complete medical history, examined the patient, performed what I considered to be the appropriate testing, and evaluated the results. My final diagnosis did not support removing the patient's appendix. In fact I found that there was nothing out of the ordinary with regard to the patient at all.

After explaining my findings to the patient, he became very agitated and demanded that I take out his appendix. " What do you care, I really don't need it anyway! Besides, my Insurance will cover it! " I discussed the facts of the case and informed the patient that, in fact, his insurance would not likely cover the surgery because my documentation did not support that intervention. " Well, I don't care! I'm entitled to surgery and if you don't do it, I'll find someone who will! I'm willing to pay our of pocket! "

This man was referred to me by a Physician who refers many of my surgical cases as I do not have a primary care practice. Accordingly, I am of course concerned about alienating this referral source. I'm also concerned about being accused of fraudulently providing services.

What do you think I should do:

-take the appendix anyway, and make a private payment arrangement with the patient?

-do a " sham surgery " and not take anything?

-if the patient goes to see another surgeon who winds up taking their appendix, should I report that surgeon?

I'm very concerned about this because I have seen my surgical cases drop now that I have been applying criteria for appropriateness of surgical intervention. If my cases drop too much, I am concerned I may have to shrink my practice (layoff staff, smaller office, etc.) which is something that I swore I would never do! At the same time, I want to have happy customers and happy payers.

Your feedback would be greatly appreciated!

Dr I. M. Conscientious

General Surgeon (But I'll do G.I. too!)