Re: Outpatient 30 minute evaluations ???

[Guest guest]

Why are we trying to set a preset limit on eval time for all diagnosis? That

means you give the same eval time to an 18 yo post-op knee menisecotmy as you

would to a pusher CVA with multiple cardiac issues, dizziness and aphasia who

just happened to have a tib/fib ORIF. In some cases that short time is justified

and others longer time is justified. Why not give the patient the time that

patient deserves for their issues? I don't see this so much as a finding red

flag issues but simply time to administer 2-4 functional tests could take that

long and longer in the complex patient. (it is more than ROM and strength) Also

don't forget some insurances want you to fax in your eval the Day of the eval or

at least prior to the second visit. You better have your 2-4 functional tests

and measures done on that first day so you can reference back when you need to

show progress. It comes down to giving the patient the quality time they deserve

for their specific circumstance. We all need to keep in mind that not all

physical therapy is outpatient and not all outpatient is orthopedic issues.

Carl Grota, PT

Sturgeon Bay WI

Re: Outpatient 30 minute evaluations ???

I don't know , if what you state with regards to lack of time spent during

an evaluation increasing the likelihood that you will miss something as so much

of our professional development takes place, or should take place, outside of

patient care. If you don't know how to identify non mechanical low back pain

then it won't matter how much time you spend. If you are aware of the CPR for

identification of DVT potential then this can be assessed almost before you

actually see the patient but if you are going to pop the patient up on the

stationary bike before you have even looked at his chart (believe me, it

happens) then no amount of time is going to save you, or him, from yourself.

Time vs likelihood of missing red flags, would make an interesting study.

E s, PT, DPT, OCS, FAAOMPT

www.douglasspt.com

>

> Armin,

>

> I actually agree with quite a few of your points. Chief among them, you

> have a point with respect to the erroneous association of time spent with

> patient and quality of service. That said, I find it interesting, that

> it's usually the same therapists making this argument that make similarly

> erroneous association between years of experience and the quality of the

> services that they provide, or the value of experience against the DPT,

> residency, or fellowship programs. Afterall, it's not the years of

> experience that matter, but rather the quality of experiences contained

> within those years . . . 20 years practice isn't all that valuable if it's

> the same year over and over again. My point is that therapists tend to set

> their bar of acceptable professional practice at just below what they

> themselves are doing (saves the time of actually doing true professional

> self-reflection I suppose), but it's rarely truly in the optimal interests

> of the profession or the patients we serve.

>

> You are more than correct that, " We typically get paid for " time " provided,

> rather then for " results obtained " , a big mistake of our acceptance - in my

> opinion. If thats the case we can't get mad when we get compared to massage

> therapists or personal trainers! " I couldn't agree more, but the fact is

> that it DOES take some measure of time to complete a quality evaluation,

> and the shorter the time of that evaluation, the greater the CHANCE that

> something potentially sinister gets missed. At the very least,

> silent culprit impairments that better explain the noisy victim patient

> complaint are overlooked --- resulting in an inarguable compromise to

> efficiency of care at best, and quality of care at worst.

>

> I can promise only this . . . you can be an acceptable therapist for most

> patients doing 30 minute evaluations, but such a therapist simply can't

> know what he or she has missed, both from a MSK perspective and a medical

> referral perspective. That therapist may have never seen a AAA causing a

> patient's back pain, or weak hip abductors that contributed to the

> patient's inability to react and avoid the plant-and-twist and valgus force

> that resulted in an ACL injury --- but I PROMISE that the shorter an

> evaluation, the more likely those sinister pathology and silent

> MSK culprits are to have seen the therapist (e.g. they existed but the

> therapist simply missed). I'm sure there are therapists out there thinking

> " Hey, I do 15 minute evaluations and I caught a (whatever) last week. " To

> those therapists I say, " Congratulations, you were lucky, go buy a lottery

> ticket on the basis of one true positive you found, and don't worry about

> the x number that you missed. "

>

> All of this is to say . . . you've peaked my interested with the " Love

> affair with writing goals, " statement, and I would welcome you opening a

> new thread on that topic . . .

>

> M. Ball, PT, DPT, PhD, MBA

> Carolinas Rehabilitation, Orthopaedic Physical Therapy Residency Faculty

> NorthEast Rehabiltation, Staff Physical Therapist

> Phuzion Institute for Physiotherapy Education, President

> cell:

>

>

>

[Guest guest]

,

Your comment piqued (but didn't peak) my interest.;-) There's a lot of opinion

and belief in your statements below which is surprising given how our profession

has put aside such subjective viewpoints to fully embrace evidence and facts

instead. Pursuing your aside relative to experience levels and clinical

competency, the clinician with a high experience level but no advanced degrees

may be a clinician who constantly pursues self improvement and education and

looks at each day and each patient anew and afresh with the curiosity of a

child's mild and the diligence and precision of a highly trained scientist.

Such a clinician as Gregg from Steamboat Springs, CO comes to mind. His

consumate clinical skills have propelled him to the apex of our profession and

have even engendered widespread national and international interest in his work

such that he is opening clinics on the opposite side of the country from his as

well as two clinics in India and one in Japan. Here is an example our

profession can emulate, both from a clinical practice perspective and from a

business perspective. International expansion is one topic that hasn't yet been

explored on this board. On the other hand, a clinician with less experience but

with multiple advanced degrees could be stuck in a pedantic rut, obsessed with

rules and numbers and unable to implement outside-the-box and non-linear

thinking and somewhat bereft of the artistic expression inherent in our craft.

We can only safely make such statements as you made in your first paragraph

about the relative virtues of experience and education based on facts and

evidence, not on opinions, beliefs, personal biases, hearsay, etc. To do

otherwise would be disingenuous.

Returning to the subject at hand, it may be interesting to pursue some research

as to optimal evaluation times for various conditions, regions, systems, etc.

There is obviously an optimal time of intervention for each type of individual

and each situation and anything short of that potentially yields insufficient

information and data to reasonably cover all contingencies whereas anything

beyond that winds up being simply a waste of time and money. If we were in a

military triage situation, I think most competent clinicians could nail down the

essential problem within a few minutes. In civilian life in a non-emergency

situation with the spectre of medicolegal implications hovering over us and also

wanting to establish that all-important rapport with the patient at the first

visit, I tend to be overly generous in allotting time for the initial

evaluation. In that way, I'm thorough, unstressed, and have more than

sufficient time to fully address all the patient's problems and concerns, even

in complex cases. Hearkening back to a recent topic on this board, sometimes

matters as seemingly unrelated to physical therapy as the patient's nutrition

can have major implications. I've personally picked up problems ranging from

Vitamin A toxicity causing osteogenic pain and muscular weakness to Vitamin B6

toxicity causing peripheral neuropathy to consumption of raw cauliflower and

broccoli with their goiterogenic effects causing thyroid induced myofascial

pain, etc., all of which were overlooked by medical practitioners and all of

which would have been missed with less time to investigate the full spectrum of

the patient's musculoskeletally related health issues. Time devoted to the

patient doesn't necessarily translate into quality but progressively less time

devoted to the patient progressively raises the risk of compromising quality of

care.

Most assuredly, we face the difficulty of being accurate and efficient with our

evaluations and measurements of what needs to be measured versus putting a

number on absolutely everything, a path of action which can easily become

dehumanizing and can lead us to drift from functioning with the humanity of our

patients in mind to becoming dutiful, number generating robots, obediently

working for an all encompassing, money-making machine put into place by our Wall

Street/banker controlled and driven economy. Productivity and profitability

obviously have their place but when they are gradually being forced down your

throat to the exclusion of all else, there comes a time when one must speak up

and act or suffer the consequences and be slowly suffocated. I wouldn't be

surprised if Lynn's comments on ACOs relate to this matter. Whenever

large, powerful, and connected monied interests, whether private or government

or the combination of the two (otherwise known as fascism), tell you they are

doing something for your safety or benefit or for your patients' safety or

benefit, you can be almost certain that there is a price to be paid and a

carefully veiled agenda that is self-serving for those interests.

, PT, OCS

Re: Outpatient 30 minute evaluations ???

Armin,

I actually agree with quite a few of your points. Chief among them, you

have a point with respect to the erroneous association of time spent with

patient and quality of service. That said, I find it interesting, that

it's usually the same therapists making this argument that make similarly

erroneous association between years of experience and the quality of the

services that they provide, or the value of experience against the DPT,

residency, or fellowship programs. Afterall, it's not the years of

experience that matter, but rather the quality of experiences contained

within those years . . . 20 years practice isn't all that valuable if it's

the same year over and over again. My point is that therapists tend to set

their bar of acceptable professional practice at just below what they

themselves are doing (saves the time of actually doing true professional

self-reflection I suppose), but it's rarely truly in the optimal interests

of the profession or the patients we serve.

You are more than correct that, " We typically get paid for " time " provided,

rather then for " results obtained " , a big mistake of our acceptance - in my

opinion. If thats the case we can't get mad when we get compared to massage

therapists or personal trainers! " I couldn't agree more, but the fact is

that it DOES take some measure of time to complete a quality evaluation,

and the shorter the time of that evaluation, the greater the CHANCE that

something potentially sinister gets missed. At the very least,

silent culprit impairments that better explain the noisy victim patient

complaint are overlooked --- resulting in an inarguable compromise to

efficiency of care at best, and quality of care at worst.

I can promise only this . . . you can be an acceptable therapist for most

patients doing 30 minute evaluations, but such a therapist simply can't

know what he or she has missed, both from a MSK perspective and a medical

referral perspective. That therapist may have never seen a AAA causing a

patient's back pain, or weak hip abductors that contributed to the

patient's inability to react and avoid the plant-and-twist and valgus force

that resulted in an ACL injury --- but I PROMISE that the shorter an

evaluation, the more likely those sinister pathology and silent

MSK culprits are to have seen the therapist (e.g. they existed but the

therapist simply missed). I'm sure there are therapists out there thinking

" Hey, I do 15 minute evaluations and I caught a (whatever) last week. " To

those therapists I say, " Congratulations, you were lucky, go buy a lottery

ticket on the basis of one true positive you found, and don't worry about

the x number that you missed. "

All of this is to say . . . you've peaked my interested with the " Love

affair with writing goals, " statement, and I would welcome you opening a

new thread on that topic . . .

M. Ball, PT, DPT, PhD, MBA

Carolinas Rehabilitation, Orthopaedic Physical Therapy Residency Faculty

NorthEast Rehabiltation, Staff Physical Therapist

Phuzion Institute for Physiotherapy Education, President

cell: