Autonomous Practice and Patient Empowerment
As physical therapists (PTs) continue to expand their role in autonomous practice, we must understand our added responsibilities. One issue that we haven't fully addressed is a concern involving the risk of overutilization, which might occur among PTs who are comfortable ceding their own authority to a doctor or a patient. This lack of professional responsibility could put our profession at risk.
Many PTs entered the profession to help others, or because they themselves were helped by PTs. But what exactly does "help" mean? Does it mean relieving pain? Or does it mean improving function? If we have relieved pain without improving function, have we done our job?
APTA, in identifying its 2004 goals, states as Goal 1: "Physical therapists are universally recognized and promoted as the practitioners of choice for persons with conditions that affect movement, function, health and wellness." (1) While decreasing pain may be a means to an end, it is not within our scope to continue treating if there is no appreciable improvement in function.
What do we do with the patient with a shoulder injury who we have seen for 10 visits and only reports 10% improvement in function? Do we send him on? How about the patient with fibromyalgia who loves to get soft tissue work and feels great for a couple of days but then returns about the same? Are we really helping these people to improve their function over time, or are we simply applying a bandage that will fall off once the insurance runs out?
It is very gratifying to have a patient appreciate what you do; to have them compliment your skills. They may say, "your hands come straight from heaven" or "I just don't know what I would do without you." We surely are accomplishing our goals of helping people, right? But when we develop this relationship with our patients, aren't we taking the power of healing out of their hands? When they get another ache, what will they do? Is it possible to establish a plan that enables the patient to manage her symptoms on her own?
Or are we disempowering our patients to build up our own egos?
Robin McKenzie, in the introduction to his book, The Lumbar Spine: Mechanical Diagnosis and Therapy, writes: (2)
Ultimately, do we wish to make the patient feel "better," albeit briefly, or do we wish to offer the patient a means of self treatment and understanding so that there is a strong possibility they will benefit from our services in the long term?
As autonomous practitioners, we have to set goals within the limits of our practice. Decrease in pain is not an adequate goal because it does not address any change in function.
In addition to setting functional goals, our professional responsibility is to make sure those goals are adequately assessed and pursued. Frances Welk, APTA Treasurer, wrote in the May 2004 issue of PT Magazine that APTA defines autonomous practice as "practice characterized by independent, self-determined professional judgment and action." (3) [emphasis added]
Should we then be surprised that insurance companies are denying claims? Our documentation too often fails to provide a clear justification for continuation of treatment. In the plan section of progress notes I often see "per MD discretion" or "continue as planned." If after one month we haven't even reached 25% of our goals, why should we "continue as planned"? Shouldn't we change the plan? Ask yourself: What is in this note that proves to the physician and to the insurance company that this patient is in the right place to adequately heal? What assurance have you provided that indicates he or she will get better with more visits?
Sometimes the best help we can provide is to refer someone on to another health care professional. Sometimes it's best to say, "I know this feels good, but it won't help you in the long run, and that's what we're here to do." Leave the "feel good" stuff for others.
We have earned our right to practice autonomously. Let's avoid getting carried away with our ability to do whatever makes someone feel better, and stick to the task. Any other course of action will only come back to haunt us.
1. "Goals That Represent the 2004 Priorities of the Association" (HOD 06-03-07-09). Available at www.apta.org/About/aptamissiongoals/aptagoals. Accessed November 23, 2004.
2. McKenzie R, May S. The Lumbar Spine: Mechanical Diagnosis & Therapy. 2nd ed. Minneapolis MN: Orthopedic Physical Therapy Products; 2003:4.
3. Welk F. Understanding autonomy. PT-Magazine of Physical Therapy. 2004;12(5):22-25.
Reprinted with permission from The McKenzie Institute® USA
Spineline, 2005, Vol. 9, No. 2
Autonomous Practice-Patient Empowerment.pdf