This week’s “Treat Me, but No Tricks Please,” article in The New York Times has elicited a wide range of emotions throughout the profession – and probably more emails to my inbox on any one topic than I’ve received in recent years. While many of you are angry at the suggestion that some treatments employed by physical therapists are not backed by evidence, others are thrilled that the profession’s efforts to become more evidence-based were noted.
Somewhere in the middle, I think we can all agree on one thing: evidence is imperative, but it must be combined with the unique clinical knowledge and skills of a physical therapist. As I point out in a letter to the editor of The New York Times, evidence alone cannot help a patient heal. With the best available evidence at hand, a health care provider must use his or her own clinical judgment and assessment of a patient’s needs to develop a plan of care.
This is true across all health care professions. It must also be noted that the responsibility to practice based on evidence does not fall to our profession alone. Studies have indicated that less than 50 percent of all current health care interventions have evidence to support their use. Fortunately, the body of evidence has grown exponentially in recent years, including the research in physical therapy.
As we all know, physical therapist researchers are actively involved in contributing to the body of research to determine the effectiveness of physical therapy for various conditions. APTA supports and is reinforcing evidence based practice through many initiatives. We support physical therapist research and work to translate available research into clinical practice through a variety of tools and documents, including an evidenced based journal, the development of research based clinical resources, an online summary of research pertinent to physical therapist practice and the development of an electronic database (Research Match) that can be used by clinicians and researchers to form collaborations to conduct studies that will answer clinical questions. In addition, APTA recently convened researchers and clinicians to develop strategies to improve the integration of research into clinical practice and to help researchers respond to the most important questions to study.
For those of us who have been interviewed by a reporter and then see the result of that interview in print, we are sometimes painfully aware that we cannot control what is ultimately published. In hindsight, I know Dr. Irrgang wishes he had chosen a different word than “voodoo” to describe treatments not backed by science. He also didn’t intend to describe all of physical therapist practice in this manner. But my friend and colleague Dr. Irrgang and the Orthopaedic Section should be commended for the evidence-based initiatives they are undertaking that were featured in The New York Times article.
As researchers and clinicians well know, there is a lot more to the story. Ice and heat, for instance, might not be sole treatments for an injury, but they can be effective in helping manage pain and swelling to enable a physical therapist to enlist other techniques directed at the clinical problem.
I know there are many APTA members reading this blog who are still angry and are having trouble finding a silver lining in this article. Perhaps the sting will be lessened a bit by taking a look at the multitude of comments following the article – more than 180 last time I checked, and the vast majority from patients who are praising the benefits of physical therapy. I encourage you and your patients to add your comments to The New York Times Web site.
I’d also love to hear your thoughts on this blog.
Friday, January 8, 2010
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42 comments:
While the underlying premise of this article caused me to cringe, I couldn't help but be grateful for it. The ignorance of the author and the interviewed physician served as strong reminders that the perception of physical therapy in society can be lacking (to say the least). And, it is these negative perceptions that should motivate us to participate in evidence based research, improve our professionalism, upgrade our skills, and initiate community involvements.
I usually try to find time to look at the health section of the NY Times as it usually has good topics for patient education. I was highly offended by Gina Kolata's cavalier use of voodoo. Reading the comments from patients who were so positive about their experiences with PT.
I am also pleased that APTA leadership responded to this article. Thanks for the PR!
In a sense, the APTA has created a conundrum for consumers and practitioners of physical therapy by moving toward the consistent use of the term "evidence-based practice." Every time I see that term, I wonder if patients think "what's been going on all these years in PT if it's just recently becoming evidence-based." My experience with many excellent physical therapists' has shown that education and research must go hand in hand with clinical experience. It is the marriage of both that equals the effective therapy that heals our patients. Sadly, there are PTs and PTAs in practice who are simply going through the motions. It is up to us as professionals to encourage the best of both worlds and wean out those who permit the word "voodoo" to even be used when referring to our practice.
Marla Steiner, PTA, MS
What was so alarming about the NY Times' article, was that it exposed the truth that we are not entirely what we say we are. Truthfully, there are two physical therapies in our profession. There is: 1. the care we provide to motivated patients. With them, palpation skills and evidence-based practice carry the day.
2. But what of those patients for whom poor motivation to exercise is the root cause of what brought them to our attention in the first place?
Rather than mis-label part of our practice as "voodoo", perhaps we should accept, and teach that we do a lot of motivational psychology with our patients. We smile, coach, plead, cajole, coerce, and criticize, all in an attempt to motivate the patient to do what we know needs to be done. Can we measure the effects of that "soft science" in evidence-based practice? Nope. Does it work? Seems to. We are not physicians administering chemistry and we shouldn't portray ourselves as such, as was exposed in the article. Therapists are fundamentally different from physicians in two ways. 1. We work entirely with what exists in front of us. We add nothing tangible such as meds or implants. 2. We work with the logical and emotional sides of the brain. Should we work to eliminate modality-only practice and become evidence-based practitioners? Of course, but in our rush to become doctors of movement dysfunction, we seem to have forgotten and to have ignored that art of motivational psychology, without which our skills are so much dust. If we pretend that's not in our "bag of tricks", then we deserve the publicity that we get. -Brendan Armitage, PT
Unfortunately Dr. Irrgang did not realize that when speaking with a reporter, one must be extremely careful in one's choice of words. He also was probably unaware of Ms. Kolata's previous writings which have caused the NYTimes major retractions, not to mention her other pieces that chronicle her passion for running and ignoring her pain and then dealing with a stress fracture. The woman has a huge bias and Dr. Irrgang did not take this into account and spoke rather naively, not understanding the power a reporter has in turning your words around. You can say what you want about the positive dialogue this has generated, thats not the point. The point is that when a reporter clearly is questioning and denigrating an entire profession, we expect our leadership to respond in a meaningful, serious way, not to use language that can get thrown in our face and taken out of context.
I am a first year DPT student with a marketing undergrad.
The consumer feedback in and around this article is consistent with my own experience and perception once upon a time. And as we all know (evidenced by frustration and surprise that PT's expressed about the article), perception IS reality.
My point in writing is: in pursuing change in the public perception of physical therapy (which I believe is at the core of the issue here), are we treating symptoms or the pathology?
As a DPT student I can say that I'm aware of how important changing public perception is, and of the huge effort being put into that change.
As a marketing student I can say a lot, but none of it matters. Only consumer sentiment matters.
As a consumer I can say: my "once upon a time" ranges from 8 to 20 years ago while current consumers have the very same to report.
The NYT Comments section is closed but the thread has been picked up at...
http://www.tothecenter.com/news.php?readmore=12098
...by a retired physician who advocates 4 visits of PT following THR.
This physician is highly educated and demonstrates high self-efficacy and expects all of her patients (even those depressed and fearful) to be the same.
Try to go and comment to her 'opinion pieece' and defend physical therapy from those who profess to know better.
Tim
timrichpt@physicaltherapydiagnosis.com
www.physicaltherapydiagnosis.com
Although I am not that surprised to see an orthopedist supported attack on physical therapy, one however would have much higher expectations for Hospital for Special Surgery physician, as featured in the article Joseph Feinberg.
Much bigger issue is Dr. Irrgang's interview. I was terrified to learn that he is a PRESIDENT of APTA Orthopeadic Section. If he does not step down on his own or is impeached I will seriously reconsider being a member of this section.
How can you say that what we do is to teach patient a few exercises, stretches that they can do at home or in the gym and that is all we can offer? Well, maybe Dr. Irrgang does. If so I am really sorry for his patients and students. In my practice I use whole array of physical agents (including extremely effective - supported by evidence- class IV laser) as adjunctive treatment to inhibit pain, inflammatory response, whole variety of manual therapy techniques (including high velocity thrust - evidence supported, again) to help remodel soft tissue and influence it's tension with spine segment or peripheral joint mobility restoration and also to facilitate postural awareness and proper body biomechanics. My patients mostly exercise on their own by I frequently modify their programs to achieve adequate response. To call manual therapy "massage" and say that patients can just learn a few exercises that they can do at home is outrages. I know that they are therapists out there who practice "touchless" physical therapy and act as overpaid technicians with no real skill or compassion for the profession but so there are out there "butcher" surgeons and do-not-ask-a-question-I-know-better physicians. I do not want Dr. Irrgang to represent my profession. I want him to step down and apologize to fellow therapists and their patients who, based on his interview are just a bunch of idiots who waste money on ineffective "voodoo" treatments.
I found Gina Kolaitis' article very short sighted, incomplete and with a closed mindedness that that is frightening. She as much as indicted an entire profession based on personal experience and lack of evidence regarding modalities. I have 3 disturbing issue relating to the Gina Kolaitis article:
1. In dealing with the art and science of caring for people with dysfunctions which may be treatable by physical therapy we know that "one size fits all" doesn't work. That is exactly why we do an examination and then an evaluation of our findings. A person with a shoulder impingement syndrome may be treated in a variety of ways, all depending on the results of the examination. There may be evidence that demonstrates that certain guidelines are best for treatment, but it all must be matched to the individual being treated. Treating a 68 year old with impingement is very different than treating an overhead athlete with the "same diagnosis". Certainly, treatment of many sports injury hamstring strains may be similar, but there can be a variation of muscle imbalances between individuals that require a variation of or quite a different treatment. We know that people can have different responses to the same stimulus - for osteoarthritic pain, one person may take Tylenol. another Advil and yet another Aleve. Do we say that the Tylenol worked and the others were placebo or do we understand that there is individual variation?
2. Ms. Kolaitis stated that PTs use modalities as time fillers, time wasters and to increase revenue. Where are the facts here? Has anyone told her that in NY no insurance pays for heat or ice and the reimbursement for e-stim is negligible. It can cost more to have a PTA set up heat and e-stim than the reimbursement received. And while I am on reimbursement - what is up with this $150 treatment. In NY, the average reimbursement for a treatment is about $60 (range from $27 - $100). Most PTs in private practice in NY have seen a 30% decrease in reimbursement in the past 15 years.
3. If Ms Kolaitis is so evidence based, why did she undergo a controversial treatment such as platelet replacement therapy. Practice what you preach!
I think the response to the NY Times article was incomplete at best. It basically said we need to improve on what we do- basically agreeing with the article. We need the public to know what OTHER skills besides modalities Physical Therapists use- manual techniques, muscle re-education, proprioceptive activities, etc... and maybe, just maybe, the writer went to a facility that has their PTs see multiple patients, allowing little time for one on one instruction. Or maybe the PT that the writer went needs to re-evaluate his/her skills. We need to show the public what we CAN do, based on research. Very, very poor and weak response.
Rachel Miller
ProAction Physical Therapy
Let's face it....as long as their are PTs who lack basic science skills, believe in energy medicine, practice Reiki and bill manual therapy codes, and think that MFR is gonna cure your restless leg syndrome, we are going to get this kind of criticism.
The article reminded me of an article in Wall Street Journal about 15 years ago- about a "bad back meeting 10 or 15 physical therapists". It negatively portrayed our profession and evoked in me the same passion I felt all those years ago... What we need to do is help the general public distinguish between good physical therapy and bad physical therapy. Everytime we are interviewed for any article we have an opportunity to shed a positive light on PT on what we do. The use of the word voodoo was a bad choice and of course taken to the extreme by the author. There is no intervention that we provide that could be perceived as voodoo- no matter how poor the treatment is. There are so many great physical therapists out there who do what they know to be best for their patients and they achieve very successful results. Let's give the public guidelines for finding good therapy out there, how to avoid those 20 session traps that go nowhere. Let's train our students better.
The evidence is limited, I agree. But it is limited for so many factors. You know how difficult it is to obtain funding for research, then we factor in the ethical issues involved in placebos or control groups. How do we treat these patients and give them the best possible interventions in the shortest amount of time and conduct studies at the same time?
I am not sure how I feel about ultrasound, phono, ionto or estim - but heat and ice do make patients feel better while they are recovering, they do not cure the problem, of course. What heat does is create a more relaxed patient, perhaps, to allow for soft tissue or joint mobilizations. Ice may help cool things off after a rigorous treatment. Does it matter? We don't charge for heat and ice anyway (at least we do not at this facility).
When I see a patient and spend a few minutes talking to them and taking a history, I may put my hands on them and learn how they like to be touched, if at all. I cannot necessarily prove this with research. I may tell them to trial heat and ice at home and let me know if it is helpful. I then guide them on when and how much to use it.
Healing people with chronic or even acute musculoskeletal conditions is not cut and dry. There is a whole interconnected system of muscles, bones, fascia, ligaments, lymph, circulation, etc..... Within minutes of an injury-- EVERY SINGLE system gets involved. You just can't test the effect of one intervention on one impairment and call it valid and reliable. That would be missing the point on treating the whole person. Who would pay for that?
Yes, we need more evidence. But we also need to let the insurance companies and world know, it is not that simple. Let's find a way to eliminate the therapists who are making a mockery of our profession. Let's find a way to prove that looking at the whole person is really what's best in rehabilitation. Putting our hands on people. Feeling them out. Holistic medicine. Can we combine that with some of our more concrete approaches? Pretty soon insurance companies will be paying for all sorts of holistic interventions and PT will be left in the dust because we are being bullied into believing that without concrete evidence it is voodoo.
First, there is nothing positive to come from that NYT article, no matter how many ways one spins it. While I agree with the fact we need more evidence based practice, I do not think is behooves us as a profession to imply to the public that most of what PTs practice does not have strong research behind it. From a PR standpoint to suggest to a reporter that some intervention is "voodoo" or to agree that patients should be seen 2-3 times than D/C to a HEP is terrifying. Yes insurance companies and Medicare are constantly looking to cut our reimbursement, if they haven't already, and we as PTs will have to become more practical. But, to give these same companies even more fuel to keep cutting reimbursements by stating in an NYT article that we should be treating patients for less visits, by the president of the orthopedic section, does not help our profession. The fact that a person in an elected position would freely submit answers to an article with such a lack of foresight is not acceptable. While some people are of tremendous benefit to our profession as researchers or educators, this does not mean these same people are great at handling PR for our profession. If one is unable to understand the ramifications of what they say and is unable to represent the profession in a positive light regardless of the situation, that person should not be speaking for our profession.
There is a large faction of PTs in the community who feel that it is justified to say all practice should be evidence base or not done at all. And while this statement has merit, it is an ideal standard that we should be working toward as a profession, within the profession. But to demean the profession in its current state, in public, at the cost of meeting this ideal, only hurts our profession.
When we feed at the trough of third party reimbursement, this is what we should expect. When a third party is paying the bill then they have the right to ask if what they are paying for has value. Hence, all the attention on evidence based practice, outcomes and so on. We are trying to prove our worth to the third party payer to ensure we get our piece of the reimbursement pie.
If our patient was the payer, then it wouldn't really matter what evidence said. The patient would decide - was what they were paying worth it to them, on a personal level? All this jumping through hoops that we do now would go away. The best PTs would thrive, the weaker ones would not.
Let's face it...much of what ails our profession (and in health care to a substantial degree) comes from living in a third party payment system. It is called "moral hazard" in economic terms. Presently, the provider and patient have little incentive to control cost or utilization. They payer enacts draconian cost control measures as a result. Providers are put in a bad position of having to squeeze productivity standards in order to make it. This is not a good system.
And here we are, left fighting among each other. The attention is always on our "ethics" meaning basically are we following the rules of the payers. What about the ethics of doing what is right for the patient?
I am most disappointed that APTA did not come out in support of health care reform proposals that would have placed more emphasis on individual responsibility and individual control of health care decisions. We are going more and more in the direction of third party control, whether it is insurance companies or government. We are basically giving up our professional autonomy in the process.
This NYT article is just a symptom of the larger problem.
The NYT article specifically addresses the author's running injury and the poor physical therapy treatment he received. Our article, An Evidence-based Approach to the Orthopedic Physical Therapy Management of Functional Running Injuries, specifically addresses many of the issues that the author attacks. This was submitted just last week to OPTP. For review and publication.
The article by Ms. Kolata made it seem as though our profession was not really a profession but rather and industry. Her book "Ultimate Fitness" clearly, and most of the time accurately illustrates, the fads that exist throughout the fitness industry. Having read the large majority of the text it is clear that she turned her attention to health care and after receiving an email from a physician decided to write an article that essentially equivocated fitness fads to the use of modalities. Where she made a mistake is by not investigating our profession as a whole and how honest & self aware the profession is.
Ms. Kolata sees herself as a *truth detector* and instead of looking to our profession as a valuable resource in the war against fitness fads and the improper execution of exercise programs decided to denigrate the profession to a short list of modalities. At the heart of the discontent w/ her article is the plain and simple fact that she fails to grasp that PT is a profession, requires a high level of skill/eductation and completely omitted the professions work in other practice areas that help people regain function following stroke, joint replacement, amputation etc.
I too am very disappointed in the professional response to the questions she posed to our elected leaders. Soo much of what we have done has been to reduce cost and enhance the quality of patient care. The profession is working towards refining what and how we provide and that should have been a central theme in the article.
Ms. Kolata clearly cherry picked a handful of diagnoses and a few modalities for the purpose of diminishing the profession. Even if as fellow therapists you agree that more research needs to be done and that modalities should be used sparingly the belittling of our profession by a reporter who failed to grasp such basic information should be rebuked.
Dr. Irrgang stated: "I would not be surprised if most physical therapists responding to Ms. Kolata’s article only found out about the Section’s guidelines when they read her article and in that light I think she has done a service to the profession."
and
"My interactions with Ms. Kolata have lead me to consider that the Orthopaedic Section should create information summaries for consumers that summarizes the clinical practice guidelines – that is what works and does not work for their condition in terms that they can understand."
I applaud activities which will provide greater access to and understanding of the value and evidence of physical therapy.
The APTA Board of Directors was charged by its House of Delegates many years ago to develop an interactive consumer web portal. While I am assured we will see one someday it is hard to overlook the APTA has not yet done so and has fallen far short in positioning the profession optimally for consumers and health policy makers.
The APTA must promote the value of PT in terms of patient outcomes as well as the cost effectiveness and safety of PT as compared to other interventions such as surgery, medication, and advanced imaging.
Most professional societies issue press releases and time releases of practice guidelines to reach broad audiences. The APTA and Ortho Section have not effectively done so to date. I am hoping this NYT article will accelerate the process.
Douglas M. White, DPT, OCS
Dr. Irrgang, where are these guidelines of which you speak? I have just been to the website of the Orthopaedic section, and I find nothing. Not even a mention of them. Is it that one has to be a member to access them? If so, is that helping the profession or the section?
The repeated use of the word 'voodoo' unnecessarily offers our professional competition a leverage point with legislators, regulators, insurers, and can unwittingly introduce skepticism among the consuming public.
I would have much rathered the discussion focus on evidence-based approaches vs. non-evidence-based approaches and the strides our profession is taking to ensure our patients are treated with the maximal skill and clinical reasoning.
And *if* the 'voodoo' modalities are, in fact, voodoo...then the APTA should take steps to refuse advertising dollars from the makers, distributors, and educators who gain from advancing these treatments.
Health-Care-For-Profit motives have and will continue to sully the waters of PT - encouraging focus on revenue streams rather than optimal care. We've all seen it or heard about it. Regardless, Dr Irrgang's statements were thoughtless especially considering his elected position. His lengthy "spin" does not change that and an apology and resignation are due. What we do works and, as evidenced by the overwhelmingly positive patient responses, our patients know it as well. We are involved in a healing art and that cannot be overlooked (or go unsaid)- a multitude of emotional and psychological factors as well as genetic variation which cannot be measured by simple studies affect patient outcomes. Dr Irrgang truly missed the mark in not reframing the questions that were asked and needs to stay away from the media.
I do not agree with the notion that because we have some "miracle" therapists out there we have to accept being called voodoo workers. Every single health profession has "miracle" healers out there. Are all physicians professional, skilful and make no mistakes? If you believe so you either have never had health problems nor you examine and listen to your patients. PTs are people and PT people are being people like any other group of people with "strange" individuals being part of this group like any other large enough group out there. Why do we have to try and be perfect as a whole if it is not possible? There are excellent, good, average, bad and just plain ridicules PTs, physicians, politicians, mechanics, etc. We have to stop beating ourselves and except the fact that there have been, there are and always will be bad PTs out there, as much as there are bad surgeons, musicians, managers and even Presidents out there. But that does not mean that our profession is voodoo work based on water. We also need to stop beating ourselves over lack of sufficient evidence with some things that we do. Science is science and practice is practice. If we do not know how something works not necessarily that it should not be a part of our practice. Many studies have conflicting results. Many studies are poorly designed. Many studies are plainly biased. Orthopedists themselves did a research study on arthroscopic debridement for knee osteoarthritis. The results indicate that there is no benefit to it, yet it continues to be one of most commonly performed procedures out there. How many MRIs of patients with back pain bring any value to clinical management of these patients? How many times and for how long "epidurals" work for back patients? Is mechanism of antidepressants as many other medications understood?
How many patients are given antibiotics for viral infections? We are talking about billion dollars worth treatments here, which work part of the time and can give patients fatal side effects including death - like antidepressants for example. In this light debating effectiveness of electrical stimulation with moist heat as a preparatory treatment for manual therapy and therapeutic activities with its reimbursement value is almost ridiculous. How many patients get sick from electrical stimulation and how many patients would like to have their tissue or spine mobilized without any prep? Not that many and it is at the fraction of a cost of other big ticket medical procedures that are much more questionable and can actually do harm - like unnecessary CAT scans, for example. I am all for research study and making our profession better, more efficient and reliable but we just can not be enslaved to research studies alone since they are not 100% reliable either. That is why we are clinicians and our job is to correlate our findings with our own empirical evidence, available scientific evidence, and patient's unique needs to apply most appropriate interventions which we feel comfortable with and then monitor the process for effectiveness. Cognitive reasoning - if you will. And this is what we should be mostly paid and recognized for. Skilled PTs put it all together, as one of my patients said. Why should I go see an orthopedist and a chiropractor, and a massage therapist, and a personal trainer if you can do it all for me in one comprehensive package? In this light direct access makes all the sense for public. Otherwise we are just mere technicians at the mercy of physicians and scientists, who are not worth the money that we make.
Very well said Adam! I make the same point regularly about PT's consolidating good clinical information, research and individualizing it to the patient instead of having them run all over town to several different professionals. I hope more professionals will see this as a wake up call and get involved within their communities about the substantial role physical therapists can play in improving their lives in terms of function and fitness.
I commend Dr. Irrgang on his overall stance. While some of his comments may have been misconstrued my the author, this article piece sheds a new light on the profession and makes us look introspectively at what we do. This is not a time to become defensive about constructive feedback. It is time to question ourselves and really take a look at our individual practice patterns, to make sure we can justify what we are doing through research or at least clear concise scientic thought processes. Some will like what their self evaluation reveals, and some may not. But your self evaluation needs to be true. Whatever we do, we can't cross our arms, lean back, and get in that defensive position as if someone is attacking us or what we do. We are in a physical therapy practice. It's called a practice because every single day we treat should be spent trying to get better and more effective. If you are doing the same thing today for that patient with low back pain that you did two years ago, five years ago, whatever the time frame is, pick one, you must really look at yourselves and ask if you are trully living up to that word of "practice" and looking at the evidence.
Dr. Irrgang, Dr. Delitto, and their group at the University of Pittsburg have created much great evidence and his institution has brought about the likes of Dr. Fritz, Dr. Hicks. All important contributers to the research in our field. He has worked diligently in the arena of ACL rehabilitation along with significant research in other areas of physical therapy. He certainly has the right to impress upon us that, that we need to make sure our practice is based on evidence. To comments regarding if recent push to push towards evidence based practice suggests we have not been using evidence based practice in the past, the truth may be a hard pill to swallow. But the past is the past, we need to look at what is going on presently and how we can improve the future of not only the field of physical therapy, but the future regrading the care we provide our patients.
This piece in the NYT gives us a fantastic opporunity for growth as a field and as individual practitioners. But, if we become defensive and put our heads under our proverbial shell, or stick our head in the sand to pretend questions and efficacy of what we do exist, we will never continue to grow to meet the potential of the very intelligent people that make up our field. We will continue to languish in complacency thinking what we do must be effective because in general, our patients like us. We need to think of some faults our practice pattern may have and not deal with them as a weakness, but an area for improvement/development. All you supervisors out there, think of your performance appraisals with your staff. Strengths, and areas for improvement. You take measures to continue making sure your strengths grow, and you set goals to work on your areas that need improvement.
President Irrgang, as an elected official representing the APTA and our profession, should have responded with our best interests and those of our patients. He should have promoted our profession showing how we could treat injuries. It was an opportunity that many of us don't get to demonstrate just how affordable and beneficial physical therapy is. Instead he created confusion among the public and medical community. We are cheap healthcare. We prevent surgeries every day. We get people back to work and life. Instead, President Irrgang threw us under the bus to promote his agenda.
What is the responsibility of an elected official in the APTA if not to promote Physical Therapy at all times?! When sworn in as President of the Orthopedic Section was there a statement about not undermining the profession? As an elected official you are held to a higher standard. You are accountable for everything you say at any time, especially to the media. Your reckless behavior has hurt our profession.
Your response here Mr. Irrgang is nice, but the damage has been done. The response here is private. There is no taking it back from the millions of patients, doctors, government committee members, and lawyers.
Already I have received one letter from a local orthopedic surgery group. The letter included a photocopy of the NY Times article with one of our scripts stapled to it. On it was written some mocking remarks. I practice on the west coast. The damage is that far reached.
This was an epic failure in promoting our profession. I am in agreement that a formal letter to the NY Times apologizing for your remarks and a resignation from your post are in order.
amir burstein, M.A., PT.
no one will argue that more scientific substantiation of one's clinical practice is always desirable.for ANY profession.Dr. Irrgang's comment :" are there randomized trials to demonstrate the effectiveness of orthopedic surgery?" - perfectly hits the spot re. the effectiveness of ANY profession.
He clearly needed to make that (or similar) comment to Ms. Kolatta. however, without getting into the appropriateness of Dr. Irrgang's exact words to the reporter, just judging by the article makes it clear Dr. Irrgang should have considered his words much more carefully than he did.words such as voodoo are, by definition, derogatorily - laden, & he should have kept to himself his (negative)criticism of how well the P.T profession substantiates its clinical practice.
I'd suggest the APTA consider assigning someone experienced, highly academically & clinically qualified withing the profession to write & submit an op-ed (rebuttal) article to the NYTimes.
in it, they should give a wide - range review of what the profession has been doing in the area of scientific research & substantiation of clinical practice &its dissemination in PT's education. if well written, such an article would go a long way towards bringing the public (at least the readership of the NYTimes)up to the date on PT & its far - reaching, positive, NOT RANDOMIZED - contribution to high quality, effective health care.
@Anonymous 1/12/10 9:13 AM, as well as any others who are wondering:
The Orthopaedic Section guidelines are published in JOSPT and are available open-access on the web at www.jospt.org. You can find the heel pain guidelines referenced in the article at http://www.jospt.org/issues/articleID.1407,type.2/article_detail.asp
Guidelines on neck pain (http://www.jospt.org/issues/articleID.1407,type.2/article_detail.asp) and hip pain (http://www.jospt.org/issues/articleID.2324,type.1/article_detail.asp) have also been published, and as Dr. Irrgang mentions, more are to come in the future.
I find it surprising that leadership in the APTA uses terms such as "voodoo" to describe common treatments in physical therapy. It is precisely behavior such as this that limit physical therapists ability to practice physical therapy. When the general public hear certain physical therapist preach that some aspects of physical therapy "don't work" or are based on "voodoo science" they assume that ALL physical therapy does not work resulting in limited visits and decreased interest in physical therapy. Actually, every modality that we use has the ability to "work". Now, is it the modality or the skill and interaction of the therapist and patient that "works"? How do you separate the 2? How do we define "work"? In my education, I did not study any "cures" that were available to physical therapists. My education stressed evaluation, plan of care, documentation and it was the "ART" that was gained through clinical experience that would guide treatment philosophy. I hope that physical therapist will stop the bludgeoning of our profession. We should support physical therapy and not chop it down.
Stuart Jones, DPT
APTA appreciates the thoughtful, professional debate that has unfolded here. That’s precisely what this blog is for!
APTA would like to make readers aware that The New York Times has published several letters related to the article you’ve been discussing. Unfortunately APTA’s letter wasn’t published. However, the author’s physician has written in to defend physical therapists and the author herself has responded as well.
Dr. Joseph H. Feinberg’s response includes the following:
“Physical therapists are uniquely trained to restore function, improve mobility, relieve pain and prevent or limit reinjury.”
Gina Kolata’s response includes the following:
“I appreciate the clarifications from physical therapists. In my column, I did not intend to cast aspersions on an entire profession but instead to ask what sort of rigorous clinical trial evidence supported certain physical therapy treatments for common sports injuries.”
Click here to read these and other letters in full.
Instead of callin it "vodoo treatment"....you should have said that PTs do way too many visits on patients.... that way you really could have given the insurance industry ammo to finish off our profession.
What an unfortunate article that was. It was obvious to me that the author had some poor experience with PT. She implied that PT was ALL about hot packs, ultrasound and ice. And maybe a few basic exercises and simple massage. We all know that is simply not true. We all know that there is plenty of evidence for our profession and that it improves every year. And we all know that the art of our profession is every bit as important as the evidence. But unfortunately the author's bad experience and biased attitude have reached a far wider audience than we, as individuals have access to. Yes, there was overwhelming support for PT in the comment section but what about all those readers who don't have any experience with PT? It's time for us to do some damage control. We may not have the ears of as many people as the NYT but if we can each reach out in our own way, in our own communities hopefully we can educate the general public to truly understand and respect our profession.
The thread of comments here has acutely reminded me once again where our problems lie as a profession.
The most telling point is the level of defensiveness exhibited. Having a writer essentially "call out the profession" isn't the problem. Our response is the problem.
Instead of being up in arms over this, we need solutions - not more problems. We, as a profession, continue to turn a blind eye to these professional issues. Health care is moving towards improved self care and consumer awareness - and a more active involvement by the patient. Heat, ultrasound, estim and the like foster patient dependence. Simple. Oh, and the evidence doesn't tend to support it's use either. So how many reasons do we need to move forward and away from what has become "acceptable" to our profession?
And for those who think that the "misuse of modalities" represents a small portion of our profession - I suggest you make a few phone calls to clinics in your area. It's a far larger portion than you think.
Our association has missed the boat in terms of gaining consumer support and awareness - at a prime time to do so. "Well, every profession has a problem with evidence" isn't a reasonable answer. Spending 24 cents on the dollar for direct access isn't a solution. Writing a letter to Harry Reid and Nancy Pelosi, without having direct access as the number ONE issue for PTs in health care reform, is insane at this juncture in the reform debate. Once again, we "talk" about how we are the "provider of choice for movement dysfunction", but we don't "walk the walk". No wonder the consumer is confused about what we do.
That's not to say that there aren't some great PTs utilizing evidence and clinical reasoning (and no, clinical reasoning isn't an art, it's a skill). There are. Thankfully.
Imagine if we had payment based on the outcome, relative to the diagnosis and demographic. Those who utilized evidence and clinical reasoning skills to attain a good outcome would be well-paid. And those that didn't? You know the answer.
Could it be as simple as a patient being educated in the appropriate exercises and sending them on their way? Sure it could. Is our role as a "fixer" or a "mentor"? Perhaps before we can attain all that we desire as a profession it will require a subtle yet elemental change in viewpoint of what our role is in the care of the patient.
Ask many other professions what the best solutions look like in their field. They tend to exhibit "elegance in simplicity". Doing more, or doing more "stuff", isn't necessarily the best option.
As they say - "If you don't stand up for something, you will fall for anything". It's time we do so.
I am pleased with the prompt response from the APTA. The original response from the orthopedic section president, Mr. Irrgang PT was weak and not representative of a leader in our profession. I feel a person in his position that represents us should always have his guard up to respond to such uninformed remarks, I know I do. In addition, another point that should have been stressed in response to "doing these exercises in the gym on my own" was the skill involved in the appropriate individualized exercise prescription. As if we didn't have enough things working against us!
28 years of experience and a return to school to successfully obtain a DPT have shown me more than anything that the political correctness of evidence based medicine at times does more to hurt our profession than help us. Joe Kahn, PhD the father so to speak of many of our electro modalities had grand success. Too many PT "researchers" today seem to have biases towards various treatments PT 's have used successfully for years yet many of their study cohorts do not match mine so all they are to me are interesting studies not practice changing break throughs. Clearly, many therapeutic modalities are over used or are used as the only treatment which is clearly inappropriate but when used appropriately as adjunctive treatments they show their worth. It is distressing when "professors" speak before thinking feeding their own ego's before thinking about how their commentary can effect the profession. PT's have always been known for doing more good than harm. Reporters will most of the time take the low road always looking to sensationalize or give a negative spin. Let us collectively be wary of this and always seek to build up the profession and not tear it down.
Paul Kleponis, BSEd, PT, DPT
I am a physical therapy patient of Dr. Marilyn Moffat's, and I work in the health care field (though I am not a clinician). Upon reading Gina Kolata's article, I was prompted to write about the effect of insurance coverage on provision of physical therapy, a point I think Kolata missed entirely.
As I state in the piece, "Insurance company protocols for covering physical therapy are often perverse." The piece, "Insurance-Defying Fitness: In Praise of Marilyn Moffat," can be found at http://rainingacorns.blogspot.com/2010/01/insurance-defying-fitness-in-praise-of.html.
I'd be interested in hearing from anyone who reads it and would like to make a comment.
Just wanted to respond to posts, that say it is actually good and thought provoking to attack own profession and that it is high time to do that, etc. Answer yourself a few questions: 1. Is NYT an appropriate platform to do that? 2. When was the last time you witnessed physicians questioning their own treatments on NYT forum and agreeing that what their colleagues do is voodoo? How professional is this to do? It is OK to agree, disagree and have your opinion but how about some sense of integrity and respect for the profession? Do not we have enough professional magazines, blogs and forums where we can beat each other to death and even call names if so inclined? There is this thing called time and place. NYT platform is neither. For those of you who write modalities off I would like you to check Barbara Headley's PT website. As sEMG evidence clearly spells out, way too many times touchless therapists try to strengthen a muscle group, which is not able to respond to such interventions since it is physiologically "locked down". Too often patients with these problems are written off as incurable or worst yet being told that it is all in their head. Can you help them with modalities? No. Can you help them with manual therapy? No. Can you help them with exercises? No.
Can you help them utilizing all three in a proper sequence and based on clinical assessments? See for yourself. Being paid based on outcome measures? I would love that. Having patients self refer based on previous experience and outcomes? I am already enjoying it to the full extent.
A good post above. The only problem is that currently we do not live based on research. Based on research most of us should be consuming much less calories, exercise much more, quit smoking, sleep at least 8 hours a day, etc. That alone would probably cut medical costs at least 50%, if not more. Based on research also fibromyalgia does not exist, yet so many people suffer from it. I am afraid that as long as people are just mere people, in terms of not conforming to scientific regimens, we will always have a mix of "art" and science in health care industry. The hope is though that most of us will at least not be driven by profit margins (in terms of providing unnecessary procedures or leaning towards most expensive ones) while delivering care. On the positive note I see that more and more patients ask questions, do their own research and make decisions themselves after weighing all the options and opinions.
I read the NY Times article to my students – 2nd professional year DPT – and asked them to describe their initial reactions. The responses I received were varied; some of their main points were: the article provides no perspective on the scope of physical therapy practice; the author needs to use the same standard to analyze medical interventions, many of which are not supported by evidence; sometimes physical therapists practice in ways that do not reflect well on the profession and this hurts us all; patients have a responsibility too and sometimes are noncompliant and move on when they do not hear what they want to hear.
So the students were challenged to become agents of change.
Much can be said about the issues raised in the article. I would like to think, for example, that the author’s physical therapist would have educated her on the importance of rest and controlled loading of her injured tendon. We need to portray ourselves more as problem-solvers (diagnosticians) and teachers. We need to decide whether we are part of the problem with regard to the health care crisis, or part of the solution. I agree with the comment that physical therapists should be seeing a greater percentage of the population, but only for the number of visits that can be justified.
Marcia Miller Spoto, PT, DC, OCS
Nazareth College of Rochester
I see the greatest problem as the failure of APTA and state organizations to directly and genuinely challenge the current medical hierarchy and break from the allied health schema. We need to collectively decline hospital and physician based employment and self employ as independent practitioners. APTA please halt the feel good, kumbuya campaigning and offer something of substance, something tangible. Let's evolve!
Speaking as a lay person who has spent much time in physical therapy, I know my surgeries would have been for naught had I not been willing to commit to continued work with a physical therapist. Surgery without access to PT seems senseless. And it pains me that there is such a debate about covering such services.
bluestarmoon.wordpress.com
I think that instead of turning out therapists who can do research out the wazoo and instead can do actual treatments would be a positive move in the right direction. I've been treated by therapists and worked with therapists who only know how to do modalities and one exact set of exercises that are applied to every patient regardless..... The therapists I like to work with and the ones who done the most good for my shoulder injury were able to think of each patient as an individual and create a treatment plan that worked for that patient. Therapy works and most insurers will pay for it - and patients are more compliant if they are getting treated with treatments routines designed for them. This means using things we know work but creating a program to meet the needs of the individual patient.
While evidence is important, efficacy of treatment is even more important. PT is at a fragile time in its history. Reimbursement is declining, medicare is scheduled for bankruptcy, and purported socialized medicine is right around the corner. According to some, the very existence of this profession is being challenged.
It seems to me that what is apparent is the PT profession needs to redefine itself as a necessary, not ancillary, component to healthcare. PT needs to demonstrate that it provides cost-reductive, effective, and NECESSARY care. The concepts of the need for the existence of conservative management, pain management, and post-surgical management need to be "sold" to those making policy decisions and persuaded that these are indeed necessary services for healthcare cost containment. COSTS is the big important word. Persuade the policy makers into thinking why it is in their best interests to assure PT is a critical player in healthcare reform debate.
APTA member persuade other PTs to pay there dues because they are your profession's voice. With this be proactive in shaping the APTAs vision to meet your own. Don't just pay your dues and don't have a voice. On top of this write to your representative and describe why PT is a necessary component to healthcare. Motivate your patients to do the same.
Right now is the time to act. Being passive won't make your voice heard. All while someone else's voice will be heard and this will be shaping healthcare reform efforts. There's no better time than right now!
Excellent post and writing style. Bookmarked.
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