Thursday, January 22, 2015

Follow up on 'Ways you will be paid'

Follow up to PTE Speech in 2012: Ways you will be paid.

I said in that speech that "The people who need you the most might not be able to pay you the most."  I thought about that this morning, because several things that I did are not 'reimbursable.'

The idea of my talk to those students was to tell them that over the longer course of their careers that it is likely that they will make enough money to repay their student debt, but that it would be short-sighted to measure success in monetary terms because sometimes the ways you are paid can't be identified as a quantifiable amount in your Account Receivables, or it might not be noticed by the widget counters that reside in the Halls of Productivity, Outcomes, and Cost-Control.

This morning a mom called to cancel their appointment, and then asked sheepishly, "I have a question, and I hope that you don't think it is silly.  My son deleted his Minecraft world and do you have any idea how we might be able to get it back?  He is just beside himself and it is really a concern for us."

The reason why I loved this question is because somehow this parent received the message that I am in tune with children's interests, and she also received the message that I care about her child.  I don't consider her question silly at all; in fact, it might be the best question I have been asked in a really long time.

So I researched the Minecraft problem and provided a solution that I hope might work.  I spent an hour on the issue, because "Needs are an indispensable part of human nature, and imperatively demand satisfaction," and if she thought enough of me to ask that question then I have a responsibility to generate a top-quality response.  I also made a note to myself to check on the child's situational coping over this issue, because we have been working on coping skills in therapy.  There is no CPT code for this, but that is why I got to thinking about my PTE speech.

My second non-reimbursable task was writing a letter to a child's MD.  The parent brought the child to see me due to concerns with intolerance to clothing.  The mom carried the child into my office, and all the while the child was having an Epic Meltdown.  No developmental or sensory assessment was possible, and based on the whole interaction it was obvious that there were some acute contextual elements that were contributing to the Epic Meltdown.  After 30 minutes the parent was able to get the child back OUT the door, and the entire encounter that is not a billable encounter was a stressful event for both the parent and the child.  After they left I called the pediatrician and wrote a letter of my observations and recommendations.  I hope that they can help the family with those acute contextual problems, because they are clearly in distress.  There is no CPT code for this either, and that is why I got to thinking about my PTE speech for a second time today.

I write about this because I feel some frustration.  I am NOT frustrated about the parents or the children.  I am NOT frustrated with the lack of CPT codes or that these are not reimbursable activities.  I am frustrated because it bothers me to see our profession slip into the clutches of 'care' models that are all about accountability, documentation of outcomes, cost-savings, designated care pathways that are 'evidence based,' etc etc.  All of that is fine, and I don't really disagree with many of the conceptual values, but when we adopt those 'care' models we also generally lose our focus on the kind of caring that people needed in my office today.

Today I was not productive by the measure of my accountant or by Higher Powers that place quantifiable metrics on my activities.  But actually I was very productive by the measure of the people who needed help.

Like I told those PTE students, I have a Faith that the financial piece will all work out in the end.  And in the meantime, I keep reminding myself that "The people who need you the most might not be able to pay you the most.  Pay you the most money, that is."

Wednesday, January 21, 2015

The hands of a pediatric occupational therapist

When I get home from work I have things to do, like everyone else, and sometimes those things make my hands dirty.  Sometimes it is some minor maintenance on my car, or repairing something in the house, or doing a little gardening.  I know that I have to scrub my hands clean after these activities so that there is no evidence of dirt or paint or grease.  I keep my fingernails very short for precisely this reason.

What would I tell a parent the next day - that I have the residual stain of grease on my hands because I was elbow deep into my engine compartment the night before?  I suspect that most parents would understand, but it would not feel comfortable.  If you work on cars or paint a room you know how difficult it is to remove all traces of those occupations from your hands.

Cultural stereotypes abound surrounding the nature of a person's hands.  We even have idiomatic language about 'getting your hands dirty.'  This is a positive concept that means someone is not afraid to engage something or to work on something 'hard.'  Oddly, we have an opposing idiom about 'keeping your hands clean' which is supposed to be a positive attribute also.  I find it interesting that we have developed language with opposing analogies that are both meant to reflect something positive.

I guess I try to keep my hands clean, but I am not afraid to get them dirty when it is required.

My hands get 'dirty' in my job as an occupational therapist also.  A parent came in this morning and as I joyfully picked up her two year old into my arms she looked at my hands, which were undeniably marked by my occupations earlier in the morning.  "Looks like you have been doing some coloring with markers today, Dr. Chris!" she said with a smile.  There was no concern that my hands were 'dirty' because every mom knows that even the so-called water soluble markers don't come off in one scrubbing.

I guess that people ascribe meanings to things based on their perceptions.  The marker on my hands was a sign to this mom that I was elbow deep in trying to help some child learn how to write, and that made her smile.  It is a different kind of engagement than working on my car or in my garden, which might not have been met with a smile, even though my hands would have been no less 'clean.'

I guess there will come a day when I will no longer have marker all over my hands.  Someday I will not have to be so cognizant about how my hands look.  But today it is still a badge of engagement and I will wear it with honor.  I am a pediatric occupational therapist, and this is what my hands look like every day.

Wednesday, January 14, 2015

The impossibility of standardized international theory in occupational therapy

I was interested to read the comments of Dr. Moses Ikiugu who is a candidate for AOTA delegate to WFOT.  His full post addressing the AOTA's future priorities in context of the Centennial Vision can be found here.

First of all, I would like to thank Dr. Ikiugu for sharing this thoughts because this is an important topic and not all candidates take the time to document their positions.

One of his more interesting comments was a call for WFOT to develop and support  theory-based clinical decision-making.  He states:
The hallmark of professionalism is the ability to explain how what we do in the process of providing our services works to address the problems that are within our domain of practice. This explanation usually comes from the theoretical base of the profession. That is why we should develop a strategy to ensure that theories that guide occupational therapy practice are clear and every occupational therapy practitioner in the world can use such theories to guide clinical decision-making... What seems to be problematic as indicated by may (sic) research reports (see for example Ikiugu, 2012) is the lack of uptake of these theoretical conceptual practice models by the rank and file of occupational therapy practitioners. If we are to survive as a profession, this adoption of theory-based clinical practice is essential. WFOT should ensure that this threat to our survival is addressed by developing policies that define global standards for theory-based clinical decision-making in the profession. As a delegate, I would strongly advocate for such a strategy.

I am interested in the idea that there could be global standards for theory-based clinical decision making.  I am also interested in the idea that 'rank and file' practitioners resist the use of theory-based clinical decision making. 

The reason why this concept makes me pause is due to the vast literature that has been generated by academics who are interested in the notion of multiculturalism and occupational therapy.

As a starting point of definition, multiculturalism relates to recognition and action related to the rights of minority populations within a society.  It can be held against the notion of cultural assimilation, which is the dominant American model that was popularized by Zangwill's play 'The Melting Pot.'

Hammell (2010) was concerned about theoretical imperialism, which she defines as power structures that would force theoretical constructs on less powerful people.  Kinebanian and Stomph (2010) believe that we need to reflect on "the underpinning values of occupational therapy which until a decade ago were mainly derived from white middle class norms and values.  Individualism, independence, and autonomy are highly valued in western societies, whereas collectivism, interdependence, and communalism might be valued more highly in other cultures.  However, it seems that the influence of these western norms and values is diminishing due to rapidly changing international relationships."

There have been many calls from leaders in the occupational therapy profession to "embrace diversity." (Abreu and Peloquin, 2004; Iwama, 2007; Clark, 2013).   A common theme in all of these calls is that there is intrinsic discrimination based on power differentials between people and that the most correct pathway to address those problems is by promoting multiculturalism and the idea of 'cultural competence.'

Despite all of the internal conversation about diversity, some authors remain critical about historical diversity in the profession (Black, 2002).  Munoz (2007) suggested that cultural competence was not really possible, so a more reasonable objective would be "cultural responsiveness." 

Given the rather strong vocalization of many occupational therapy academicians about the problems that the profession has with matters of diversity, it is difficult to know exactly how to promote global standards.  Here everything begins to make me a little dizzy: According to diversity experts in our field existing power structures need to be removed or their power needs to be taken away, we need to promote multicultural understanding and respect, and we need to promote diversity in the workforce because presumably that diversity is the best solution for meeting the needs of minority groups.  However, we also need to somehow promote some standardization in our theoretical approaches while we are clamoring about the need for sensitivity about diversity.

I do not know how it is possible to construct a workable practice theory of occupational therapy that has cross-cultural meaning and relevance given the very different value sets that people place on occupations.

Additionally, a confused ethic is promoted by the same organizations that want to promote cultural competency or cultural responsiveness.  For example, the WFOT position paper on Telehealth (2014) states that "The WFOT's mission to develop occupational therapy worldwide presupposes access to services that are contextualized to local culture, resources, and occupations... Occupational therapy services are ideally delivered by locally trained and culturally competent occupational therapists."  A contradictory set of  objectives seems to be promoted.  On one hand we should value multiculturalism and diversity, training practitioners toward those objectives.  On the other hand we should acknowledge that culturally competent care can be best provided by locals.

I am kind of wondering: if culturally competent care is ideally delivered by locals, then what is the point of all the self-flagellation about needing to be more culturally competent?

Over the last year I have presented arguments about the problems associated with the United States occupational therapy community adopting global public health philosophies.  Global conceptualizations of health are not compatible in an American context, just as our conceptualizations are not compatible with others.  What kind of theory standard can there be?

This seems rather plain because it should be obvious to even casual observers of world events that the United States has its own cultural context that is decidedly not multicultural in its orientation.  Judging by headlines in Europe right now it seems that quite a few countries are reconsidering the value of their own multicultural contexts.

It is surprising that some would promote global standards when there is not enough agreement to create a standard.  There is no consensus on the nature of occupation because occupations are embedded in culture - and any attempt to hierarchically organize or conceptualize a way to promote occupation will be met by some person somewhere screaming "HEGEMONY" at the top of their lungs.  Even WFOT knows that, it seems, based on their statement that OT should be conducted by local folk.

The irony in the WFOT position, of course, is that preferential promotion of OT by local folk is condescending to those who would attempt to be 'culturally responsive.'  It fits with the notion that cultural competence is not even possible anyway.

In context of American theory, Mary Reilly (1962) asked "Is America the place to test the hypothesis" and she went on to discuss the concept of a "drive to action" that was part of an "American spirit which hates to be confined."  These are American ideals, deeply embedded in everything that defines occupational therapy in an American context.  That context is different than the context of other countries.  The notion of multiculturalism is an anathema to this culture - and if we promoted multiculturalism there would no longer even be a hypothesis that Mary Reilly proposed!

Of course that does not mean that cultural 'other-ness' is not present to some degree among all racial or ethnic groups in that American context.  It also does not mean that practitioners should not have sensitivity to those differences and work to incorporate them when understanding a patient's needs and goals.  However, we have to go back to consider the reality of the American context - and that reality is based on cultural assimilation, specific American values, and NOT on a value for multiculturalism.   Americans of all political persuasions understand cultural assimilation.  I fondly recall debating disarmament with my sociology professor in college.  He had an amusing strategy: he wanted us to unilaterally disarm because he could not wait for people from China or Russia to invade the United States and 'taste' our notion of American freedom, which in his opinion would lead to the final collapse of Communism worldwide!

As I have previously stated, we need to reconsider what seems to be the endless academic flirtation with multiculturalism and global standardization of our theoretical constructs.  The two ends do not meet, and they will not meet as long as we have different cultures.  Street level practitioners seem to already know this, and do a great job in my opinion of attending to the cultural needs of the people they serve.  Is it perfect? - probably not - and it can always improve - but I know that in the American context there is a respect for diversity as long as it is culturally assimilated.

It may come as a shock, but most people in the United States don't ascribe to the notion that cultural assimilation in an American context is inherently prejudicial. 

References:

Abreu, B.C. and Peloquin, S.M. (2004). The issue is: Embracing diversity in our profession. American Journal of Occupational Therapy, 58, 353-359.

Black, R.M. (2002). Occupational therapy's dance with diversity. American Journal of Occupational Therapy, 56, 140-148.

Clark, F. (2013). Farewell Presidential Address, 2013.  As viewed from above: Connectivity and diversity in fulfilling occupational therapy's Centennial Vision. American Journal of Occupational Therapy, 67, 624-632.

Hammell, K.W. (2010). Resisting theoretical imperialism in the disciplines of occupational science and occupational therapy. British Journal of Occupational Therapy, 74(1), 27-33.

Iwama, M.K. (2007). Embracing diversity: Explaining the cultural dimensions of our occupational therapeutic selves. New Zealand Journal of Occupational Therapy, 54 (2), 16-23

Kinebanian, A. and Stomph, M. (2010 May). Diversity matters: Guiding principles on diversity and culture.  World Federation of Occupational Therapy Bulletin, 61, 5-13.

Reilly, M. (1985). The 1961 Eleanor Clarke Slagle Lecture: Occupational Therapy Can Be One of the Great Ideas of 20th Century Medicine in AOTA (Ed.), A Professional Legacy: The Eleanor Clarke Slagle Lectures in Occupational Therapy, 1955-1984, (pp. 87-105). Rockville: AOTA.
 
World Federation of Occupational Therapy (2014). Position Statement: Telehealth.  Downloaded from http://www.wfot.org/ResourceCentre.aspx


Tuesday, January 13, 2015

Attending to the Manifesto: The importance of idiographic data collection in pediatric occupational therapy

The occupational therapy profession is unique because it is positioned as a stepping point to help people escape the despair of a liminal disability state and move toward the function that people wish to achieve, for themselves or for their children.

I have written previously on the occupation of writing and the notion of interactivity through written text.  I have come to understand over time that parents are Manifesto-writers, often taking pen to page to attempt to make sense of their parenting occupations.  I frequently evaluate children and in that context am handed Manifestos of parents who have so much to say and want to be sure that their message is adequately conveyed during what they perceive as an all-critical evaluation process.

The evaluation is a moment in time that is pulled outside of the stream of other normal interactions and it is often elevated in contextual importance.  The parent may have expectations that the evaluator is expert and many hopes are precariously stacked on the possibility that the evaluator will be able to help the parent with the meaning making process, or even to possibly find some pathway that will make sense for their child's development.

Of course the parent doesn't view any of it in such a detached phenomenological way, but nonetheless this is what often happens.

It is my hope that occupational therapy evaluators will spend more time analyzing and considering the Manifestos of those they evaluate.  Sadly, many occupational therapists don't even avail themselves of the idiographic parent Manifesto.  Instead they restrict their information to nomothetic data sets and the results are a rather incomplete understanding of occupational problems.

I am concerned that theoreticians don't spend enough time talking to actual parents and reading their Manifestos.  As a result, I imagine it must be very difficult for them to understand that the grist of the occupational therapy profession is found in the everyday stories of people who ask for help.  It is not found anywhere associated with some governmental think tank that wants the field to start bending cost curves for some nebulously defined objective of improving population health. 

One parent wrote to me:

Somedays I feel guilty for wishing my problems away.  I love my children, but I don't always love the reality that we are dealing with disabilities.  So what am I wishing away?  Some day my refrigerator won't be covered with crudely drawn images of flowers and hearts, rainbowed by the words "I love you, Mama."  I will never step on a lego, and cut my foot, leaving a blood trail from the play area, through the living room and hall into the bathroom again. Some day I will actually, at times, have to throw out milk before I get a chance to drink it all. I will do laundry once a week and all of my dishes will always be clean.  I will lose my official title of "Mom" and be forced to live the rest of my days as, simply, "Ma'am."  Is that what I really want?  I just want help.

Another parent wrote this stream of consciousness for me:

My son lives in a video game world.  I am so sick of video games.  He plays them from the time he wakes until he goes to bed.  I have to force him outside and play for a while and he doesn't ever want to leave the house.  When I force him to take a break he acts out the games saying "I am the big end guy and you are the witch so I have to hit you three times and I win" and so on and so on.  It is heartbreaking for us to see him like this.  He used to watch videos when he was younger but he would watch the same part over and over again until the tape broke.  I thought the world would end each time those tapes broke.  He takes everything literally so he is not a child that you can tell to 'hop out of the tub' because he will actually try.  When he was a baby he showed no preference to us and he would be just as happy with my sister.  But then at an appointment he thought I was leaving the room and he attacked the therapist, scratching her until she bled, because he was terrified.  The school won't give him OT because he is too smart and because he knows how to write his name.  They didn't care when I told them that he was obsessed with worksheets last year and wrote his name on papers hundreds of times a day.  What am I supposed to do?  He can write his name perfectly but every moment of every day is a stressful disaster for him and for our whole family  How can I even send him to school?

Who else can parents write to?  Sartre tells us that writing provides a medium for interactivity between the inner world of ideas and the outer world of reality. All good writing is social writing.  Solitary writing is only a dream or hallucination; real writing is a process constructed by the writer and the reader.  By this definition, I can’t write as a lone individual – there must be some ‘Other’ that answers or responds to my assertions.  In this sense, writing becomes an act of witness, and a medium for self-affirmation.

The issue for therapists to tune in to is the Appeal, typically found in whatever form the Manifesto takes.  Sometimes it will be an actual written Manifesto.  Sometimes it will be a comment.  Sometimes it will be a phone call.  Sometimes it will be unspoken, but if you are paying attention, you will read it all over the face of the parent who brings their child in for an evaluation.

The Appeal forms the basis of our social contract and it is why people come to us for help.  If we fail to attend to the Appeal and if we only gather nomothetic data to satisfy the outcome recording requirements for our government patrons then we have really missed the point, and our actual responsibility.

Friday, January 09, 2015

The professional abandonment of people who have developmental disabilities

Last year I bumped face first into a gnawing problem.  I was discussing practice trends in a professional context with an impressive panel of colleagues who were subject matter experts.  I raised the topic of the role of OT in planning transition services for adults who have developmental disabilities, and the more general topic of services to adults who have developmental disabilities was bantered about.

My own personal perspective is that OT has a critical role in providing services to this population, and in fact concerns about adults who have developmental disabilities have been discussed in this blog more    than    a    few    times .

 The problem I ran into is that among the opinions of the subject matter experts who represented diverse geographies around the country, not all could confirm that occupational therapists were an important part of the care plan for this population.  In some contexts, subject matter experts indicated that it would be a potential role for OT, and that it certainly fit from a theoretical standpoint, but that in practice there could not be consensus that OTs were routinely associated with these care contexts.

I argued for a while out of shock and then blasted myself back into form because the point of the conversation was to reach consensus and clearly there was none to be found.  I trusted the group, and I trusted the process, and I left that conversation with a hole blown into my conceptualization of the role of OT with people who have developmental disabilities.

How did we get to this point?

Denial is a useful method to avoid cognitive dissonance and that is what I have done with that conversation for over a year.  Recently I experienced a couple of events that brought the topic back to the front burner of my consideration.

I attended a CSE meeting recently where a child who has severe autism was being recommended for a decrease in occupational therapy services.  The child is still learning and developing and in my estimation requires skilled professionals to be deeply involved in his educational plan in order to promote continued learning.  I have been fighting a decrease in this child's service levels for three years straight (in accordance with the parent's agreement, of course).

Each year the special education program trots out a new OT who makes a determination that services should be decreased.  Each year I address the data.  One year I demonstrated how the program-administered SFA indicated severe school performance deficits.  This year I pointed to data that the child had not met any of the educational objectives on the IEP.  I don't consider any of these OTs as SMEs, and I can't be certain that they aren't under pressure because the program's history is to decrease related services dramatically after ANY child in the program turns 8.  For every child I have ever had in that program, the consistent argument is that related services are not needed because the children receive what they 'need' via the structure of the program itself.

So this year the program stated, "We have had three different OTs across three school years all recommend a decrease in services."  Even though I don't consider those opinions expert or free from prejudice, as a rational person I have to ask myself the question:  What are other people seeing or believing that I am not seeing or believing?

It is certainly not a matter of functional performance, because there is absolutely no question that this child and other children just like him have severe performance deficits.  What is at question is the fundamental moral value of whether or not these children should receive benefits like related services such as therapies - or if the pre-packaged (dare I say 'institutional') special education programs provide something that is 'good enough' based on program structure alone. 

As referenced in the articles above,there are some concerns about how our systems are constructed and whether or not we are keeping our moral promises about care for this population.

On a regular basis I talk to parents who desperately want professional care for their children (including adult children) and I sit in meetings trying to fight back an obvious tide of opinion that says that paraprofessional services are 'good enough.'  It is just as if Willowbrook never happened and that the definition of 'appropriate' in FAPE is something that can be equivocated.  People ASK me to help them get services - defending the radical concept of therapy for people who have disabilities is mentally exhausting - because it is unbelievable to listen to myself having to re-litigate civil rights issues that I thought were already settled.

After the exhausting meeting that ended poorly and will lead to mediation or legal action, I started some database searches to understand why I was fighting so hard for something that I didn't think needed to be fought about.

In my searches and meanderings I ran across a really good study done by a student at the University of Puget Sound.   The descriptive study was a survey of community programs for adults who have developmental disabilities to find out what their utilization of OT was.  It was interesting that the staff surveyed identified concerns that could be addressed by OTs but that those services were not consistently provided to the population.  The paper identifies key issues that may contribute to this dynamic including reimbursements and inability to develop community based programs following deinstitutionalization.

A rational person can't ignore data points from SMEs and data points from surveys that indicate low utilization of occupational therapy.  Similarly, I don't know how a rational person can ignore the civil rights legislation and all that it took to achieve services for these populations.

Since people come and ask me for help I can throw the individual starfish back into the ocean and say to myself that my efforts when advocating at CSE meetings made a difference for 'that one' but I can't ignore the larger issue.  I know that children and adults who have developmental disabilities come to my office and we are able to help them all through their insurance (most often Medicaid).  I also understand why the programs that they attend (schools, day treatment programs, sheltered workshops) can no longer afford related services because there just isn't enough money in the allocated daily rate schedules to support the professional staffing.  The problem is that there are virtually no OTs working in private contexts that can help people via their private insurance or Medicaid.  And since the programs are all cutting services or not even offering the services any longer, there are just no options for getting services within the existing program structures.

The only answers are to either increase funding that would support professional staffing, or to promote and encourage more private practice.  Since there is little appetite for local municipalities to take on more Medicaid burden for 'unfunded mandates' I see private practice as the only viable solution to the service delivery and funding problem.

What are the chances that there will be a sudden influx of OTs into private practice contexts to develop new models for community based care?  Slim to none, by my estimation - and that is something that should demand an awful lot of our attention.

The end game is that this is another example of a population that is  being professionally abandoned.  Of course people have the right to self-determine, and I would not promote a patriarchal system that forces people into therapy contexts.  Unfortunately, when the professionals leave the service system, those who still want access to those related service supports are left with nothing.  That is a moral problem that we need to spend more time on.

Reflections on inclusiveness for those who would be leaders

I was interested to read Dr. Braveman's blog post yesterday on Triple Aim.  In that post he stated "What did surprise me was the call for volunteer leaders to stop sharing their opinions and perspectives on such issues with the rationale that the issues can be interpreted by some as political and partisan."  You can read the whole post at http://otconnections.aota.org/community_blogs/b/brentbraveman/archive/2015/01/08/why-we-should-hear-more-about-health-policy-issues-such-as-the-triple-aim-of-healthcare.aspx

He doesn't reference what 'call' he was referring to, but I would like respond to that statement because of the statements I have made on that topic.  I am not aware of any other statements on this topic, but if there was some other 'call' I would like to read it.

In any event, related to my postings, I am not aware of any statements I made that could be reasonably interpreted as a call to stop sharing perspectives on issues - what I have 'called' for is respect for political diversity and a decrease to the politicization of the profession.  When AOTA leaders repeatedly promote extreme liberal ideology related to health care reform it can have a chilling impact on the participation of members who do not ascribe to those political methods.

This becomes an important issue because if a professional association with a presumably diverse membership begins being driven into a single ideological direction then that is not healthy for the notion of diversity and inclusiveness for the membership.

One can't 'turn off' their political inclinations, and certainly one can't cleanly separate health care policy from those inclinations, particularly in context of the ACA which represents increased governmental regulation of the health care system.  However, responsible leaders will understand that holding the reigns of such leadership should not be carte blanche approval to run roughshod over an entire membership by promoting a partisan policy approach.

Here is a specific example: Please consider the impact of elevating and promoting a 'Triple Aim' methodology for structural health care reform in context of the architect of that method lauding the British National Health Service for not letting their health care system “play out in the darkness of private enterprise.”  For those members who are interested in entrepreneurship and private practice, do you think this would make them feel confident that the membership association is supportive of their efforts?

Furthermore, responsible leaders will not engage in preemptive false accusations like stating that there has been a call to stifle conversation.  The reason why I label this as a preemptive false accusation is  because it is the setup to the logical fallacy known as the "Tu Quoque."  In simple terms, when preceded by the preemptive false accusation, this is accusing your debate opponent of doing precisely what you are doing yourself.  It is distraction.  It is equivocation.  It does not serve us well.

I am not aware of any other person who makes more calls for inclusive conversation on social media than I do.  Within the last month I attempted to generate conversation about habilitation definitions, about the Triple Aim, and about inclusiveness and nondiscrimination within the profession.  That is just on the OT Connections forums alone in the LAST month. 

Reasonable people are able to determine who is responsible for stifling or limiting conversation.  It is stifling conversation to make preemptive false accusations.  It is stifling conversation when leaders fail to respond to  calls for debate on important policy topics.  It is stifling conversation when there is deletion of message threads that are uncomfortable.  It is stifling conversation when there is deletion of Tweets that are challenged.  It is stifling of conversation when there is a blocking of your debate opponent from your Twitter account.

I am not suggesting that all of these actions were taken by Dr. Braveman, because they were not - they are a collection of actions of several people, specifically including other BoD members.  It reflects poorly on our intellectual culture.

What I would like our leadership to consider is that these types of actions are chilling to many people.  We have precious little participation from our membership related to these important health care and policy debates.  I am an unabashed conversationalist, but that is not what I believe the norm to be in our membership.

I am not aware of any call to stifle conversation.  In fact, what we need is an end to equivocation and we need even more conversation.  Only with more conversation can there be some chance that leaders will get a message that the membership organization is not a place for partisan ideologies.

Tuesday, January 06, 2015

Enough is enough: Stop the politicization of the American Occupational Therapy Association

A recent article published in the American Journal of Occupational Therapy furthers the politicization of the professional association by issuing another full-throated endorsement of the Institute for Healthcare Improvement's 'Triple Aim.'

 Leland et.al. (2015) state that "Failure of the profession to clearly demarcate what constitutes high-quality occupational therapy and demonstrate its contribution to the broader patient outcomes that value-based care will measure may marginalize occupational therapy in the rapidly changing health care environment."

Unfortunately, the authors align the concept of 'value' with the IHI 'Triple Aim' that includes "improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations." (Berwick, Nolan, and Whittington, 2008).  These objectives sound quite noble, but they break the primary social contract that health care providers have with their patients - namely to provide competent and ethical care that is based on needs and that promotes health.

The 'Triple Aim' is a politically oriented initiative that seeks to control the costs of health care as it is being taken over by governmental structures.  It has very little to do with actual care.  Gur-Arie (2013) summarized the proper concern that people should have about 'Triple Aim' best:

When you find yourself in a strange room, partially covered by a large paper towel, and otherwise completely naked, contemplating the upcoming prodding of your most private body parts by shiny instruments and strange hands, what do you want to know most about the person about to enter the room? Would you feel better knowing that the stranger turning the knob on that door has an iPhone compatible website for you to peruse from the comfort of your cubicle at work? Would you feel safer knowing that he or she has financial responsibilities and commitments to a faceless corporate office for which your naked body is just a line item on the balance sheet, perhaps a socially responsible balance sheet, but a balance sheet nevertheless?  If it’s your small child under that paper towel, would you be comforted knowing that this person’s prime directive is to minimize your child’s “per capita” cost (not price) of care? And when you’re done making imaginary deals with your God or the devil, would you experience great relief knowing that the doctor walking into the room now is not really “your” doctor, but the shepherd of “populations” and the averter of deficits and fiscal cliffs?

The IHI and its founders who champion the 'Triple Aim' are interested in nothing short of the complete socialization of the American Health Care system into a model like the British NHS.  The founder of the IHI has rather infamously stated, "Any health care funding plan that is just, equitable, civilized and humane must, must redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent health care is by definition redistributional."  For those who want to hear it with their own ears:


 Occupational therapists who oppose the unabashed politicization of the profession need to stand up and tell the leaders of the American Occupational Therapy Association that enough is enough. 

The professional association needs to return to a focus on supporting occupational therapists, promoting the profession, and setting apolitical standards that promote the highest quality of care.

Occupational therapists need to put an immediate end to the use of the professional association as a lever arm in some partisan agenda that is in absolute contradiction to our historic values and beliefs.


References:


Berwick, D. M., Nolan, T. W., and Whittington, J. (2008). The Triple Aim: Care, health, and cost. Health Affairs, 27, 759–769. http://dx.doi.org/10.1377/hlthaff.27.3.759

Gur-Arie, M. (2013 February 9). How pushing the Triple Aim ignores doctors and their patients. KevinMD.com Medical Weblog. Available from http://www.kevinmd.com/blog/2013/02/pushing-triple-aim-ignores-doctors-patients.html

Leland, N.E.; Crum, K.; Phipps, S.; Roberts, P. and Gage, B. (2014).   Advancing the value and quality of occupational therapy in health service delivery. American Journal of Occupational Therapy, 69, 6901090010p1-6901090010p7. doi: 10.5014/ajot.2015.691001.

Thursday, December 18, 2014

Time to update the AOTA Position Paper on Nondiscrimination and Inclusion

Politically controversial conversations continue to spew from the social media accounts of AOTA leaders.  These conversations represent perspectives that are not reflective of the broad membership and are highly partisan.  The steady stream of ideological thinking is concerning because it represents a pattern where some leaders don't know how to separate their personal political inclinations from the mission of a diverse professional association.

We often associate topics of diversity and nondiscrimination and inclusion in racial or ethnic or religious perspectives.  However, in what is supposed to be a politically neutral environment like a professional association, we can also consider the negative impact that is caused when leadership adopts a partisan and biased political agenda.

This is not a new problem with the American Occupational Therapy Association.  The inclusion of Social Justice in the Code of Ethics was the first major foray of leaders into political partisanship.  What makes this situation challenging is that many who supported Social Justice in the AOTA Code of Ethics refused to acknowledge that Social Justice itself was even a political concept!  Those refusals to accept the political realities of the term are well documented.  

This week we have a blog post that supports of the role of occupational therapy to assist in data mining to improve population health.  That AOTA leader writes: "As occupational therapy practitioners we can contribute to understanding the needs of individuals, communities and populations, help to design interventions at all levels and help interpret big data to translate it to meeting the needs of individuals."

On its surface, the objective here is hardly arguable - who would NOT want to help design multi-level interventions that prevent disease or illness or dysfunction?   That is a very noble goal.

However, consider what needs to happen in order to achieve that.  The Carolinas Health Care System has been using EHR data to predict patient health and medical system use.  Buried deep in their own admission of data mining is this statement: "Earlier this year, Carolinas HealthCare System also joined the Data Alliance Collaborative; a first-of-its-kind initiative aimed at improving population health on a national scale through data analytics and shared business intelligence."

Well what does that mean exactly?  Watch this brief video of Bloomberg Health Reporter Shannon Pettypiece discussing the problem:



For a more detailed discussion, read Pettypiece's original article entitled "Hospitals are mining patient's credit card data to predict who will get sick.

It is true that a very large healthcare system in the United States is playing around the edges of this extremely controversial marriage between 'Big Data' and our health - and that is unfortunate.  That does not mean that occupational therapists want to or even should jump on this kind of very controversial bandwagon that infringes on personal liberties and is associated with a political ideology of increasing State control.  

In another incident, last week it was disappointing to see one of our AOTA leaders re-tweet a statement that was overtly political and that was not reflective of the broad diversity of political opinion that AOTA members hold.  That tweet was:

"The opposite of disease is not health or wellness. The opposite of disease is justice."

That AOTA leader has since deleted the re-tweet that was sent out after I responded to it and called it 'Newspeak.'

What I wish that AOTA leader realized, and what is important for members to know, is that this statement that was re-tweeted was made by a presenter at the Institute for Healthcare Improvement's (IHI) annual conference.   The IHI is a group that purports to promote healthcare improvement but they are also known to be heavily populated by very partisan thinkers.  The group admits the following: "As we entered our third decade, we recognized a new need for health care as a complete social, geopolitical enterprise. To accelerate the path to the health and care we need, IHI created the Triple Aim, a framework for optimizing health system performance by simultaneously focusing on the health of a population, the experience of care for individuals within that population, and the per capita cost of providing that care."  www.ihi.org/.../History.aspx

In simple terms, they promote a socialized model of health care.  Their founder has heaped praise on the British model.

Dr. Berwick (founder and former CEO) was an Obama appointee as head of Centers for Medicare and Medicaid. www.whitehouse.gov/.../president-obama-nominates-dr-donald-berwick-administrator-centers-medicare-and-medi

What the White House release does not tell you is that he had to be appointed through a recess appointment and that he ended up resigning because there was no way he would ever be confirmed.  www.nytimes.com/.../dr-donald-m-berwick-resigns-as-head-of-medicare-and-medicaid.html

Dr. Berwick is (in)famous for quotes including (easy reference on Wikipedia page en.wikipedia.org/.../Donald_Berwick):

1. "The decision is not whether or not we will ration care - the decision is whether we will ration with our eyes open."

2. "Any health care funding plan that is just, equitable, civilized and humane must, must redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent health care is by definition redistributional."
These are Marxist statements.  Berwick has attempted to dance around these statements and claims that people take him out of context but it is difficult to interpret these statements in any way other than what they plainly say.

The point here is that the IHI is a liberal think-tank that is eyeball deep in its connections to a partisan agenda to socialize our healthcare system.  It is not shocking at all when statements get tweeted out of that conference like "The opposite of disease is not health or wellness. The opposite of disease is justice."

It is very difficult to understand how there can be any equivocation about the politicization of our profession when our leaders re-Tweet this kind of partisan nonsense.

I ask all of our leadership to respect the political diversity of our profession and to keep politics out of our association.  I also ask the leadership to steer clear of other politically controversial initiatives like 'Big Data' mining.

At this point in time it is becoming evident that some AOTA leaders are either tone deaf or they simply don't care and they are willfully infusing controversial politics into the profession.  We have reached a point where it is now necessary to make a specific procedural request that our profession avoids partisan ideologies and toxic political agendas that alienate members who do not share those political philosophies.