Thursday, June 09, 2016

Sometimes the most logical thing to do is to stop being logical

An issue came up today that probably needs some discussion.  A parent of a young child was worried about protecting the child's remaining kidney with a kidney guard.  The doctor was not interested in supporting the request for the kidney guard, mostly based on evidence that there is no reason to believe that they are effective and also based on the fact that kidney injuries are quite rare.  (Grinsell, et al, 2012).

One particular recommendation regarding kidney protection by Psooy, 2009 reads as follows:
Parents should try to keep things in perspective: If they are not going to restrict a child from an activity based on the child having only one “head,” then they should not restrict the child from that activity based on having only one kidney
Evidence – Level 3: Those activities most associated with high-grade renal trauma (bicycling, sledding, downhill skiing, snow boarding and equestrian), have more than a 5 × relative risk of head injury compared to renal injury

This is all very logical but perhaps it is a little too logical.  It might be so logical that it is in fact an insensitive perspective.

What is missing from the doctor's evidence-based recommendation is consideration of the journey that parents might be on relating to coping with a child's chronic illness.

Why would a child only have one functioning kidney?  There are many reasons.  The child could have renal agenesis.  The child could have renal scarring from undetected vesicoureteral reflux.  The child could have polycystic kidney disease.   The child could have had the other kidney removed because of cancer.  Any of these conditions are potentially frightening for a family.  Let's extrapolate some more.  Maybe the mother had preeclampsia and now has end stage renal disease.  Maybe a grandparent is on dialysis.  Maybe the parent is just frightened because it is their child and there is only one kidney left and it does not matter if the child also only has one brain and one spine and one heart.

The point is that not everything can be managed with logic.  I am just as fond of a Spock-like orientation as anyone, but I am not foolish enough to believe that you can present a logical piece of evidence to a parent who is frightened and expect a good outcome.

And what are parents to think anyway?  Prior to all this 'evidence' about the questionable value of avoiding contact sports it was relatively standard fare for doctors to tell parents that they needed to PROTECT THE REMAINING KIDNEY AT ALL COSTS!!!!1!  In fact, many doctors still tell this to their patients despite the evidence.

Anyone who has spent any time in a children's hospital understands the twisted perspective one gets by working in that environment.  That twisted perspective occurs because even if something tragic happens rarely, when it does finally happen they will show up at the children's hospital.  I assure you all that your mothers were correct.  You should not run with a lollipop in your mouth and you can put out your brother's eye by swinging around a toy golf club.  This stuff all really does happen.  Listen to your mother.

Despite the studies, despite the statistics, despite any evidence - the fact is that some child with one functioning kidney will in fact take a hockey or lacrosse stick to their remaining kidney and they will be hospitalized and there will be some level of medical disaster associated with the event.  Even though the odds of it happening to any single child are infinitesimally small, it is at this point of singularity that the recommendations of the AAP all go out the window because the event will achieve instant Internet fame as it is posted on Facebook and Twitter for everyone to see.  People all over the world will see the tragic story and they will all quietly think to themselves, "Wow, that person DID NOT listen to their mother."

I know, none of it is likely.  Even less of it is logical.  But there is nothing logical about a child receiving a traumatic injury.  In fact it is the most illogical thing in the world.  Kids are not supposed to be hurt.  Ever.  When they do it is illogical and tragic and horrendous.  Statistics be damned.

 Parents actually know how to deal with this.  There are two solutions.

Solution one is to be logical and follow the advice of the doctor.  If you have a logical orientation then it is all good.  Your logic might even be so good that even in the face of an unmitigated disaster that no one expected, you can still be saved by your logical analysis that you are the unfortunate recipient of an absolutely unlikely event.

Solution two is to tell the doctor to shove their logic, go on or some other site, and just order the relatively inexpensive kidney belt for yourself.  If you want you can go order a helmet and some bubble wrap too.  It is your child, and you can do whatever you want - even if someone else states that it is illogical.  In time you might come to change your mind.  Or you might not.  Either is OK.

In my experience, kids tend to survive either approach. Well, as long as nothing illogical happens.

So I say let parents order the kidney guard.  It really is not that big a deal.  It is not a surgery.  It is not a medication.  There is no damage caused by wearing a kidney guard in gym.  It is benign - and it might actually make a parent feel like they are doing something.  Or having some control.

In an illogical world where unexpected things happen at rates that are almost too small to measure it might even save a child's life.  Who knows?

In the long run parents can make choices about the risks they are willing to incur, but it is important to remember that families are on a journey when they are dealing with chronic illness.  Not everyone will be at the same point of logical understanding as everyone else at exactly the same time.  Or even ever.

If doctors spent more time listening to the real concerns of parents, no matter how "illogical" those concerns are, they might have better relationships and be better able to meet their needs.


Grinsell, et al (2012). Sport related kidney injury among high school athletes.  Pediatrics, 130(1), e40-e45.

Psooy, K. (2009). Sports and the solitary kidney: What parents of a young child with a solitary kidney should know. Canadian Urological Association Journal, 3(1), 67-8.

Friday, May 27, 2016

The demise of authentic makerspaces: From Dad's workbench to Angie's List

Makerspaces or hackerspaces are terms used to describe environments where people build or create with materials, to learn how to share resources and work together to make things.  In their current iterations they are often found in libraries, schools, or even community centers and people are invited to come into the environment to work on individual or shared projects.  Here is a picture of a modern makerspace:

Occupational therapists are becoming more interested in makerspaces, perhaps based on a seemingly genetic interest in the concept of a constructed milieu where people can come together to develop skills.  This is what early occupational therapy makerspaces looked like:

This is a picture of occupational therapy at the Trudeau Sanitarium in the Adirondack region of New York State.  Patients would come to this area of the country to 'chase the cure' for their tuberculosis.  Attracted by the cold and crisp and clear air of the region, when people were not sitting in their Adirondack chairs breathing in the fresh air they were often found in these makerspaces.  This particular occupational therapy clinic developed into the Saranac Lake Study and Craft Guild, which I encourage readers to learn more about by clicking here.  The Guild became a patient-driven and patient-controlled community.  Modern day lingo might attempt to apply the term 'client centered' but actually that descriptor would fall short of describing the actual community that existed.

The Saranac Lake Study and Craft Guild represents the type of project that Consolation House might have turned into - except that George Barton died while still in the early years of his occupational therapy experiment.  I have some additional materials about Barton's use of makerspace culture that I will be posting in the upcoming months.

At the turn of the century, occupational therapy makerspaces were created to meet an exigent need of convalescing tuberculosis patients. What drives the makerspace movement today?  Are these makerspaces properly located in libraries or schools or even in some DIY classes at Home Depot on Saturday mornings?  Here I want to wax nostalgic in a personal direction, because I think I have a cultural yearning for something that is dying. 

I am wondering if my yearning is related to the fact that I don't perceive authenticity in our modern makerspaces and that the modern makerspace contexts seem unusual to me.

In my personal experience, the only makerspaces that I knew about while growing up were in my Dad's workshop.  We didn't have these resources in schools or anywhere else.  Maybe not as many Dads have those spaces any longer?  Or maybe modern Dads are just relying on YouTube videos when they need to replace the broken float in a toilet so those cluttered workbenches with parts and projects all over the place don't exist?  Or maybe families are just working so much that there is less time for those activities?

I purposely use the descriptor 'Dad's workshop' because in fact that is the best way to describe what existed.  Maybe Dad's workshop is not as common because of evolving social and gender roles that impact division of labor responsibilities between modern parents.  Or maybe it has something to do with the high divorce rate and too many children only seeing a non-custodial parent on a constricted schedule?  Or maybe it has something to do with a modern notion that 'good' parenting means taxiing your children to endless organized recreational experiences and not on a child watching or helping as Dad works away on some project.

My own Dad didn't write a lot, but he shared some of his writing with me before he died, and it is so on point to this topic I thought I would share it here.  What I love best about this story that he wrote is his use of the word 'occupation' which he did independent of my influence.  He called this "My Hovel"

I can’t remember when I went to live in the cellar. In those days the seven of us shared 3 bedrooms. My brother and I had the bedroom off the kitchen and the girls and my younger brother shared the back bedroom adjoining my parent’s bedroom. I had occasion to recall the furnace room where I lived recently in a conversation with my son. There was a coal box beside the boiler and although the boiler had been converted to oil before I moved in, still the coal box remained. And because the area of the furnace room where I lived had been a coal bin, I think for many years after I moved in, still the coal dust remained. No matter how I swept or washed, the coal permeated the walls and floor for years after the coal bin was removed. That may explain why I was able to commander this darkened end of the furnace room without much opposition from any other family member. I just can’t remember the early years in the furnace room, like every occupation, I must of started off small and gradually expanded to fill the area of the old coal bin next to the boiler. There over the remaining coal box I placed an overhanging desktop and glass writing area. Later I built book shelves for the books I purchased from second hand stores in the city. I built a two by six plank workbench adjoining the coal desk along the back wall of the room and stored scrap wood for building under the workbench. I collected large dry cells from friendly telephone workers and made projects of simple electrical circuits. Years later it developed into a radio hobby, building power supplies and oscillators and studying code. Through grammar school I would do homework, work at the workbench and do carpentry work all through the evening hours. Every evening of the week was spent in my work area. The early years of photography developed in this area and I remember constructing an enormous lateral enlarger from a large bellows camera. While everyone lived upstairs, I lived in the cellar. And, I remember most how peaceful and quiet the furnace room was compared to the sometimes pandemonium upstairs.

My Dad created this makerspace and he carried that value and that mindset into his adulthood.  Of course I never knew about this space that he created as a child, but I remember his adult workspace quite vividly.  I remember spending hours sitting with him and helping on all kinds of projects.  We would do carpentry jobs, fix broken appliances, made our own ham radio equipment.  We would scour flea markets for 'treasures' and bring them back to the workspace where they would be put to use or saved for some future project.  That was the norm of my own experience.   It was a very typical childhood experience, I believe, but I am not sure if it is so typical any longer.

Here is another narrative that he wrote explaining his motivation and process for re-finishing the attic into a bedroom for my brother and I.  He called this "The attic bedroom"

You can’t imagine how dirty and dark the attic on Orchard Street was when we bought the house. A winter clothes storage room had been built in the south wing of the attic below the high window and the oversize beams supporting the slate roof were dirty and rough. A single light bulb hung in the middle illuminated the room and the upper half of the windows were colored glass which permitted little light to enter the room on even the sunniest day.
Yet, the staircase was well constructed and the balloon construction lifted the perimeter walls sixteen inches off the floor in such a way that the sloped roof attic walls never seemed constraining as attics often do. The center of the main section of the attic roof reached fourteen feet off the floor so that an eight foot ceiling could be constructed through the large section of the room. The new "Miami" windows were installed from the inside of the room because the height of the house could not afford safe installation by ladder from the exterior of the house. The electrical cable runs were over 250 feet of lighting and outlets and I used 1800 square feet of sheet rock over the insulation I installed. I think I taped the sheet rock for weeks. Before the floor was installed, my son wanted to move in, I think he was only five. I bought the large office desks from a moving company for fifty dollars each including the swivel chairs. I piped the sink and waste to provide some relief for the busy bathroom on the second floor which the six of us shared. Later I built the bookcases which we promptly filled with large library of collected books we loved. I remember how we loved to read the Readers Digest "Wonders of the World"

It became my favorite room, probably because I remember how dark, expansive and dirty it was and later how airy bright and comfortable it became.

What is interesting in this narrative is that you can see the carryover of his makerspace mindset, but also the repeated theme of taking a dark and unused space and creating something out of it.  In this second narrative, he was able to create something for his children in the attic that he was not really able to create for himself in the basement.  The attic bedroom was not a hovel!

I enjoy sharing this narrative because my Dad was not a writer and he was not purposely constructing allegory.  It is just folk intentionality.  Plain words - his words.  That is what gives authenticity to his story about the use of makerspaces.

I wonder sometimes if the makerspace context of a Dad's workbench is not as common as it used to be.  I have a workbench, full of all my father's tools - and I do in fact use them - but life is so busy sometimes I just use Angie's List and will find someone else to do a job for me.  Dad would never have done that.

Perhaps that is why the new makerspaces are not in our homes and not as commonly located in a Dad's workshop - and that is why we have the DIY Network and Bob Vila on the television telling us how to do a project.  Maybe that is why schools are creating these spaces because Dads are not doing it as much.

I think it is a good thing that the spaces are being created, but I have some nagging thoughts that it might not be the best way to meet those needs.  What meaning is created by going to a sterile hackerspace in a school every other Thursday for your scheduled time?  How does that serve our own narratives about creation and meaning that might fit into our own lives?

Would there have been a hovel and then an attic bedroom if my Dad didn't have his own makerspace?

I think these are important questions.

Friday, May 20, 2016

Collected thoughts on narrative in occupational therapy documentation

About ten years or so ago I wrote about the potential power of using writing and hypertext as a qualitative methodology for understanding human narrative.  I got that idea back in high school, actually, after reading the Langston Hughes poem, Theme for English B:

The instructor said,

      Go home and write
      a page tonight.
      And let that page come out of you—
      Then, it will be true.

I wonder if it’s that simple?...

The poem is all about identity, and expression, and trying to understand point of view.  I struggle with this concept of documentation as representation of life.  Can documentation represent life, really?  I think it can when I read Langston Hughes, but when I focus in on a short essays like in the Humans of New York series I can't read more than one or two of them.

I object to them, mostly, because when I read them I feel like someone is distilling a life into an evocative photo and 60 seconds worth of reading.  It is just too neatly packaged.  The impression that I believe the reader is supposed to be left with is one of a point of understanding.  Instead, I am left with the idea that someone's life has just been Facebooked into farcical representation of actual reality.

I don't know if 'Facebooked' is an actual term.  I just made it up.

What is worse, the distillation, or reading the distillation and believing that it is real?

I believe that people's lives are messy or complicated, full of commas and ellipses and misspellings and confusion and misplaced modifiers.  How can we represent or understand reality in a tightly controlled text box read by a disconnected set of eyeballs?

I try not to be guilty of the same thing here, but it might be misconstrued because I also write clinical vignettes.  When I write my stories here, I am not attempting to encapsulate the life of the people I am writing about.  I am attempting to encapsulate how that intersection impacted me.  It is selfish expression, to be certain.  I try to use it for good though.  The whole idea is to find ways to understand what I am trying to accomplish for other people.

The problem with my writing here now is that some ideas are spread out over a ten+ year span.  I think there is a lot more to it than all this, but I wanted to collect some of the thought I had on this in one spot for future reference.

Writing as occupation

Destruction and deconstruction of occupational therapy documentation

The best way to discharge a patient


Tuesday, April 26, 2016

The impact of the janitor on an occupational therapy practice

Owning a private practice is a never-ending adventure that usually causes the owner to take on many different job roles.  This Saturday I put on my janitor clothes and tried to take care of some things that were starting to turn from minor annoyances to full blown problems.

I am not embarrassed to talk about the presence of these things that need fixing or adjusting, mostly because I have a comfort level with the humble nature of our mom-and-pop therapy shop. The families that come to us seem to understand that, I think, because sharing stories about the tribulations of trying to get things done probably resonates with the busy and complicated lives that they are also leading.

The only problem is that I am not a janitor, or even a poor excuse for one.  That means that only sometimes I get things right.  So I cheered as I won a battle against the broken copier,  looked proudly on my successful taming of the broken heating vent - but then I met my match.

I could not repair the broken lighting ballast in the evaluation room. 

At first I thought it was just a matter of changing the long fluorescent tubes.  That didn't work.  Then I thought that perhaps the fuse was tripped down in the basement.  That wasn't it.  I jiggled things.  I poked at things.  I avoided electrocuting myself, but I was defeated.

So I did what any good janitor would do: I got another light on a temporary basis until someone who knew what they were doing could intervene.

 It looked like a fun option, but I had no idea what a 'hit' it would become.  Every child that enters that now (slightly dark) room falls in love with that stupid lamp and they all ask the same thing with a sense of wonderment: "Who brought that lamp here?"

The lamp is taking on mythical qualities.  The kids just stare at it in awe.  My favorite response came from a little four year old - and there is no way I can capture the cute-ness in written form, but just imagine the most beautiful child in the world staring up at you from knee-height saying from the bottom of their heart, "Oh Dr. Chris.  I love your lamp!"

Because I am teaching part time my staff keeps in contact with me via text or email or phone throughout the day when I am at the college.  Now the lamp is being incorporated into handwriting practice.  I got this letter today:

 So the janitor at ABC Therapeutics wants to make a recommendation to all aspiring pediatric private practice owners...


And then tell the janitor not to bother fixing the broken fluorescent lights.

It will make you the most revered occupational therapist in the entire practice.

Wednesday, March 30, 2016

From elite social clubs to personal atonement: The history of the formation of Consolation House.

Private and elite clubs were vehicles of socialization and business transaction during the Gilded Age.  Clubs were often restricted in membership and members were highly scrutinized before being offered the opportunity to join. 

The Tavern Club in Boston is one example of an elite social club.  It was established in 1884 and was a gathering place where the members were focused on fine dining, lectures, and the arts.  Notable members included Charles Eliot Norton, William Dean Howells, and Henry Cabot Lodge.  Herndon (1892) described the club as "an organization of good fellows, mostly artists, musicians, and lawyers, who breakfast and dine together with more or less regularity in their snug and artistically fashioned club-house on Boylston Place, just off the busy thoroughfare of Boylston Street by the Commons."  The entrance dues in 1892 was a $50.00 fee.  The approximate 'economic status' of that amount in 2015 terms is $11,100.00, which provides some current-day comparison to understand the social prominence associated with the Tavern Club.

Hornblower (2000) provides additional perspective on the nature and function of Boston social clubs, including the Tavern Club.  He reports in tongue in cheek fashion

"The Tavern (1884) is said to be so exclusive that the man who proposed forming the club, a teacher of Italian descent, was denied admission. Sort of... The club was founded to promote “literature, drama and the arts.” Today it more or less pursues that mission...In the late ’80s, the Tavern was perhaps the most vocal opponent to sexual integration. One production, included a song entitled, “We love the ladies.” Its final refrain: “But we’d rather have the place in embers/ Than see them as regular members.”'

In 1988 the Supreme Court ruled in NEW YORK STATE CLUB ASSOCIATION, INC., v. CITY OF NEW YORK et al. that such private clubs were forbidden to discriminate based on race, creed, sex, and other grounds.  Opinions about the social value of clubs has changed and fewer people place value and importance on membership.  This is very different than how those clubs were viewed during the Gilded Age.

George Edward Barton served on the Elections Committee of this exclusive club from 1901-1903

This fact becomes relevant because it provides useful background information when attempting to understand Barton's methodologies for creating the National Society for the Promotion of Occupational Therapy (NSPOT), which later was renamed the American Occupational Therapy Association.

Many occupational therapists consider the NSPOT meeting in Clifton Springs, NY as the 'founding' of the profession.   It is important to consider that the NSPOT meeting was a function of a larger enterprise that eventually became known as the Consolation House Convalescent Club (CHCC).  The NSPOT meeting occurred during the middle of Barton's occupational therapy work on March 15, 1917.

Consolation House was opened on March 7, 1914 and marked the beginning of Barton's activities that ultimately led to the incorporation of the CHCC on April 1, 1922.  The purpose of the Club was to provide a location where people who were disabled could rehabilitate themselves and develop skills for economic self-sufficiency.  Every article or product made by a disabled person was to be stamped with the image of a phoenix which was the official emblem of Consolation House.  The motto "Beauty for Ashes" was also supposed to be stamped on the product so that anyone making a purchase would know that "this article was made by a sick man who is doing his very best to support himself."

Barton's earlier experience among the most elite members of society served as the basis for his creation of a new kind of club.  The use of a Club as a means of social expression was normative in his perspective.  However, due to his illness, Barton believed that he had lost everything.  He stated to Elwood Worcester (1932), 
"What is the use of talking to me?  My life is utterly ruined, my health, my power of movement, my beautiful profession, my wife and child, my home, my capacity for earning money are taken from me.  All that is left for me is to sit in this chair, a beggar, a pauper and to suffer like hell..."

Barton's choice of the Phoenix represented his belief that something new could be born out of such loss.   His choice of the naming of Consolation House and the motto "Beauty for ashes" also reflects his spiritual conversion at the assistance of Worcester. 

Worcester was not a social elite - he was a preacher in Boston - but many of those club members came to his church.  He provided Barton with the relevant scripture that would send him on his way to recovery and also lead him to his new occupational therapy mission.

Isaiah 61:3 states
To appoint unto them that mourn in Zion, to give unto them beauty for ashes, the oil of joy for mourning, the garment of praise for the spirit of heaviness; that they might be called trees of righteousness, the planting of the LORD, that he might be glorified.

The methodology for mourning in biblical times was to sit among ashes and to rend your clothing.  The message in this passage from Isaiah is that people can be comforted.  And consoled.   And happy again.  Barton existentially depended on such an atonement, reformation, and rebirth.  Barton's actions need to be considered within the context of his personal life story.  When some historians lacked that information, his behaviors were labeled as 'zealous' and 'sometimes irrational' and he was described as a 'difficult person' who lacked 'interpersonal skills' (Quiroga, 1995).

These characterizations of Barton are incorrect.  He was just a man who held a particular station in life and perceived that he had lost everything.  He used the tools he knew best to create a solution for himself, and that solution ended up contributing to the creation of the occupational therapy profession.

As reported in the Clifton Springs Press, one of the founding directors of the Consolation House Convalescent Club was Elwood Worcester, the minister who brought the Emmanuel Method to Barton as he convalesced in Clifton Springs, NY.

When you consider the historical context and motivations of George Barton, it becomes quite evident that Consolation House was aptly named.  He was a man who believed that he had a mission, and fulfilling that mission was an expression of hope for his own recovery as well as the recovery of other people similarly situated.


embedded links, and...

Herndon, R. (1892). Boston of today: A glance at its history and characteristics. Boston: Post Publishing Company.  Retrieved from

Hornblower, S. (2000, April 27). Fifteen minutes: The old boy's clubs.   The Harvard Crimson.  Retrieved from

Quiroga, V. (1995). Occupational therapy: The first 30 years.  Bethesda, MD: AOTA Press.

Worcester, E. (1932). Life's Adventure: The Story of a Varied Career.  New York: Charles Scribner's Sons.

Tuesday, March 22, 2016

Check your patron

Reciprocity.  It is customary in ethics to discuss the connection between purpose and values in terms of reciprocity.  The body of knowledge in any discipline - that is, the reflective concepts and the action of technology - is derived from its reciprocal relationship to the purpose of its services... Searching for patronage and constructing a new support system is a dangerous venture for any discipline.

...The shift to a client system represents, perhaps, a desperate strategy to survive under the awesome pressure of the self-interest of medicine.  - Reilly, (1984).

Last year I noted that an article published in the American Journal of Occupational Therapy furthers the politicization of the professional association by endorsing very partisan approaches to health care (aka 'Triple Aim' model).  The chronic difficulty with labeling something as 'partisan' is that there will always be that segment of the population that agrees with that approach and does not see it as 'partisan.'  I take the risk in labeling anyway and hope to show why there is reason to pause and carefully consider these approaches.

The authors of the article (Leland, 2015) 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).

Occupational therapists should ask themselves and their professional association when it became their duty to control for the amount of cost that the government is incurring in health care.  Responsible therapists should always be economically prudent and should be properly cognizant of the costs associated with their services, but is it the job of occupational therapists to meet the economic goals of a governmental patron?

If the purpose of occupational therapy is overtly stated as 'reducing the per capita costs of care for populations' then how does that position us ethically when it comes time to deliver care?

Simply put, the government defines 'value' in terms of dollars spent.  Most occupational therapists define 'value' in terms of people helped.  Those are not mutually exclusive objectives, but aligning your professional purpose with cost-saving methodologies changes your entire ethical system.

Where can we find 'value' propositions where occupational therapists have unexpectedly aligned themselves with government patrons?  Look at the slogan from the College of Occupational Therapists in the UK:

The important consideration here is that most occupational therapy services in the UK are delivered within the context of a single-payor government-run health care system.  That is not the case (yet) in the United States, although it is the particular objective of many partisans who are interested in fully socializing our health care payment system.

Who, exactly, does occupational therapy serve in this context?  The patient?  Or the government-patron?  Take a look at this other twitter-post from COT and decide:

/Edit: 3/23/16: Here is another depiction from the COT on what OT is supposed to accomplish:

Note that there is nothing in the messaging about improving function or quality of life for the patient.  Perhaps that is implied?  Who is the COT marketing to?  Are they marketing to the government patron so they know that length of stay can be decreased?  The COT provides a reference for this ability to reduce length of stay (Barnett, 2015), but it seems to be a rather stunning claim that needs further scrutiny.  Most OTs would argue that they could contribute to decreasing length of stay but I don't know anyone who would make a claim like this - it would be interesting to know how the researchers came to this statement.


From a US perspective, this is a confused approach that places therapists into what I call 'morally untenable zones of practice.'  Ethically, how is a therapist supposed to meet the occupational needs of their patients while at the same time meeting the economic objectives of their government patrons?

I understand that it sounds very noble to hear about 'care of populations' but this kind of orientation is actually very foreign to most OTs practicing in the US.  Do US practitioners think that they should have 'Saving Money' in their tagline?  Or that they should go out on ambulance rides and find ways to prevent hospital admissions?

I have great respect for all of my international OT colleagues and the systems that they function within but there is a deep and pernicious problem with accepting the methodologies of other countries and assuming that they are aligned with practice in another country.  Some occupational therapists have complained about 'colonial' attitudes of Western theories. (Hammell, 2011).  Certainly this concern travels bidirectionally.

The straw-man argument that is often used when I bring up this issue is "How can you possibly not be concerned about costs of care and improving quality?"  But remember - we should always be concerned about costs and we should always be concerned about quality (when it is properly defined) but that does not mean that we have to become stooges for a single-payor health care system and do their bidding to save money.  That is not the 'great idea' of occupational therapy (Reilly, 1985).

Simply put, you can walk and chew gum at the same time, but you can't do so when the government is defining 'quality' in your practice and basing it on economic terms.

I am concerned that some American occupational therapy leaders are not thinking deeply enough about the models that they are asking us all to support.  In another recent issue of AJOT we had more endorsement of population-based models (Braveman, 2015).  The author promotes further re-definition of the occupational therapy profession and states that we should "identify specific competencies related to population health and public health and include them clearly in the Framework."

Braveman proposes an expanded role for practitioners that includes policy work for non-profit organizations or in federal health agencies.  Certainly, occupational therapists can function within these roles but it is rather important to distinguish between the things that one might do with  occupational therapy training vs. what constitutes occupational therapy practice.  Suggesting that OTs work in these roles is fine, but suggesting that the PRACTICE Framework be changed is another matter entirely.  A different set of ethics is required when working with patients vs. working in the interest of public health.  One approach values autonomy and individual choice.  The other focuses on the good of the broad public (including its economic good).

In a previous blog post I laid out an explanation that population health models are focused on broad community needs and frame concerns in broad population statistics.  Occupational therapists have been carefully warned that public health models are incompatible with occupational therapy (Reed, 1984).  Specifically, Reed suggests that "occupational therapists must be careful to differentiate between the public health model and the health education and wellness model."  Unfortunately, occupational therapists are now confusing these models and in fact are even naming public health as a goal of occupational therapy.  Braveman asks, "How can we demonstrate occupational therapy's distinct value in improving the individual experience of care, improving the health of populations, and reducing the per capita cost of care?"

The answer to this question is that we can do it by socializing our health care system, aligning our purpose with the goals of the government-as-payor, and abandon our social compact to provide care to people.

That is incompatible with the current American system, and occupational therapists practicing in the United States are right to question if this is the correct direction for the profession in the United States.


Barnett, D. (2015) From ‘assess to discharge’ to ‘discharge to assess’. What a difference a year makes! In: College of  Occupational Therapists (2015)  College of Occupational Therapists 39th annual conference and exhibition, plus Specialist  Section Work annual conference, 30th June–2nd July 2015 , Brighton Centre, Brighton, Sussex: book of abstracts. London:  College of Occupational Therapists. 25.

Berwick, D. M., Nolan, T. W., and Whittington, J. (2008). The Triple Aim: Care, health, and cost. Health Affairs, 27, 759–769.

Braveman, B. (2015).  Population health and occupational therapy.  American Journal of Occupational Therapy, 70, 1-6.

Hammell, K.W. (2011). Resisting theoretical imperialism in the disciplines of occupational science and occupational therapy. British Journal of Occupational Therapy, 74(1), 27-33.

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.

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. 

Reilly, M. (1984). The importance of the client vs. patient issue for occupational therapy. American Journal of Occupational Therapy, 38(6), 404-406.

Thursday, March 17, 2016

Update on occupational therapy and case management

One year ago I posted about the American Occupational Therapy Association process of an Ad Hoc committee to delineate the role in case management for occupational therapy in primary care and mental health.

My concern at that time centered around two primary points:

1. Case management is not a recognized domain of concern of occupational therapy practice.

2. There is a difference between 'things that can be done with OT skills' vs. 'what constitutes OT practice.'  I believe that occupational therapists should be delimiting practice and clarifying professional roles, not blurring them.

My objections have nothing at all to do with case management, which I consider a worthwhile and valuable endeavor.  It is my opinion that these are worthwhile and valuable endeavors for others and should not be something that OTs concern themselves with excessively.  The concern has a lot to do with resource allocation.

Despite this type of feedback that was given to the RA, the Ad Hoc Committee was created anyway.  Today I was given a copy of the committee's report to the RA by some colleagues who were aware that I had concerns about this issue last year.  Getting this report also coincides with my reading of the lead article in the March/April 2016 American Journal of Occupational Therapy entitled: Role of occupational therapy in case management and care coordination for clients with complex conditions.

I don't expect that it is any coincidence that such an article would be published just as the RA is considering the report about the topic and new motions on case management.  Clearly there are forces at work to push the case management agenda for the profession.

Unfortunately for the cause, the report to the RA reveals major problems for those who would like to think that OTs can act in a case management capacity.  Here are some rather stunning details in the report:

1. Of employers surveyed 98% LIMITED the case management role to nurses and social workers.  The vast majority of primary and medical employers required that the position be filled by a nurse only.

2. Of insurance plans surveyed in 14 states, 98% DID NOT allow occupational therapists to fulfill the role of a case manager.  Again, the majority stated that a nursing degree was required.

3. The committee survey attempted to find OT practitioners working as case managers only FOUR could be located in the entire United States.  Adding to the SEVEN members of the Ad Hoc Committee that is only ELEVEN OTs in the United States working in this capacity.

4. Not all state license and practice acts identify case management as a legitimate role for occupational therapists.

Despite the overwhelming lack of justification for any consideration whatsoever, the Ad Hoc group proposes several motions including AOTA lobbying license boards to recognize case management courses for OT continuing education credit, for AOTA to develop an official document on the role of OT in case management, and the creation of an online special interest section for professional networking of OTs working in this area.

The lead paper in the AJOT this month presents a similarly surprising argument given the overwhelming lack of supporting evidence.  Claiming that the Affordable Care Act is a "game changer both for the insurance industry and for health care providers" the authors state that "one group of providers that can be more than they are now is occupational therapy practitioners." (Robinson, Fisher, & Broussard, 2016).  It is very unclear why these authors think that OTs need to be more than what they are now, or what evidence exists outside of their own perceptions that such changes are needed.  They seem to lean heavily on the premise that occupational therapists should (for some inexplicable reason) be responsible for contributing to the highly partisan and controversial Triple Aim philosophy, which has been discussed here previously.

Why would a lead article in AJOT that offers nothing but the opinion of the authors as evidence be accepted as a legitimate argument to change the role and scope of the occupational therapy profession?  And why would such a paper be published just as some Ad Hoc committee makes recommendations to pour scarce resources into a project that benefits ELEVEN occupational therapists in the entire United States?

To be fair, not a lot of resources would be required to enact these proposals, but what justification exists for allocating any at all?

Isn't an Ad Hoc committee and a lead article in the professional journal and the volunteer efforts of RA members who are now forced to spend time on this issue enough to meet the needs of eleven occupational therapists in the United States?  Or do we really need to now spend money on more meetings and more papers and more conversation?

Spending time on case management roles for OT is wasteful.  These efforts have no practical relevance to the profession. There are certainly more pressing issues for members of the association to attend to.


AOTA Representative Assembly (2016, January 8). Report of the Ad Hoc Committee on the Role of OT as Case Managers, Bethesda, MD: Author.

Robinson, M., Fisher, T.F., & Broussard, K. (2016). Role of occupational therapy in case management and care coordination for clients with complex conditions. American Journal of Occupational Therapy, 70, 7002090010.