Tuesday, July 07, 2015

Occupational therapy and CPT coding


Different people are interested in the things that I do each day, and they are interested in them for different reasons.

The people who come to me asking for help with a problem are interested in whether or not I will be able to summon the requisite knowledge to address their concern (Competency Test A).  They are also interested in whether or not I am a 'nice guy who cares' while engaging in that process (Competency Test B).  As an example, this morning a mom wanted my opinion on how to solve a problem with the positioning of her child's head and neck, because of being tilted over to one side.  I have seen hundreds of cases of torticollis, but none of them are "routine" to me.  Every one of them is treated with as much seriousness and concern and diligence that I can muster.

If I treated them as 'routine' then I probably wouldn't take the time to meet the parent's Competency Test B (the 'nice guy who cares' test).  Fortunately I was able to summon the requisite knowledge and give the parent some treatment opinions.  As I was doing so I interacted with her children and made such an impression on the youngest that he wanted to give me a big hug when he left.  I passed all the tests!

The reason why I pass the tests is not only because of my knowledge about torticollis.  The problem is not only that his head is tilted to the side.  The problem is that it MIGHT stop him from running a fly route, craning his neck in every direction to find the ball, and then catching the game winning Hail Mary pass when he makes it to the NFL.  Nothing is routine when you are asked to help a parent with their concerns about their child.

Don't tell that to the insurance company though.  They are also interested in what I am doing.  Based on a proposed CPT coding system they want to know if what I am doing is a low complexity or a high complexity task.  I understand their interest because they are trying to find ways to develop coding systems that will control costs.

I am not really interested in their definitions of Value (Cost-Cutting).  On a moral level I don't know how to answer the question about complexity.

If it was a simple or low complexity problem then why would the parent be concerned?  I can state factually that parents don't seek out occupational therapy services routinely.  They tend to take care of a lot of things on their own.  In fact, this parent was working on the problem themselves for quite some time before they called me.

I understand that doctors measure complexity in mechanical ways.  Should I be doing that as an occupational therapist?  Is it correct to measure concern or complexity based on how many body parts are broken or impaired?  Do I start counting how many different ways the child is impacted?  Is it low complexity if the child just can't turn his head to one side?  Is it moderate complexity if his gross motor skills are delayed?  Is it high complexity because the parent is concerned that he won't catch the game winning touchdown pass and the Buffalo Bills will never win the Super Bowl?

Should I never consult the parents and shut out that data stream from my decision making?  Things get really simple when all we are concerned about is clockwork systems like degrees of motion in the cervical spine.  Is that what I am to be reduced to doing?

This weekend my lawnmower wouldn't start.  Single cylinder engines are pretty understandable, even for a novice like me.  The complexity is low.  I decided that it wouldn't start because the spark plug was fouled.  So I changed it, and the engine started, and the lawn got mowed.  Easy.

The lawn mower did not have a mom who was worried about whether or not her baby would make it to the Super Bowl.  It was just a lawnmower, and I think I even cussed at it once or twice while I was trying to get it fixed.    Low complexity stuff.

So as I consider this new proposed coding system that is asking me to rate complexity in my treatment of babies I think I will just protest and refuse to participate.  All of my cases are complex, and I was actually trained to consider them that way.  In fact, I was told that if I stopped considering the complexity of my patients that I might as well stop being an occupational therapist.

If I failed to consider complexity, I might miss something, and that is not an acceptable standard of care for an occupational therapist.

Occupational therapists should not be forced to be reductionistic thinkers who count up how many body parts are damaged or how many performance areas are impaired.

These cockamamie coding systems will come and go.  That is one benefit of having done this for 30 years.  I know better than to fall for the latest payment scheme and coding fad.

If the insurance company wants me to label and then fix something that is low complexity, maybe they can drop off their lawnmowers.

Otherwise, I plan on considering every single child I see as high complexity, and if your occupational therapist doesn't do the same, go find another one who will.

Wednesday, June 17, 2015

How NY State will enact the entry level OTD


Laws, like sausages, cease to inspire respect in proportion as we know how they are made.
  (John Godfrey Saxe)

The occupational therapy profession is considering a change to requiring a doctoral degree for entry level practice despite the overwhelming opposition to the concept by most practicing occupational therapists.  The current requirement for practice in NY State includes training at the Masters level.  Academic programs can't begin offering an entry level doctoral degree until they receive approval from the State.  Because the OTD is a new degree, Sections 3.47 and 3.50 of the Rules of the NY Board of Regents related to Title VIII of the Education Law that lists approved degrees will need to be amended.

There is a lot of confusion and misinformation about this process.  This blog post attempts to explain what is happening at both the surface level as well as 'behind the scenes.'  The purpose of discussing the process is educational and represents my opinion based on information that I have tried to document via embedded links.

The American Occupational Therapy Association's Board of Directors has stated that "ultimately, the only body with regulatory authority to mandate the entry-level degree is the Accreditation Council for Occupational Therapy Education (ACOTE®). ACOTE is recognized as the accreditation agency for occupational therapy education in the United States by both the United States Department of Education (USDE) and the Council on Higher Education Accreditation (CHEA). USDE and CHEA regulations require that all actions and decisions of the accreditation agency must be made independently from the parent association(s). Historically, ACOTE has been careful to consider the positions and policies of the profession’s leadership groups when determining entry-level degree requirements."

Although it is technically true that ACOTE has decision making authority to MANDATE this on a profession-wide basis, it is not how the process is unfolding and it is not how the move to the entry level doctorate will occur in NY State.

As background for understanding this process it is important to consider the relationship between the national member association and its credentialing arm, which is technically a separate organization.  In my opinion, AOTA and ACOTE are functionally indistinguishable.  The AOTA Board of Directors issued a position statement promoting the change to entry level doctoral education.  ACOTE is an "Associated Advisory Council" of the AOTA Executive Board.  Although ACOTE has theoretical distinction from its parent organization, there are other issues to consider when evaluating the statement that the authority rests with ACOTE.  “In a ballot election concluded October 31, 1994, the AOTA membership approved the proposed AOTA Bylaws Amendment that reflected the creation of AOTA’s new accrediting body and establishment of ACOTE as a standing committee of the AOTA Executive Board.”  As such, it is notable that intertwined relationships exist between the two groups since the creation of the credentialing group.

ACOTE has its own Board of Directors, but ACOTE itself is staffed by AOTA employees who all answer to the AOTA Executive Director, who answers to the AOTA Board of Directors.

Accreditation income generated by ACOTE amounted to over $1.4 million of revenue for AOTA in fiscal year 2014.  That level of income calls to question the actual separation between the two groups.  Source: April 2015 Report of the Treasurer downloaded from http://www.aota.org/-/media/Corporate/Files/Secure/Governance/ABM/2015/Treasurer.pdf on June 2, 2105.

I am sure that all USDE and CHEA requirements for disentanglement are legally satisfied, but people can decide for themselves what kind of real separation exists in context of the outlined financial and organizational relationships that are present.

In my opinion the American Occupational Therapy Association Board of Director's 'recommendation' to move to the entry level doctorate is a dog whistle call to academicians to begin readying for a change to an entry level doctorate.  As has been openly stated by a member of the Ad Hoc group that recommended the change, "The entry-level clinical doctorate is coming, like it or not."

When asked to explain this statement from a member of the Ad Hoc group the response from AOTA BoD members is that the 'final decision' to move to an entry level doctorate rests with ACOTE.  This is a distraction because what the 'dog whistle' accomplishes is a call to action for educators who then rush to make sure that they are competitively positioned.  No academic program wants to be the 'last program' that is offering the masters level because they will lose market position to programs who are granting a doctorate.

So in order to grant a new entry level doctoral degree there needs to be an approval from NY State Department of Education.  Enter a cabal of NY State OT academicians, who are now lobbying the NYS Board of Regents to approve the new entry level doctoral degree designation (the OTD).  One university started the process by asking the Regents to approve the new degree.  When the Regents received the request they solicited input from the State Board of OT and the New York State Occupational Therapy Association.  According to memos from the State Board, they reviewed the proposal at a 2/13/15 meeting and supported the authorization of this new degree.  Then on 4/17/15 comments were solicited from faculty and administrators from OT programs in NY as well as from NYSOTA.  The Department received eight comments supporting the proposed amendment and no comments objecting to it.

The next step will be publication of the proposed degree in the Register and there will be a public comment period.  If adopted, the proposed amendment would become effective on October 7, 2015.  The school that started this whole process will apply for a charter amendment in September 2015.  Expect all of the other NY State schools that have OT programs to also make such application shortly thereafter.

This is how the educational programs in NY State will transition to the entry level doctoral requirement, without ever receiving any official 'mandate' from ACOTE.

ACOTE does not initially HAVE to mandate the change to the entry level doctorate because academicians are already making the changes to their own programs following the AOTA BoD recommendation.   Any mandate that ACOTE announces will be ex post facto.

The reason why this process should concern everyone is that it is all happening behind the smoke and mirrors of the AOTA statement that 'ACOTE makes the decision.'

ACOTE is not making this decision; they are watching the process play out behind the scenes.  On its surface there will be an appearance that the educational system came to this point on its own and that subsequent market pressures dictated the wholesale change to the new degree level.  Nothing could be further from the truth.

AOTA made a recommendation, the dog whistle to the academic programs was blown, and then the academic programs worked collaboratively with the member associations (New York and AOTA) to enact the recommendation.  Key leaders of both NYSOTA and AOTA have been copied in on emails from the State Board about this matter.  The leaders of the member associations are fully aware of the process.  This will not be a natural evolution of degree requirements based on market demand.

NYSOTA members should take note that their member association was asked to provide comments.  Someone might ask NYSOTA where the public discussion is about this matter, and how NYSOTA could have provided informed opinions from the membership without the public discussion.

AOTA members should take note that their member association obfuscates the truth by stating that only ACOTE can make the recommendation to move to the entry level doctorate.  Someone might ask the AOTA Board or its staff why they would make such statements when they are fully aware that their recommendation has sounded the dog whistle and prompted action by the New York OT Academic Cabal.

It is important to note that members of this academic group have told me specifically that they take such action based on what they believe is both inevitable and what is best.  I disagree with this position.  More importantly, I disagree with the process by which this change will be enacted.  In my opinion this process lacks transparency and does not facilitate the participation of occupational therapists, employers, or the consuming public.

There will be an open comment period which the public and most occupational therapists will never even hear about.  The reasons why most OTs won't hear about it are related to apathy, a lack of knowledge, and because the member associations are not publicly advertising their support for the proposals that are rolling through the bowels of NY State regulatory approval.

The Board of Regents will incorrectly think that asking the Academic Cabal and the member associations will be a proper form of soliciting input.  The Regents don't really care - they view academic credentials as a nuclear arms race and they know that education programs escalate degree requirements constantly.  For them it is 'just another day.'

There are many reasons why most practicing occupational therapists disagree with an escalation of entry level degree requirements.  The pragmatic street concerns about student debt, accessibility of programs to minority applicants, and whether the public even NEEDS a higher degree for this profession will never even get a fair hearing.  The fact that most street level occupational therapists think that the entry level doctoral requirement is unnecessary will never even be heard.

What is the best way to sum this all up?  I received an email from an occupational therapy political action committee last week and it contained this quote that was attributed to Thomas Jefferson:


We in America do not have government by the majority. We have government by the majority who participate.

There is only one problem.  Thomas Jefferson never made such a statement.  It is a spurious quote, but it perfectly represents the thinking of people who would use a process to pursue their own agenda.  An entry level doctorate does not serve any public need - and is primarily supported by members of the Academy - not practitioners.

Ask the average OT on the street if the entry level doctorate is necessary and you will hear a loud and resounding response that it is a bad idea.  Escalating the entry level degree meets the needs of academic programs and their enabling cohorts that populate the ranks of leadership in the member associations.

Democracies fail when people don't participate, and most practicing occupational therapists will not participate in this process.  As a result of non-participation we do have governance by the majority of those who participate, but this is most certainly not the method that would have been supported by Thomas Jefferson.  

Saturday, May 30, 2015

Problems about the perception of 'advocacy' for parents in special education contexts


I went to an IEP meeting with a parent the other day and was greeted with hesitance by the occupational therapist on the educational team.

"Why are you here?" asked the therapist.  "Are you here because you are actually treating the child or are you here as an advocate?"

Neither characterization seemed correct.  I paused and thought for a few seconds as I was not sure why it mattered.  I also was not sure if I was free to divulge the information.  I ran for the safest middle ground I could find and responded, "I know the child and I am helping the family."  Both were true.

I know that the word "advocate" is often perceived negatively by school based practitioners.  I have been attending IEP meetings as an 'outside' therapist for over 20 years and I tend to avoid the term 'advocate' because it engenders a lot of negativity.  I see a lot of reactivity in educational teams when an 'advocate' is involved.

Bruce and Christiansen (1988) first promoted the notion of OT as advocate in context of increased sensitivity about word usage and awareness of environmental barriers.  That value was subsumed into the thinking of most OT practitioners over time, but the word "advocacy" made a re-appearance in the second edition of the Occupational Therapy Practice Framework (2007) with a new definition.  In the OTPF 2nd edition advocacy is defined as "The “pursuit of influencing outcomes—including public policy and resource allocation decisions within political, economic, and social systems and institutions—that directly affect people’s lives.”  That is an unfortunate change because without an anchoring notion of what constitutes fair or reasonable allocation it is a little difficult to know where this begins and ends.

The OTPF 3rd edition (2014) redefines advocacy again stating that it includes "Efforts directed toward promoting occupational justice and empowering clients to seek and obtain resources to fully participate in their daily life occupations. Efforts undertaken by the practitioner are considered advocacy, and those undertaken by the client are considered self-advocacy and can be promoted and supported by the practitioner."  This is also an unfortunate definition because of a similar lack of boundary around the limits of seeking and obtaining resources.  These more recent definitions redefine our domain of concern from the needs of an individual to the social justice needs of a population, which is also paradigmatically troublesome for the OT profession.

I avoid the 'advocacy' term because I prefer to understand my role in meetings with parents as one of support and skill-building.  That way I am meeting the needs of parents and children - and I am not caught up in some undefined notion of 'rights' that doesn't really seem to have any boundary.

I don't know if the seemingly unbounded notion of 'occupational justice' is why many education professionals don't like 'advocates.'  A lot of the dislike that I witness has to do with the fact that parents are often asking for 'too much' for their children.  If you pause and think about objecting that parents are asking 'too much' for their children enough you begin to understand that it is a silly objection.  By my thinking this doesn't mean that people should be entitled to anything - but that it is understandable when parents want 'what is best' - again a very difficult standard to put into operation.

These are my ongoing concerns about the 'advocacy' word - it is misunderstood and sometimes maligned by educational staff, and the definitions themselves are not logically compatible with the traditional OT Scope of Practice.

So when I go to IEP meetings I go because parents ask me to go.  I formally evaluate the children so I understand their needs.  I also assess the parent's coping ability and their communication skill - sometimes formally and sometimes informally - and make sure that I am directing all of my efforts in ways that support their interests and objectives.  I also assess the school district and educate myself on the procedural systems related to nuanced delivery of special education within each location.  Then I stand in the middle of all these concerns as they orbit around and do my best to help.

I blogged about the need to support the mental wellness of parents over eight years ago.  Not much has really changed in eight years and I believe that my observations about these needs are as valid today as they were then.  I stated "It is now evident that parents need more directed efforts to support their mental wellness. All occupational therapists who work with children should look for ways to support the mental health of parents."

I think that is why I bristled a little when the therapist asked me, ""Are you here because you are actually treating the child or are you here as an advocate?"  I guess that the therapist hasn't really been tuned in to the needs of parents and couldn't understand why I was involved.

I find that parents are often very anxious about their children's special education programs.  Burke and Hodapp (2014) listed several factors that are present in parents with higher anxiety about school related concerns: autism diagnosis, engagement of procedural safeguards, and increased levels of self-advocacy.  These research findings support my observations.  Harper et al (2013) discussed the value of respite care in decreasing stress and promoting marriage quality for families who have a child with autism.  There is an abundance of literature on the topic of family stress and special education, and that is why it is surprising to have an occupational therapy colleague openly question why I would be at a meeting to help support the efforts of parents.

The idea of an occupational therapist supporting a parent's mental health is often misunderstood by school personnel.  Attending an IEP meeting is the ultimate occupation-based intervention.  The occupational therapist is working in context with the parent to help them develop skills in navigating a very confusing special education system.  Concurrently, that same therapist understands the needs of the child and understands the system in place that has to be accessed to support that child.

School-based occupational therapists, perhaps more than anyone else, should understand and appreciate the efforts of a colleague who is helping a family with the special education process.  The value of doing so from outside of the system-in-place is that I am not 'bounded' by only addressing the educationally relevant needs of the child.  That actually is a very constricted rule-set when you are trying to practice occupational therapy.

Occupational therapists should carefully reconsider the definitions of 'advocacy' as outlined in the Practice Framework.  Those definitions are really not helpful and don't reflect the patient-centered objectives of a therapy process that is oriented to meeting occupational needs.  Perhaps if we defined this term better there might be a little less confusion.

I hope for a day when I walk into a meeting with a family and am not questioned about my intentions and motives and qualifications.  I also hope for a day when the OT profession develops supporting literature that does not confuse meeting the needs of families with driving an advocacy and 'justice' agenda.



References:

American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62,625–683.

American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48

Bruce, M.A. and Christiansen, C.H. (1988). The issue is...advocacy in word as well as deed.  American Journal of Occupational Therapy, 42, 189-191.



Burke, M.M. and Hodapp R.M. (2014) Relating Stress of Mothers of Children With Developmental Disabilities to Family–School Partnerships. Intellectual and Developmental Disabilities, 52(1), 13-23.
 
Harper, et al (2013). Respite care, marital quality, and stress in parents of children with autism spectrum disorders.  Journal of Autism and Developmental Disorders, 43, 2604–2616.

Thursday, May 14, 2015

A critical juncture for the New York State Occupational Therapy Association

The New York State Occupational Therapy Association is planning to make significant changes to its bylaws and governance in the very near future.  Since so little information has been available on these changes I took the initiative to gather data so that occupational therapists in NY would have more information to assess these proposals.

I will begin my analysis with an apology, because it is my longstanding belief that to be an appropriate critic one needs to be a member of the group that is being held to scrutiny.  For purposes of transparency I will divulge that I ceased my NYSOTA membership approximately ten years ago in protest of inappropriate accounting practices.  However, I remained in close contact with many therapists around the State who continued their participation with the membership association.  Many of these members are currently upset about the proposed changes to governance.  Some don't want to make their protest public and have given me copious information to analyze about this topic.  I believe in transparency and openness that can lead to improvement, and that is why I am sharing the information that was given to me.

To begin with, it is important to know background demographics about occupational therapists in NY State.  According to the New York State Office of the Professions as of January 1, 2015 there were 12,254 occupational therapists and 3,912 occupational therapy assistants.  That is a total of 16,166 occupational therapy practitioners in NY State.

According to NYSOTA documents that I have reviewed, there are 548 occupational therapist members (4.5% of all NY OTs), 168 occupational therapy assistant members (4.3% of all NY OTAs), 1,308 student members, and 19 'other' members.  As students are not practicing professionals they should be excluded from any calculations.  So, there is a total of 716 practicing OT/OTA members (4.4% of all NY practitioners).

Social disengagement in traditional membership structures was brought to the forefront of attention in Putnam's classic work Bowling Alone.  The occupational therapy profession in NY State reflects this trend.  During the period of time from  2006 through 2014 NYSOTA OT/OTA membership declined 24%.  Most of that loss is declining OT membership; in fact, OTA membership increased over that time period.

The challenges associated with diminishing membership caused the American Occupational Therapy Association to attempt governance restructuring several years ago.  Those efforts failed when they were voted down by the Representative Assembly.  Unfortunately, records of those discussions have been purged from the AOTA website and can no longer be viewed there.  My recollection of those conversations are that many people were concerned that elimination of the RA and replacing it with another structure was considered inadequately 'representative' for members.  I always considered it unfortunate that AOTA leaders were not able to successfully explain to members why a different structure was needed, or to present a structure that was palatable.

Based on an analysis of the proposed changes to the NYSOTA bylaws it appears that a similar proposal for governance restructuring is being attempted.  Below are some highlighted and important changes:

Districts are being eliminated.  NYSOTA will be governed by 9 people.  Four will be officers elected by the members, four will be members-at-large elected by the members, and one will be appointed by the elected Board members.

This is a very unusual configuration because the distributed membership around the State is very uneven.  Additionally, allowing the vote of students who represent the largest membership block sets a problematic scenario where academics who know those students and are responsible for giving them grades have a lopsided advantage in elections.  Having one person randomly appointed to the Board is also unusual and leads to questions about why such a configuration would be suggested. Aside from geographic concerns, OTAs are also notably absent from Board representation.

2. Another immediate concern is a proposed change in the stated purpose of the association.  The current bylaws state that NYSOTA is "dedicated to the advancement of the occupational therapy profession and to the improvement of the quality of occupational therapy services."  The PROPOSED bylaws state that NYSOTA will be to "promote the OT profession within the State of NY, to promote and advance education, training, and research in the profession, and to engage in any other such activities determined to be advantageous to the Association and its members."  This is a dramatic and different role for the membership association and completely steers away from the previous purpose that explicitly sought to improve the quality of OT services.

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There are additional troubling elements to this restructuring plan given the historical financial context of the membership association.  There were longstanding accounting difficulties dating back many years and at one point prior to 2006 caused the resignation of the NYSOTA attorney and several members of the Executive Board because of non-compliance with standard accounting practices.  Those concerns were never really explained to the membership and to my knowledge the resignation letters of the attorney and some members of the Executive Board were never shared with the membership.  This was a troubling lack of transparency.

I have been informed by several members that those accounting concerns were remedied by a consolidation of finances that now allows centralized auditing.  That consolidation has not gone without criticism from some districts and members.  A look at the recent balance sheet indicates some concerns.  According to available documents, net income has been in the red for seven of the last nine years.  In the last two years, net income has been near a $60,000 loss each year.  Expenses averaged approximately $100,000 per year from 2006 through 2012, but jumped up above $150,000 for each of the last two years.  Clearly, something is dramatically changing to cause such an increase in expenses in the last two years.  This significant increase is financially unhealthy, particularly given the historical instability of conference revenue which is being relied upon more and more on recent balance sheets.

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The sum of this analysis is that NYSOTA is at a critical juncture.  A governance change that appears to be less representative than before is being proposed, but the previous structure was admittedly unwieldy.  The Board seems to be at war with some of its own districts, stating that at least three districts should have been dissolved according to provision of current bylaws.  That may be true (details are unknown to me at this time), but this is not a healthy situation.

Expenses are rapidly increasing, dues paying membership is rapidly decreasing, and (free) student members inflate the membership rolls.  The very purpose of the association is being re-defined.

My recommendation to the NYSOTA BoD is to slow track their proposed changes and explore new methodologies for inclusive planning to meet this acute crisis.  The fact that several sources from different districts are leaking out documents to me should be an indicator of the heightened dissatisfaction from the dwindling membership that remains.  I expect some criticism for putting this information out for people to see, but my motivation is to create a context where members will be involved, represented, and able to participate in some consensus decision making.  NYSOTA has not been healthy for many years, and a change is needed that will involve a much greater level of participation from ALL OTs in NY State - members or not.

Right now, that is apparently not happening.

As I have previously done, I willingly offer my time and abilities to help solve these very challenging problems.

Friday, May 08, 2015

Social justice in occupational therapy: Where to from here?

After a multi-year debate there was some small capitulation regarding the social justice language in the AOTA Code of Ethics.  The previous section labeled 'Principle 4: Social Justice' was removed and replaced with a more generic section on 'Justice' that focuses on procedural aspects of the Justice construct.  A passing reference to a social justice construct was included in the Preamble.

It is difficult to know if it is even fair to say 'capitulation' because we have not had precise commentary from the Ethics Commission on those changes.  What we have are the comments of the EC Chair Dr. Lea Brandt who stated

It is correct that in the section on Core Values there is still terminology referring to social injustice.   This reflects the membership feedback which called for inclusion of the concept of social justice while tempering that perspective with a group of members who requested to have the term removed.  The term “Social Justice” was removed from the Principles and Standards of Conduct section which outlines the enforceable areas of practice, but was retained in the aspiration section of the Code.  
 In short, standards which contained language that could appear ambiguous to some or more challenging to enforce were removed or modified; however aspirational language related to social justice concepts was relocated to the Preamble section accommodating the large number of requests to strengthen and include this language consistent with the profession’s Centennial Vision.  The intent in doing this was to develop a Code which includes further clarification of the potential interface between the professional Code of Ethics and state licensure laws and the roles and responsibilities of each.

One of the primary arguments about a social justice requirement was that it could not be enforced.  The EC attempted to separate enforceable principles from non-enforceable values but actually created an illogical division that has concepts listed in both.  Obviously, enforceable and non-enforceable are mutually exclusive divisions and that makes the current Code very confusing.

For example, Justice is listed in both divisions.  How can Justice be both an enforceable principle and a non-enforceable Core Value?  An excellent analysis of this illogical classification scheme was posted by Alex Duran and can be viewed here.

I understand the intent to separate Non-Enforceable (aspirational) v. Enforceable ethics, but it appears to have been done poorly.  Perhaps a model that attempts a more clear distinction between the two categories would be the APA Code of Ethics.  The APA Code does not seem to re-label and confuse the two categories.  Rather, the Enforceable Ethics (Standards) are rather specific and relate to very concrete practice and research oriented concerns.

The APA Ethics Director stated "The distinction between aspirational and enforceable is central to the code's structure and differentiates between the ideals and goals to which psychologists aspire and the rules by which psychologists must abide. When adjudicatory bodies blur this distinction, psychologists may inappropriately be held responsible and possibly disciplined for not fulfilling the profession's ideals and striving toward its highest goals."

As the AOTA Code of Ethics is unfortunately embedded in the license law of several states by reference, it is critical that the Code is clear and coherent.  In this there has been a clear failure.

So although there have been improvements with the removal of some of the Social Justice language, large problems have been created with an illogical division of enforceable principles and non-enforceable values.  With functional classification schemes readily available (APA), it is disappointing that this kind of error was made.

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What remains problematic in this entire ethical debate is that there continues to be a disconnect for many American therapists about what the social justice construct actually represents and what it means when it is adopted as a value.  There are some agenda-driven therapists who are fully aware of the implications of their advocacy for a social justice concept but there are also large numbers of people who go along with it because it 'sounds' good.  I am not certain that much has changed since 2011 when the debate started on OT Connections - at that time many people were arguing that social justice was not a political construct and they thought it just meant that we should try to help poor people.  Of course the issue is not the objective (trying to improve the lives of people) but the problem is with the methodology (redistribution and governmental control).

It is my wish that American therapists would watch or read the news of the 2015 British elections and see the unfortunate result of a health system that has become hopelessly intertwined with politics.  The commentary from UK colleagues and even the COT is telling and demonstrates the angst and concern that is created because the conservative party performed much better in elections than was initially predicted.

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As an interesting and related point of reading, I encourage occupational therapists who are still confused about what the social justice construct represents to read Adam Swift and David Brighouse's recent 'scholarship' on the topic.  They are promoting the concept that "familial relationship goods" are unfairly distributed because some families are able to confer advantages based on values, relationships, opportunities, etc.  This hit the lay press last week associated with Swift's appearance on a radio show where he was discussing the 'unfair advantage' that was conferred by some families reading bedtime stories to their children - so of course the extension of this bizarre thinking is that reading bedtime stories should not be allowed.  It is fortunate that the lay press grabbed a hold of the odd 'ban on bedtime stories' because sometimes it takes just such a soundbite to bring the agenda and dangerous thinking to the fore.

I don't expect that Swift and Brighouse actually want to control people's bedtime story routines with their children, but this type of thinking and 'moralizing' helps to prop up the notion that the State has to be an arbiter of fairness and distribution because there is no other mechanism to ensure equal distribution of "familial relationship goods."

I wish that this soundbite was available during the debates on social justice in the Code of Ethics.  I would love occupational therapists to explain how they are supposed to "abide by the highest standards of Social Justice" (as was required in the 2010 Code of Ethics) when Social Justice crusaders state that we need to make the distribution of familial relationship goods "fair" for everyone.

I already blogged about this in context of Melissa Harris Perry's objectionable statement that children don't belong to their parents and need to be raised by a collective community.  This remains an issue for the Ethics Commission to address, because it is very difficult to understand how Dr. Brandt can continue to state that such collectivism is a Core Value of the occupational therapy profession when so much evidence points to the contrary notion that the profession has always emphasized autonomy and individual responsibility.

My opinion is that this Social Justice conversation should continue as long as there are elements in the (USA) profession who mistakenly believe that it is a Core Value.

And now we have the introduction of a new unfortunate confusion about what is an enforceable principle and what is a non-enforceable Core Value.  There is work still to be done.

Thursday, April 23, 2015

When it becomes more important to state 'why' you do something

If you ask 100 occupational therapists what they do you will get 100 different answers, because the nature of the profession is to help people do the things that are important to them.  Every patient has their own priorities, and that makes all the stories different.

Instead of focusing on the 'what' I like to focus on the 'why.'  When I need to be reminded 'why' I do what I do I like to drag this story out.

I knew a young family and they were unable to conceive.  After spending many thousands of dollars they made some arrangement with a young teenage mom so that they could adopt her baby (just about to be born).

So they go to get the baby and sign all the papers and get on the plane.  The baby was only a couple days old. On the way back home the baby goes into cardiac arrest and the new mom (a trained health care professional) gives this new baby rescue breathing and chest compressions. They are admitted directly into the intensive care unit when they get off the plane.

It turns out that the baby had several STDs: syphilis, gonorrhea, chlamydia, plus other bad infections including CMV - any of which could be deadly in a newborn. If that wasn't enough the baby had a poorly developed liver and developed a condition called necrotizing enterocolitis - they had to take out most of her small intestine as it had died inside her. They also put in a feeding tube and a tracheostomy (the baby's lungs were underdeveloped too and she couldn't breathe except with a ventilator). The baby also had a colostomy bag.

So the next eight months were a constant vigil in the ICU for these parents and their family. The feeding tube could never work properly so they had to provide liquid nutrition directly into an artery - a process called hyperalimentation. It is effective for the short term but ultimately will burn out your liver, and that is what happened to the baby. She became so jaundiced and sick that as a last ditch try they flew her to another city that had a great transplant program and prayed for a miracle. Unfortunately, the child's mesenteric artery which supplies the liver was also malformed and so she was not a candidate for any transplant. They sent her back to the hometown hospital.

Now I imagine that everyday these parents faced a fork in the road and could choose to either keep forging ahead or they could throw up their hands and give up. I am not sure if anyone could blame them if they did that - after all, they did not bargain for this situation: months in an ICU with a sick child that is not biologically theirs, and running up hundreds of thousands of dollars in medical bills (of course insurance companies at that time balked at coverage given the adoption and that this was 'pre-existing'). But the parents never quit anyway. They kept with it, every day, every night. Sleeping in chairs in the ICU. The baby had some moments of real quality - she was not neurologically impaired and so with regards to her cognition she was a normal 8 month old baby.

In the end, it was apparent that the baby was in pain, close to death, thrashing inconsolably, and jaundiced the color of yellow-green mustard.  The parents made an unthinkable decision and chose to end her life by withdrawing the ventilator support. The baby was alert and cognizant of her surroundings, which made the decision to withdraw support so much more complex. I can't understand the depth of love it took to do this for their child. Their child - not really theirs. But theirs nonetheless.

The baby died in her real mom's arms one night. After so many months in the ICU and with every day an act of love I think that these parents deserved to be called the baby's "real" parents, regardless of the biology.

This is not a story about heroic doctors.  It is not a story about caring nurses or diligent occupational therapists.  Most of the real stories and the daily events that are out there are about the people we care for.

I provide occupational therapy because every parent has an unbelievable mission to help their own child, and when things go wrong OTs help them do things that matter to them.  It is not so important 'what' you do because those stories will change with every patient and every family.

What matters is 'why' you do it.  I do it because it is all about human need and the value of normal occupation like the dreams and hopes of a family, even in the face of impossible situations.

This is a story that I use for the purpose of focus.

Thursday, April 16, 2015

On persevering in leadership and its relevance to free speech


An interesting quote was attributed today to Amy Lamb, the President-Elect of the American Occupational Therapy Association.  Here is the quote as it appeared on Twitter:



I initially consider that the timing of such a statement that "No means not now" could possibly be related to the recent decision by the US Senate to refuse to support the Cardin-Vitter amendment that would repeal the Medicare outpatient therapy cap.  Therapy leaders have been trying for many years to get the cap repealed and it was a stinging defeat.

I asked for additional context and clarity about the quote and was informed that it was generally stated as an important leadership principle.

The reason why this caught my attention is because of my own experience with the way that the occupational therapy profession deals with divergent opinions.

In 2013 I attempted to reach out to a former Ethics Commission Chair to discuss ongoing concerns with the Social Justice construct.  That Chair was not interested in any conversation, and instead of receiving a note from that person I received a letter from an AOTA attorney that stated, "I understand your perspective on the Social Justice provision of the Ethics Code, and would note that it is settled business at this time."  From the tone of that letter, the philosophy in play was clearly that 'No means no.'  In fairness, that attorney also stated that there might be opportunities to discuss matters when the Code was re-written (in 2015), but that turned out to be a false promise because there was virtually no dialogue allowed with the Ethics Commission members during the current revision period.  In fact, that lack of dialogue and unwillingness to engage the membership contributed to rather serious errors that have been pointed out regarding the Code that was just approved by the RA.

Another example was in conversation with another OT leader about a banal debate in 2014 regarding patient vs. client terminology.  Specifically, I was stating that a lack of philosophic consistency is present in our terminology and ends up getting reflected in our meandering and inconsistent focus on our definition of practice.  In that conversation I was told that "I would describe the “name” issue as essentially resolved in OT and a non-issue."  Again, since the conversation was not of interest to the leader, it was clear that 'No means no.'

These two examples demonstrate clearly that divergent opinions are not always welcome and that sometimes there is a disinterest in even hearing other people's opinions.  When people tell you that something is 'settled' or 'already decided' that is a rhetorical method that cuts off conversation.

In a rather stunning juxtaposition of the 'No means no' methodology there has been evidence of conduct that indicates that 'No means no' only when it is expedient to the beliefs of those in charge.  Specifically,  the OTA Ad Hoc Entry Level group conducted a study that clearly demonstrated the membership's disinterest in moving the OTAs to a bachelor-level degree, but then still advanced a motion to explore how to be successful if a change is ever desired.  There have been several statements by leaders about the entry level OTD issue that show a similar lack of interest in member input - 'The decision has already been made' and 'The entry level OTD is happening like it or not.'  These kinds of statements clearly show that 'No means no' only when applied in certain directions.

So the public statement that acknowledges the value of persevering is something new and I am hopeful that this philosophy will be applied evenly, particularly when members speak out about important matters.  This becomes important because of the new Code of Ethics that states that 'negative online comments' may constitute an ethics breach if someone believes that those comments serve to stifle conversation.  Obviously, persevering and lobbying a position to one person could be considered 'badgering' by someone who holds an opposing view.  This is a very dangerous provision in the new Code of Ethics that could be used to limit the participation of members.  Someone could simply state that another person's opinions are 'badgering' and 'limiting the speech of others.'  Such a provision is a serious threat to free speech.

This is why it was so interesting to see the statement about persevering in leadership.  I am very hopeful that this statement will be universally applied and that this might signal a new day for the way that occupational therapists deal with conflicting professional opinions on the important matters of the profession.

If 'no' actually means 'not now,' and if persevering is a value, then people should be encouraged to persevere in their opinions and lobbying whether or not anything has been 'settled.'  That is the ultimate value of free speech.