Saturday, August 29, 2015

Investigating the status of "The Pledge and Creed for Occupational Therapists"

A little over a year ago I presented an argument that the Emmanuel Movement provided important core values for the occupational therapy profession.  This argument was constructed in context of a debate on whether or not Social Justice was a historical value of the profession.

I was curious as to why we neglected to include the Emmanuel Movement when we discussed our values and beliefs.  In the beginnings of the 20th century the Emmanuel Movement was based on the notion that a new method was required to address the social problems of disability and illness.  That new method was a philosophy regarding responsibility and self reliance - and surrounded by Christian values of charity.

Furthermore, that method was most certainly not based on a governmental model of redistribution or in a new age construct of oppression and liberation.  That fact is what made some of the recent social justice debates so curious.

Shannon (1977) warned that "a discipline that forgets its founders may be lost."

I have been studying these Values and Beliefs articles for a couple years and I recently noticed something that seemed to be missing.  In the initial article for the series covering the dates from 1904-1929 there is no mention of the  Occupational Therapy Pledge and Creed.  Certainly a Pledge and Creed would be an important document that would reflect both values and beliefs. 

The Occupational Therapy Pledge and Creed was submitted by the Boston School of Occupational Therapy and adopted by AOTA in 1926.  What is noteworthy is that the Pledge and Creed is mentioned in the book of one of the authors of the Values and Belief series (Reed and Sanderson, 1999, p. 408).  The Pledge and Creed states:

REVERENTLY AND EARNESTLY do I pledge my whole-hearted service in aiding those crippled in mind and body.

TO THIS END that my work for the sick may be successful, I will ever strive for greater knowledge, skill and understanding in the discharge of my duties in whatsoever position I may find myself.

I SOLEMNLY DECLARE that I will hold and keep inviolate whatever I may learn of the lives of the sick.

I ACKNOWLEDGE the dignity of the cure of disease and the safeguarding of health in which no act is menial or inglorious.

I WILL WALK in upright faithfulness and obedience to those under whose guidance I am to work, and I pray for patience, kindliness, and strength in the holy ministry to broken minds and bodies.

Most interestingly, Reed and Sanderson document that this Pledge and Creed "remains official today" when their book was published in 1999.  Since Reed wrote about the Pledge and Creed in 1999 certainly she was aware of it when she wrote the Values and Beliefs series.  I am not sure why it would not be mentioned in the series.

I have not been able to locate any documentation or announcement that this Pledge and Creed has ever been rescinded but this is an area that I am continuing to investigate.

Aside from the curious omission from the values and beliefs series it is important to note that such a Pledge and Creed incorporates a view of occupational therapy that is at severe odds with the changes that have been espoused by some therapists in the last twenty years.  Values of social justice, political redistribution of resources, client-based ethics, and redefinition of who we provide services to (whole communities, agencies, non-human entities, etc) are all severely out of step with the Pledge and Creed.  

The words 'pray' and 'holy ministry' are certainly interesting and I wonder if that is why the Pledge and Creed are not mentioned by those who espouse a secular interpretation of occupational therapy history.

I am not advocating the position that OT has to be explained in Christian terms but perhaps the inability to advance and explain the spiritual dimension of practice is why we have become so lost with our definitions. The existence of the Pledge and Creed presents itself as a philosophic conundrum for the profession.  

The Pledge and Creed is not on the AOTA website.  Has it been rescinded?

Does it 'remain official today?'

Is it the will of the association to rescind the document if it has not already been done?

If not expressed in specific terms of Christian ethics, how does the occupational therapy profession express its interest in spirituality?  We have lost our way on this topic. Howard and Howard (1997) asked "What does spirituality have to do with occupational therapy?"  They mentioned the early influence of the Immanuel (sic) movement, but it is clear that even in attempting to cover the topic that they apparently missed the mark.  Christiansen (1997) stated that "by failing to acknowledge a spiritual dimension, occupational therapy practitioners lose important opportunities for understanding the full potential of occupation to enhance the health and well-being of clients."

Egan and Swedersky (2003) state that "given the diverse definitions and the multiple meaning of spirituality in practice it is perhaps not surprising that studies of American, British, and Canadian occupational therapists are unsure of the role of spirituality in practice."

But even with these acknowledgements of spirituality in practice we have approached the subject as if we are doing so for the first time.  What an unusual position for a profession to be in when its very roots were based in a notion of mind-body-spirit healing!


embedded links, and...

Christiansen, C. (1997).  Acknowledging a spiritual dimension in occupational therapy.  American Journal of Occupational Therapy, 51, 169-172.

Egan, M. and Swedersky, J. (2003). Spirituality as experienced by occupational therapists in practice.  American Journal of Occupational Therapy, 57, 525-533.
Howard, B.S. and Howard, J.R. (1997). Occupation as spiritual activity.  American Journal of Occupational Therapy, 51, 181-185.

Sanderson, S.N. and Reed, K.L. (1999).  Concepts of occupational therapy, 4th ed. Philadelphia: Lippincott, Williams, and Wilkins.

Shannon, P.D. (1977). The derailment of occupational therapy. The American Journal of Occupational Therapy, 31, 229-34.

Friday, August 28, 2015

Ethical occupational therapy practice in nursing home care

I teach ethical decision making to occupational therapy students.  One of the most common concerns that I hear from students each year is the pressure that they experience regarding productivity and 'meeting minutes requirements' in skilled nursing facilities.  Nursing homes receive higher rates of reimbursement based on intensity of rehab services that are provided, so there is an incentive for facilities to provide as much 'high intensity' therapy as possible.

Typically, the students express ethical distress because they often believe that the recipients of these services are receiving marginal or no benefit from their participation.

As a population, OT students feel disempowered about expressing concerns in this area during their fieldwork experiences because

a) they perceive that they are 'just students' and don't want to make waves
b) they feel confused because their clinical preceptors are all engaging in the behavior
c) they have competing pragmatic concerns, like graduating on time, having to find a new fieldwork, etc

Students report that many practitioners 'go along' with the push for more therapy because they become concerned with job security or that they simply accept these practices as 'being the way things are done.'

The Wall Street Journal wrote an excellent investigative article on this issue that I encourage others to read fully and carefully.  The article can be found here:

The article describes massive increases in therapy that advantage Medicare payment rules:

"The ultrahigh-therapy rise stretches from small operators to chains. Genesis HealthCare Corp., among the largest nursing-home providers, cited ultrahigh therapy in 58% of days for which it billed the system in 2013, a Journal analysis of Medicare data shows, up from 8.1% in 2002.

Kindred Healthcare Inc., which runs nursing homes and provides therapy at other facilities through its RehabCare unit, did so 58% of the time in 2013 at its own facilities versus 7.6% in 2002. Kindred and Genesis declined to comment.

HCR billed for ultrahigh services 68% of the time in 2013, versus 8.8% in 2002. In December, the Justice Department joined a whistleblower lawsuit alleging HCR pressured employees to provide unnecessary therapy and overbilled Medicare."

The leaders of the speech, physical, and occupational therapy member associations responded to the article with this letter that can be found here:

The response pays appropriate concern to the problem, but I believe that the member associations need to do more than simply "dialogue with industry to address the issue of volume-based versus value-based care and to improve compliance" and "help clinicians navigate complex regulation and payment systems, emphasize their responsibility to report unethical care provision and promote value-based patient care."

Some therapy groups named in the Wall Street Journal Article declined to comment but they also have direct relationships with the member associations, including sponsorships, clinical affiliation agreements, and other opportunities where they 'partner' with the member associations.

I believe it is reasonable to suspend these kinds of partnership arrangements until there can be a more thorough investigation about the practices of these companies.  Membership associations can't claim to be concerned about possibly unethical or even possibly illegal practices that are discussed in the Wall Street Journal article while they are forming partnerships with these agencies at the same time.

Writing a letter in response to the article only pays lip service concern, particularly when partnership agreements with these agencies remain in force.  Temporarily suspending partnerships pending investigations is prudent and sends a much stronger message about the actual concerns of member associations.  Partnerships can be renewed if there is no wrongdoing.  If there is wrongdoing, the member associations should not be partnering with these groups.

Monday, August 17, 2015

The occupational therapy profession's indecisive step toward its Centennial Anniversary

The Accreditation Council for Occupational Therapy Education released an unexpected set of decisions last week.

In sum, the two decisions promote the concept of dual entry levels for OTA education and dual entry levels for OT education.  The OTA dual entry (associates and baccalaureate) is an entirely new concept while the OT dual entry (masters and doctoral) follows a year-long debate on whether or not the profession should adopt the doctoral level as a single point of entry.

The reason why each of these decisions was surprising is because they contradicted the publicized opinions of the American Occupational Therapy Association, the member group for the profession.

As such the 'problem' with the decisions doesn't rest with ACOTE alone, but rather represents a community of professionals that are at odds with themselves and unsure of how to move toward the future.


Regarding OTA education, an Ad Hoc Committee of AOTA looked at the complex issues surrounding OTA education and came up with three recommendations.  Those recommendations were:

1. Keep OTA education at the associate level
2. Have only one level of degree entry for OTAs
3. Articulate strategies to succeed if the association ever decides to transition to a higher degree level for OTAs.

The reports states that "While there may be some benefits to the two entry-level-degree model, they do not  outweigh the inconsistencies created when  there are  two different degree levels qualifying  graduates for a single set of entry-level competencies."

The full report is available at


Regarding OT education, an Ad Hoc Committee of AOTA looked at the complex issues surrounding OT education and came up with nineteen recommendations.  The most relevant regarding entry level was:

"AOTA adopt a mandate that entry-level-degree for practice as an  occupational therapist be a  doctorate by 2017 with a requirement for all academic programs  transition to the doctorate by 2020."

The full reports is available at


The ACOTE decisions now recommend dual entry for both levels and apparently disregard concerns stated in the above reports in promoting what they are calling 'flexibility.'  ACOTE recognizes inherent difficulties with lack of differences in program outcomes between different levels, difficulties with infrastructure needed to support doctoral programs, and the paucity of fieldwork sites.  These are significant barriers that have been correctly identified.  The full statement is available at

Flexibility is certainly achieved by having dual entry points but also shows a profession that lacks leadership, direction, and ability to make definitive decisions and move toward a consensus.  In the parallel example of multiple entry points for the nursing profession, Smith (2009) states, "The requirements for entry into and completion of these programs vary by state and are controlled by forces within each state’s higher education system and healthcare-related interest groups, and the nursing profession itself."  This is what will also occur within the occupational therapy profession and is already on display in New York State.  A group of academicians, supported explicitly by the State OT board and tacitly by the State member association, is laying the groundwork for an eventual doctoral level entry point.  See here for details.

Not every state has interest groups that will powerfully drive the issue toward a conclusion.  There is a severe maldistribution of occupational therapy educational programs in the United States.  States with few or no programs and weaker State Associations might be among the last to promote a voluntary doctoral level entry point.  This will cause compounding problems with lack of consistency.

Smith (2009) lists several factors that likely contributed to the nursing profession's inability to agree on escalating degree requirements.  Use of a 'top down' decision making strategy was a major impediment that turned many nurses off of the idea of escalating entry level.  Also, the use of 'policy entrepreneurs' who were knowledgeable and well connected backfired on nurses because those people were not viewed as 'one of us' by the average nurse who would be impacted by the decision.  These same factors came into play for occupational therapy.


Several actions are recommended in order to move the occupational therapy community to a consensus decision point.

1. Recognize that "flexibility" is a euphemism for indecision and confusion.  Study the nursing profession example to understand what "flexibility" has accomplished and not accomplished.

2. Place an accreditation moratorium on development of ALL entry level doctoral OT programs and baccalaureate level OTA programs.

3. Outline a process that will encourage a critical analysis of accreditation standards and align their minimal purpose with meeting evidence-based entry level occupational therapy practice competencies.

4. Develop profession-wide consensus on essential educational components based on practice analysis of entry level and advanced level skill sets through research.

5. Listen to and address the relevant concerns of the entire constituency that is impacted by such a decision: academia, clinicians, employers, the public, and other stakeholders.  Most importantly, don't drive this from a top-down perspective.

6. Develop final consensus based on a comprehensive consideration of ALL THE ABOVE.


The current recommendation to promote dual entry levels will allow a condition of indecision to persist.  From a vacuum of indecision we can expect more special interest meddling from within different States.  We can expect a lack of uniformity that can complicate if not jeopardize third party reimbursements.  We can expect continued maldistribution of personnel.  We can expect uneven practice competency.

The occupational therapy profession is about to celebrate its Centennial Anniversary.  Confused and indecisive entry level education standards are not the way to put a best foot forward into a new century.


Smith, T., (October 5, 2009) "A Policy Perspective on the Entry into Practice Issue" OJIN: The Online Journal of Issues in Nursing Vol. 15 No. 1. 

Tuesday, August 04, 2015

OTD 45 day comment period coming to a close next week

This post represents continuing analysis of the process to change the entry level educational requirements for practicing occupational therapy from the masters level to the doctoral level.  The analysis is offered as a public critique of the occupational therapy profession's methodology for enacting such a change.

The 45 day comment period on a new rule that will authorize the conferral in New York State of the degree of Doctor of Occupational Therapy (O.T.D.) will come to a close at the end of next week.

The American Occupational Therapy Association reports:

In June 2015 AOTA staff also surveyed the 152 accredited master’s-degree-level programs, with 131 (86%) responding to the survey. Of the 131 programs that responded, 106 (81%) indicated that they had started working on a transition to the doctorate and planned to have this completed within 10 years (86 within 5 years). 

As I stated recently, "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."  Looks like my analysis was spot on.

The American Occupational Therapy Association also reports:

What is clear from the data collected is that overall, the occupational therapy community is split on this issue, and that the overwhelming majority of participants in the dialogues see both potential threats and opportunities in moving the entry-level degree requirement to the clinical doctorate. 

I note the careful use of the word 'split,' which casually implies equal or near equal parts - but we are living in Orwellian times where words are carefully used this way.  A more accurate representation of this 'split' opinion in OT is probably near 75% in opposition and 25% in support.  Most of the support comes from academicians.

I based this on my own reading of the OT Connections forums and other social media sites and from the expression of opinion in the Town Hall at the AOTA National Conference.

The word-crafting does not end with the word "split."  It is also notable that in the Representative Assembly discussions nearly all the commentary from reps was negative.  On March 31 I posted the following in the RA feedback forums: (link is restricted to AOTA members)

AOTA members should take careful note of the strategies employed in the discussions about the move to an entry level doctorate. In several of the threads discussion was started - and that discussion was almost universally negative or hesitant about the move to an entry level doctorate. Then the Task Group Leaders in a couple threads suggested that Reps use a SWOT analysis in order to express their opinions, because "It will help when gathering and organizing the comments from the four task groups." Use of a SWOT analysis format FORCES reps into making statements that they were not naturally making. Prior to the directive, reps were responding naturally with perceptions of weakness and threats associated with the change. Now their comments are being naturally counterbalanced because they are being asked to include Strengths and Opportunities. Someone made the decision to ask for SWOT, and reps should all wonder where that request came from and why it was made. SWOT does not make data gathering any easier - all it does is balance out the feedback and artificially promote positive comments. That is how the thumb is placed on the scale and influences feedback. It is a detail that does not escape the notice of the membership who is watching this process closely. 

ACOTE will release the results of a survey of 3000 respondents sometime later this month.  It will be interesting to see the results of that poll, and an analysis will be posted here.

One refreshing point of honesty from AOTA was mentioned in their latest statement when they reported "It is likely that student debt will increase, and that continues to be a concern"

The debt issue alone should mobilize some students and parents to write a letter to NY State Department of Education and offer some feedback about the rising cost of higher education and whether or not there is evidence to continue escalating degree requirements and subsequent costs.

I posted a question on the NYSOTA Facebook page two weeks ago asking for their public comment on the OTD proposal.  That question remains unanswered.  According to NYSOTA documents from a couple months ago, there were 1308 student members, which constitutes approximately 65% of their membership.  Perhaps that is why they don't want to answer this question?

This change will probably happen anyway primarily at the whim of academics who have decided the issue for everyone else.  Readers have until next week to register an opinion with the NY State Department of Education.  Write to:

Office of the Professions,
Office of the Deputy Commissioner
State Education Department 
State Education Building 2M
89 Washington Ave.
Albany, NY 12234
(518) 486-1765

Friday, July 24, 2015

Celebrating TEN YEARS of occupational therapy blogging!

Ten years ago I posted this first entry:


Hi everyone...

This is the ABC Therapeutics weblog. We are occupational therapists in Western New York.

More coming soon...


Well it has been ten years!

Sometimes the entries were patient stories.  Sometimes they were opinions on professional matters.  Sometimes they were analyses and criticisms of the systems we work in.  Sometimes the entries were pithy and academic and sometimes they were pedantic and boring.

No matter what it all has been, I hope that I have been faithful to my mission of creating an ongoing experiment in a mostly open-source exploration of occupational therapy.  No ads.  No bias other than 'just me - '  straight shooting commentary from the hip of a street level practitioner.  Sometimes that resonated and sometimes it created enmity - but it is all dialogue and that is something that we all need a lot more of.

No matter what, it seems appropriate to take the opportunity to thank those who have read, debated, agreed, disagreed, pondered, acted, and  contributed by commenting or sharing ideas here.

I'll be re-linking some 'blasts from the past' all week as I celebrate this ten year achievement!

Here's to the next ten years!

- Chris

Tuesday, July 21, 2015

Open letter to the NYS Board of Regents on the OTD degree

The New York Department of State's Division of Administrative Rules (DAR) publishes the weekly State Register.  This document contains newly proposed amendments to state agency rules and provides interested parties an opportunity to comment on actions before an agency adopts each rule.

The July 1, 2015 Register contains a new rule that will authorize the conferral in New York State of the degree of Doctor of Occupational Therapy (O.T.D.).  There is a 45 day comment period that will soon come to a close.

The Register states that 
The purpose of the proposed amendment is to authorize the conferral in New York State of the degree, Doctor of Occupational Therapy (O.T.D.). The proposed amendment arose from a request to confer this degree by one of the institutions of higher education in New York.  The O.T.D. degree is recognized by the Accreditation Council for Occupational Therapy Education (ACOTE) and is an authorized degree in 26 states, which include California, Connecticut, Florida, Georgia, Massachusetts, Pennsylvania, and Virginia. Adding this degree will benefit occupational therapy students and practitioners in New York by affording them the opportunity to earn a doctoral level degree. The O.T.D. degree in New York will expand practitioners’ access to higher level research and lifelong learning, which ultimately translates to better client care in the profession. Because the O.T.D. degree is a new degree in New York, it is necessary to amend sections 3.47 and 3.50 of the Rules of the Board of Regents related to requirements for earned degrees and registered degrees.  The State Board for Occupational Therapy supports the authorization of this new degree title.

The argument that this degree is necessary because it is not available to NY therapists is a canard.  Many NY State practitioners have engaged distance education to pursue the OTD degree.  Offering the degree in NY serves higher education in NY and does little to nothing with regard to overall access to educational opportunities which are already plentiful elsewhere.

What the Register does not reference is the push from the Board of the AOTA to move the profession to a mandatory entry level OTD.  As most educational programs are 'credit heavy' this will be a default elimination of the masters level degree.  As one possible example, when students are presented with an option of completing an MS program in approximately two years or a doctoral program in approximately three years it is likely that they will opt for the doctoral program.  This dynamic has been discussed from a competitive standpoint by the AOTA Board of Directors when they stated, "The current high credit load in master’s programs makes it very difficult to add additional content in specialized areas of practice. At this time the occupational therapy master’s programs greatly exceed the average credit load of other master’s programs, prompting students to ask why their colleagues in other professions are graduating with a doctorate when, in most cases, they are only in school for 1 to 2 more semesters."

This fact makes the following statement in the Register incorrect:

The amendment simply adds a new degree option and imposes no costs on any parties.

In fact there will be significantly increased costs to students who will be cattle-herded into doctoral programs.  They in turn will attempt to increase the cost to employers because students will believe that they are entitled to high pay associated with their doctoral training.  That can increase the cost to consumers.

A Regulatory Flexibility Analysis was not required and not prepared because the proposed rule states that there will be no impact on business or local governments.  This is false.  Permission to grant this degree will ultimately lead to the elimination of the masters educational level and can increase costs at every level.

A Job Impact Statement was not required and not prepared because the proposed rule states that there will be no impact on jobs or employment opportunities.  This is false.  Increased costs are likely to lead to job loss and will encourage increased attempts by employers to use lower cost or alternative providers.  This will not meet the objective of improving quality of care to consumers in the State.

The Register states that "the State Board of Occupational Therapy supports the authorization of this new degree title."  However, they do not recognize the inherent conflict of interest that many State Board members have because they are employed by institutions of higher education, which would all profit from expanding their degree offerings and escalating the entry level degree.

The Register also does not address the fact that this matter is being internally debated within the occupational therapy profession but that there are extensive flaws in the process that have been documented here and here and here.  During an open forum at the 2015 AOTA Conference the vast majority of commenters argued against the OTD.  At this time there is no consensus on whether or not the entry level OTD should be encouraged.

This proposal from the members of the Occupational Therapy Academy in NY State is in direct contradiction to the overwhelming opposition to the OTD that was evident at that AOTA forum.  This proposal is an end-around the entire process because the escalated degree requirement will ultimately lock out other degree options, and the members of the Academy know this very well because the same scenario played out when programs moved from the baccalaureate to the masters level.

The Board of Regents is well aware of degree inflation and its negative impact on economies.  There is no compelling reason to expand this educational version of a nuclear arms race to the occupational therapy profession.  Health care costs are already spiraling out of control, and it is not necessary to contribute to this trend by encouraging over-training of health care professionals.

Occupational therapists should be concerned because the evidence cited and the comments from the field do not support this change.  I understand the retort that 'this doesn't mandate anything' but in fact we all know precisely where this will lead - and we should have veracity when we are promoting such large policy shifts.

Occupational therapists should also be concerned because this initiative is timed when nearly 30% of the workforce (that is located in pediatric/educational settings) is less likely to notice because they are employed in a pattern associated with the school year calendar.  Occupational therapists should also be concerned because there has been virtually no public comment on this matter from the State OT Association.  In fact, as previously documented, there is evidence that NYSOTA and AOTA are fully aware of this initiative because they have been copied on all internal emails between academic programs who have been discussing this change.  I do not believe that most occupational therapists in the State are even aware that this is happening.

At the time of this publication, this blog stand as the only place that is publishing this information to the occupational therapy community outside of the Register itself.

Constricted publication and notice serves the needs of the few - and hardly represents a democratic process.

There is no evidence that an OTD is necessary.  It will increase student debt, it may unnecessarily lead to economic costs to the State, and it does not meet the needs of consumers of occupational therapy services.  The proposal itself does not accurately reflect the broad range of concerns that are present about this change, and it should be rejected.

Comments will close on this proposal in the near term.  I encourage everyone to provide feedback on this proposal.  Data, views, or arguments may be submitted to:

Office of the Professions,
Office of the Deputy Commissioner
State Education Department
State Education Building 2M
89 Washington Ave.
Albany, NY 12234
(518) 486-1765

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.