Wednesday, July 03, 2013

Will a public health model make occupational therapy more relevant?

I just finished watching the COT 2013 Annual Conference plenary by Michael Iwama.  You can listen to his lecture by clicking here.  Hopefully we will have accompanying slides in the near future.  I was very anxious to listen to this presentation after watching the Twitter feed coming from the conference that included statements about our 'preoccupation with the individual' and that our 'practice has stalled' and that we were at a crossroads where we had an opportunity to take on a new role in a broader public health initiative.

I was a little concerned about some of these statements and was not sure that I agreed.  I am in the beginning stages of my own Twitter-acceptance and was not sure if those conference tweets fairly represented the presentation.  I am happy to report that the quotes and concepts that people were tweeting from the conference were actually quite accurate and representative of the presentation.

I encourage people to listen to the whole presentation, but if you can't I will summarize it as briefly as I can in outline format:

I. Question: Is occupational therapy functioning near our capabilities and are we a relevant profession?
II. Current problem: We function from the perspective of individual embodiment, from the medical model, and our practice is shaped more by policies and remuneration than by good theory.
III. Statement: We have had good theory development (OB/MOHO/OS)
IV. Analysis: We are  hampered by our frameworks, we are not relevant, and we are not responsive enough to needs.
V. Reasons: We are stuck in understanding problems from what Durkheim's described as the cult of the individual.
VI. We need to focus on meta-environmental factors that shape people's life-course such as:
       - social factors - we need to adopt postmodern and relativistic perspectives
       - economic factors - we have to understand that globalization (Monsanto/Exxon/etc) impacts us
       - environmental factors - we have to understand how climate change, catastrophe, and oil dependence impacts us
       - technology advances - our use of technology and communication impacts us.
VII.  The public health model is our new choice so we can be relevant.  The community is our patient and changing society is our goal.
VIII. How can OT contribute to public health?  We should DO OT on the field of public health.
IX. Health disparities in affluent societies are unconscionable.  WHERE IS OT?
X. Role-emergent OT practice is a new path to relevance.  We do good work on the medical path and we still need to be there, but will we walk this new path?

The presentation was a little thin on examples, and Dr. Iwama expressed that he would need more than the time allotted to more completely express what clinicians and researchers and administrators need to do.  I am hopeful that we will learn more about specific public health interventions in the future.

The central question of relevance is what I would like to explore first and will be the focus of this particular post.  Is it possible that I am not relevant, or that my practice is not relevant - and I just have not noticed?

Relevance is an interesting concept.  The question of relevance is a question if something is practical, or if it is at all material to the problems at hand.  The charge of irrelevance or of being less relevant than what should be is a rather serious charge and is worthy of exploration.

In a free market, relevance can be measured by existence - because if something is irrelevant than certainly it will not persist unless it is propped up by something else.  Alternately, if something is not as relevant as it could be than it is likely that it would not flourish or that if it did manage to exist it would be weak or perhaps sickly and something else could be seen as being much more healthy.  We can use these metrics to determine if occupational therapy has any relevance.

I am not sure how to apply some measurement to the entire field of occupational therapy so I will apply Fuller's Guinea Pig B methodology to the problem.

My occupational therapy clinic, which is quite humble, has persisted as my primary means of economic sustenance in a free market context for thirteen years.  It has not been propped up by anything other than the fact that people walk into my front door and transact business with me.  I provide an occupational therapy service and then I receive some money.  In order to be practical I need to listen to the people who come into the front door and I need to meet some need of theirs that is valuable enough to them that they would engage a transaction.  In a broader sense, 13 years of continuous operation is a metric I use to conclude that people have perceived the transactions as relevant - meaning that I provided something practical that was material to their problems at hand.

What have those transactions consisted of?  Here Guinea Pig B methodology is helpful because I can very explicitly report what I do and I can do so with absolutely no reporting error.  I can report that I have provided individual occupational therapy services to people of all ages who have needs ranging from developmental disabilities, learning problems, accidents or injuries, emotional problems, and many other conditions that could probably be labeled within a 'pathological' or 'medical' context.  I can report with absolutely no error that the focus of those occupational therapy services has been related to the impact of those conditions on the occupational problems of concern to the individuals and their families.

I have reported relevance from an economic argument of continuity of existence in a free market context, but there have been other points of evidence about relevance along the way.  Here are a couple I can think of off the top of my head just from this week:

1. We received an envelope in the mail yesterday from the parent of a child who had very constricted tolerance for foods.  After a short course of therapy the child made great progress and was discharged.  On the envelope the parent wrote: "We miss seeing you so much but we are doing GREAT!"  I interpret this message written on the envelope as a sign of relevance, because if we were not relevant the parent might have written "Take this money that I owe you and shove it - this was all a ripoff and not helpful at all!"  I think that the fact that the parent was happy to publicize her gratitude and well wishes on the front of the envelope is a rather powerful message about her perception of our relevance.

2. Today a parent told me, "I really think that Jasmine will be ready for school in September.  I did not think that before, but you have helped us so much."  Jasmine's progress in therapy has even surprised me it has been so dramatic - and I actually credit the parents for most of the work because THEY are the ones who were so willing to follow through on recommendations and were so diligent in changing  routines at home.  When I analyze the situation I understand that it was the partnership that made all the difference, and I know that my recommendations were relevant to their needs - the proof is as plain as that child's kindergarten readiness.  Very powerful evidence.

Interestingly, I believe that these examples indicate that we were responsive to the needs of the people who were asking for services, EVEN THOUGH the families self-defined their problems from the perspective of the 'cult of the individual.' 

There does not seem to be any evidence that we were hampered by policies or remuneration.

These families did not define their problems in any post-modern terms and they did not ask me to deconstruct their lived experience.  As a former participant in occupational therapy doctoral studies I am fully competent in the academic playground of hermeneutic analysis and narrative interpretation but really all these parents wanted was for their children to eat healthy foods and to be ready for kindergarten.  They parent of the child with feeding problems was not overtly concerned about globalization and whether or not Monsanto was genetically modifying their wheat.  I don't recall any conversations about climate change.  I tried to attend to their needs, to be RELEVANT, and I just didn't notice any of these meta-environmental themes expressed as being of primary concern.

If I think about it, I would have to state that the intervention was relevant and it was responsive to their needs.

This leads to some questions.  If it seems evident that the intervention was relevant and responsive to their needs, why do academics in the occupational therapy profession worry so much that occupational therapy is not relevant and responsive to people's needs?

Some of my favorite occupational therapy 'textbooks' are those written by Cheryl Mattingly.  If I am remembering correctly, she is an anthropologist by training.  In her books she explores in great detail how occupational therapists meet the needs of their patients, in both explicit and implicit ways.  Maybe some of the academicians should read Mattingly's books again - and maybe they should come visit my humble little clinic for a little dose of Guinea Pig B evidence.

I would like to challenge occupational therapy academicians to provide some evidence that occupational therapists are failing to meet the needs of their patients and are not relevant.  It would seem to be important to provide some evidence to support this theory before we embark on some whimsical traipse into a public health experiment.

Perhaps, somewhere, there are people who are quite angry at their occupational therapists because the OT was focused on something silly like teaching them how to get dressed after they had a hip replacement, when the real issue at hand was whether or not getting a hip replacement at all was fair given all the health disparities on the planet and also whether or not recommending adaptive equipment was just propping up the medical-industrial complex and driving up health care costs unnecessarily.  Maybe the patient really wanted the OT to partner with them on a letter writing campaign to their politicians to protest the lack of social justice that contributes to these problems?

I hope this will serve as a springboard into a long conversation about whether or not occupational therapy as currently constituted is relevant enough and meets the expressed needs of those seeking services.


Anonymous said...

Thank you for your review and comments. I will listen to the podcast later today, but I trust that your review accurately captured the gist of the presentation.

I am reminded of the way Steven Covey describes an individual's impact. He spoke of two concentric circles, one larger than the other. The larger is the scope iof interest...everything that you have an interest in. The smaller circle is your scope of impact...things that you actually can do.

For me global warming is in the outer circle...choosing an efficient car and combining trips are in the smaller circle as actions I can take.

Covey stated that when you work within your circle of control it gets larger. I have experienced that in my career...where I have been asked to sit on committees or to join teams that were making system-wide recommendations because my expertise and effectiveness in working with individuals was recognized.

I did not start out at the system (population) level, but my work with individuals allowed me an opprutunity to impact system issues.

Would I be less of an OT to decline invitations to work at the system level and remain at the individual level only? Of course not. Not all OTs have the skills, analytically or interpersonally, to be successful at the system level, and most therapists who do continue to work clinically with individuals as well.

Covey indicated that you cannot effectively work outside your personal circle of control...just because I recognize that economic banking policy impacts the declining availability of entry level jobs in small and mid sized businesses does not mean changing banking policy is in my personal circle.

If the profession of OT wishes to increase the number of practioners who are working at the population level we should emphasize working within our clinical circle with excellence in order to expand into system areas. This is not an entry level activity.


Christopher Alterio said...

Thank you for your excellent commentary, Claudette. I am interested in how you describe Covey's explanations and I will try to learn more about them.

Part of my concern is that when you start at broad system levels it may be that you lose focus on who you are and what your objectives might be. I base my concerns on some reading of how some OTs have described how interventions look when you practice as a 'sustainable' occupational therapist or when you are addressing broad population-based concerns within a social justice framework. It seems to me that this perspective changes the essential nature of what occupational therapy is.

I think it is important for OTs to recognize system issues and to even address concerns - but still from the perspective of the individual who is receiving services and at their direction. General systems theory hierarchies help us to define these issues clearly. However, I agree that we need to work within our circles of control with people.

People have very different perspectives on those systems and I think we need to respect that broadly lest we end up pushing our own broad system agenda and forgetting the needs of the people in front of our noses.

Thank you again for your comments.

Kathryn said...

Mr. Alterio,
I appreciate your post.
This is not a new issue in our profession (the focus of academia on ethereal goals and future invasions into other fields). I knew 7 months into OT school 14 years ago that I had chosen the wrong school and perhaps even the wrong profession. During a lecture with invited guest speakers from other disciplines, my professor attempted to explain the role of the OTR/L in a phys disability acute rehab setting. While the PT and the SLP clearly defined evaluation of balance/ambulation and swallow and communicative functions respectively, my professor

Kathryn said...

My professor mumbled something about adaptive equipment and modifying the environment and one handed shoe tying. Nothing about addressing the actual hemiplegia / paresis of the dominant UE.

OT will be relevant when we can address and improve the affected area rather than work around, modify the environment and offer bulky compensatory techniques.

I realize the nature of OT is holistic, but to be relevant we must foster change, and in the most relevant sense "change" would be improved function, preferably long term.

To borrow from the Christian saying of "don't be so heavenly minded that you're no earthly good", Occ Therapy shouldn't be so globally minded that we can't help a person who's had a TBI learn to re-write his name.

I acknowledge that rehab (OT) in areas of neurological impairment (SCI, TBI, CVA) are frustrating for the OTR since we are tasked with helping one regain lost functions that require a higher level of neurological control and coordination; donning a sock and shoe is harder than walking - as evidenced by 11 months old walking and 5 years later a child ties his shoe. Making a sandwich is harder than climbing stairs or swallowing (huge generalizations I know, and the area of infarct greatly determines the deficit)... My point is, everyone wants to learn to walk and swallow. But so many many many neuro patients have told me, I want my arm to "work". While I'm delighted they are free of aphasia and can communicate with me, their attitude of " I just need to walk. My spouse or daughter will dress me, make me breakfast, write my checks" shows that patients view us as irrelevant. Since we can perhaps tape their subluxed shld, show correct pelvic tilt positions and side lying methods and do family edu on toilet transfers and ways to effectively "cope" with a subluxed shld to reduce or eliminate pain with ADLs we get our dozens of "OT eval and treat" orders. But I wonder, truly wonder, how much useable function is gained from going from requiring 75% A to 25%A? It still requires a caregivers assist.

. I am in no way blaming the patient for us not being relevant. I'm merely stating that a lack of individual focus and skills to foster an improvement in function automatically makes us irrelevant.

Yes, I've heard those comments about ADLs and BADLs hundreds of times since graduation from all ages and demographics.

I'm trained in NDT but as we all know, it can only go so far.

Sarah said...

Whenever I find myself concerned about something in our profession, I always seem to wander my way back to this blog!

The article that led me here specifically concerned the issue of "Will OT be relevant in 25 years?", and contained a link to your blog.

The article focused mainly on hospital-based adult practice, citing issues such as a cringe-worthy quote from a New York Times article lamenting a $600+ bill for OT services that included an evaluation and the provision of an necessary sock-aid. What stuck with me about this article, and what concerns me the most about the profession, is that we struggle so hard to define ourselves. The article also said that we cannot define ourselves as "people who give good tips"---AMEN.

I am concerned that I sort of agree with the Times article regarding OT in that context--the article points out that perhaps nursing or another professional could easily have provided the service given to that patient--unnerving, yes?

I also work in pediatrics, as do you. And rarely do I ever question my relevance--sometimes I struggle with the significant crossover between OT or PT or SLP, especially between SLP and OT with my lower ASD kiddos, as we do so much of the same activities in terms of play skills, but perhaps this is only a reflection of my lack of experience. There is also a huge crossover between PT and OT with my little babies, but I find that the parents don't care as long as they're getting great services. But it does make me feel a little weird sometimes.

Could it be that it's easier to define our relevance in pediatrics? Do we see more progress than the myriad of adults who simply get an "OT/PT EVAL and TX" referral from their MDs post-surgery? Are OTs in adult settings seeing people who don't really need services, just because they're in the hospital and they need to keep up their productivity and they get the go-ahead from an MD who couldn't tell you the difference between OT and PT if they were asked?

I also don't understand why we would move away from an individual approach to therapy...when I was in school just a few years ago, there was a bit of a push to place OTs in more of a health promoting position in the larger community. There are also non-therapy professionals with Health Promotion degrees at the bachelor and masters level (I have two friends with such degrees), so what exactly is our role there?

I feel my response rambled, but these are the things that go through my mind when I wonder how the need to reduce healthcare costs in this country come to the forefront of the minds of citizens and governing officials will affect OT. I do very much want OT to be able to market us as "experts" in something very specific, much like PT has latched onto the "DPT" to market themselves as "movement experts."

As an aside, down here in Atlanta, I see more and more SLP services being declined for reimbursement in peds, due to the service being "not medically necessary" unless there is an injury or specific ailment. Autism is getting the shaft here, for example. It's scary stuff, and I don't want it to happen to OT.