Saturday, October 01, 2016

The Case of Lena, Part III: George Barton's promise to help others who were in pain

The original book "The Counterpane Fairy" was written and illustrated by Katharine Pyle in 1898.  It is a fanciful story of a fairy who visits children in their beds as long as they do not cry.  The fairy brings some comfort to these children and has the ability to magically transport them away from their circumstances if they focus on one of the squares of their counterpanes (bedspreads).

Occupational therapists may not be aware of how this story is relevant to the profession's history.  This post will conclude the exploration of 'The Case of Lena' and explain how Pyle's story influenced George Barton.

Barton did not write much about children but as previously noted he was struck by the 'Case of Lena' and that prompted him to write to his newspaper's editor in January of 1920.  It is hazardous to guess a person's motivation from such a distal historical vantage point, but we do know that Barton referred to Lena as "a very real and dear little girl" whose situation required attention.  We also know that Barton despised confinement  in the sanitarium and that he also was previously in deep despair over his life circumstances.  As described by Elwood Worcester (1932) "When I first saw George he was in the spiritual condition of a mad dog.  He blasphemed God for bringing such misfortunes on him, and cursed me roundly for daring to think I could help him."

Clearly, Barton knew pain.

It is important to consider the time frame when 'The Case of Lena' appeared in his newspaper.  The NSPOT meeting occurred several years prior in March of 1917 and he passed the reigns of the society's presidency to Dr. Dunton in the Fall of that same year.  His work at Consolation House continued, and at the same time that 'The Case of Lena' was published in the local papers George Barton was likely thinking about children of his own.  George Barton married his secretary, Isabel Newton, on May 6, 1918.    His son, George Gladwin Barton, was born on October 16, 1920.

He had already experienced how his own tuberculosis contributed to his previous wife and child leaving him (Worcester, 1932) and he read the story about Lena's father who also had tuberculosis and now how Lena might need to be removed from the home and how a newborn child might also be at risk.  Barton knew how tuberculosis shattered families - from personal experience and from reading the stories of others.

For George Barton, tuberculosis caused pain.  And tragedy.  For adults and children.

In 1920, in context of all of these events, George Barton wrote another article for The Trained Nurse and Hospital Review.  The article was called "The Counter-Pain Fairy.  I have not seen any mention of it in any previous summaries of Barton's writing or regarding occupational therapy history.  Exploring the relevance of Barton's fairy tell is necessary.

I attempted to find some connection between George Barton and Katharine Pyle but at this point an uncertain if they knew each other.  They used the same publisher (Houghton, Mifflin, and Co.) and certainly they may have been in similar social circles.  Katharine Pyle lived in New York for four years in the 1890s but at this point I do not know if she could have offered any 'blessing' upon Barton's use of her work but will update this space if I can locate any information.

Barton, as he was wont to do, engaged in word play with 'counterpane' by re-naming the story "The Counter-Pain Fairy."  Unlike Pyle's story, Barton's fairy achieved her magical powers and ability to help others through self-sacrifice.  Barton's fairy (first just a princess) was overcome with sadness at the sight of a little girl who had lost her legs and so arranged to have her own legs removed so that she might gain magical powers and be able to help other children who were sick or in pain.

"Then the princess understood that, if she was to help Biddy, she must lose her own beautiful legs and it just seemed as if she couldn't do it; but when she thought of all the other little boys and girls who had cried out to her, then she thought she might; and all the time she could not forget the radiant face of the lovely lady, so sweet and full of love; and 'way down in her heart she knew she would.  And she cried and cried, but still she told the Wizard that she cared enough --yes, even to give up her own two legs-- to help Biddy and all the other children...

First the Wizard (because she had loved other sick children enough to give up her own legs for them) changed the princess into a fairy.  That's how she got the name of the Counter-pain Fairy-- because she never comes to anybody but children who are sick enough to be in  bed and covered up all snug and warm with a counterpane-- (yes, it's spelled differently but its all the same thing)...

Again, it is hazardous to guess motivations but understanding context and considering other known sources there is justification for some conjecture on why Barton might write such a story and submit it for publication in the journals.  It is known that Worcester's "ministry of redemption" intervention (1932) with Barton was multi-faceted, and included admonitions about Barton's responsibility for other people.  Worcester wrote:

"He was perfectly able to return to his architecture, but by this time he had discovered a new form of architecture which he greatly preferred to the old-- building up again the broken lives of men and women who were suffering as he had suffered, under the eye of Doctor Mumford and the physicians of Clifton Springs.  With the help of a few rich friends he built his "Consolation House" and equipped it with splendid workshops, where, through the sweetness of his new personality, and his knowledge of crafts and arts, he did a wonderful work for years... More than once he has told me that his sickness marked a turning point of his life for good and that he would not have missed one incident of it.  How often this happens!  How frequently the sorrows and misfortunes of life turn out to  be God's messengers to us which close the old doors and seem to end the past, in order that we may find our way to the future, to the new life God has held in reserve for us."

Quiroga (1995) identifies Barton as a zealot but it is important to consider his motivation in context.  Rothman (1994) documents the spiritual context of tuberculosis sufferers:

"Evangelicalism had a particular appeal for invalids, and its influence in their life histories is marked.  Weighed down by the burdens of disease and deeply apprehensive that their present afflictions were punishment for past sins, many of them participated actively in the revivals.  The experience not only provided personal comfort but enabled some of them to turn a vagabond life and voyage for health into a spiritual Odyssey."

Isabel Newton, Barton's wife and Consolation House partner, wrote (1917) "The Rev. Elwood Worcester, of Emmanuel Church, Boston, convinced him that perhaps living was not worth the effort for himself, it would be worth while to get well for the sake of the "other fellow."  With this idea he started out to discover what could be done for that "other fellow," the other sick man.

Barton's fairy-tale "The Counter-Pain Fairy" has not previously been mentioned in the occupational therapy literature.  In context of Barton's loss and recovery and the pending birth of his own child it provides an interesting perspective on his reactions that were published in response to the sad story of a little girl from his area who would be forced to enter a sanitarium for treatment.  To him, Lena indeed was "real" and the problems associated with her disease required attention.  Helping others was as important as a promise to him, and he took it very seriously:

"And that's the story of how the princess was turned into the Counter-pain fairy, and why she will come to see you if you really want and need her.  Only you mustn't forget the conjuration, as the Wizard calls it; and, of course, you really mustn't cry; and you mustn't forget to promise twice because that makes it a real promise."



Embedded links, and...

Barton, G.E. (1920). The Counter-Pain Fairy.  The Trained Nurse and Hospital Review, 65, 493-497.

Newton, I. (1917). Consolation House. The Trained Nurse and Hospital Review, 59, 321-326.

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

Rothman, S. (1994). Shadow of Death: Tuberculosis and the Social Experience of Illness in American History. New York: Basic Books.

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

Correcting the record: The relationship between Barton and Dunton

The 1992 article "Point of Departure: A Play About Founding the Profession" written by Robert Bing, has some notable inaccuracies that require correction.  The article has incorrect dates, incorrect attributions, and factual errors.  The article was written in a somewhat whimsical fashion in the form of a play.  However, it is important for such a telling to correctly reflect the historical record.  It is possible that poetic license, used in context of history, does a disservice to our proper understanding of events as they actually occurred.

In an article relating to historical documentary methods, Dunne, Pettigrew, and Robinson (2016) state that researchers must be cautious about facts and that simple linear accounting may be helpful to establish basic narratives.  Bing's article does not meet this criteria in that some reported events in his 'play' do not always match the archived records of the American Occupational Therapy Association.

One initial characterization that requires clarity is Bing's statement that Dunton had the following belief about Barton: "Because he had some physical problems himself, he was mainly interested in the hospital as a 're-education institution.'"  There is no doubt that Barton had ailments, and it is certainly likely that this fact contributed to his interest in the occupational therapy topic, but it is probably incorrect to explain his interest in such a constricted way.  In fact, one of Barton's initial letters to Dunton dated November 10, 1914 states specifically, "I am not a doctor and have no particular interest in medicine, but I may perhaps lay some slight claim to being a socialist however insignificant, and my great aim is to use the hospital as a re-educational institution."  As such it is clear that Bing's characterization of Barton's motive is incomplete and not fully accurate in accordance with the actual correspondence.  As documented previously in this blog, Barton was influenced by Ruskin and Morris, both of whom were 'socialists' and interested in applying their design ideas for the betterment of society.  Barton (1917) later published an entire book focused around social criticism of existing systems and his desire to influence broad social policy.  He was not simply motivated by his own ailments.

Another point of curiosity is Bing's characterization of Barton's antipathy toward Dr. Herbert Hall.  It is true that deep-seated antipathy was present.  However, there are some rather complex issues regarding the relationship between Dunton, Barton, and Hall that I am still exploring.  There were notable philosophical differences about occupation that might not be fairly reduced the way they were in Bing's article.  In fact those relationships and the differences of opinion about the primary function of 'occupation work' might make for someone's entire doctoral thesis someday.  I hope to write more about that at some point in time.

Bing's article continues and he makes an unusual and inaccurate assertion.  He states (in Dunton's voice) "In that same letter, dated December 9, 1916, George (by this time we were on a first name basis, even though we had yet to meet), took me to task about my use of the term occupation worker."  There are several concerns.  First, there is no evidence in the correspondence that Dunton and Barton regularly used each other's first names.  In fact, almost all of the correspondence uses "Mr. Barton" and "Dr. Dunton" with several instances where Barton simply addresses his colleague as "Dunton."

Second, it is difficult to know if Dunton's correspondence used "George" because there is so little of it and what is available is very difficult to read.  The archives at the Wilma West Library that have this correspondence are almost all unidirectional with many more letters from Barton than were written by Dunton.  Many of the letters written by Dunton are only available as a carbon copy and presumably are those that were kept in the files of Dr. Dunton.  The reason for this is that Dunton was much more fastidious in preserving records, and he kept the original letters written by Barton and copies of his own letters, although most of them are very challenging to read because of fading, age, being carbon-copied, etc.  In fact Dunton was sensitive that he only had unidirectional records of the founding because he wrote to Isabel Newton after George Barton's death asking her if she had records of his original correspondence.  On March 18, 1926 Newton wrote, "Forgive my delay in answering your request for your letters to my husband, relating to the formation of the National Association, but I have had to delay until I could go over the files in the attic.  I fail to find any of the correspondence during the years you mention and I am sure they must have been destroyed a year or so ago when I cleared out some of the files.  I am sorry if this means serious inconvenience to you."

Third. the letter that Bing states that was written on December 9, 1916 was actually written on December 20, 1916.  Barton's statement in that letter was, "One thing I cannot and will not stand for is the use of "occupation workers."  It means nothing, --does not even suggest the hospital to the casual reader, and it is bad English.  We cannot, I think, lose a single opportunity to rub in the word "therapeutics."  I shall insist always that this be the matter of prime importance, both from my interest in development of a new line of medicine, and from my horrid vision as a sociologist of what may occur if therapeutics is forgotten."

Fourth, there was not a separate letter ten days later suggesting "National Society for the Promotion of Occupational Therapy."  That suggestion was made in the same letter actually dated December 20, 1916.  Bing asserts that this was a change from Barton's suggestion 13 months earlier of "Occupation for Re-Education."  I could not find any such reference.  The only previous suggestion was made in a letter dated November 11, 1915, where Barton adds a post script to Dunton that reads, "What do you think of 'The Society For the Promotion of Occupational Re-education' as a title."

Another confusing inaccuracy is Bing's characterization of Slagle's alleged fear of confrontation with Barton.  Bing writes (in Dunton's voice), "Meanwhile, I had been keeping Eleanor Slagle informed about all that was going on.  I did not let Barton know this; after all, you don't have to tell everything you know.  Mrs. Slagle wrote me that she was bringing a pair of boxing gloves to the meeting, since she was certain she and George would get into some kind of combat."  This accounting is factually inaccurate. On March 10, 1917 Barton wrote the following to Dunton: "I dislike at this early day to feel that I am a tale-bearer or a gossip, but I feel it will be my duty to warn you that Mrs. Slagle announces her intention of bringing boxing gloves in anticipation of some bout with you.  I look forward to the event with interest."

Bing characterized Barton's assumption of the Presidency of NSPOT in an unusual way.  He writes (in Dunton's voice), "Barton was elected President, a position he nominated himself for some weeks prior to the meeting."  This is only partially accurate.  In a letter dated November 11, 1915 Barton wrote to Dunton discussing a 'call' to find other occupation workers.  He wrote, "As to the position which I should assume in the society, that is a matter of comparatively slight importance.  I am willing to do whatever seems advisable.  Your assurance of assistance is in itself a great help and I thank you most heartily, both for myself and in the name of the many whom I trust may be benefited by our collaboration."  In continuing correspondence Barton acknowledges the role that Dunton played when he stated in a letter dated January 24, 1917, "Now that you have succeeded in getting me started, I am anxious to force things along."  Dunton was a facilitator and in fact he did not want to be the leader.  Barton wrote in a subsequent letter dated February 13, 1917 "Now in order that we may be in accord, I wish to give you my idea of how our work can best be divided.  Had it not been for the suggestions that I should take the lead in this organization, I have, I think and hope, sufficient natural modesty to make me hesitate to assume that leadership.  However, as I consider the work which I know the other members of the Big 5 are doing I cannot but believe, not that I could do it better, but that I am so situated as to be able to do it with far less trouble than any of the rest... I should be glad, therefore, if the Committee so desires, to assume the Presidency."

Furthermore, when Barton announced his resignation from the Presidency he asked Dunton to take over.  In a letter dated July 27, 1917 Barton wrote to Dunton and stated, "I have accomplished what you asked me to do, --namely, to get the people together and get the thing started, but little has yet been done; and I feel that it will be greatly to the benefit of the society, and to the ease with which the president's duties may be performed, if your hand takes the helm at what, to all intents and purposes, is the beginning of the society... I regret very much relinquishing this office, but I am confident that it will be in more worthy hands; and, I pledge you my continued earnest support and hearty cooperation."

In a letter also dated July 27, 1917 Dunton writes to Slagle and states, "He [Barton] had suggested that I be made President. I do not want the  job but at the same time I think it is very essential that our society be continued."  In a return letter dated August 3, 1917 Slagle encourages Dunton to take the lead and stated, "I am particularly pleased at the prospect of your being selected to the Presidency of the Society.  It is of the greatest importance that a person of vision and broad understanding of and with the problems be made President.  What do you think has happened to pique Mr. Barton?"


In sum, Bing's descriptions of Barton's correspondence include dating errors, negatively slanted attributions, incorrect attributions, and plain factual inaccuracies.  These errors go beyond mere poetic license in constructing a whimsical 'play' about the founding of the profession.  It is possible that these characterizations influenced subsequent historical accounting.  There is ample evidence that Barton was eccentric, and perhaps even frequently misunderstood, but some of Bing's characterizations fall outside the ranges of an accurate telling.  Barton was a complex character who was more socially connected and savvy than any of the other Founders.  He was highly competent, yet also prone to metaphorical and allegorical flourish that could be misunderstood.  He was also struggling with the constant threat of relapse of his 'consumption,' a reality that impacted every single one of his actions and decisions.  He was a strong personality, perhaps even fairly characterized as dominant, but he was also genteel and self-deprecating all at the same time.  These layers of complexity need to be acknowledged if we are to understand the actual Founding efforts and the true relationships between the Founders.

For all of the quotations from letters that are referenced above, I have copies of the original correspondence that I made at the Wilma West Library as part of my ongoing research into this topic.  I am happy to share the source materials if anyone would like to see the documents that I am citing.  Please submit all requests in email.


Letters referenced above

Embedded links above

Barton, George E. (1917). Re-education: An analysis of the institutional system of the United States. Boston: Houghton Mifflin Co.

Bing, R.K. (1992). A Point of Departure (A Play About Founding the Profession). American Journal of Occupational Therapy, 46, 27-32.

Dunne, B., Pettigrew, J., and Robinson, K. (2016). Using historical documentary methods to explore the history of occupational therapy.  British Journal of Occupational Therapy, 79, 376-384


Monday, September 19, 2016

The Case of Lena, Part II: Barton's response to 'A Common Man'

Continued from Part I - Read here.

This exploration of some of Barton's writing outside of professional journals is offered for additional context to assist readers in understanding his concerns and passions that related to the occupational therapy profession.


The story of Lena got one reader of the Geneva Daily Times "all choked up."  This reader called himself "A Common Man" and wrote a letter to the editor on January 19, 1920 asking more about Lena's story:

Now what I don't understand is this.  It was too bad that Lena couldn't take that elegant job in the 5&10 and I guess the manager was sorry too because they say it's hard to get good girls like Lena and her father would be glad of her help I'll say so.

Well what I want to know is this.  Why couldn't Lena learn something at Oak Mount so that when she got well again she could get a better job... that would help her father more and the extra pay she's get would sort of make up for the time she spent at Oak Mount when she didn't have the 5&10 job.

Maybe I'm just crazy but do you see what I mean?

That letter to the editor motivated Barton to write his own letter to the editor on January 24, 1920, calling it his 'duty and pleasure' to respond.

First, it is interesting to note Barton's compassion for the little girl - indicating that the subject "is not 'just a story' but a very real and dear little girl."   He went on to state that 'A Common Man' "has expressed the very essence of one of the greatest of the problems which now face the United States in this period of reconstruction, of which so much is being said, and so little actually done.  That children and "grown ups" also can be taught much of value to themselves and to society during the long period of convalescence is an assured fact."

Barton had no shortage of criticism for the health care system or existing power structures, a theme which is repeated in his letters to Dr. Dunton.  Representative criticism is in his letter to Dunton dated May 19, 1917 where he states, "So far I have failed to find any one in Washington who seems to know where anything is or should be, though I hope for inside information shortly."  The criticism of health care and government was repeated throughout his book and was just as evident in his Letter to the Editor:

I shall be glad personally to champion these ideas of "Just a Common Man" anywhere, their only weakness lying in the fact that they are in advance of the times.

When enough like him dare to protest against the present hospital method of treating the sick, then the hospitals will change their method because they need his money for their support.  The teachers will study and qualify: and "chasing the cure" will cease to be the awful, dreary, discouraging process it is made to be at present; and Lena will be sent home with resistance to her disease increased, knowing more than she knew before (able to take a better job), and an active home missionary to fight intelligently against tuberculosis.

Until then all that Lena will learn is the discouraging if not disgusting stories of the lives of the other victims with whom she is confined.

What is notable about this Letter to the Editor is that it demonstrates Barton's ongoing passion and commitment to the occupational therapy cause after he stopped participating as formally in the National Society for the Promotion of Occupational Therapy.  Quiroga's characterization of the 'momentary brilliance' of Barton's career needs to be reconsidered.  Barton's journal submissions and book writing ended mostly by 1918 but his work at Consolation House continued in earnest.  Barton did not 'suddenly burn out' but instead just focused his efforts in different directions.

Barton's passion about occupational therapy extended to children, notably evident in his writing about the 'Case of Lena' - and would very soon play out in his life in ways that he might have only been imagining at the time he was writing letters to his local newspaper editor. 

To be continued...


embedded links, Fulton History (newspaper archives), and...

Quiroga, Virginia A.M. (1995). Occupational therapy: The first 30 years 1900-1930.  Bethesda: AOTA Press. 

Friday, September 16, 2016

Occupational Therapy Can Be One of the Great Ideas of Myopic 21st Century Health Policy Experts

(with deep apologies to the memory of Mary Reilly)

Social media has been one long party this week in the occupational therapy world with therapists and membership associations popping champagne corks over the recent article that appeared in Medical Care Research and Review entitled "Higher hospital spending on occupational therapy is associated with lower readmission rates."  Click here for the abstract, but please go read the whole thing.

Once you get beyond the abstract you get straight to the nut of the problem where the authors admit right in the introduction that "the relationship between hospital spending and poorly understood in the literature..."

For background reading on this precise issue and concerns about how people are defining 'quality' in health care outcomes click here and here .

There is unquestionably some 'value' (however one may choose to define that term) in decreasing hospital readmission rates.  People who are NOT in the hospital are almost certainly better off than those who are in the hospital, even if we reduce our operational definition of 'better off' to some biomedical metric of their health status.  So to be clear it is important to note that some 'value' is achieved in decreasing readmission to hospitals.

That point being stipulated, we must return to the larger concern for the profession of occupational therapy:

Is it the intention of the profession of occupational therapy to serve the myopic perspectives of 21st century health policy experts?

Is this what Mary Reilly intended in her Slagle lecture?

There is no blame directed at the administrators and Boards of Trustees of hospitals - it is their jobs to make sure that the hospital is able to financially function and in fact prosper.  This is not an either/or situation either, because by extension any employee of any hospital also has some responsibility for contributing to that financial health of an institution.

But where does the profession draw the line between meeting employment obligations to their worksites and becoming willing stooges to make sure that the myopic perspectives of cost control are realized?

When we define our profession is it our hope to serve the greater needs of Man and his need for competence and achievement and participation in the world, or do we reduce ourselves to a metric of being a band-aid that serves to cover the immediate problem of hospital readmission rates?

Perhaps avoiding hospital readmission is the first step to achieving a more broad vision and purpose, but I warn you all not to allow the financial interests of an institution to define the type of practice that is delivered by this profession.  Read deeply into the article and you will already see the scheming machination of the authors to determine exactly what kind of intervention will be best for the occupational therapists to provide.

Be careful, occupational therapy.  You might just become exactly what a hospital administrator or health policy expert wants you to be. 

Is that your big purpose?


Rogers, A., Bai, G., Lavin, R.A., and Anderson, G.F. (2016). Higher hospital spending on occupational thearpy is associated with lower readmission rates. Medical Care Research and Review, 1-19.

Thursday, September 01, 2016

The Case of Lena

History provides context for understanding.  We are so far removed from the daily life struggles of 100 years ago and our own experiences are so very different that it is difficult for us to develop a clear understanding of  why events unfolded the way that they did.

Occupational therapy is a health related profession that was born from the crucible of American society and culture at the turn of the 20th century.  As such, events from those times greatly influenced the thinking of our primary founders.

George Edward Barton lived in Clifton Springs in Ontario County on the street behind the Clifton Springs Sanitarium (private) which had a capacity of 400 patients.  The Ontario County Sanitorium for Consumptives (Oak Mount) was the public facility, previously known as the County 'Poor House' in nearby East Bloomfield and had a capacity of around 40 patients.

Barton was motivated by realities of the public health crisis of tuberculosis.  He was motivated because of living in the shadow of the Clifton Springs Sanitarium, and by the stories that he read in his local paper (below), and by the reality that he was also afflicted with this terrible disease.

Understanding Barton's motivations yields important information about his values and beliefs and the 'cure' that he believed could be achieved through occupation.  This reprinted article is an exemplar of daily struggles that people had at the time, and subsequent blog entries will outline his specific response to this newspaper article.

Reprinted from the Geneva Daily Times, Friday January 16, 1920.

That morning the Teacher had sent Lena home from school.  Coming in from the cold air, the child's cough had been worse than ever, and the Teacher had said: "You better go home.  And don't come back till your cold is better.  It is not safe for the others."

All the rest of the morning and while she ate her hasty boarding house dinner, the Teacher had been haunted by the look in Lena's blue eyes.  There had been something she had wanted to say and couldn't.  So much at least was clear; and the teacher determined to take the long walk down to Lena's street after school and see her mother.  She remembered that the child had had a cold ever since the chilly autumn day when she had come to school with wet feet and had a chill.

Lena herself opened the door.  The same frightened look came to her eyes.  She said her mother was out working but would be back about five.  Yes, the Teacher could come in and wait.  After some hesitation she led the way to a back room.  "Pa's in here.  You can come in.  We've got a boarder in the parlor."

The room was small and clean.  It served, one could see for living room, kitchen, and dining room.  A hot fire burned in the stove and near it is a rocking chair sat the shadow of a man, who coughed, much as Lena coughed.

The Teacher sat down and the father told her how he had to give up work, and how his wife had to go out now.  He asked if the Visiting nurse had sent her there.  She replied that she was Lena's teacher.  At that he seemed relieved.  He said the Nurse had wanted him to go away to Oak Mount, but he loved his family and did not want to leave home.  He like ma's cooking better than any other too.

"But we get's on fine and dandy," chimed in Lena.  "We rent the parlor to Mr. Kominsky and two ladies that works at the factory rooms in the back room.  We could of got fifty cents more a week for the front room but we couldn't get both the beds and the crib in the back one."

Just then the back door opened and Lena's mother came in.  She was as neat as Teutonic as her little daughter, than whom no more loyal American ever saluted the flag.

Awkwardly she returned the Teacher's greeting.  The same frightened look came into her eyes when she was told that Lena must stay away from school until her cough was better.

"I'm sorry" the Teacher began, when Lena's mother rose and went into the front hall.  She beckoned to the Teacher and then shut the door.  "Did you come here from the Board of Health?" she asked.


"You can see how pa is," she returned.  "But he does want to stay home with me."

"But aren't you all sleeping in the same room?"

"Honest, lady, it's the only way we can get along.  You ain't going to report it, are you?  Oscar's well of his cold now."

"Who is Oscar?"

"He's my baby.  He's two.  Mrs. Schmitt, she take care of him when I'm away.  He's awful cute."

"May I see your room?"

"Sure.  But you won't report him?"

"Not now," and the Teacher followed up the stairs.

It was too terribly true.  One room.  One window.  Two beds under the sloping roof.  Oscar's crib between.  All neat and clean.

"Your husband is so ill.  It is not safe to have Lena here.  Will you let me send her to the hospital?" asked the Teacher.

"Hospital?"  She might as well have said "Prison."  The look of terror, dispelled for a moment by pride in her beautiful white beds, returned.

"I know the people there.  They will take care of Lena if there is room and I think there is.  And they will be so kind to her.  She will have good food and can stay there until a better place for children can be provided."

"Mein Gott.  I don't want Lena go away.  She's just a little keed."  Tears were rolling down the weary face.

"But it isn't right to expose her."

"I don't want her to get sick.  But honest, lady, I keep pa very clean."

"I know you do."

"But you won't tell about my baby?"

"Not now if you will promise Lena can go to the hospital."

"Lena did want to keep on learnin.  She's most fourteen.  She could get an elegant place at the five and ten."

"If you let her go and get well, she can go back to school next year."

So Lena is with the other children at the hospital in the contagious building.

But what about Oscar?

And what about all the other children in Ontario County who should be removed from infection, or who already have the dreadful disease, and who can be cured if you "do it now?"

Monday, August 15, 2016

Time to throw in the towel on sensory processing assessment

Today's Wall Street Journal includes the standard article in its Life/Health section on Sensory Processing Disorder that we are all accustomed to seeing published every six months or so.

The general idea of these journalistic offerings includes the standard trope of expert occupational therapists who can identify a disorder that the medical community can't quite agree on.  It also includes the standard ethical bombshell that occupational therapists can't bill insurance for this therapy and that the costs are $175 per session and are needed for 18 or 30 sessions, depending on who you ask.  Maybe it depends on credit card limits in different geographic localities, I am not sure.  The fact that the cost for this therapy can range from $3000 to $5000 is in itself a red flag that should make most parents squeeze their wallets shut and run for the hills.  The fact is that there is no consensus on frequency of these interventions and there is also no consensus if this 'intensive sensory' approach has any merit.

None of this is to say that some children don't have difficulties that can impact their behavioral regulation or motor skills.  The problem is with the never-ending profiteering off of the 'problem' when there is no evidence to support the intervention.  In the interest of full disclosure, I see some children in my practice with behavioral and motor difficulties.  The difference is that we only bill what the insurance will pay for, which is generally $50 or so a session.  We also only see most families once weekly for a few months for consultation, home programs, and education.  We use cognitive-behavioral and motor learning strategies that are evidence based.  We use this model of consultative empowerment and evidence based practice because we find it to be accessible to families and we also find it to be effective.  We also use this model because in the absence of good evidence for sensory-based interventions this seems to be reasonable and conservative.

The occupational therapy profession is wholly responsible for perpetuating a message about sensory processing assessment and interventions that in my opinion is irresponsible and unethical.  An example is noted in the just published article "A Review of Pediatric Assessment Tools for Sensory Integration" that was published in the American Occupational Therapy Association's SIS Quarterly Practice Connections.

The purpose of the article was to "provide clinicians with a current, comprehensive list of robust pediatric assessment tools specific to sensory integration."  A case example was included in the article.

Of the nine assessment tools listed in the article, four are either 'in development' or 'used in research/not clinical settings.'  That takes us down to five.

Of the remaining five, two are parent report instruments that are subjective and not an actual measure of child performance.  That takes us down to three.

Of the remaining three, one is not a measure of sensory processing at all, and in fact is described by the publisher as a test of functional motor skills.  That takes us down to two.

Of the remaining two, one is a criterion measure based on a convenience sample of only 130 children in a single geographic region.  The other was normed on 85 children in 2005.

The biggest offense in this article is that the case study discusses the use of one parent report instrument, a questionnaire not listed in the article, and also the Sensory Integration and Praxis Tests, which was also not listed as a recommended assessment.  Maybe it was not listed because it was published over 25 years ago and has outdated norms which are no longer appropriate for clinical use.  It is confusing that it would be used as an exemplar of sensory processing assessment in the case study.

Nine years ago I blogged about how the SIPT was outdated.  In that post I commented that I had hope that the partnership between USC and WPS would lead to new norms and a more robust certification process.  Now that those two organizations have severed ties it seems that won't happen.  I figure that a school like USC can't really associate itself with a product that is so outdated, but the reasons given for the split were kind of vague.

People may argue that science takes time and that there is a compelling reason to be patient but the fact is that there is no current mechanism to assess for sensory processing disorder, even if such a construct exists separate from other identified disorders.  Clinicians have been very patient.  More importantly, so have families who are relying on clinicians for guidance.  Research into a distinct sensory processing disorder construct has been going on for over 40 years and the best that we have in 2016 is a list of clinically irrelevant tools, continued promises that more things are 'in development,' and exemplars of outdated assessments.  Time to throw in the towel.

Most clinicians, even those skeptics in the medical field, understand that some children have anxiety, dysregulation, and even some motor planning difficulties to varying degrees.  Those problems undoubtedly can impact functional skills.  That is not what is controversial.

What is controversial is the idea that there is some distinct sensory processing disorder construct and some specific sensory-based intervention.  The reality is that we do not even have a way to assess for what some occupational therapists are claiming exists.  The scarier reality is that we do not even have a consensus on what 'sensory processing disorder' even means.  At best all we have is the belief that something exists because parents describe concerns to us on standardized questionnaires.

We have seen enough articles in the popular news press discussing the problem that only occupational therapists know how to identify and treat.  We have seen enough of the $175 per treatment session that can only be paid privately because insurance doesn't reimburse for experimental or controversial interventions.

Now it is time to turn the page, examine the research on anxiety and regulation and motor learning that is not so controversial, and find conservative evidence based interventions that insurance companies pay for and our medical colleagues accept.


(embedded links, and...)

Mori, A.B., Clippard, H., del Pilar Saa, M., and Pfeiffer, B. (2016 August). A review of pediatric assessment tools for sensory integration. SIS Quarterly Practice Connections, a supplement to OT Practice, 1(3), 7-9.

Thursday, July 21, 2016

How to damage OTA practice and diminish the OT profession in three easy steps.

1. Promote mission and scope creep of community colleges without thoughtful vetting of the consequences.

2. Purposely ignore the impact of minimum wage increases on the nonprofit human services sector.

3. Ignore the feedback of a professional membership that strongly opposes increasing OTA education to the bachelor's level.

It is very important to click the embedded links (above) to fully understand the scope of this issue.

What is left to do?  Get involved and demand more thoughtful decision making from the OT leadership.

Or watch it crumble.

Your choice.


Thursday, July 14, 2016

Occupational therapists want the general systems funk

Specialization is an unfortunate by-product of expansive knowledge.  It is challenging to remain abreast of developments in multiple fields and in the busy lives of modern day humans people come to rely on the comprehensive thinking of 'others' while they busy themselves with their specialized thinking.

Few stop to consider whether or not those 'others' to whom great power is ceded for their comprehensive thinking are actually up to the task.  Or, if they are up to the task, who is doing the checking to make sure that the use of said power is being delegated for the broader good?

In particular, occupational therapy is a broad field with multiple areas of specialization.  As such, practitioners working in geriatric long term care facilities may not be paying much attention to the goings-on for their pediatric school-based colleagues, and vice versa.  In a complicated world where specialists struggle to function within their own constricted spheres of operation it is hard to get people to attend to immediately relevant concerns much less concerns that may not seem so immediately relevant.

So when CMS (the governmental entity responsible for the Medicare program) asks for information about creating or updating CPT codes, the immediate response from those in power is to delegate authority to those who have experience with the Medicare program, which is mostly oriented toward care for the elderly.  Those specialists come up with recommendations that make local sense for the profit-driven environments in which they work - which is exactly the system that is being proposed.

Lack of comprehensive thinking is evident because the recommendations that make local sense don't even share consistency with the philosophical orientation of the parent organization.  Whether one agrees with the philosophical orientation of the parent organization is another matter.  Specifically, the new coding proposal suggests thinking that is reductionistic in its orientation and asks practitioners to parse function into subsystem levels of function.  So, the more subsystems that you consider in your evaluation, the more 'complex' that evaluation is determined to be, and the more you will be able to be reimbursed for such activity.

So on an esoteric level, there is philosophical incoherence when considering the contradistinction between a reductionistic coding proposal and the stated philosophical orientation of the profession, which notably does not talk about counting up numbers of systems-level performance deficits.  

Perhaps worse, the incoherence is carried into the realm of treating different areas of specialization differently.  On a practical level this coding proposal will have the obvious impact of causing operators in Medicare settings (through direct action or through employer mandate) to search for ways to include the minimal number of performance deficits in their evaluations so that reimbursement can be maximized.  Anyone who has spent any amount of time in a Medicare environment will attest to this kind of thinking.  This action will not serve the needs of those who are recipients of services, but will definitely serve the interests of the profit-driven long term care industry.

CMS is not dumb, and they see the upcoding coming like a freight train.  They rebut the proposal by suggesting budget and payment neutrality, which basically nullifies the whole point of a tiered coding system.  But not really - because as soon as employers catch wind of CMS paying the same for a 30 minute evaluation or a 60 minute evaluation take one guess on what employers will demand from employees - that's right - nothing more than a 30 minute evaluation for any patient because the reimbursement will be the same!

The upcoding planners who came up with this multi tiered system will have to wait for a year when no one is paying attention and they can sneak in payment differentials, perhaps when the budget is not so lean.  The whole scheme stinks to high heaven.  In any case the patients are not being served well.

Medicare is a system that tends to set a standard for the rest of the insurance industry.  So, what is adopted in Medicare will eventually filter down to state Medicaid programs, and other insurance programs serving other patient populations.  How will promotion of a subsystem level orientation to billing that maximizes profits for savvy operators impact other systems?  Will we come around to a for-profit mentality in school systems?  Will school based therapists begin counting up areas of performance deficits to maximize their billing?  If not - what is the difference and why are these two systems so different?

Here the specialization problem is evident, and the assignment of different local actors to specialized areas of policy causes grand incoherence.  For example, in school systems  professional associations are promoting the concept of 'workload' instead of 'caseload.'  By doing this they are promoting a kind of thinking that is in direct opposition to the coding systems that they are creating in the Medicare system that will eventually come down and settle into Medicaid reimbursement.  Operating on a 'workload' type of thinking means that time needs to be created in the day for non-reimbursable activities like talking to teachers, attending meetings, providing non-billable consultation, and many other activities.

Why not promote a system that facilitates 'workload' type of thinking in long term care environments that are being reimbursed by Medicare?  Here is a question for those in leadership who are responsible for the disconnected policy decision to promote profiteering in one sector and not in another:  WHY?

Does it have something to do with the fact that long term care environments are for-profit oriented?  Is that why we are creating a system where we try to click as many boxes in our electronic health record, knowing that the more boxes we click means that we will get more revenue?

And is it because school systems are municipal funded, meaning no one is trying to make a profit?  Is that why professional associations are more free to suggest 'workload' level approaches to care that are undoubtedly more costly and less efficient and less profit oriented?

This all leads to some pretty important questions.  Are we so specialized that our own leadership lacks the ability to see the obvious disparate methods we are using in different systems?  Have the operators within systems found ways to pull the strings of the professional associations in such a way that methods are promoted that maximize billing opportunities?  Or is this all rather planned, and is the leadership in charge absolutely aware of their philosophic incoherence, and they are just counting on the professional specialists working in one area to never speak with the professional specialists working in the other area?

In either case, my suggestion is for the therapists to pull their heads out of their specialist niches.  Maybe then the therapists working the streets will not be manipulated into ridiculous levels of productivity in one system and ridiculous levels of cost control in the other.

To paraphrase that famous philosopher George Clinton, 'Free your mind and your other parts will follow.'