Thursday, December 18, 2014

Time to update the AOTA Position Paper on Nondiscrimination and Inclusion

Politically controversial conversations continue to spew from the social media accounts of AOTA leaders.  These conversations represent perspectives that are not reflective of the broad membership and are highly partisan.  The steady stream of ideological thinking is concerning because it represents a pattern where some leaders don't know how to separate their personal political inclinations from the mission of a diverse professional association.

We often associate topics of diversity and nondiscrimination and inclusion in racial or ethnic or religious perspectives.  However, in what is supposed to be a politically neutral environment like a professional association, we can also consider the negative impact that is caused when leadership adopts a partisan and biased political agenda.

This is not a new problem with the American Occupational Therapy Association.  The inclusion of Social Justice in the Code of Ethics was the first major foray of leaders into political partisanship.  What makes this situation challenging is that many who supported Social Justice in the AOTA Code of Ethics refused to acknowledge that Social Justice itself was even a political concept!  Those refusals to accept the political realities of the term are well documented.  

This week we have a blog post that supports of the role of occupational therapy to assist in data mining to improve population health.  That AOTA leader writes: "As occupational therapy practitioners we can contribute to understanding the needs of individuals, communities and populations, help to design interventions at all levels and help interpret big data to translate it to meeting the needs of individuals."

On its surface, the objective here is hardly arguable - who would NOT want to help design multi-level interventions that prevent disease or illness or dysfunction?   That is a very noble goal.

However, consider what needs to happen in order to achieve that.  The Carolinas Health Care System has been using EHR data to predict patient health and medical system use.  Buried deep in their own admission of data mining is this statement: "Earlier this year, Carolinas HealthCare System also joined the Data Alliance Collaborative; a first-of-its-kind initiative aimed at improving population health on a national scale through data analytics and shared business intelligence."

Well what does that mean exactly?  Watch this brief video of Bloomberg Health Reporter Shannon Pettypiece discussing the problem:



For a more detailed discussion, read Pettypiece's original article entitled "Hospitals are mining patient's credit card data to predict who will get sick.

It is true that a very large healthcare system in the United States is playing around the edges of this extremely controversial marriage between 'Big Data' and our health - and that is unfortunate.  That does not mean that occupational therapists want to or even should jump on this kind of very controversial bandwagon that infringes on personal liberties and is associated with a political ideology of increasing State control.  

In another incident, last week it was disappointing to see one of our AOTA leaders re-tweet a statement that was overtly political and that was not reflective of the broad diversity of political opinion that AOTA members hold.  That tweet was:

"The opposite of disease is not health or wellness. The opposite of disease is justice."

That AOTA leader has since deleted the re-tweet that was sent out after I responded to it and called it 'Newspeak.'

What I wish that AOTA leader realized, and what is important for members to know, is that this statement that was re-tweeted was made by a presenter at the Institute for Healthcare Improvement's (IHI) annual conference.   The IHI is a group that purports to promote healthcare improvement but they are also known to be heavily populated by very partisan thinkers.  The group admits the following: "As we entered our third decade, we recognized a new need for health care as a complete social, geopolitical enterprise. To accelerate the path to the health and care we need, IHI created the Triple Aim, a framework for optimizing health system performance by simultaneously focusing on the health of a population, the experience of care for individuals within that population, and the per capita cost of providing that care."  www.ihi.org/.../History.aspx

In simple terms, they promote a socialized model of health care.  Their founder has heaped praise on the British model.

Dr. Berwick (founder and former CEO) was an Obama appointee as head of Centers for Medicare and Medicaid. www.whitehouse.gov/.../president-obama-nominates-dr-donald-berwick-administrator-centers-medicare-and-medi

What the White House release does not tell you is that he had to be appointed through a recess appointment and that he ended up resigning because there was no way he would ever be confirmed.  www.nytimes.com/.../dr-donald-m-berwick-resigns-as-head-of-medicare-and-medicaid.html

Dr. Berwick is (in)famous for quotes including (easy reference on Wikipedia page en.wikipedia.org/.../Donald_Berwick):

1. "The decision is not whether or not we will ration care - the decision is whether we will ration with our eyes open."

2. "Any health care funding plan that is just, equitable, civilized and humane must, must redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent health care is by definition redistributional."
These are Marxist statements.  Berwick has attempted to dance around these statements and claims that people take him out of context but it is difficult to interpret these statements in any way other than what they plainly say.

The point here is that the IHI is a liberal think-tank that is eyeball deep in its connections to a partisan agenda to socialize our healthcare system.  It is not shocking at all when statements get tweeted out of that conference like "The opposite of disease is not health or wellness. The opposite of disease is justice."

It is very difficult to understand how there can be any equivocation about the politicization of our profession when our leaders re-Tweet this kind of partisan nonsense.

I ask all of our leadership to respect the political diversity of our profession and to keep politics out of our association.  I also ask the leadership to steer clear of other politically controversial initiatives like 'Big Data' mining.

At this point in time it is becoming evident that some AOTA leaders are either tone deaf or they simply don't care and they are willfully infusing controversial politics into the profession.  We have reached a point where it is now necessary to make a specific procedural request that our profession avoids partisan ideologies and toxic political agendas that alienate members who do not share those political philosophies.

Wednesday, December 17, 2014

Why there is not much more to say about the NYS Early Intervention Program

I got an interesting question in email today so I decided I would answer it publicly.  The email asked:

You used to write a lot about early intervention, but there hasn't been much on that topic lately.  Providers are still struggling, there are provider shortages in some areas, lots of people lost their businesses and either went into agencies or gave up on early intervention.  Are you still working in this area and will you still be writing about how we are struggling with early intervention?

Here is my answer:

The reason why I don't write about early intervention as much anymore is because everything that I predicted about the municipal takeover of the system has come to fruition.  There just isn't anything left to say about it, and now the program will limp along in a reduced capacity just as planned.  The transition to the State Fiscal Agent system was intended to destroy the program as it was previously designed and that objective has been met.  In place of the previous system the new system is served only by larger agencies that have better capacity to withstand the new inefficiencies because those agencies operate on larger volume and have other revenue streams.

The impact on families is significant, particularly for those areas that have had intermittent provider shortages.  In insurance lingo, constricted provider pools are known as 'temporary revenue enhancement functions.'  In family lingo, constricted provider pools are known as "Oh my goodness, what will my child do without their physical therapy sessions???"

Families have been conditioned in our new welfare state to accept what is given, even when what is given is not particularly functional.  This facilitates a two-tiered care system.  The lower tier is populated by people who are conditioned to accept whatever service they can get for free out of a municipality.  The higher tier is populated by people who know that the lower tier solution is only for those families who don't have other options or other resources - and they go and find private solutions.

This was all predicted.

Many MDs in the community who have figured out that it is simply more efficient to refer their patients to me privately and for me to bill insurance directly.  Those families are very happy with that option because they don't have to wade through the bureaucracy of the EI system and they know in advance who they are getting as a service provider.  Unfortunately, many families don't have that option.

So there just is not much to say.  The new system is unwieldy and ineffective and bureaucratically deceptive.  The State Fiscal Agent reports the following statistics for 2014, through the third quarter:

Claims submitted to insurance: $67, 938, 442
Claims paid by insurance: $8, 958, 843
Percent reimbursed: 15%

It must be that new math that I don't understand, but whatever.

Imagine if any private health care practitioner could only collect such a low rate on claims?  And guess who gets to pay for every dollar that this inefficient behemoth can't collect?

This is the pathetic and expensive Early Intervention Program that NY taxpayers are paying for.

Tuesday, December 02, 2014

The incompatibility of population-based public health models with the occupational therapy profession

The following Twitter conversation underscores the problems with use of a population health model in an occupational therapy context:


Framing a conversation about the need for older drivers to consider their abilities underneath a context of population statistics is in direct conflict with the profession's Core Value of respect for patient autonomy and individuality.

Although it may be true that there are descriptive statistics about driving safety, numbers of accidents, and other factors associated with elderly drivers, when we lead our conversations with talk about the broad population we are adopting a potentially ageist stance that restricts the freedom of many drivers who are not falling within those normative ranges.

This is the problem with use of a population health model for meeting the needs of individuals.  To describe this problem within a general systems theory framework, consider the following chart:


Within this traditional framework of intervention, the correct focus and domain of concern is centered around the individual person.  Due attention is given to levels above and below the person because of their contextual relevance, but the focus of concern is the person.

Now consider a shift toward a population health model, where the focus and domain of concern is centered around the community:


In this type of public health framework the ability to focus attention on the individual and their abilities and their autonomous choices is lost.  This is why people state that public health models are inherently paternalistic and are not considerate of the needs of individual people.

The ethics required for supporting action in each scenario are radically different, and you can't populate a health care profession with a competing set of ethics where one focus respects patient autonomy and the other focus promotes paternalism and concern for a 'common good' that might not respect individuals.

Population health models are focused on broad community needs and frame concerns in broad population statistics.  It is philosophically incorrect to lead into an issue citing population statistics and then follow up with statements that individual assessments need to be considered.

What is the message?  Based on current life expectancies in the US, do people hand in their car keys when they are 70 because our population statistics indicate that this is when the elderly population statistically begins demonstrating concerns?  Will occupational therapists become the gatekeepers for driving, based on their assessment of abilities?  Will they solve those problems by paternalistic messaging that once you are 70 you are automatically placed in that high risk pool?

Occupational therapy was a profession that was established to help individual people when they had illness, disease, or disability so that they could productively engage in their lives.  Now there are some therapists who are trying to be gatekeepers to population health, wielding statistics and clipboards to make broad recommendations about when people need to start giving up their freedoms and autonomy.

 It is a disturbing philosophical turn that breaks our social contract with the people who would come to us for help.

Wednesday, November 19, 2014

Pushing back against a 'Fourth Paradigm' in the occupational therapy profession


Occupational therapists have a century long tradition of identity confusion and that has been complicated by incrementalism in how the profession defines its scope of practice.  A significant victory against incrementalism was realized in the 2014 Fall Representative Assembly Meeting when the Philosophy of Education document that was proposed was not supported, but an amended document passed that removed references to the 'occupational needs of institutions.'  The amended document now reads:

"Occupational therapy (OT) education prepares occupational therapy practitioners to address the occupational needs of individuals, groups, communities, and populations"

The motion was to replace the word "institutions" with the word "groups" as individuals, groups, communities and populations have human occupational needs as OTs know and understand them, and it makes the language of the new document consistent with the Occupational Therapy Performance Framework (3rd edition).  This motion passed the RA on a vote of  38 Aye, 11 Nay, and 1 Abstention.

Concern expressed by delegates was that occupational therapists worked in the contexts of institutions but not directly on or with institutions.  That may seem like parsing words but there is a critical distinction.  Arguments focused on the fact that occupational therapists work with people who have occupational needs, and that stating we worked with institutions was potentially confusing to external stakeholders.  There was some opposition who wanted an expanded definition of OT that did not make distinctions between 'therapy' and 'things that a therapist might do but that don't constitute 'therapy.'

The attempt to modify the definition of OT is part of a recent string of attempts to change the nature of occupational therapy practice.  As previously noted, this trend began with the international influence of occupational therapy scholars (Townsend, Langille, and Ripley, 2003) who began thinking that it would be more valuable to intervene at the levels of systems instead of at the level of individual (or groups) of people.  This was followed by a more explicit exploration of social justice as occupational therapy (Townsend and Wilcock, 2004).  These ideas were subsumed wholly into the thinking of many American scholars, who in turn began infusing these concepts into AOTA official documents, including the Code of Ethics and Practice Framework.

Over time there has been significant pushback against including these models as evidenced by the motions to remove Social Justice from the Code of Ethics and this recent effort to stop the incremental redefinition of the scope of occupational therapy practice.  At the core of these objections is a tacit appreciation for our 'Third Paradigm' as expressed by Kielhofner (2009).  That 'Third Paradigm' refocused the field on occupation as a means and ends of the therapy process, and actually includes a strong consideration of contextual elements.  However, it did not intend to make the contextual elements the focus of therapy - which is what happens in a social justice framework where we are said to be focusing on 'systems' or 'institutions' in our work.

That focus on systems and institutions is what I call the 'Fourth Paradigm' - but it is being rejected by many therapists in the United States.

The primary reason why the 'Fourth Paradigm' is rejected is because it places health care professionals into the realm of economics and public health.  The 'Fourth Paradigm' takes our focus away from the individual.  Of course there is a need to address larger issues, and certainly within a General Systems framework we are aware of those other contextual levels -  but we do not re-define a profession and abandon our core philosophy in pursuit of those contextual methods.

Occupational therapy is not alone in its flirtation with making contextual elements a focus of practice.  An example of loss of focus would be Toronto physician Gary Bloch who is interested in the impacts of poverty on health.  He perceives the physician role as "prescribing income" and he does so by encouraging his patients to access governmental welfare benefits and advocating for more governmental funding to solve poverty problems.  I am sure that he has good intentions, but he has forgotten his medical mission and replaced it with the mission of a social worker and community activist. 

This is the kind of loss of focus that occurs when we consider institutions as our point of intervention, or social justice as our health care mission.  As additional consideration is the immorality of forced redistribution of other people's resources.  It is curious that Dr. Bloch does not discuss how he offers some of his own wealth or whether he would promote alternate economic policies that would provide jobs and shrink the dependence on governmental systems.  One can hardly imagine how as health care professionals it has become our New Ethic to promote lifelong welfare-state dependency.  That kind of philosophy of promoting social justice through Rawlsian redistribution and welfare dependency hardly seems compatible with Reilly's (1961) core premise that "man has a need to master his environment, to alter and improve it."

Occupational therapy scholars pursue the 'Fourth Paradigm' perhaps out of frustration with the slow pace of clinical change (Molineaux, 2004).  I am not as disheartened, and I think that the Third Paradigm continues to gain ground.  It is notable that important paradigm shifts in the profession have always been driven out of the clinic environment.  The First Paradigm was born out of the efforts of Barton, Tracy, Slagle, and others who were working with people.  The Second Paradigm was born out of the efforts of Brunnstrom, Bobath, Rood and many other clinicians who worked with people.  The Third Paradigm was born out of the efforts of Reilly and all of her students - steeped deeply in actual practice with people and then refined in academic study.  This is precisely why proponents of a 'Fourth Paradigm' are falling flat with the field - they do not represent the values or realities of street level practitioners.  That is not to say that the Academy has never or will never be an important driver of practice models - but unless those models gain traction in the real world experiences of clinicians who are working everyday they are likely to falter. 

That is particularly true of 'Fourth Paradigm' models that are congruent with the values of socialized medical systems - which is precisely what we do not have in the United States - and if the current political context is any suggestion, we will see continued pushback from the public because that is not the way that they want their health care system constructed or run.  This has been the fundamental misunderstanding of the American Academy when it readily adopted the values and beliefs of international scholars that are working in culturally and politically divergent contexts.

There always has been and will continue to be a role for occupational therapists to exercise their knowledge and skills in service of systems or institutions.  But that should always be called CONSULTATION and it should not be conflated with PRACTICE - which means PRACTICE in the interest of actual human beings in a direct manner.

References:

Kielhofner, G. (2009). Conceptual Foundations of Occupational Therapy Practice.  Philadelphia: F.A. Davis.


Molineux, M. (2004). Occupation in occupational therapy: A labour in vain? In M. Molineux (Ed). Occupation for occupational therapists, Oxford: Blackwell Publishing.

Reilly, M. (1985). The 1961 Eleanor Clarke Slagle Lecture: Occupational Therapy Can Be One of the Great Ideas of 20th Century Medicine in AOTA (Ed.), A Professional Legacy: The Eleanor Clarke Slagle Lectures in Occupational Therapy, 1955-1984, (pp. 87-105). Rockville: AOTA.

Townsend, E., Langille, L., Ripley, D. (2003). Professional tensions in client-centered practice: Using institutional ethnography to generate understanding and transformation. American Journal of Occupational Therapy, 57, 17–28

Townsend, E. and Wilcock, A. (2004).  Occupational justice and client centered practice: A dialogue in progress.  Canadian Journal of Occupational Therapy, 71, 75-87.

Tuesday, November 11, 2014

Notes on the AOTA Continuing Competence Standards Draft

The American Occupational Therapy Association has a Commission on Continuing Competence and Professional Development (CCCPD).  The CCCPD is conducting a 5 year review of its standards on continuing competence.  This is a good opportunity to assess the AOTA efforts in this area.

Links to the draft document and a survey can be found here: http://www.aota.org/Publications-News/AOTANews/2014/CCCPD-standards-review.aspx

Here are my concerns with the document:

1. I find the document to be rather vague, and the standards are not evidence-based.  There is no citation that provides information on how these standards were established or how they were developed.  In comparison, NBCOT develops practice standards that are based on a Practice Analysis and they can be viewed here: http://www.nbcot.org/practice-standards

2. The standard on Knowledge is vague and self-referential: "OTs and OTAs shall demonstrate understanding and comprehension of the information required for the multiple roles and responsibilities they assume."  That is saying that they need to know what they need to know, which is not a standard.  That is an empty statement.  The bullet points that follow are similarly vague: "Mastery of the core of the practice and profession of OT," "expertise in client centered OT practice and related primary responsibilities," etc.  These have no meaning.  The purpose of standards is to have something to hold performance up to in comparison.  There are no specifics because it is apparent that these standards were not based on any evidence.  Again, reference the NBCOT document in comparison, that lists specific Domain and Task knowledge needed for competent practice.

3. The section on critical reasoning is incomplete and does not reference the multiple ways that OTs engage in reasoning processes.  Notably lacking is any reference to Mattingly's (1994) work on narrative reasoning, which seems to be a rather unique and distinctive method employed by OTs.

4. The section of the Draft document that relates to Ethics references a 2015 Code of Ethics source that has not even been approved by the RA or presented in any final form.  It is irresponsible to cite documents that do not even exist.

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I am trying to understand why AOTA is in the continuing competency business.  These standards are vague, self-referential, not evidence based, and cite documents that have not even been written yet. 

The AOTA website states that it represents 50,000 members.  BLS data indicates that there are over 100k+ practicing OTs.  According to the AOTA website (http://www.aota.org/education-careers/advance-career/board-specialty-certifications.aspx) approximately 230 people have pursued the specialty or board certification programs.  That is a barely measurable less than 1 percent participation rate when you measure it against AOTA members.  The percentage of participation in the whole population of practicing OTs is even less.   In my opinion that is rather strong indication that the AOTA continuing competency program is a waste of resources.

It is obvious from that kind of evidence that AOTA does not belong in the continuing competency business.  I suggest that AOTA should use our member resources more responsibly and leave continuing competency to NBCOT who has developed evidence based standards and administers a robust program that already addresses this concern and are used by the vast majority of practitioners. 



References:

(see links above)

Mattingly, C., & Fleming, M. H. (1994). Clinical reasoning: Forms of inquiry in a therapeutic practice. Philadelphia, PA: F. A. Davis Press.

Thursday, October 30, 2014

Why students will be making elevator speeches to define OT for another 100 years


A new day, a new document, a new definition for the profession:

For many years, the American Occupational Therapy Association has stated that students need to promote the profession by developing an effective 'elevator speech' explaining occupational therapy. This essay explains that the reason why students will be making elevator speeches for the next 100 years is because the leaders of the profession keep changing definitions about what OT is and who it serves.

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There is a new draft document on The Philosophical Base of OT Education that is going to be debated and voted on by the Representative AssemblyThe current document was published in 2007.

There are contrasting statements in the two documents.  From the 2007 document:
Occupational therapy education promotes integration of philosophical and theoretical knowledge, values, beliefs, ethics, and technical skills for broad application to practice in order to improve human participation and quality of life for those individuals with and without impairments and limitations.

And from the proposed document:

Occupational therapy (OT) education prepares occupational therapy practitioners to address the occupational needs of individuals, institutions, communities, and populations. The education process includes both academic and fieldwork components. The philosophy of occupational therapy education parallels the philosophy of occupational therapy, yet remains distinctly concerned with beliefs about knowledge, learning and teaching.

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The new document seems to suggest that in the last seven years there has been a consensus paradigm shift in that the profession of occupational therapy has a professional scope of practice that now includes addressing the occupational needs of individuals, institutions, communities, and populations.

I understand that there are some members of our Academy who believe this to be true, and I also understand that there have been some successful efforts to get this kind of wording into Model Practice acts, but I would like to know the practical and field evidence that supports this kind of wording, outside of what some people are wishing to be true.

This kind of language takes us out of sync with many state practice acts that still identify OT as a health related profession.  Most state practice acts do not support the notion that OTs are licensed to solve the occupational problems of entire communities and populations.

At some level, I suggest that we need to have congruence between what we say we teach and what the field actually does.  If our leadership fails in this, then they place our entire profession in peril.

Many states primarily define occupational therapy around treatment of individuals.  The word 'client' is used but generally refers to human clients, and the regulations supporting the practice act are all oriented around 'client factors' that are typically addressed.  Additionally, practice requires involvement of the MD to provide referrals in most cases.

The newer definition of ‘client’ is individuals, institutions, communities, and populations.   There is no consistency in how we have defined 'client' over time.  Rather, there is a steady stream of incrementalism in our professional documents that continues to drift away from our philosophical core.

The ongoing changes to the Practice Framework provides prima facie evidence of incrementalism.

There is a new focus in the OTPF 3rd ed. in that "Clients are now defined as persons, groups, and populations." (p.S2.).  The document itself lists this as a "MAJOR REVISION" (p. S2).  Use of the term "MAJOR REVISION" is taken directly from the document and makes a claim of consistency difficult to understand.  The OTPF 2nd edition made some reference to 'broader definitions of client' including populations of people but the OTPF 3rd edition is more explicit.  Furthermore, additional MAJOR REVISIONS include "The relationship of occupational therapy to organizations has been further defined." (p. S2).

In fact, the document now more boldly states "Services are provided directly with clients using a collaborative approach or on behalf of clients through advocacy or consultation processes." (p.S3).  The extension of the definition of occupational therapy goes even further: "Finally, organizations employ occupational therapy practitioners in roles in which they use their knowledge of occupation and the profession of occupational therapy indirectly.  Practitioners can serve in positions of dean, administrator, and corporate leader.  These positions support and enhance the organization but do not provide client care in the traditional sense." (p.S3).

The Practice Framework states that it "builds on a set of values that the profession has held since its founding in 1917."  (p.S3).  This is outright revisionism.  I would like to see some citation from the founders of the profession that would support calling a college dean or an administrator an 'occupational therapist' as they function in their non occupational therapy jobs.

This is all just evidence of severe drift from our purpose as a profession.  100 years ago we started as a health and perhaps social service profession that directs its efforts toward individuals so that they can function more independently for the benefit of themselves and the benefit of society.    Now we are stating that occupational therapy promotes social and occupational justice, advocates for laws and social policies, and has an expanded view of client that now includes institutions so that being a dean can now be practicing OT, if you are using your OT knowledge.

The failure of the Practice Framework, and the potential failure of this new document on the philosophy of education, is that the reality of what most OTs actually do in their jobs is lost.  It is replaced by this expanded conceptualization of OT.  I will again state that there is absolutely nothing wrong with occupational therapists using their knowledge and skills in service of many different job functions.  That does not make everything that an OT can do 'occupational therapy.'

Professions have a social contract, and the public has an expectation of what services a profession will provide.  The OTPF and this new Philosophy of Education document includes an incremental redefinition of our profession.

Presenting ourselves as occupational therapists is not the same as claiming that everything we do is 'occupational therapy.'  When we fail to make this distinction, we are breaching our social contract.

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 Why we need to have a defined scope of practice that comports with reality

Aside from any definition that may or may not be included in any practice act, it would be helpful to know how much of what people are identifying as OT intervention is being carried out on buildings and oppressed communities and populations of people.  It is a big world and I don't doubt that there may be a few people who are providing occupational therapy to buildings, but before we change the definition of our profession any further we should probably consider evidence.

It is my belief that we should be protecting our actual scope of practice with actual language that reflects what most people do.  We should not be populating our definitions and our practice acts with erroneous ideas about what constitutes occupational therapy.

We need to start making distinctions between THE WAYS THAT PEOPLE USE THEIR OT SKILLS and WHAT CONSTITUTES OT PRACTICE.

When a lawyer enters politics, they become a politician and they cease being a lawyer.  They use their law skills but it is NOT PRACTICING LAW.

The same is true for occupational therapy.  When you design an accessible playground you are using your OT skills, but you are not PRACTICING OCCUPATIONAL THERAPY.   LOTS of other people can do that job too, and they are not PRACTICING OCCUPATIONAL THERAPY.  If we define our practice as things that many other people can do, we no longer have a profession that is worthy of licensing!

That does not make designing accessible playgrounds an unimportant task.  If we want to survive in the health care arena we need to start distinguishing between what actual 'therapy' is and what 'use of OT skills in related tasks' is.

A core need in a regulated profession is to have congruence between what its Academy says it does and what its professionals do on a daily basis when they are practicing their profession.

As a part of regulation, State practice acts tend to spell out the specifics of intervention in terms that are labeled 'scope of practice.'  This 'scope of practice' defines the legal activities that the public can expect from the licensed professional.  This list protects the public and prevents professionals from engaging in activities that are beyond its legal scope.

In all professions, there are MANY ancillary activities that professionals may engage in that don't precisely represent 'practice' of the profession.  Many of those ancillary activities draw upon the related knowledge of the professional.  However, since those activities might be reasonably completed by a number of people with a number of different skill sets, engaging in those tasks can't be considered a unique scope of practice of any particular discipline.

As an exercise that demonstrates this, consider which professional is most appropriate for the job:

1. Consulting to planners on ADA requirement for bathroom accessibility in a new office complex
2. Leading a community group that investigates universal design elements in a playground
3. Developing a falls prevention program and presenting to a senior citizen group
4. Promoting a clubhouse model when developing a community mental health program
5. Providing a bullying awareness program in an elementary school
6. Advocating at a common council meeting for curb cuts in a downtown shopping area
7. Participating on a design team in developing powered mobility devices for toddlers
8. Raising awareness of human sexual trafficking and suggesting alternate policing strategies
9. Developing an after-program fitness event for parents and children in a local Head Start
10. Writing a grant to obtain funding for more library materials for people with visual impairments

In these ten examples, you might expect that different people would write in OT, PT, nurses, doctors, architects, engaged citizens, social workers, generic human service workers, grant writers, civil engineers, and an almost endless list of other people who might be qualified.

The point is that this kind of systems consultation, or service to populations, or whatever it may be called - does not represent a unique practice role for occupational therapists.  That does not diminish the importance of these tasks.  It just does not make them unique to the OT Scope of Practice.

When we conflate the profession of occupational therapy with the ancillary good things that an occupational therapist might do with their skills we WEAKEN our ability to express a cogent message to the public about what the profession is.

Many practitioners struggle with reimbursement in a health care context.  What messages are we sending when we say that the practice of OT also involves ancillary consultative activities that might be carried out by any number of professionals?

What kind of unnecessary resource drains and legal challenges do we expose ourselves to by conflating our ancillary activities with our actual professional practice?

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How do we solve this problem?  

We solve this problem by distinguishing "OT Practice" from "Fun things you might do with your OT credentials someday."  I strongly speak against the continued push to put this language in our official documents.  We can respect the good work that OTs do in these areas without continuing to confuse our public about what our profession is licensed to do in a therapy context.

As there has been a call for fact-based information, I offer the following for consideration by the RA when they discuss the proposed document:

The NBCOT Practice Analysis is a useful tool to help determine level of frequency of occupational therapy tasks engaged in by new practitioners.  The activities of new practitioners should be a good point of critical reflection for educators when they are considering documents about the philosophy of education.  Hopefully, there is some congruence between the way that educators are preparing students and the tasks that those students engage in once they are in the field.

Dunn and Cada (1998) reported the results of the 1998 NBCOT Practice Analysis and in this article they identified population-based services as a practice area of new emphasis.  That Practice Analysis included a survey of over 3000 occupational therapy practitioners.  Validated knowledge and skill statements were rated for frequency.  Population based services were rated at a low frequency of 4% to 5% but this was adequate frequency that it was included in the analysis report.

In the subsequent Practice Analysis (NBCOT, 2008) services to populations was no longer a separate domain as it did not reach the level of frequency that was evident in the previous analysis.  Instead, services to populations had diminished frequency and was reflected only as an isolated point of knowledge, underneath the larger domain of "Selecting and implementing evidence based interventions."  Accordingly, a much smaller percentage of items on the exam reflected this area.

The most recent NBCOT Practice Analysis (2012) surveyed nearly 3000 practitioners and there was again very low frequency of population based services.  In the most recent analysis such services are reflected at the task and knowledge level related to overall program development and advocacy.  There was not a high enough frequency that this would be listed at a domain level.

I have significant personal and institutional knowledge of all these Practice Analyses as a function of my volunteer record with NBCOT.  I recall with specificity the issue of population based services when it appeared in the analysis.  As a member of the Exam Development Committee, and later as a leader of that group, I recall item writers struggling because so few people had any direct experience with population based services at that time and there was a paucity of reference materials that could support an item on the certification examination.

I have very specific and direct recollection and validated my recollections by discussing this issue with other people who were deeply involved at that time.  At that time of that 1998 Practice Analysis we had conversations wondering why population based services appeared as a validated domain.  People have mused that it may have been related to the BBA of 1997 changes at the time that left so many OTs unemployed and looking for 'ancillary' work where they could use their OT skills.  It was notable that the reported frequency of those activities dropped in the 2008 and 2012 Practice Analyses, once the immediate BBA crisis subsided.

Frequency of task engagement is a functional metric that should be used by the profession when it is defining its activities and scope of practice.  Services to populations or whole communities are a low frequency activity and do not represent a common area of occupational therapy practice.

When combined with the other pragmatic challenge of determining if such activities even represent a unique occupational therapy role, it remains rather puzzling that this is a continued point of emphasis in our professional documents.  When we are creating broad-reaching documents about the philosophy of the occupational therapy profession and how we are educating future clinicians, it is difficult to understand why there would be an extensive focus on such a constricted area of actual practice.

Bottom line questions for the RA: 

1. Should we define our profession in such terms that only represent the activities of a fractional portion of our membership as has been verified by Practice Analysis?

2. With stipulation that ancillary activities are valuable in their own right, on what justification do we define our practice by minority activity, particularly when there is not evident consensus that these activities even represent a unique role of occupational therapy?

3. Just because we have a history of shifting definitions that don't make good sense, is it adequate justification to continue down a path once we have facts that should cause us to stop and pause?

References:

American Occupational Therapy Association (2008). Occupational Therapy Practice Framework: Domain & Process 2nd Edition.  American Journal of Occupational Therapy, 62(6), 625-683.

American Occupational Therapy Association (2014). Occupational Therapy Practice Framework: Domain & Process 3rd Edition.  American Journal of Occupational Therapy, 68, S1-S48.

Cada, E. and Dunn, W. The National Occupational Therapy Practice Analysis: Findings and Implications for Competence.  American Journal of Occupational Therapy, 52, 721-728.

NBCOT (2008). Executive Summary for the Practice Analysis Study. Registered Occupational Therapist OTR®. Retrieved Oct 30, 2014, from http://www.nbcot.org

NBCOT (2012). Practice Analysis of the Occupational Therapist Registered OTR®. Retrieved Oct 30, 2014, from http://www.nbcot.org

Tuesday, October 21, 2014

Comments on 'Validity of Sensory Systems as Distinct Constructs'


Chia-Ting Su and Diane Parham (2014) wrote an interesting article that appears in this month's American Journal of Occupational Therapy.  Their study involved use of confirmatory factor analysis to test constructs within sensory integration theory.  Results of their analysis have rather broad implications and raise many important questions.

A highly popularized notion based on Dunn's (2001) Slagle lecture is that sensory processing can be identified as occurring within different systems where there might be over or under responsiveness to incoming stimuli.  Su and Parham applied data to this model and could not confirm that this conceptualization fit their data.  This in itself is a significant finding because it puts into question whether or not SOR/SUR models are the most appropriate way to explain problems with sensory processing.

Also germane to this finding is the concern that tools like the Sensory Profile confound analysis by including questions about temperament that may not have much or anything to do with a distinct 'sensory processing' factor.  Su and Parham (2014) state, "the inclusion of items on the Sensory Profile that are highly sensitive to temperament is another plausible reason why the Sensory Profile factors differed from ESP factors in the current study." This is an issue that I have blogged about previously, particularly in context of the Shea and Wu (2013) article about children in the criminal justice system.  I stated
This analysis should help us to more deeply understand that our current assessment tools, which are apparently measuring something, may not just be measuring a sensory processing construct.  In my opinion, the assessment tool also includes many questions that are broad and general and could represent a number of behavioral phenomenon, primarily dependent on the interpretation or labeling of the examiner.

I believe that we should consider pausing when we use tools like the Sensory Profile to report an incidence of "sensory processing disorder."   It is apparent that atypical scores on this assessment may indicate co-morbid issues that are interwoven with a number of other behavioral and social and psychiatric diagnostic constructs.

The prevalence concern may be even more significant.  Claims about prevalence (Ahn, Miller, Milberger, and McIntosh, 2004; Ben-Sasson, Carter, and Briggs Gowan, 2009) of a proposed 'sensory processing disorder' have to be reconsidered in context that the Dunn Model may not adequately parse out sensory concerns from temperament concerns.  Again, this is something that many clinicians have known for a very long time but this study validates those opinions.

The reality is that significant damage is done when non-validated or non-replicated research is rushed into clinical practice.  One can only speculate on the efforts that will be required to unwind these notions that turn out to be only partially correct.

There are other important issues raised in the Su and Parham (2014) study.  The authors state that one of their primary interests was to "test the discreteness of sensory system measures in preparation for further research examining whether functions of the tactile, vestibular, and proprioceptive systems serve as a foundation for visual and auditory functioning, as Ayres theory proposes."  I do not understand why occupational therapists are still interested in applying hierarchical models to describe complexities of neurobehavioral function.  For over 25 years that I have been studying and lecturing on sensory processing concerns I have left out hierarchical models because of all the research that has been done that supports heterarchical organization.  There is simply too much research to even begin making citations, but descriptions of heterarchical neural organization can be found across all disciplines from neurology to psychology to robotics and computer engineering.  As a primer into the notion of heterarchy and multilevel cross-disciplinary understanding of neurobehavioral concerns I recommend any of the articles written by Berntson and Cacioppo (seminal articles on heterarchy and social neuroscience referenced below).

Even if we can discretely reduce processing concerns into modality-specific categories, where is this going to lead us?  It is very difficult to understand why occupational therapists continue to be interested in sensory-level intervention strategies when we have had such historic challenge with finding strong evidence for this kind of treatment approach. In contrast, other disciplines are developing evidence based cognitive-behavioral methods for addressing regulatory problems or for mediating stress-level responses.  As an example I refer to research being conducted by Stanley (2009) that is being applied in a military context but that I suspect will be gaining much broader consideration due to the raw effectiveness of the techniques.

In summary, the Su and Parham (2014) study provides many interesting discussion points for occupational therapists who are interested in sensory processing and resultant behaviors.  It is promising to see that there is some progress in our research that validates concerns that have been expressed by practitioners.  However, there is evident need that as a profession we need to continue questioning our basic premises.  So many other professions have moved beyond models of hierarchical organization, now embrace hetararchical and dynamic systems explanations for behavior, and are in the process of validating alternate non-sensory based intervention methods.   Reading the literature of other disciplines provides strong evidence that occupational therapists are not at the forefront of relevancy on ideas about sensory processing and regulation.


References:


Ahn, R. R., Miller, L. J., Milberger, S., and McIntosh, D. N. (2004). Prevalence of parents’ perceptions of sensory processing disorders among kindergarten children. American Journal of Occupational Therapy, 58, 287–293

Ben-Sasson, A., Carter, A.S., and Briggs Gowan, M.J. (2009). Sensory over-responsivity in elementary school: prevalence and social-emotional correlates. Journal of Abnormal Child Psychology, 37, 705-716.

Berntson, G.G., Boysen, S.T. and Cacioppo, J.T. (1993).  Neurobehavioral organization and the cardinal principle of evaluative bivalence, Annals of the New York Academy of Sciences, vol. 702, pp. 75–102.

Cacioppo, J.T., Berntson, G.G., Sheridan, J.F., and McClintock, M.K. (2000).  Multilevel integrative analyses of human behavior: Social Neuroscience and the complementing nature of social and biological approaches.  Psychological Bulletin, 126(6), 829-843.

Dunn, W. (2001). The sensations of everyday life: Empirical, theoretical, and pragmatic considerations.  American Journal of Occupational Therapy, 55, 608-622.

Shea, C. and Wu, R. (2013). Finding the Key: Sensory Profiles of Youths Involved in the Justice System. OT Practice 18(18),  9–13.

Stanley, E.A. and Jha, A.P. (2009). Mind Fitness: Improving operational effectiveness and building warrior resilience. Joint Force Quarterly, 55.4, 144-151. 

Su, C. and Parham, D. (2014). Validity of sensory systems as distinct constructs, American Journal of Occupational Therapy, 68, 546-554.