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.

References:

(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.'

Thursday, June 09, 2016

Sometimes the most logical thing to do is to stop being logical


An issue came up today that probably needs some discussion.  A parent of a young child was worried about protecting the child's remaining kidney with a kidney guard.  The doctor was not interested in supporting the request for the kidney guard, mostly based on evidence that there is no reason to believe that they are effective and also based on the fact that kidney injuries are quite rare.  (Grinsell, et al, 2012).

One particular recommendation regarding kidney protection by Psooy, 2009 reads as follows:
Parents should try to keep things in perspective: If they are not going to restrict a child from an activity based on the child having only one “head,” then they should not restrict the child from that activity based on having only one kidney
Evidence – Level 3: Those activities most associated with high-grade renal trauma (bicycling, sledding, downhill skiing, snow boarding and equestrian), have more than a 5 × relative risk of head injury compared to renal injury

This is all very logical but perhaps it is a little too logical.  It might be so logical that it is in fact an insensitive perspective.

What is missing from the doctor's evidence-based recommendation is consideration of the journey that parents might be on relating to coping with a child's chronic illness.

Why would a child only have one functioning kidney?  There are many reasons.  The child could have renal agenesis.  The child could have renal scarring from undetected vesicoureteral reflux.  The child could have polycystic kidney disease.   The child could have had the other kidney removed because of cancer.  Any of these conditions are potentially frightening for a family.  Let's extrapolate some more.  Maybe the mother had preeclampsia and now has end stage renal disease.  Maybe a grandparent is on dialysis.  Maybe the parent is just frightened because it is their child and there is only one kidney left and it does not matter if the child also only has one brain and one spine and one heart.

The point is that not everything can be managed with logic.  I am just as fond of a Spock-like orientation as anyone, but I am not foolish enough to believe that you can present a logical piece of evidence to a parent who is frightened and expect a good outcome.

And what are parents to think anyway?  Prior to all this 'evidence' about the questionable value of avoiding contact sports it was relatively standard fare for doctors to tell parents that they needed to PROTECT THE REMAINING KIDNEY AT ALL COSTS!!!!1!  In fact, many doctors still tell this to their patients despite the evidence.

Anyone who has spent any time in a children's hospital understands the twisted perspective one gets by working in that environment.  That twisted perspective occurs because even if something tragic happens rarely, when it does finally happen they will show up at the children's hospital.  I assure you all that your mothers were correct.  You should not run with a lollipop in your mouth and you can put out your brother's eye by swinging around a toy golf club.  This stuff all really does happen.  Listen to your mother.

Despite the studies, despite the statistics, despite any evidence - the fact is that some child with one functioning kidney will in fact take a hockey or lacrosse stick to their remaining kidney and they will be hospitalized and there will be some level of medical disaster associated with the event.  Even though the odds of it happening to any single child are infinitesimally small, it is at this point of singularity that the recommendations of the AAP all go out the window because the event will achieve instant Internet fame as it is posted on Facebook and Twitter for everyone to see.  People all over the world will see the tragic story and they will all quietly think to themselves, "Wow, that person DID NOT listen to their mother."

I know, none of it is likely.  Even less of it is logical.  But there is nothing logical about a child receiving a traumatic injury.  In fact it is the most illogical thing in the world.  Kids are not supposed to be hurt.  Ever.  When they do it is illogical and tragic and horrendous.  Statistics be damned.

 Parents actually know how to deal with this.  There are two solutions.

Solution one is to be logical and follow the advice of the doctor.  If you have a logical orientation then it is all good.  Your logic might even be so good that even in the face of an unmitigated disaster that no one expected, you can still be saved by your logical analysis that you are the unfortunate recipient of an absolutely unlikely event.

Solution two is to tell the doctor to shove their logic, go on Amazon.com or some other site, and just order the relatively inexpensive kidney belt for yourself.  If you want you can go order a helmet and some bubble wrap too.  It is your child, and you can do whatever you want - even if someone else states that it is illogical.  In time you might come to change your mind.  Or you might not.  Either is OK.

In my experience, kids tend to survive either approach. Well, as long as nothing illogical happens.

So I say let parents order the kidney guard.  It really is not that big a deal.  It is not a surgery.  It is not a medication.  There is no damage caused by wearing a kidney guard in gym.  It is benign - and it might actually make a parent feel like they are doing something.  Or having some control.

In an illogical world where unexpected things happen at rates that are almost too small to measure it might even save a child's life.  Who knows?

In the long run parents can make choices about the risks they are willing to incur, but it is important to remember that families are on a journey when they are dealing with chronic illness.  Not everyone will be at the same point of logical understanding as everyone else at exactly the same time.  Or even ever.

If doctors spent more time listening to the real concerns of parents, no matter how "illogical" those concerns are, they might have better relationships and be better able to meet their needs.


 References:

Grinsell, et al (2012). Sport related kidney injury among high school athletes.  Pediatrics, 130(1), e40-e45.

Psooy, K. (2009). Sports and the solitary kidney: What parents of a young child with a solitary kidney should know. Canadian Urological Association Journal, 3(1), 67-8.


Friday, May 27, 2016

The demise of authentic makerspaces: From Dad's workbench to Angie's List

Makerspaces or hackerspaces are terms used to describe environments where people build or create with materials, to learn how to share resources and work together to make things.  In their current iterations they are often found in libraries, schools, or even community centers and people are invited to come into the environment to work on individual or shared projects.  Here is a picture of a modern makerspace:



Occupational therapists are becoming more interested in makerspaces, perhaps based on a seemingly genetic interest in the concept of a constructed milieu where people can come together to develop skills.  This is what early occupational therapy makerspaces looked like:




This is a picture of occupational therapy at the Trudeau Sanitarium in the Adirondack region of New York State.  Patients would come to this area of the country to 'chase the cure' for their tuberculosis.  Attracted by the cold and crisp and clear air of the region, when people were not sitting in their Adirondack chairs breathing in the fresh air they were often found in these makerspaces.  This particular occupational therapy clinic developed into the Saranac Lake Study and Craft Guild, which I encourage readers to learn more about by clicking here.  The Guild became a patient-driven and patient-controlled community.  Modern day lingo might attempt to apply the term 'client centered' but actually that descriptor would fall short of describing the actual community that existed.

The Saranac Lake Study and Craft Guild represents the type of project that Consolation House might have turned into - except that George Barton died while still in the early years of his occupational therapy experiment.  I have some additional materials about Barton's use of makerspace culture that I will be posting in the upcoming months.

At the turn of the century, occupational therapy makerspaces were created to meet an exigent need of convalescing tuberculosis patients. What drives the makerspace movement today?  Are these makerspaces properly located in libraries or schools or even in some DIY classes at Home Depot on Saturday mornings?  Here I want to wax nostalgic in a personal direction, because I think I have a cultural yearning for something that is dying. 

I am wondering if my yearning is related to the fact that I don't perceive authenticity in our modern makerspaces and that the modern makerspace contexts seem unusual to me.

In my personal experience, the only makerspaces that I knew about while growing up were in my Dad's workshop.  We didn't have these resources in schools or anywhere else.  Maybe not as many Dads have those spaces any longer?  Or maybe modern Dads are just relying on YouTube videos when they need to replace the broken float in a toilet so those cluttered workbenches with parts and projects all over the place don't exist?  Or maybe families are just working so much that there is less time for those activities?

I purposely use the descriptor 'Dad's workshop' because in fact that is the best way to describe what existed.  Maybe Dad's workshop is not as common because of evolving social and gender roles that impact division of labor responsibilities between modern parents.  Or maybe it has something to do with the high divorce rate and too many children only seeing a non-custodial parent on a constricted schedule?  Or maybe it has something to do with a modern notion that 'good' parenting means taxiing your children to endless organized recreational experiences and not on a child watching or helping as Dad works away on some project.

My own Dad didn't write a lot, but he shared some of his writing with me before he died, and it is so on point to this topic I thought I would share it here.  What I love best about this story that he wrote is his use of the word 'occupation' which he did independent of my influence.  He called this "My Hovel"

I can’t remember when I went to live in the cellar. In those days the seven of us shared 3 bedrooms. My brother and I had the bedroom off the kitchen and the girls and my younger brother shared the back bedroom adjoining my parent’s bedroom. I had occasion to recall the furnace room where I lived recently in a conversation with my son. There was a coal box beside the boiler and although the boiler had been converted to oil before I moved in, still the coal box remained. And because the area of the furnace room where I lived had been a coal bin, I think for many years after I moved in, still the coal dust remained. No matter how I swept or washed, the coal permeated the walls and floor for years after the coal bin was removed. That may explain why I was able to commander this darkened end of the furnace room without much opposition from any other family member. I just can’t remember the early years in the furnace room, like every occupation, I must of started off small and gradually expanded to fill the area of the old coal bin next to the boiler. There over the remaining coal box I placed an overhanging desktop and glass writing area. Later I built book shelves for the books I purchased from second hand stores in the city. I built a two by six plank workbench adjoining the coal desk along the back wall of the room and stored scrap wood for building under the workbench. I collected large dry cells from friendly telephone workers and made projects of simple electrical circuits. Years later it developed into a radio hobby, building power supplies and oscillators and studying code. Through grammar school I would do homework, work at the workbench and do carpentry work all through the evening hours. Every evening of the week was spent in my work area. The early years of photography developed in this area and I remember constructing an enormous lateral enlarger from a large bellows camera. While everyone lived upstairs, I lived in the cellar. And, I remember most how peaceful and quiet the furnace room was compared to the sometimes pandemonium upstairs.

My Dad created this makerspace and he carried that value and that mindset into his adulthood.  Of course I never knew about this space that he created as a child, but I remember his adult workspace quite vividly.  I remember spending hours sitting with him and helping on all kinds of projects.  We would do carpentry jobs, fix broken appliances, made our own ham radio equipment.  We would scour flea markets for 'treasures' and bring them back to the workspace where they would be put to use or saved for some future project.  That was the norm of my own experience.   It was a very typical childhood experience, I believe, but I am not sure if it is so typical any longer.

Here is another narrative that he wrote explaining his motivation and process for re-finishing the attic into a bedroom for my brother and I.  He called this "The attic bedroom"

You can’t imagine how dirty and dark the attic on Orchard Street was when we bought the house. A winter clothes storage room had been built in the south wing of the attic below the high window and the oversize beams supporting the slate roof were dirty and rough. A single light bulb hung in the middle illuminated the room and the upper half of the windows were colored glass which permitted little light to enter the room on even the sunniest day.
Yet, the staircase was well constructed and the balloon construction lifted the perimeter walls sixteen inches off the floor in such a way that the sloped roof attic walls never seemed constraining as attics often do. The center of the main section of the attic roof reached fourteen feet off the floor so that an eight foot ceiling could be constructed through the large section of the room. The new "Miami" windows were installed from the inside of the room because the height of the house could not afford safe installation by ladder from the exterior of the house. The electrical cable runs were over 250 feet of lighting and outlets and I used 1800 square feet of sheet rock over the insulation I installed. I think I taped the sheet rock for weeks. Before the floor was installed, my son wanted to move in, I think he was only five. I bought the large office desks from a moving company for fifty dollars each including the swivel chairs. I piped the sink and waste to provide some relief for the busy bathroom on the second floor which the six of us shared. Later I built the bookcases which we promptly filled with large library of collected books we loved. I remember how we loved to read the Readers Digest "Wonders of the World"

It became my favorite room, probably because I remember how dark, expansive and dirty it was and later how airy bright and comfortable it became.

What is interesting in this narrative is that you can see the carryover of his makerspace mindset, but also the repeated theme of taking a dark and unused space and creating something out of it.  In this second narrative, he was able to create something for his children in the attic that he was not really able to create for himself in the basement.  The attic bedroom was not a hovel!

I enjoy sharing this narrative because my Dad was not a writer and he was not purposely constructing allegory.  It is just folk intentionality.  Plain words - his words.  That is what gives authenticity to his story about the use of makerspaces.

I wonder sometimes if the makerspace context of a Dad's workbench is not as common as it used to be.  I have a workbench, full of all my father's tools - and I do in fact use them - but life is so busy sometimes I just use Angie's List and will find someone else to do a job for me.  Dad would never have done that.

Perhaps that is why the new makerspaces are not in our homes and not as commonly located in a Dad's workshop - and that is why we have the DIY Network and Bob Vila on the television telling us how to do a project.  Maybe that is why schools are creating these spaces because Dads are not doing it as much.

I think it is a good thing that the spaces are being created, but I have some nagging thoughts that it might not be the best way to meet those needs.  What meaning is created by going to a sterile hackerspace in a school every other Thursday for your scheduled time?  How does that serve our own narratives about creation and meaning that might fit into our own lives?

Would there have been a hovel and then an attic bedroom if my Dad didn't have his own makerspace?

I think these are important questions.

Friday, May 20, 2016

Collected thoughts on narrative in occupational therapy documentation


About ten years or so ago I wrote about the potential power of using writing and hypertext as a qualitative methodology for understanding human narrative.  I got that idea back in high school, actually, after reading the Langston Hughes poem, Theme for English B:

The instructor said,

      Go home and write
      a page tonight.
      And let that page come out of you—
      Then, it will be true.

I wonder if it’s that simple?...

The poem is all about identity, and expression, and trying to understand point of view.  I struggle with this concept of documentation as representation of life.  Can documentation represent life, really?  I think it can when I read Langston Hughes, but when I focus in on a short essays like in the Humans of New York series I can't read more than one or two of them.

I object to them, mostly, because when I read them I feel like someone is distilling a life into an evocative photo and 60 seconds worth of reading.  It is just too neatly packaged.  The impression that I believe the reader is supposed to be left with is one of a point of understanding.  Instead, I am left with the idea that someone's life has just been Facebooked into farcical representation of actual reality.

I don't know if 'Facebooked' is an actual term.  I just made it up.

What is worse, the distillation, or reading the distillation and believing that it is real?

I believe that people's lives are messy or complicated, full of commas and ellipses and misspellings and confusion and misplaced modifiers.  How can we represent or understand reality in a tightly controlled text box read by a disconnected set of eyeballs?

I try not to be guilty of the same thing here, but it might be misconstrued because I also write clinical vignettes.  When I write my stories here, I am not attempting to encapsulate the life of the people I am writing about.  I am attempting to encapsulate how that intersection impacted me.  It is selfish expression, to be certain.  I try to use it for good though.  The whole idea is to find ways to understand what I am trying to accomplish for other people.

The problem with my writing here now is that some ideas are spread out over a ten+ year span.  I think there is a lot more to it than all this, but I wanted to collect some of the thought I had on this in one spot for future reference.

Writing as occupation

Destruction and deconstruction of occupational therapy documentation

The best way to discharge a patient


.

Tuesday, April 26, 2016

The impact of the janitor on an occupational therapy practice

Owning a private practice is a never-ending adventure that usually causes the owner to take on many different job roles.  This Saturday I put on my janitor clothes and tried to take care of some things that were starting to turn from minor annoyances to full blown problems.

I am not embarrassed to talk about the presence of these things that need fixing or adjusting, mostly because I have a comfort level with the humble nature of our mom-and-pop therapy shop. The families that come to us seem to understand that, I think, because sharing stories about the tribulations of trying to get things done probably resonates with the busy and complicated lives that they are also leading.

The only problem is that I am not a janitor, or even a poor excuse for one.  That means that only sometimes I get things right.  So I cheered as I won a battle against the broken copier,  looked proudly on my successful taming of the broken heating vent - but then I met my match.

I could not repair the broken lighting ballast in the evaluation room. 

At first I thought it was just a matter of changing the long fluorescent tubes.  That didn't work.  Then I thought that perhaps the fuse was tripped down in the basement.  That wasn't it.  I jiggled things.  I poked at things.  I avoided electrocuting myself, but I was defeated.

So I did what any good janitor would do: I got another light on a temporary basis until someone who knew what they were doing could intervene.





 It looked like a fun option, but I had no idea what a 'hit' it would become.  Every child that enters that now (slightly dark) room falls in love with that stupid lamp and they all ask the same thing with a sense of wonderment: "Who brought that lamp here?"

The lamp is taking on mythical qualities.  The kids just stare at it in awe.  My favorite response came from a little four year old - and there is no way I can capture the cute-ness in written form, but just imagine the most beautiful child in the world staring up at you from knee-height saying from the bottom of their heart, "Oh Dr. Chris.  I love your lamp!"

Because I am teaching part time my staff keeps in contact with me via text or email or phone throughout the day when I am at the college.  Now the lamp is being incorporated into handwriting practice.  I got this letter today:



 So the janitor at ABC Therapeutics wants to make a recommendation to all aspiring pediatric private practice owners...

GET THIS LAMP!!! 

And then tell the janitor not to bother fixing the broken fluorescent lights.

It will make you the most revered occupational therapist in the entire practice.