An Inevitable Practice Situation

[goyo1010]

Hey everybody,

I just finished reading a nice little book (although there was a lack of adequate editing) Physical Therapy The Truth by Monie Phillips, PT and it brought up some nice little points, actually. So, I have a question for you guys. And I'm not sure if this had been discussed previously. Let's see what you'd do. Here's the following situation (this situation is taken from the book and imagine you're a fresh PT out of PT school):

You are working in at your first job as a full-fledged physical therapist in a typical nursing home setting, in which a contract company manages the rehabilitation portion. This means you are not an actual employee of the nursing home, and the home administrator can persuade the rehab management company to a certain degree (the company wants to keep its contract with the nursing home). This means that the company may have a stronger proclivity to maintaining the contract with the nursing home rather than maintaining ethical principles.

You evaluate a patient and undergo the treatment process; however, along the line of the patient's treatment, you have no choice but to discharge the patient for failure to participate or failure to progress. You have done all you could have for the patient, but it would be ethically wrong to continue treating the patient when you have objectively determined that the patient is either not participating or can no longer progress. This then leads to an unhappy patient, unhappy family members, and/or an unhappy physician and the home administrator hears about it. The contract company that manages the rehab may feel the contract with the home is in jeopardy because of the situation and may attempt to motivate you, the physical therapist, to reconsider the decision. However, Medicare rules and regulations and state law pressures you to maintain your decision.

You are now faced with a job-threatening ethical choice:

• Will you stand up for what is an objective-based professional opinion and discharge the patient?

• Or will you succumb for the sake of politics and keep the patient on the caseload?

What would you do? Keep in mind the repercussions of both the choices (I have left them out on purpose).

---

Members don't see this ad.

 

[TheOx777]

Wow! You brought out the "big gun" questions on this one. I believe this is one of those situations where you don't know what will happen/how you would handle it until you are actually in it. My "gut" tells me that I would use as much of my persuasive skill set as possible to do what is right for the patient. If that doesn't work, then I am not sure where I would go from there.(that's how I would feel)

 

[markelmarcel]

Wow! You brought out the "big gun" questions on this one. I believe this is one of those situations where you don't know what will happen/how you would handle it until you are actually in it. My "gut" tells me that I would use as much of my persuasive skill set as possible to do what is right for the patient. If that doesn't work, then I am not sure where I would go from there.(that's how I would feel)

I agree. If I lost my job because of politics, then I would go get another one. Haha. Ok, it's not that easy. But, I'd rather think about actually getting through my first semester alive than this at this particular point.

 

[DancerFutureDPT]

I refuse to answer this because we did like 15 of these scenarios in one of my classes, including one very similar to this, last trimester and I've chosen to block that part out

 

[johncronejr]

I would try to come up with creative ways to treat the patient. Something unorthodox, or perhaps more play-like, may inspire the patient to participate and, thereby, progress.

If this did not work, I would speak with the clinic director and voice my concerns. I would let the clinic director make the call in a possible unethical situation. I would have this noted in the patient's file and ask the clinic director to note this.

If you feel strongly about ethics, and you should, there is nothing worth lsoing your license or gaining a reprimand in your file. If the clinic wants to operate that way, then have someone above you make that call. If they feel like continuing treatment in such a case is no big deal, then they should have no issue with accepting responsibility for the treatment. If they back away from responsibility for the treatment, then you know what kind of people you are dealing with and must decide if you will continue working in that environment.

Bottom line: Cover your ass. No one else is going to cover it for you when the mess hits the fan. There is ONLY ONE person that you can always count on to have your back no matter what, and that person is you.

 

[callmecrazy]

You evaluate a patient and undergo the treatment process; however, along the line of the patient's treatment, you have no choice but to discharge the patient for failure to participate or failure to progress.

I have an issue with this statement. In my opinion, a participation issue is not at all comparable to a patient that is not progressing. And then you have the question of why they were not progressing. Were they back to baseline, regressing, plateauing, or haven't progressed at all? I'd also argue with the idea that the patient has failed and that instead you may be at fault as the PT. I agree there is some ethics issues there, but I don't think you can make an informed decision based on the provided info either (obviously you would have all the details if you were the PT in question). If you're just looking for the bottom line though, you have professional obligations and ethics to uphold yourself too, period. Before you even get this far into the situation though, you should have been seeking out guidance and addressing the issue.

 

[goyo1010]

I refuse to answer this because we did like 15 of these scenarios in one of my classes, including one very similar to this, last trimester and I've chosen to block that part out

haha, that sucks. but funny. lol


@callmecrazy: this was the situation given by the physical therapist that wrote the book. He simply had this experience when he was working as a physical therapist in a nursing home setting. However, I do not know how he handled this situation, nor do I know the full details of the situation, e.g. what constituted the decision to discharge, the factors that influenced his decision, etc.

I was simply curious as to people's answers, although, you do raise important issues concerning this situation.

 

[MPhillipsPT]

Hello,
I am the author of the book. I was playing around on Google and found your post so I joined the site to say thanks for reading it and I hope you enjoyed it. I have to say, I feel honored that you used my scenario in your discussion. I hope you choose to follow the truth, the evidence based approach. I hope that when you begin your practice you choose to stick to the science and stay true to it instead of letting the pencil pushers and bean counters push you around, make decisions for you.

Thanks again,

MPhillipsPT

 

[Fiveoboy11]

I've encountered this exact scenario numerous times, especially at the last place I worked. There is a lot of pressure to see patient's as long as possible and in many cases your professional opinion is irrelevant and ignored. My contract was terminated one month early on the grounds of "insubordination." My advice would be to stand your ground no matter what. Do what you think is right. Always remember that a rehab company, the rehab manager, and the doctor are NOT in charge of a patient's physical therapy. The PT is.

 

[goyo1010]

I've encountered this exact scenario numerous times, especially at the last place I worked. There is a lot of pressure to see patient's as long as possible and in many cases your professional opinion is irrelevant and ignored. My contract was terminated one month early on the grounds of "insubordination." My advice would be to stand your ground no matter what. Do what you think is right. Always remember that a rehab company, the rehab manager, and the doctor are NOT in charge of a patient's physical therapy. The PT is.

Thanks for the advice. Too bad that's not what doctors think. They always have the final say in the patient's treatment right?

 

[jesspt]

Thanks for the advice. Too bad that's not what doctors think. They always have the final say in the patient's treatment right?

Uh, no. The patient does.

 

[goyo1010]

Uh, no. The patient does.

oh, well of course the patient has the final say in any medical treatment. what i meant was that between the doctor and the PT, the doctor trumps the PT, unfortunately.

 

[hefe]

Well a session or two before they came close to being held too long I would have seen if another PT would have some sessions with the patient. Also, I would keep a close line of communication between patient and provider regarding the efficacy of the treatment, including progress. I would try introspective review of how to improve treatment, perhaps ask others opinion.

What you don't do is sell a bill of goods, never get creative with treatment (stuck into a same rut), draw out therapy exhaustively long, and unless the patient is paying out of pocket, keep billing insurance for weeks no progress.

PT's who abuse their position, abuse the system, and lack thought into how they manage their case severely drag the profession down for those in it. Perhaps, a third-party committee should be reviewing their licensure.

Complacency kills...

 

[Fiveoboy11]

As far as a physician trumping the PT. From the standpoint of medical decisions, yes the physician trumps everyone. There is a little gray area here though since physicians seem to think that PT is a medical procedure or that they own it, which it is false. From a legal standpoint, at least in my state (AZ) and in states with unrestricted direct access, the PT is trumped by nobody from the standpoint of PT by law. However, there is politics involved. For example, if you openly challenge or do something against a "doctor's" orders, the company you work for will punish you for it, because the "doctor's" have referral power.

 

[jesspt]

As far as a physician trumping the PT. From the standpoint of medical decisions, yes the physician trumps everyone. There is a little gray area here though since physicians seem to think that PT is a medical procedure or that they own it, which it is false. From a legal standpoint, at least in my state (AZ) and in states with unrestricted direct access, the PT is trumped by nobody from the standpoint of PT by law. However, there is politics involved. For example, if you openly challenge or do something against a "doctor's" orders, the company you work for will punish you for it, because the "doctor's" have referral power.

Sounds like you need another employer.