Turning Machiavellian

Outcomes… It’s what our patients want; it’s also what clinicians want. It isn’t unusual for a patient to say, “I don’t care what we do, I just don’t want this pain anymore.” In fact, it’s what drives clinicians to deliver better patient care – better outcomes more efficiently. Better patient outcomes & experiences creates a self-reinforcing virtuous cycle of greater efficiency and consistent outcomes. It is something worth leveraging.

As far as patients are concerned, many just want to feel better. To them, the end justifies the means. They want to get well & stay well. What about the clinicians? Does The End (outcome) Justify The Means (treatment/interaction)?

Being able to justify your treatments and interactions requires the ability (& willingness!) to determine the effectiveness of your plan of care. Consistent measurement of outcomes plays a significant role here. If you aren’t continually reassessing your outcomes – both positive & negative –  then you aren’t doing yourself or your patient much justice. Determining the efficiency & effectiveness of your service is an important component of the value proposition of every clinician. The question that comes to mind is, “Am I delivering the best value that I can?”

On what basis would you answer that question? By what your boss says? By what your colleagues say? By what your patient says? Or could it be based on contemporary (latest) themes of scientific understanding?

Let’s tackle that last one first. Science always changes. The tides of data, winds of politics, and the drive of capitalism continually shape and direct the future of science. And, let’s not forget inherent biases within Scientific Research itself that funnel & lead Scientific Conclusions that both the public & private sectors leverage for their own interests. Even if we ignore the financial levers in scientific research, it’s difficult to account for the personalities involved and contemporary zeitgeists. Here’s how Craig Venter puts it in his biography A Life Decoded:

Too many times I had seen science driven less by data and more by the force of a particular personality or the story on which a professor had built his career.

Could this rising tide of Data overwhelm our ability to Keep up with The Scientific Joneses? Maybe. Here’s a study that says that there are too many studies! While some clinicians may do their best to keep up with the latest literature, many clinicians rely on webinars, weekend courses, and other aggregators of latest research. Given this, all clinicians should be familiar with Academese (Academic lingo) to help them navigate the labyrinth of terms, interpretations, limitations, and applications of research papers. Most clinicians do not (and, maybe, can not) keep up with the growing avalanche of peer reviewed literature.

In many instances, what your boss or supervisor says is coloured with the tinge of achieving pre-set numeric hurdles that may or may not involve your progress as a clinician. To a certain degree a better clinician yields better outcomes on the bottom line as well, but that could depend on business models and practice settings. In essence, reaching a target Units Per Hour does not make you a better clinician. Neither does juggling 3-4 patients per hour make you a better clinician.

What about what your colleagues say? Maybe a majority is simply Noise, and some of the rest of Signal being unintentional more than intentional. How many of your colleagues have contributed to your improvement as a clinician? While many co-workers and colleagues come & go, there will be those few that are worth holding onto; continually renovate and fireproof these bridges. Coming back to the main issue, a majority of co-workers (a few exceptions excluded) don’t necessarily make you a better clinician. At best, what you are receiving is external locus of control (creating dependency) versus internal locus of control (fostering independence).

Given this never ending climate of continual change and murk, what can we (you & I as Clinicians attending to individuals with various physical dysfunctions) do to maintain a sense of direction? Maybe we could look for things that don’t change: Nobody wants to live in pain; Nobody wants painful movement; Nobody enjoys the inability to move or return to work due to painful experience with sitting, standing, etc. Nobody is pleased with his/her difficulty walking, lifting, having sex, pushing, pulling, carrying, holding their grandchild, etc. No athlete doesn’t want to return to their favorite sport. She values the End (a pain-free functional life) regardless of a complete understanding of the Means. Many Grandparents don’t even care about how you get them to lift, carry, and hold their Grandchild, as long as they can lift, carry, and hold their Grandchild! Their desired functional Outcome generates significant value to him/her.

My basis to answer the question “Am I delivering the best value that I can?” is this: It Depends on My Patients’ Outcomes. Outcomes includes more than reaching their individual goals in Physical Therapy, it also involves referring him/her to other clinicians who could assist in their progress or take over her case, if that’s what’s needed. What patients want is to return to a pain-free life that allows them to provide for & spend time with the ones they love, to be independent, to re-experience the joy of movement, to get back to the life they once had.

As a clinician, I want to leverage outcomes to demonstrate my value to more than just my employer(s) and the insurance companies (purse holders). I want to leverage these outcomes to demonstrate my value to current & potential future patients.

Consistent & Repeatable Patient Outcomes has become such a directional indicator for me that if someone were to call me Machiavellian in this respect, then I’d take it as a compliment.

Related: This podcast by Therapy Insiders with Jerry Durham is worth your time. The last 10min or so rhyme with the post you just read.

@Cinema_Air

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5 thoughts on “Turning Machiavellian

  1. You cover so many good points:

    I feel the weight of keeping up with the ever-growing body of research. You can’t just take the conclusion in the abstract at face value– you have to read the WHOLE study with a critical eye– so it takes a LOT of time to wade through what is out there.

    I am a functional outcome enthusiast as you are. What is the point of our goniometric measurements or pain rating on the VAS if we don’t relate it to the actual LIFE that the patient is leading? I don’t mean to poo-poo objective measures by any means. It’s just that it is harder and harder to have the time to just talk to the patient about their life when you are cramming in three or four patients an hour.

    A little venting…
    Thanks

    1. Hi Bliss (love that name!),

      It’s tough. The abundance of evidence requires the use of filters (individual, conceptual, practical, accepted, contrarian, novelty, etc.) that eventually struggles to fit a square peg thru an octagonal hole. Also, Academia in PT is on the verge of turning into a fetish…if that hasn’t happened yet. Everybody seems to refer/link to studies, but most haven’t read it! Like you said, the whole study should be read to truly understand what the study is about and how it may/may not apply in practice. The “Methods” section dulls it for me at least 70% of the time.

      I’m fortunate to work in an environment where we see patients 1-on-1 for an hour.

      Confession: I haven’t touched a goniometer in 3 years!

      Thanks for the kind words.

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