Jonathan

Assessments Contract to Fit the Time Allocated.

Recently, a physiotherapist friend did two opposing things in reasonably quick succession.

Time

In the first they complained of not having a good first session with a patient as they couldn’t get to where they wanted to in the time.

In the second their initial assessment with a patient lasted two and a half hours.

We discussed the idea that pushing to achieve a particular goal in the first assessment might have stifled where the session should naturally go.

And as for the second assessment, initially they seemed to think it was OK. But in the next session the patient did say “it was a bit long”.

How Long is an Assessment?

That led me to think how long an assessment should last. Or any session for that matter. And should you have a specific goal, a number of things to cover, a load of boxes to be ticked?

Who should set the agenda for an assessment? Should it be a dry collection of the facts of the case or a freewheeling conversation about whatever comes up?

As a physiotherapist, am I an expert questioner teasing out the salient points, a data collector, a coach, a guide or a supportive ‘friend’?

Having a Goal

Without a goal when we approach an assessment we won’t achieve anything, but how set out, how rigid should that be? When we are starting out we need a more controlled structure to work with, and as we become more experienced we can take a quicker route to our goal.

If we achieve mastery of the process, we should have answered all these questions and come to an expert assessment, clearly seeing the problems and able to move the patient towards a solution.

But how many of us progress beyond the stage of collecting what we see as the facts, going through the list on the assessment form and then emerge as great interviewers?

In his first session, my physio friend had the goal of getting to a conclusion and when they didn’t they felt frustration. The goal was blocking them from allowing the assessment to take the shape it was forming.

The Shape of Assessments

Assessments have a life of their own, and we don’t know where they’re going to take us. At least that’s how I think they should be. When you sit down to assess a patient, if you have only a limited idea where you’re going to be in 30 or 60 minutes this can allow the patient’s narrative to prevail.

The clinician’s skill is to respond to how the assessment is unfolding and help the patient get across all the aspects of their issues. If you let them, the patient will take you on a journey through their life and show you how to help them get better. The assessment forms its own shape and we need to avoid getting in the way.

Cramming Stuff In

The initial assessment often includes the subjective examination, the objective examination, problem identification and a treatment plan.

Mostly this fits into a time allotted. With 15 or 20 minute sessions we will have to direct the patient and get their answers to defined questions or we’ll never get through our list.

Like Parkinson’s Law in reverse, the work is compressed into the time available for it. Having to reach a goal forces us to be rigid in the execution of the interview, and to get to the end at the end.

Targets and Capacity

Demand for appointments, the capacity of the services and the targets set for them all conspire to provide a service which could be so much better. Time is constrained, gradually more and more, to allow more throughput.

Reducing the time for initial assessments could start at 45 minutes, then it seems sensible to reduce it to 30 minutes and then to 20 minutes to get through the numbers.

Outcomes

Without outcomes to tell us how our patients are doing over the longer term, any consultation is of limited worth. We get through the numbers, reduce the list and reduce the waiting times. These things are easy to measure but we are not measuring the things that are important.

I don’t know how long as assessment should be, just that it takes the time it takes to get to a place where the patient feels understood and we feel we know what’s going on. And that should be the goal.

When I think back over all the times me and my colleagues assessed a new patient, and how we mostly collected data within the narrow confines of our questions, I reflect on how that might not have been the best course.

We thought assessment forms were essential, the modern way to quickly collect the information we needed about the case so we could move on to treatment planning. We liked the line drawings of the body, back and front, so we could put areas of pain and other sensations in different shadings, all the ‘x’s and ‘oh’s.

The forms constrained us into asking questions in a particular order and in the style of data collection, as if the patients were passive holders of the data we needed and we just had to get it out.

Fact Gathering Can Get in the Way

Fact gathering can seriously get in the way of getting to the heart of why the patient is experiencing their problems. We don’t need loads of info. At least not at first. Some facts have to be gathered, such as red flag questions, but they will intrude on the process of engaging with the patient’s experiences unless we take steps to avoid this.

Asking many questions, especially if they have yes or no or just factual answers, puts the patient into a passive role. As the patient is the only person who can help themselves, they need to be active collaborators. And they can’t be if we pursue the data collection course.

Professionals such as physiotherapists (or any health worker) can easily fall into this controlling trap, asking closed questions or multiple choices. Either way, this closes down the potential answers and reduces the chances of finding out what’s really bothering the patient.

Dr. William R. Miller, one of the founders of motivational interviewing, says: “If you listen to patients, they say more things about why they want to get better”. And about what is bothering them and how they think they might improve things.

Open Questions Promote Engagement and Share Power

The range of potential responses to a closed question is very limited but to an open question it is extremely broad.

A good approach might be “I’m really interested to hear your story about your back pain, could you tell me about it?”. And then sit back in the chair and listen, without interrupting, for as long as the patient’s flow of their story continues. This allows them to choose any angle and to start at any point in their case history, and it’s likely they’ll start with the things that feel most emphatic for them at that moment.

You’ll find that many of the facts you wanted to gather come out in their story anyhow, and you only need to fill in the gaps at the end.

Open questions mean you’re interested, gives the patient a share of the talk time, a share of the power and changes the depth and complexity of the interaction. Open, evocative questions gives them a chance to open up about their fears, beliefs and experiences which will give you invaluable guidance as to where you need to target any interventions.

If you let them, patients will tell you how to help them get better.

If you’re interested in better questioning, really listening and finding out what patents are thinking and feeling, motivational interviewing training is a great place to start. I did a course on www.psychwire.com and found it very enlightening. I have no financial or other connection with that organisation except as a satisfied customer.

There’s an Alphabet Soup of Physiotherapy Practitioners now.

Physiotherapy has been changing fast in the last ten years. Opportunities for career progression have dramatically increased as the pressures on GPs, secondary services and budgets have grown.

Managers have realised that physiotherapists can do a great number of jobs which were previously the realm of a doctor, can do them just as well and at less cost. No longer do you have to choose a management route to get to the higher levels of the profession, there are many routes now.

This has led to a variety of approaches across the UK as new ideas are attempted, and along with that an explosion in new titles with their very own acronyms.

Extended Scope Physiotherapist – ESP

This title is the first advanced role which was developed in physiotherapy. When it was first proposed that physiotherapists take on roles normally reserved for doctors, such roles were “outside the scope of physiotherapy”.

Once these roles were developed, they were called Extended Scope Physiotherapists or ESPs.

I remember a practitioner in the hip clinics in Exeter in 1989 who was one of the first in the country, reviewing hip replacement patients at six weeks, recording their ranges and checking the X-rays.

ESPs initially worked in spinal and orthopaedic clinics, alongside consultants and registrars. They could order investigations and some could list patients for surgery.

What distinguishes ESPs is that they are mostly diagnostic replacements for doctors, and don’t “do” physiotherapy in the traditional sense. They perform a triage role and refer for physiotherapy if required.

The Alphabet Soup

Since then many new roles have been developed, affecting not just physiotherapy but occupational therapy, nursing, pharmacists and other professions. This has led to a slew of new titles just in physio – orthopaedic practitioner (OP), surgical practitioner (SP), specialist musculoskeletal practitioner (SMP), advanced practice physiotherapist (APP), clinical specialist physiotherapist (CSP), first contact physiotherapist (FCP).

So, with this confusing mass of names and initials, I thought it would be worthwhile discussing some of the recent ideas in physiotherapy roles and the opportunities they afford.

Advanced Practice Physiotherapist – APP

This is now the main name for advanced practitioners, superseding extended scope practitioners as a title. APPs can work in any area, including the Emergency Department, and can diagnose, investigate, inject and refer in many cases.

APPs can incline towards the diagnosis and triage roles (the old ESP role) or towards more of a treatment role where they assess and treat patients with the arsenal of physiotherapy modalities. They also have a significant consulting and teaching role for physiotherapy staff and others, including doctors and nurses.

First Contact Physiotherapists – FCPs

Medicine and allied professions are just as prone to fashion as any other part of human life, and the fashion for FCPs is in full swing at the moment. MSK conditions make up between 15-30% of a GP’s practice, constitute a significant burden and are the realm of expertise of a physiotherapist.

The FCP could see many of these patients instead of the doctor. Evidence shows that patients are happy with this and physiotherapists can safely manage these patients. FCPs work in GP practices, seeing patients with musculoskeletal problems, the vast majority of whom do not have a significant medical diagnosis.

Clinical Specialist Physiotherapist – CSP

CSPs are advanced “traditional” physiotherapists, with specialist skills in examination, diagnosis and treatment. They may also inject and prescribe.

The role of the CSPs, apart from treating patients with advanced skills, is also to promote best practice, support physiotherapy teams, teach and mentor more junior therapists and write and review treatment pathways and patient information.

Physiotherapy’s New World

Physiotherapists have developed several routes to increase their skills and responsibilities over the last ten years. This has included prescribing, injecting and diagnosing in orthopaedic clinics.

By a process of profession creep, physios have been chipping away at the “lower levels” of the doctors’ roles, taking on more responsibility and becoming the independent clinicians we have legally been for some years.

This provides a great opportunity for up-and-coming physiotherapists to make a strong impact in their local medical communities by becoming experts in a particular role or clinical area. This should also free up doctors’ time to make the more complex, judgement-based medical decisions that only they can make.

This process is likely to continue as capacity and cost pressures continue to rise. So if you want a career which takes you into the expert clinical realm, then physiotherapy is now a better option than ever.

Change is Occurring at the Top and at the Bottom of our Professions

The Coming Healthcare Revolution

Healthcare is changing. The technological and information revolution which has blown through retailing, taxis, hotels and music is now blowing through healthcare. Demand is always quoted as the driver for these changes, but there are other drivers which may be more important.

Medicine is at the top of our particular pyramid. They diagnose and treat us and have the ultimate responsibility for our health. As science and technology progress, they can do more and more and their specialities become narrower.

Now the medical profession has a problem. By constantly acquiring new skills and techniques at the top end of their abilities, their field is continually widening and filling up with new treatments. Profession creep for the doctors means more complexity and the cutting edge.

They can treat conditions that were previously not treatable or can treat them better with new techniques. The pool of potential patients increases and looks like it will continue to do so. This process shows no sign of stopping or slowing and will likely accelerate with our ageing populations.

Medicine has dealt with this with varying success. As there is nothing “above” the medical profession it’s interesting to note what’s happening “below” medicine. Doctors are being forced to give up some of their functions to continue on their path.

Demand means that they can’t hold on to everything they have been doing. The stresses on the system have steadily increased as patients complain they can’t get to see their doctor and waiting lists rise. And that’s not considering the stress, burn out and early retirement of many doctors, a result of impossible demands.

At medicine’s cutting edge, technology and research move inexorably forward, forcing increased specialisation. Something has to give.

Profession Creep – Advancing the Profession

Nurses and physiotherapists are taking over the lower levels of doctors’ roles. Advanced practitioners exist in many medical areas and carry out procedures that doctors would normally do, such as inserting a central line or running a spinal clinic. This process is now in full swing and will continue to accelerate.

The Rise of Physiotherapy

The greatest profession creep in physiotherapy is occurring in the musculoskeletal (MSK) field. GPs have a huge and varied caseload, and MSK diagnosis and treatment is not generally one of their fortes. 15 to 30% of the patients they see have an MSK problem and as spending on this group of patients continues to rise, results are not keeping pace.

Physiotherapists, already skilled in assessing, handling and managing MSK patients, are the natural group to take over this workload. Many have taken post-graduate qualifications and become highly-skilled diagnostic clinicians in this field.

NHS managers have realised that they can provide safe and less costly services by having non-medical personnel trained to do specific jobs. Whether this work is effective is a subject for another post, but it is likely no less effective than when performed by doctors.

Physiotherapists are now diagnosing, requesting imaging, listing for surgery, prescribing and giving injections. They are moving into the screening and treating roles for the large number of conditions which are more routine and don’t demand advanced medical judgement.

What happens to other Professions….

Profession creep is not just happening to the doctors, it’s also happening to physiotherapy. Non-physiotherapists are routinely employed (Band 3 or 4 in NHS lingo) to do the jobs that don’t demand skilled assessment or handling by a qualified therapist.

The NHS now employs large numbers of trained and skilled people who can do the more routine work of physiotherapy, such as mobilising patients after operation or injury. This leaves the physiotherapist free to assess and treat more complex cases.

These challenges will increase, particularly for medicine. The rise of machine learning and eventually AI will heavily encroach first on the interpretation of imaging and then on diagnosis. Physiotherapy, with its emphasis on direct handling of people, is more insulated from being replaced by an algorithm.

What does an MRI Scan Say about Future Back Pain?

If the MRI scan findings are important in low back pain, we could expect them to predict how our back pain is going to be in the future. That doesn’t seem to be the case.

The Study

A group of people were given MRI scans and then followed up 10 years later.

This showed the findings on MRI scans (disc bulges, high intensity zones, modic changes and spondylolisthesis – all presumed indicators of back pain) did not predict the back pain the patients had in the following ten years.

The frequency of disc degeneration increased from 50% to 85% across the ten years, which was expected. And 77% of people who had no back pain during that time also showed disc degeneration. Similar results were found for the high intensity zones, disc bulges and modic changes.

Overall, the back pain over the following ten years was not predictable by looking at the initial MRI scans. And many people had “abnormalities” on their MRI scans but had no back pain.

This questions the idea that MRI scanning gives us objective information about our backs. And that the results mean anything for our future pain or disability. And that “abnormalities” condemn us to suffer back pain or neck pain in the future. They don’t seem to.

Many of the findings seem to be incidental, perhaps indicators of how long we have been alive, rather than a pain-producing pathology.

This also makes it hard to connect MRI scan results with a person’s back pain. If disc bulges and all the other changes are present in people without back pain and don’t mean anything for future back pain, how can we be reasonably certain they are relevant?

And even if the changes are relevant to the pain, how will they alter the treatment? If they don’t change the treatment, this may be an example of spurious diagnostic accuracy, an accurate diagnosis that means little.

Reference

Tonusu, J., et al. (2017). The associations between magnetic resonance imaging findings and low back pain: A 10-year longitudinal analysis. PLoS ONE 12(11): e0188057. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0188057