Clinical decision making in physical therapy: a practitioner's perspective.

Clinical Decision Making in Physical Therapy: A Practitioner's Perspective The purposes of this presentation are to describe and categorize the diverse clinical decisions currently made by physical therapists and to discuss the factors influencing those decisions. My views on the subject of clinical decision making are deeply rooted in the soils and toils of clinical practice and are not influenced by the mathematical and statistical models of decision making (eg, medical decision analysis). I have spent almost every day of my 38 years of professional life involved in direct care of patients. This experience has allowed me to participate in and be a witness to the expanding role of the physical therapist in clinical decision making.

The expansion of practice into more independent modes presents numerous challenges. A substantial challenge, for example, will be to successfully educate current and future generations of practitioners in the methods and intricacies of clinical decision making. This challenge must be met if a broad spectrum of physical therapists are to deal effectively with the responsibilities associated with more independent methods of practice. The degree of success we experience in meeting the challenges of implementing a larger decision-making role for physical therapy practitioners will determine the degree of our future professional enhancement.

My task in this presentation is to provide you with an overview of how physical therapy is practiced and then to discuss the various clinical decisions being made by physical therapists as well as factors influencing those decisions.

Overview--Profile of the

Average Physical Therapist

Before delving into a discussion on physical therapy practices, I would like to develop for you a profile of the average physical therapist engaged in practice today who will have the responsibility for clinical decision making. This profile was developed from the American Physical Therapy Association's 1987 Active Membership Profile Survey. [1] I believe it is important for us to look at this individual critically to identify those qualities that might either contribute to or detract from the clinical decision-making process, once that process has been defined.

Our average physical therapist is a Caucasian woman under age 34 years who graduated from a baccalaureate educational program at age 23 years. She is employed in a salary arrangement and earns slightly more than $30,000 a year. She spends most of her time in direct patient care, and it would not be unusual for her employment to have been interrupted at least once during her career as a physical therapist. It is not common for her to provide initial evaluations without practitioner referral, and even rarer for her to treat patients through a direct-access method. This physical therapist will participate in two continuing education courses a year and thus far in her career will have attended one Annual Conference. Half of her peers claim to have sufficient working knowledge of research design and methods of statistical analysis to critically read and evaluate reports of research published in Physical Therapy and other professional and scientific journals.

Overview of Physical Therapy

Service--Environment and

Delivery

Providing you with an overview of where and how physical therapy services are delivered and practiced today will not only provide a foundation for our future discussions in the area of clinical decision making, but also will remind you of the numerous and rather substantial changes that can occur in an evolving profession.

In 1950, about 80% of employed physical therapists worked in hospital settings. About 20% were employed in inpatient rehabilitation centers, visiting nurse programs, and schools, and a very small percentage were in private practice. By 1983, the number of physical therapists employed in hospitals had decreased to 41.9%, and a practice survey conducted by the Professional Examination Service in 1986 revealed that the number had declined even further to 36.8%. That same survey revealed that the number of physical therapists in private practice had increased to 18%. The remainder of the work force was equally distributed among home health care agencies, rehabilitation centers, extended care facilities, school programs, and academic institutions (APTA Department of Professional Relations/Practice, personal communication, September 1988).

The exodus of physical therapists from the hospital environment has been dramatic, as has the increased number of physical therapists entering private practice. It is my belief that these events deserve closer examination with respect to both our topic of clinical decision making and our profession in general.

All of you are aware that the manner by which patients are referred for physical therapy services or consult with a physical therapist has changed drastically in recent years and will in all probability change even more if reimbursement considerations keep pace with evolving methods of physical therapy practice. This, by the way, is no small matter. At the time this presentation was being prepared, 21 states had enacted legislation that permits patients direct access to physical therapists, and I am certain that most in our profession view this change as a significant accomplishment. However, it would be well to remind you that just recently one of the largest underwriters of health insurance in this country imposed restrictions on physical therapy services in some of its plans that take our profession back at least 20 years. [2]

The practice of calling on physical therapists to evaluate and treat patients has become the more common referral method, and if and when independent practice becomes the force we expect it to become, physical therapists will be infinitely more responsible and accountable for the outcomes of their interventions with patients. We will not be able in that atmosphere to attribute a patient's failure to respond to treatment to the referring physician who has locked the physical therapist into an unalterable treatment plan that is not appropriate for the patient's condition.

I have advocated a slow growth with respect to the attainment of independent practice status for our profession. [3-5] Over the years, I have tried to clarify my reasons for this stance. I am not currently, nor have I been in the past, opposed to this concept. What I have opposed is attaining this privilege without the knowledge to cope with the issues we are certain to confront in this method of practice. Physical therapists must be prepared to meet the numerous challenges independent practice will present. The ability to make sound clinical decisions becomes, in my opinion, the keystone to this entire process.

General Comments About

Clinical Decision Making

The evolution of clinical decision making in our profession has been an interesting development to observe over the years, and in reality parallels the growth and maturation of our profession. There can be little doubt that we have come a long way in this matter of clinical decision making. I can remember when referral sources believed the only decision we should make about patients' welfare was when to excuse them to use the rest room.

Fortunately, today we practice in an environment that for the most part is far less restrictive in terms of how physical therapists are perceived and those latitudes that limit practice. The constraints that do exist are to a degree self-imposed and relate to our own ability to competently perform given aspects of patient care. In your wildest dreams did any of you believe 10 years ago that it would be possible to have enacted direct-access legislation in 21 states by 1988?

Numerous clinicians in our profession have been making sound clinical decisions for years; however, as our profession moves toward a role of increased independence, the requirement for the masses of physical therapists to become more proficient in this process takes on even greater importance. We, therefore, not only must attempt to analyze the practices, behaviors, and competencies of those who possess clinical decision-making skills, but we also must gain a far greater understanding of the process itself.

Role of Intuition

Some have suggested that intuition plays an important role in clinical decision making, and for that reason quantification of the process is extremely difficult. [6] I would agree that intuition does play a large part in clinical decision making, provided we all share a common definition of the word "intuition." I fear that some people believe that intuition-like good common sense is some mystical quality, resting in the pits of our stomachs, that enables those who possess this quality to make sound decisions where others might fail. If this is your belief, then intuition has no place in clinical decision making.

As we investigate the process of intuition more closely, I think we will discover that intuitions, when applied to clinical decisions, are derived from our base of theoretical knowledge and from practical experiences that intelligently influence our courses of action. I think that we will also discover that without these elements of knowledge and experience, even though they may not appear to surface or become apparent as rational thought processes, decision making of substance cannot occur. Can any of you conceive of a reasoned decision made in the absence of these elements? There is only one other way to make a choice--not a decision--about a particular course of action, and that is to take a chance.

Role of Technology

Another factor that has had and will continue to have a great influence on clinical decision making, and that will perhaps revolutionize it to a degree that would have been difficult for our progenitors to comprehend, is technology. The technology available today to assist physical therapists in the very complex process of clinical decision making is abundant. Even a "computer illiterate" such as I can envision the intriguing possibilities that might result from inputting a list of patient complaints into a computer and having a high-speed printer emit the best courses of action to effectively treat the patient. Ergo, decision making made simple, but not clinical decision making. We must be careful today and in the foreseeable future not to rely so heavily on technology that we forsake the art of physical therapy practice.

I would like to present the following article written by a Stanford University student and published in the Los Angeles Times (February 24, 1988; p 7) to emphasize this point and also to remind you that medicine is not the only discipline being duped by too much reliance on sophisticated technology.

A year ago I slipped into the grip of modern medical technology. Today I am celebrating the impossible: I am alive.

Last January I developed stomach pains. Soon they became so intolerable that even codeine gave me no relief. The pain was diffused throughout my abdomen; it was sharp and constant. Food and water caused me to vomit. I had severe chills and a high fever. Within a few days I developed a second pain in my lower back.

I checked into a university hospital, and for two weeks was subjected to a staggering number of tests--blood tests and X-rays by the dozen, scans, an endoscopy, a barium enema, an upper GI series, two ultrasounds, a bone scan and a white blood-cell scan. None of the tests revealed the source of my pain. My fever persisted, and other signs of raging infection got worse. I was dying. But with the cause unknown, there was no treatment.

Now that a year has passed since my recovery, I have a more objective understanding of my illness. I recall that the tests themselves caused some of my worst misery. I was subjected to a painful barium enema when my resistance to pain and discomfort was already unacceptably low. After my system had rejected oral fluid intake for almost two weeks, I had to swallow a gallon of barium-laced "lemonade" for my CAT-scan. And since I was already depressed and prone to fits of crying, I had no ability to fight the claustrophobia that seemed inevitable in the closed barrel of an MRI (magnetic-resonance imaging) scanner; my time in that coffin-like tube was the worst hour of my life.

Though I was in absolute agony as I lay alone in my hospital room, it was the barrage of tortuous procedures that pushed me to the point of complete hysteria.

Modern medicine and technology go hand-in-hand. Nobody can deny that such technological advances as a CAT-scan and MRI have revolutionized medicine and accordingly have improved the entire human condition. But with all the technology there is a risk of dehumanization: I became a folder full of X-rays and computer printouts, and not a 20-year-old squirming in pain.

My doctors were impotent, it seemed to me, because they were not examining me so much as they were examining pictures of me. My pain, while growing worse for me, had become a constant to them. The elusive cause was all, not the effect, which was a person in agony.

Medicine is an inexact science. How can computers and scanners be expected to always provide precise answers to questions that are inherently inexact? The physician is necessary in any diagnosis.

While I was sick, my father, who is a physical, outlined my case to a physician with whom he had worked many years ago. This doctor is an old man now; he no longer practices. But he is from a generation of doctors who had to rely on their medical intellect and savvy to make diagnoses. "Your son," he told my dad, "has a ruptured appendix."

When my father told my doctors about the older physician's opinion they simply responded that none of my tests had shown a ruptured appendix.

After four weeks the tests finally indicated something that suggested an intestinal blockage.

It was only during an abortive bowel resection that the surgeon found the source cause of my misery; a ruptured retrocecal appendix. My doctors had not detected it for four weeks.

As a pre-medical college student who had become a patient in a teaching hospital, I gained great respect for the training process; the purpose clearly was to hone the young doctors' medical intellect and instinct. Unfortunately, it seemed to me as the patient, the ideals reflected in this process were too easily violated in a quixotic attempt to find a wonder scanner that would instantly reveal all of the answers to my problem. In the end, this attitude almost killed me. And it was extremely expensive.

I have heard many people in the field explain that, legally, they are required to explore every possible avenue in order to restore a patient to health; these days, that means using whatever high-tech equipment is available. I don't think that is necessary.

In legal jargon, the physician should send the patient to the radiology suite only when there is "probable cause." Technology alone, no matter how advanced, cannot be expected to provide all of the answers every time.

I'm living proof of that. (*1)

Thus far, profession has been relatively devoid of the numerous technological innovations that have inundated medicine in the past 20 years. There are those in our profession who believe this situation has been to the benefit of the physical therapist because it has not dulled our therapeutic intellect and, if anything, has caused physical therapists to sharpen these intellectual skills. Although I believe this is true, I fear that many physical therapists would jump at the opportunity to obtain any gadget that would facilitate and perhaps even validate or make more reliable our treatment of patients. The best case in point is the isokinetic testing and treating devices, the only quasi-technological equipment available to physical therapists today. Much of our exhibitors' floor space of Annual Conference is taken up by these devices, and they are being purchased despite their astronomical costs.

I believe it will be difficult to interject a great deal of technology into physical therapy practice in the years ahead simply because of the very nature of what we do. Our profession, for the most part, remains a hands-on profession. Therefore, I would expect that we will reign supreme among those health care practitioners who must rely on their intellect to make clinical decisions.

Role of Diagnosis

I would like to briefly address the matter of diagnosis as it relates to clinical decision making and I hope clear the air for my subsequent discussion of this topic. As you know, much rhetoric has gone on in our profession of late about the importance of diagnosis before referral for well-conceived physical therapy interventions can be administered. And I must admit I have contributed to his dilemma in a somewhat tangential manner. There are certainly many diagnostic entities in medicine that classically describe a patient's condition and for which specific and effective treatment can be prescribed. However, many of the musculoskeletal conditions that physical therapists are called on to treat cannot be clearly defined in a diagnostic sense. Therefore, for many of the patients referred to physical therapists for treatment, the diagnosis accompanying the patient merely points the evaluating physical therapist in the direction of the patient's problem and less frequently provides specific and necessary information on which to base sound clinical decisions.

How many times do patients arrive with technically acceptable coded diagnoses that simply direct you to a particular body part but fail to accurately relate to the patient's real problems? Although these "wastepaper-basket" diagnoses may provide the referring practitioner some measure of comfort and perhaps have relevance for reimbrusement, they often contribute little to the intelligent management of the patient's disorder. Think of the implications of patients referred with a diagnosis of knee strain when in reality they have sustained ruptures of the anterior cruciate ligament, or of patients who are diagnosed as having a bursitis of the shoulder but who indeed have rotator-cuff tears, or of the numerous conflicts that can and do arise in the management of musculoskeletal disorders affecting the spine. [7]

Sometimes information about a patient's diagnosis can be extremely complete, such as may be the case with a patient referred with a cerebrovascular accident. Diagnostically the exact location of the neurological deficit can be determined precisely, as can other pertinent factors about the patient's diagnosis. Interestingly this abundance of information rarely influences the specific methods we use to treat such patients.

Therefore, we must be alert when dealing with patient diagnoses in many areas of physical therapy practice and make certain that we rely more heavily on a patient's symptoms and signs and our critical assessment of these clinical data. In the final analysis, it is these clinical data and our findings that really provide the basis and the direction for most of the services we render.

Importance of the Initial

Evaluation in Clinical

Decision Making

Many of the factors that will influence our clinical decision making in most patient situations will be ascertained at the time the patient is initially evaluated. This process is the cornerstone of any well-conceived treatment program. Therefore, we must attach a great deal of importance to the evaluative skills of the physical therapist, but I also agree with Nancy Watts that the patient evaluation should not be wasteful exercise that provides that evaluator the opportunity to obtain far more information than is required to design an effective course of treatment for the patient. [6] It has been my observation that this is understandably the greatest area of weakness for many physical therapists, let alone recent graduates. In the clinic, you are presented with a "Catch-22" situation. On one hand, you recognize the importance of allowing those therapists who are inexperienced in this process to gain experience. Conversely, you are also aware that these evaluations improperly performed stand an excellent chance of influencing treatment outcome in a negative manner.

The only way of this dilemma is to have the more experienced clinicians work closely with the less competent physical therapists to better prepare them to carry out this most important clinical function. In our department, we do not allow those competencies to perform any clinical procedure, let alone initial evaluations. This approach is certainly not unique to our practice. Even though some consider this approach archaic, we remain steadfast in our belief and can find considerable support for our position in other endeavors where people are entrusted with the safety and welfare of others. I do not suspect any of us would be overly enthusiastic about having surgery at the hands of a physician who had not been proctored in the operation, nor would we take great comfort in flying in a plane whose pilot had not been certified to fly that particular aircraft. Yet I do hear some in our profession saying, "The only way people can learn is by performing the task," and I would agree provided that in the process they are being observed by someone competent to perform that task. Failure to do this will only make imperfect perfectionists out of those people by virtue of their repetitious errors.

Categories of Clinical

Decision Making

I have attempted to categorize those factors that in my opinion must be considered when evaluating or reevaluating patients and that in my judgment will contribute to the art and science of clinical decision making. I recognize the pitfalls of trying to arrange things in "neat boxes," but for the purposes of this discussion I thought it would be permissible.

I have identified just four categories, and believe that most clinical decisions will fall within them. These categories are

1. Decisions that relate to direct patient care.

2. Decisions that relate to indirect patient care.

3. Decisions that relate to accepting a patient for treatment.

4. Decisions that relate to referral to another practitioner.

I am certain that most of us agree that when we think of clinical decision making in physical therapy, our attention is focused immediately on those choices or options of treatment available that would most effectively alleviate the complaints of a patient referred for care. I have categorized these treatment options or choices as decisions that relate to direct patient care. However, in addition to those decisions related to direct treatment options, there are a host of factors that do not relate directly to the treatment of patients but that can have a significant impact on clinical decision making and treatment outcome. These factors represent the remaining categories that I have identified.

Decisions Related to Direct

Patient Care

Before delving into the categories more deeply, I would like to call your attention to some areas where I have repeatedly observed difficulties encountered by both inexperienced and experienced physical therapists in their clinical judgment abilities.

Psychosocial problems. We are all aware how the psychosocial behaviors of patients can influence treatment outcome and how difficult it sometimes is to effectively treat patients because of these manifestations. This matter takes on even greater significance because so many patients whom physical therapists are called upon to treat may exhibit such behaviors. We must also recognize that this is an extremely sensitive and dangerous area in which to meddle because the consequences of improperly identifying a particular psychosocial behavior can be devastating to all concerned. Despite this risk, our failure to identify certain patient behaviors can have serious implications not only for how we treat the patient but also for the results that are achieved.

Malingering. Evaluating the patient who is suspected of malingering or who has some type of anxiety neurosis or even a frank conversion requires unusual tact and skill. If you are successful, you will be able to substantiate and document your impressions in an objective manner without alarming the patient and thus driving his or her symptoms even deeper into his or her conscious or subconscious mind. This entire process takes on even greater significance when the referral source has no clue of the patient's psychological problems.

Dealing with patients who, for whatever reason, have complaints that are inconsistent with their physical findings and test results can be an exasperating experience for the clinician. Interestingly it can also be one of the most rewarding aspects of practice. But generally these patients will put your clinical decision-making skills to the supreme test. It is not unusual for even the experienced clinician to misjudge such patients. The consequences, however, can be serious regardless of the side on which you err.

If you have incorrectly evaluated a patient whose symptoms are not physiological and subject that patient to care, the probability of your treatment failing is quite high. On the other hand, the consequences of the reverse situation lead to the epitaph on the tombstone of the chronic complainer: "No one believed me." Dealing with difficult patients can be one of the most challenging aspects of physical therapy practice, and recognizing the nature of these patient types will facilitate the clinical decision-making process.

Role of experience in clinical decision making. Another area I wish to identify wherein clinical decision-making skills can have a direct impact on treatment outcome is the physical therapist's experience. Numerous examples of the inexperienced physical therapist's direct impact on treatment outcome can be identified. I will provide you with just a few examples.

1. Planning treatment. Consider the physical therapist who in his or her zeal to do a good job on the patienths first visit to the department carries out a far too vigorous and lengthy exercise program and then cannot understand why the patient fails to keep subsequent visits. Or the physical therapist who persists in unsuccessfully teaching an elderly patient with a hip fracture the use of crutches rather than a walker aid because the treatment order called for crutch training. The examples could go on endlessly, but these examples may identify some of the subtleties of the clinical decision-making process and the important role experience plays in such decisions.

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2. Identifying nonmechanical musculoskeletal pain. We are all aware that numerous patients with musculoskeletal pain are referred to physical therapists, and this large number of referrals is certainly understandable. However, we must be ever alert to these patients with musculoskeletal complaints whose symptoms do not originate from musculoskeletal pathology. This is the one area of independent practice that is the most frightening to me and in which I can see monumental errors in clinical judgment being made even by more experienced physical therapists.

The classic case, of course, is the patient with back pain whose discomfort is related to metastatic disease. But also consider the patient with a threatening myocardial infarction who is complaining of arm pain or disease of the kidney, bladder, or prostate that masquerades as back pain, or the patient with cholecystitis whose most severe discomfort is in the shoulder, or the female patient with endometriosis whose primary complaint is of low back pain. The list is endless.

Think of how our profession's image would be elevated by referring such a patient to a practitioner who is competent to deal with the problem, and then reflect on the potential harm that could occur to our profession through the improper treatment of such a patient.

Final comments--A selected potpourri. Decisions related to direct patient care, as stated previously, are the first considerations that come to mind when discussing clinical decision making. And that is as it should be because all else is lost if we or other practitioners who are attending the patient fail to provide the appropriate treatment for the patient's condition. I include other practitioners because our treatment will be of little value to the patients we are treating for a diabetic neuropathy if their diabetes is not being properly controlled through either medication or diet.

The broad range and scope of decisions that exist in this category are mind-boggling, as are the implications of the judgments we make to a patient's welfare. The process is so complex that it is nearly impossible for me to describe for you the numerous considerations we must take into account when weighing the risks and benefits of decisions we make just in this category alone. In some instances, our judgments can be quite simple and based upon the pathophysiological or pathokinesiological realities of the condition confronting us. Will heat or cold provide the patient relief? Is rest or motion indicated? If rest is indicated, for how long; if movement is indicated, what type? But all of you are able to recognize the complexities that can arise from even these supposedly more simplistic management decisions.

It is in this area of direct patient care decisions that physical therapists rely on their colleagues for input, provided of course that such colleagues are readily available to assist the inquiring person. Such availability can be both a help and a hindrance to the person seeking assistance--helpful in the sense that the colleague may point the person toward the correct decision, but harmful in the sense that the person did not go through the agonizing process of ferreting out a decision on his or her own.

All who have cared for the sick and injured have been admonished to listen to the patient because in many instances subjective information can provide you with tremendous insight to a patient's problem. Listening to patients' subjective complaints can be difficult because of the sheer amount of irrelevant complaints sometimes offered up by patients. But like a good detective, you must identify those complaints that have implications for the patient's condition.

A classic example of what can be learned about listening concerns the patient with severe complaints of calf pain. The patient describes to you that while performing some physical activity that required either a vigorous contraction or stretching of the gastrosoleus muscle group, he or she sensed a sudden, piercing pain in the medial compartment of the calf, as if he or she had been shot. Shortly thereafter the patient noted swelling of the calf and ankle with increasing difficulty in extending the knee or dorsiflexing the foot as well as problems with weight bearing on the affected extremity. The process of listening, you observe that the patient has overdeveloped calf muscles.

The experienced clinician, in dealing with such conditions, at this point would have arrived at an impression about the etiology of the patient's problem: suspected plantaris muscle rupture. In the course of examining the patient, the experienced clinician would have ruled out other possible causes such as heel-cord rupture but, unlike many uninformed practitioners, would not have mistaken this condition for a deep vein thrombosis, which might have required a course of anticoagulant therapy and immobilization of the extremity and (obviously) referral to another practitioner.

The distinction that accounts for sound clinical management in this case is not so much that there may have been difficulty in distinguishing between a Homans's sign and a Thompson's test, but rather failure to listen to how the injury occurred and to waht conditions predisposed the patient to that injury.

Where my intuition, if you will, played a role in this decision was that I have rarely seen a patient develop such a problem who did not have overdeveloped calf musculature. And when you couple this fact with the patient's history, the correct diagnosis is close at hand. Listening and observing are important clinical decision-making tools. Substantiating or discrediting subjective complaints by more objectives tests, or measuring phenomena subjectively or objectively, is critical to the entire clinical decision-making process.

Physical therapists are often called on to consult or render an opinion about a given patient that may or may not result in the treatment of that patient. The decisions are often complex and can have serious consequences for the patients or their families.

Let me provide you with just such an example. Consider the case of the 72-year-old male above-knee amputee brought to our department via wheel-chair by his ailing wife for us to evaluate for consideration of a prosthesis and subsequent training. The patient was certainly perfectly oriented, a somewhat frail man who provided us with an excellent past history of his medical problems, which included a moderately successful femoral popliteal graft on his right extremity performed about three years ago and a failed bypass surgery on the left extremity that resulted in an above-knee amputation just 12 months ago. The patient also had a 10-year history of chronic obstructive pulmonary disease, which obviously was not being helped by the package of unfiltered cigarettes that fell from his pocket at the time he transferred from his wheelchair to the treatment table.

Some of the more pertinent findings of this patient's evaluation revealed a very poorly shaped stump with unattached muscle, a 35-degree flexion contracture at the hip with residual patches of eschar-like formation over both the medial and lateral flares, and absence of pulse in the foot of the remaining extremity with complaints of claudication-like symptoms in the calf when walking to his maximum distance of 25 ft in a walker.

For all practical purposes, the patient was reasonably independent for carrying out those essential activities of daily living. His major reason for seeking a prosthesis at the time was to be able to provide more assistance to his wife, whose health was deteriorating rapidly.

I am certain that most physical therapists would recognize the pitfalls of embarking on a program of prosthetic training for this patient and that the risks would far outweigh any remote benefits of such a decision. But one of the responsibilities implicit in clinical decision making is to communicate the rationale for your decisions to others.

In the example presented, the reasons for substantiating your decision are fairly straightforward. Sometimes they are far more difficult, but your explanations are still required.

Decisions Related to Indirect

Patient Care

Financial implications. Next I would like to discuss some of the issues related to indirect patient care and remind you of the importance of this category and its influence on clinical decision making. The first issue I would like to address concerns the various financial implications related to the services we desire to provide patients. Much of the information about the financial ramifications of your proposed or ongoing treatment program can be ascertained at the time of the initial evaluation.

I am somewhat amused today by waht seems like a newly discovered concept of providing cost-effective treatment, as though it were a recent finding for health care practitioners to consider. I would propose that methods to ensure cost-effectiveness were in place long before disinterested third-party payers of health care services became interested because the premiums they charged and the profits they anticipated did not keep pace with escalating health care costs. These older systems required that the patients themselves paid for part or all of their health care bills, and somehow these patients were able to determine in most instances whether a particular service was cost effective for them.

This observation aside, there is a great need in our profession to be sensitive to the numerous financial matters that must be taken into account today, especially in view of the responsibilities we are assuming to implement care along with making judgments about the intensity, frequency, and duration of that treatment.

Often difficult decisions must be made about physical therapy intervention because of financial considerations. It is understandable why these decisions are not palatable to the practitioner, who in effect must in some cases compromise the standard of care. This is one of the vexing problems confronting health care practitioners today. I have no simple solutions to offer to remedy this situation, and I seriously believe that as cost containment becomes more of an issue in health care, this problem will only become more severe. What it suggests to me is that an entirely revamped system of health care may be in the offing and that perhaps the time is close at hand.

In the meantime, let us not contribute further to the situation by inattention to those financial considerations of which we have some control and in which our good clinical judgments can come into play. We must consider not only which physical therapy intervention is the least expensive and yet effective, but also what alternatives to physical therapy care might be more cost effective based on careful evaluation and assessment of the patient.

Ethical implications. Another area of this category in which difficult clinical decisions must sometimes be made and that will have great importance in the future of our profession concerns ethical matters arising in the clinical setting. In recent years, the impact of technology on the quality of life of the sick and injured has served to increase the importance of ethical considerations in patient care. As physical therapists assume a more autonomous role in health care delivery, ethical judgments will play an increasingly important role in the gamut of clinical decisions a physical therapist will have to make. According to Purtilo, the physical therapist faced with ethical issues relies on personal insight, the counsel of others, and the Code of Ethics of the APTA. In most instances, these sources can provide guidance for proper decision making. The key is for the physical therapist to recognize which components of a situation have moral qualities to them. [8]

Guccione has identified a series of ethical issues that occur in the clinical setting with a frequency that makes them relevant and worthy of mention because all of them have an influence on patient care. [9] Some of these ethical issues are as follows: How do we establish priority for treatment when time and resources are limited? Is it our role to inform patients or their families about the limitations we believe exists in the treatment we are administering? Is it appropriate for us to create unusual discomfort for a patient when the results of that treatment may not justify the extent of pain inflicted? How do we deal with incompetence on the part of other practitioners, including other physical therapists?

Because so many of our patients are referred to us by other practitioners, the probability of having to confront ethical issues is quite high. Therefore, physical therapists must be on their guard to identify the numerous and sometimes serious ethical issues that can arise in practice and react to them in a responsible manner. It is an area where I have seen considerable criticism levied on physical therapists and where we have been accused of making poor clinical judgments. This criticism is not entirely based on the altruistic motives of physical therapists, but rather on the manner in which they deal with the ethical issues under consideration.

We are fortunate to have a highly respected ethicist such as Ruth Purtilo in our profession. I am convinced that our future practices will be greatly influenced by ethical issues, and we must utilize the talents of people such as Purtilo to assist us in this sensitive aspect of clinical decision making. Although I have included ethical considerations under the category of indirect patient care, ethical considerations are applicable to all categories.

Decisions Related to Accepting a

Patient for Care

The frequency with which physical therapists are having to make decisions about accepting patients for treatment is increasing, and those decisions are becoming more complex. The very nature of many of the referrals we receive in practice requesting us to evaluate and treat is sufficient to have caused this change. However, it should not be implied that a referral to evaluate and treat automatically results in treatment of the patient. I wish that over the years I had kept data concerning not only the percentage of patients who were not accepted for treatment but the reasons for refusal as well.

Even though the clinical reason for not accepting a patient for treatment may not be numerous, the decision to refuse treatment will more often than not require far more explanation and justification to the patient, family, or other practitioners than the decision to implement care. The defense of these clinical decisions can be difficult and whenever possible must be presented in an objective manner.

For the most past, decisions in this category involve situations in which a patient's condition is thought to be permanent and stationary or in which there is a high probability that treatment will be of little or no value for the condition under consideration. Unusual pressures can be bought to bear upon the physical therapist to institute treatment despite the realities of the situation. Some degree of compromise may be required to mitigate the situation; however, such compromises should only be made with great tact and full understanding of the circumstances by all the parties involved.

It may appear far less difficult to base refusal for treatment on an extenuating circumstance such as a third-party refusal to pay for care, but what would be your response when patients declare their willingness to pay for their own care? While preparing this presentation, I had the opportunity to involve myself in a rare clinical decision not to accept a patient for treatment. I would like to share that story with your.

I received a request from a health maintenance organization for which we provide physical therapy services to handle a patient with a recent flexor tendor repair performed by an out-of-town hand surgeon. It soon became apparent that the hand surgeon had serious reservations about referring this patient to someone he did not know, and after speaking with him by telephone his reservations became even more apparent. When I asked the surgeon how he wanted this 3-1/2-day-old repair managed, his response was, "Well, if you have to ask, you obviously have no knowledge of how to manage such cases." The surgeon was following an accepted approach to managing tendon repairs by using immediate post-operative mobilization through dynamic splinting.

The acceptability of this management approach, however, was not the issue. What he failed to appreciate was that there are other accepted methods of treating such repairs, and that the physical therapist responsible for handling this patient must thoroughly understand the surgeon's protocols. I have seen far more failed tendon repairs than I care to remember, and given the circumstances of this situation I advised the health care administrator who wished to refer the patient to our care that this patient should be referred elsewhere. Simply stated, the risks given this surgeon's attitude were far too great for not only our department but also for the health plan. If something had gone wrong during the management of this patient's tendon repair, we and the health plan would have been implicated. Sometimes discretion is the better part of valor.

Decisions Related to Referral to

Another Practitioner

The clinical decision to refer a patient to another practitioner is a practice that is certain to increase for physical therapists as direct access and physical therapy specialization become more commonplace. Physical therapists will have to become more sensitive to this process and recognize that they cannot be all things to all people. This has not been a usual and customary role for the physical therapist to assume.

Decisions in this category for the most part will be predicated on the consideration that a patient's needs would be better served in the hands of another practitioner. These decisions, however, do not always present the physical therapist with well-defined options.

For example, it is not sufficient to determine only that the 45-year-old schoolteacher with an adhesive capsulitis of her shoulder should be placed on a treatment program aimed at restoration of shoulder motion and reduction of pain if, in the process of evaluating the patient, it is also determined that her tolerance to even minimal mobilization of the shoulder is non-existent, that her personal life is in shambles because of a pending divorce, that her 15-year-old son is institutionalized because of a drug problem, and that her health insurance expires in two months because her teaching contract has not been renewed. Despite her physical signs and symptoms, the patient is also in severe emotional distress and on the verge of going over the brink.

One clinician might believe he or she could compete with the circumstances I have described and overcome this patient's disability, whereas another clinician would carefully weigh the advantages and disadvantages of referring this patient to a practitioner who would anesthetize her, manipulate her shoulder, and then subject her to a brief period of intense physical therapy. There are inherent risks in both options, but which option is the best for this patient?

One assumes considerable responsibility when referring patients to other practitioners. Perhaps as we become more involved in this process we will gain far greater understanding of the numerous considerations confronting the referring practitioner. If the outcome of the referral is beneficial to the patient, the referring party may take credit for making a wise clinical decision. If the results of the referral are not satisfactory to the patient for whatever reason, however, the referring party's judgment may be considered suspect and he or she may be viewed as having contributed to the unfavorable result.

Conclusion

In conclusion, I will reiterate a statement that I made earlier in my presentation that the ability to make sound clinical decisions is the keystone, the one most important determinant, of autonomous practice. I know all of you share that belief. I hope that in my pragmatic manner I have reinforced that conviction and provided you with some basic thoughts for your deliberation. I would also encourage you to read the additional sources of information on clinical decision making listed in the Appendix.

Let us make certain that future generations of physical therapists can deal effectively with the numerous clinical decisions that arise in practice. We must devote more of our resources to the accomplishment of this objective. Unfortunately we seem to be more preoccupied with creating opportunities for direct access than with making certain that physical therapists possess those qualifications for clinical decision making that will ensure the future of our independence.

(*1) Reprinted with permission of Lloyd M Krieger.

References

[1] 1987 Active Member Profile. Alexandria, VA, American Physical Therapy Association, Department of Research/Education, 1988

[2] Physical Therapy Restrictions in Selected Prudent Buyer Plans. Van Nuys, CA, Blue Cross of Southern California, 1988

[3] Magistro CM: The 1976 presidential address. Phys Ther 56:1227-1239, 1976

[4] Magistro CM: The clinician's role in the 21st century. Clinical Management in Physical Therapy 4(6):10-15, 1984

[5] Magistro CM: Twenty-second Mary McMillan Lecture. Phys Ther 67:1726-1732, 1987

[6] Watts N: Decision Analysis: Clinical Decision Making in Physical Therapy. Philadelphia, PA, F A Davis Co, 1980, pp 7-23

[7] Sahrmann SA: Diagnosis by the physical therapist--A prerequisite for treatment: A special communication. Phys Ther 68:1703-1706, 1988

[8] Purtilo RB: Understanding ethical issues: The physical therapist as ethicist. Phys Ther 54:239-243, 1974

[9] Guccione AA: Ethical issues in physical therapy practice: A survey of physical therapists in New England. Phys Ther 60:1264-1272, 1980

C MAgistro, BS, PT, is Director, Physical Therapy Department, Pomona Valley Hospital Medical Center, 1978 N Garey Ave, Pomona, CA 91767 (USA).