Saturday, December 31, 2011

2011 Pushback against Fad OT Interventions

Another significant theme in my 2011 forum conversations was pushing back against fad OT interventions. I think that it is an important enough topic to be re-posted here.

Some of the fad and pseudoscientific interventions that I discussed in forums this year included therapeutic listening and other auditory interventions, deep pressure protocols (brushing programs), weighted vests, and Brain Gym.

Fad interventions were relatively common in health care until research came along - and now we have mechanisms to test and see if people's 'ideas' about something hold up to any scrutiny.

One posting asked about the validity of 'astronaut training' which is something that I get phone calls about in my private practice. I tried running database searches on 'astronaut training' and 'vestibular-visual protocol' and several other iterations that I hoped would capture this protocol and as usual for this kind of fad intervention I was unable to find any research.

I have practiced OT for 24 years. I can tell you that a lot of families contact me and ask me about whether or not I will provide Astronaut Training for their child. I tell them that it is experimental and that there has not been any research to support the specific protocol that they usually found out about through web sites or youtube. I am not going to link to those Internet sources because I don't see the value in spreading information about fad interventions. I would rather that people search the terms and come to the blog and see an opinion about pseudoscience.

Over the course of the last 20 years there have been several fad interventions in pediatric OT. These interventions are generally pseudo scientific in that they reference scientific-sounding concepts, they are promoted by "experts," they require "clinical training programs" that people need to attend so they understand how to do the protocol properly, and they have a "feel-good" quality to them that engenders hope in parents. In the end, they also have an absolute lack of supporting research.

An classic example of a fad or pseudoscientific intervention in OT is the so-called 'Deep pressure protocol.' I remember attending a conference in 1989 (22 years ago now!) and at that time the presenters were promising that there was exciting research available that would support their protocol. That research never materialized and now you can't even find a reference to that protocol in OT pediatric text books. Pseudoscientific interventions are tough to beat back into the bushes though - and even though we have 20 years of no evidence and no current references in major OT textbooks it still remains an entrenched part of what I call 'mythological' OT practice.

Pseudoscientific interventions are so resilient because they may in part have some concepts that are valid. For example, there may be something valid about how some deep pressure stimulation is calming to some people in some situations. Similarly, there may be something valid about trial practice and training for postural responses and visual-auditory orienting - but neither of these should be construed as meaning that you have to use the Fad Intervention therapy brush or you have to purchase the Fad Intervention CDs and you have to do the Fad Intervention protocol exactly the way the Fad Intervention Therapy pushers proselytize. Most importantly, you have to ask if you should be providing the Fad Intervention Therapy to a child and family unless you tell them that it is experimental and there is no supporting research.

It is probably much more important to look for supporting research, make ethical judgement about how you have to inform families about experimental procedures, and don't fall into the trap of perpetuating 'mythological' occupational therapy practice.

With persistence and continued conversation I am confident that we can advance the sophistication of how we bring ideas to a research forum without first setting our ideas loose into the marketplace where people are profiteering off of the hopes of parents and the lack of evidence-based proclivities by some forces within our own profession.

The 2011 Social Justice Debates in occupational therapy

I wondered this morning how much writing I have done on various OT message boards and I started thinking that an awful lot of my opinions are probably documented all over the Internet. I visited the forums on the AOTA website and found the equivalent of over 40 single spaced pages of my writing! Then I thought it might be interesting to see what motivated me to post on professional forums this year. Here is a summary of one interesting forum conversation:

The Social Justice Debates

Early this year there was a motion to rescind part of newly adopted AOTA ethics statements; the concern was that they unnecessarily referenced social justice concepts and that the existing ethics statements already covered that conceptual material and did so without politically charged terms like 'social justice.' The new ethics documents includes:

Principle 4. Occupational therapy personnel shall provide services in a fair and equitable manner.

Social justice, also called distributive justice, refers to the fair, equitable, and appropriate distribution of resources. The principle of social justice refers broadly to the distribution of all rights and responsibilities in society (Beauchamp & Childress, 2009). In general, the principle of social justice supports the concept of achieving justice in every aspect of society rather than merely the administration of law. The general idea is that individuals and groups should receive fair treatment and an impartial share of the benefits of society. Occupational therapy personnel have a vested interest in addressing unjust inequities that limit opportunities for participation in society (Braveman & Bass-Haugen, 2009). While opinions differ regarding the most ethical approach to addressing distribution of health care resources and reduction of health disparities, the issue of social justice continues to focus on limiting the impact of social inequality on health outcomes.

Occupational therapy personnel shall
A. Uphold the profession’s altruistic responsibilities to help ensure the common good.
B. Take responsibility for educating the public and society about the value of occupational therapy services in promoting health and wellness and reducing the impact of disease and disability.
C. Make every effort to promote activities that benefit the health status of the community.
D. Advocate for just and fair treatment for all patients, clients, employees, and colleagues, and encourage employers and colleagues to abide by the highest standards of social justice and the ethical standards set forth by the occupational therapy profession.
E. Make efforts to advocate for recipients of occupational therapy services to obtain needed services through available means.
F. Provide services that reflect an understanding of how occupational therapy service delivery can be affected by factors such as economic status, age, ethnicity, race, geography, disability, marital status, sexual orientation, gender, gender identity, religion, culture, and political affiliation.
G. Consider offering pro bono (“for the good”) or reduced-fee occupational therapy services for selected individuals when consistent with guidelines of the employer, third-party payer, and/or government agency.

My own concern was with the statements "to abide by the highest standards of social justice" and "provide services that reflect and understanding of how OT service delivery can be affected by factors such as..." Here the politically co-opted definition and political twist that is taken with the term 'social justice' was challenging because of the associated statements about distributive justice which is politically charged. Additionally, there seems to be a suggestion that there is de facto impact on service delivery because of certain issues like age, ethnicity, race, etc., and many people object to that assertion. There is no doubt that prejudices exist, but it is not correct to state that there is de facto impact.

My concern was also related to how 'social justice' was being defined in the current American political context. I tried to compare worldwide Catholic social justice definitions to American social justice definitions. Context and degree seem to be overarching factors when it comes to definitions of social justice - for example, social justice from the perspective of a person in a developing country must be very different than social justice in the United States (which has incredible wealth and where even those who are very poor have their basic needs met).

Also, a core concept of Catholic social justice is in how it is practiced - no bigger than is necessary and no smaller than is appropriate.

Anyway, what I am saying is that I understand the Catholic position of social justice because it is a world-wide religion and the concept is being applied to a very broad spectrum of human existence.

That is all very different than the way that the term is being used in the United States as a redistributive economic policy.

I don't think that the OT professions needs to avoid issues that are politically charged, but it does not seem unreasonable to have a core value of inclusiveness so that we are not disenfranchising our membership - and there were some people who were uncomfortable with including this language in the ethics documents. I don't believe it is unfair to ask the appropriate contextual question of ''What does social justice really mean in the AOTA documents' and if it is such a core concept to our ethics - then why is it just appearing now?

This really was not a new concept for people who read here - I covered this material in depth previously.

The larger issue I was driving at in the conversations was "what constitutes OT practice and how do ethics aspirations suggest us into practice areas or into practice interventions that are beyond our mainstream." In many ways that makes them beyond pragmatic use to many practitioners.

I think that people can use their OT skills in many ways - but that does not necessarily make the interventions occupational therapy - even though some people are calling it that or perhaps want it to be.

I have no objection to giving recognition or praise to efforts that further people's health and participation - even when those efforts are informed by occupational science and are not falling within the mainstream of occupational therapy practice.

My concern is that sometimes it seems like we spend a lot of time in this profession playing in the stratosphere. Lofty ideals are fun, but the atmosphere is pretty thin - and sometimes it is nice to get your feet planted back on the ground again.

I believe that we will serve our profession best if our ideals and ethical aspirations have application to the everyday concerns of practitioners. If our ideals and ethics only help us populate an academic playground to see how many different ways we can apply our concepts then I fear that we will have created a great academic discipline - but one that has very little traction in everyday practice.

As a bottom line concern, AOTA ethics documents are included in some state license laws. That means that failure to abide by generic aspirational and potentially vague language about social justice in ethics documents might cause someone to be in jeopardy with their state license. That's not so good.

I did not believe that there was a need to include ambiguous social justice terminology to maintain our consistency of belief that people who have disabilities should receive services. The proposed motion to remove the politically charged terminology rather clearly outlined that nothing is lost by removing the social justice terminology, and instead the objective is to remove ambiguity that is associated with the term.

I greatly appreciated the distinctions that were argued between political social justice and ethical social justice in those forums - but the fact remains that based on a reading of the current ethics statement and based on a reading of our literature that there has not been such a distinction made between these different iterations of social justice. In fact - the two have been blurred throughout all the conversations as well as in the literature.

It was an interesting debate. The Motion to remove the language failed. So now I will continue the 'social justice watch' to see if any of this ended up having any notable and pragmatic impact on practice.

Monday, December 05, 2011

"It's going to be very, very exciting." Not.

I don't mince words, mostly because I lack time to do so and secondarily because I lack interest in political correctness. Let's talk straight about the Patient Protection and Affordable Care Act of 2010.

For some background and additional reading on the debacles that occur when government intrudes into health care decision making click on the 'health insurance' topics in this blog.

At the 2010 Legislative Conference for National Association of Counties, Nancy Pelosi made her now famous remarks
You've heard about the controversies within the bill, the process about the bill, one or the other. But I don't know if you have heard that it is legislation for the future, not just about health care for America, but about a healthier America, where preventive care is not something that you have to pay a deductible for or out of pocket. Prevention, prevention, prevention -- it's about diet, not diabetes. It's going to be very, very exciting. But we have to pass the bill so that you can find out what is in it, away from the fog of the controversy.
Well we passed the bill and still nearly two years later we are waiting to find out what is in it.

The November 14th edition of OT Practice included an article by Jennifer Hitchon who is AOTA's regulatory counsel. Her article neatly summarizes the recently released Institute of Medicine report Essential Health Benefits: Balancing Coverage and Cost. The purpose of the IOM report was to survey stakeholders (aka insurance companies) about what products and services were deemed 'essential.' In other words - what is the bare minimum that these insurance companies are covering?

Now this is where I start to scratch my head a little - because the government determines that we need a new law to replace/supplement the 'evil profiteering health insurance companies' with government sponsored 'exchanges.' So, the government commissions the IOM to study the issue and the results of the study will go to the policy wonks who write the actual regulations that dictate what is in it. So then the IOM goes and asks the 'evil profiteering insurance companies' for their input so they can tell the policy wonks how to write better regulations than what is currently being done... oh... um.... hm.......

The IOM is non-governmental and advisory to the government and normally the IOM is a source to have faith in - but why survey/invite the fox to the hen house to determine what benefits should be considered 'essential?' I understand that the charge to the IOM was to come up with some package that was 'comparable' to what is being offered by most small business insurance plans - but how is the Affordable Care Act going to improve anything if all we do is base decisions on the cheapest available plans being offered by some small company that is already being squeezed by costs and is now choosing bargain basement health plans for its employees.

The lack of percipience into this issue is stunning, even for a government.

For fun I searched the IOM report for mentions of occupational therapy - you can view the mentions here. Most of the mentions relate to various inclusion/exclusion criteria of selected insurance plans.

The study includes some interesting statements that essential benefits should be medically oriented and not social or educational - which has rather large potential impact on all of pediatric occupational therapy practice. This same issue is being fought out state by state regarding insurance coverage for autism interventions and it will be interesting to see what the federal government does with the issue. I am curious how there will be reconciliation between exchange mandates and statutory requirements that have been written into state law about this coverage.

There are other notable exclusion points in the document related to some chronic conditions like intellectual disabilities and low vision. There is enough controversy for all. This doesn't mean that these will be automatically removed from 'essential' coverage determinations - but this all represents writing on the wall that people need to attend to.

Occupational therapists need to be watching this issue closely. Actually, the entire American public needs to watch this closely - but the complexities are beyond what many people have time or energy to follow, track, and decipher.

I encourage professional associations like AOTA to continue publishing about this issue as events unfold. However, we need straight analysis and not generic 'we will provide formal comments when the opportunity arises.' Practitioners and the public need to know the following:

  1. The government may plan to model their exchange off of the cheapest possible plan that is offered by a small business.
  2. Habilitation services could be on the proverbial chopping block, particularly if they can be labeled as 'educational' or 'social'
  3. The plan may cover things like if your eyeballs fall out of your head, because that is a medical problem. However, if you need therapy or equipment to help you function you might be out of luck because that would be a personal problem and not a medical problem.

Many professional groups (MDs, etc.) are getting out IN FRONT of these issues by publishing position papers about what needs to be covered and why. The OT community needs to do more than simply respond during the comment period. AOTA needs to publish similar position papers about including a wide range of OT services in the act and increase visibility and lobbying about these issues. Practitioners have to start by educating themselves on what they are actually facing.

For the record, I would not characterize this as very exciting. I think it may be the largest boondoggle ever perpetrated on the American public.