Wednesday, July 30, 2014

Do we need more schooling, or just re-tooling?

In a conversation on the OT Connections Forum Dr. Pam Toto stated "These other professions - PT, Pharmacy, Nursing - whether you think they are comparable or not, have evolved to a point where they feel a need for that additional training for competent entry-level practice."

I think these comments are interesting.  Dr. Toto is not the first to make these kinds of observations.  Others have stated that we need to prepare practitioners for the complexity and demands of the future.'  I have been wondering what that really means.

First of all, I would like to acknowledge that in some instances our practice tools have gotten more complex.  I can think of a few examples.  It would not surprise me if pediatric standardized tests were more complex than they were when our profession was founded.  I am actually wondering if any even existed!  I think that you could make a strong argument that splinting and prosthetics have also gotten more complex.  Of course we can say that our health care delivery systems are also more complex, although those are not practice tools.  There are other examples, but I think those are good ones where we can say that some things have gotten more complex over time.

The question to me is whether or not the practice tools and systems that have gotten more complex have hit some critical level of complexity that we can justify a need for more training or schooling.

Even if they are non-parallel examples, lets look at nursing and medicine.  Let's compare professions at the time of our founding (~1917) to today.

In the early 1900s here are 5 things that were in use that illustrate the sophistication of medicine at that time:
1. Mrs. Winslow's Soothing Syrup - a heroin concoction used for teething babies for over 50 years, finally denounced as a "baby killer" by the AMA in 1911.
2. Doctors began experimenting with lobotomies at this time, and they became increasingly common and it was as recent as 1949 Nobel Prize in Medicine was given to the originator of the procedure.  Amazing.
3. "Female Hysteria" was a very common condition and the some of the recommended "treatments" are not suitable for discussion on this board.  Trust me.
4. Mercury as a cure-all!  Mercury was used for everything.  People realize how insane the use of mercury was now, but even I remember Mom's bottle of Mercurochrome that was pulled out and used as an antiseptic every time we got a cut or scrape.  Maybe that is what is wrong with me?
5. No antibiotics!  Lots of people had tuberculosis.  Effective TB antibiotics didn't appear until 1949 with Streptomycin.

Even based on these simple examples we can see how much change has occurred in medicine in the last century.  The few things I listed don't even come close to more recent scientific advances like understanding blood chemistry, development of imaging diagnostics, and the explosion of genetic knowledge and how that has accelerated our understanding of diseases and pharmacology.  There is no question that medicine as a field has lots of reason to state that higher levels of training are needed in order to keep pace with needs of the future, whatever those are.

But what about occupational therapy?  Has it also changed?


As comparison, I would like to quote from Elwood Worcester's recounting of his first "treatment" session with George Barton.  As we now know, Barton was so astounded by his recovery that this sparked the creation of our profession when he invited other leaders to form a society for occupational therapy.  Here are Worcester's comments:

"While engaged in erecting a great sanatorium for consumptives in the mountains of Colorado, he was suddenly affected in a strange manner... When he awoke the next morning his right arm was paralyzed... his right knee was ankylosed... In consequence of his constrained and unnatural position the right foot had begun to mortify and Dr. Mumford had amputated two of his toes.  When I first saw George he was in the spiritual condition of a mad dog... He said "What is the use of talking to me?  My life is utterly ruined, my health, my power of movement, my beautiful profession, my wife and child, my home, my capacity for earning money are taken from me.  All that is left for me is to sit in this chair, a beggar, a pauper and to suffer like hell..."

Using a combination of spiritual counseling, relaxation techniques, and suggestion, Worcester "treated" Barton.

"If this were all, the story would hardly be worth telling.  The next time I saw George he was in Boston.  He ran up my stairs two steps at a time and seized my hand with his once paralyzed hand in such a blacksmith's grip that I was obliged to remind him that I had no fingers to spare.  He was perfectly able to return to his architecture, but by this time he had discovered a new form of architecture which he greatly preferred to the old - building up again the broken lives of men and women who were suffering as he had suffered, under the eye of Dr. Mumford and the physicians of Clifton Springs.  With the help of a few rich friends he built his "Consolation House" and equipped it with splendid workshops where, through the sweetness of his new personality, and his knowledge of crafts and arts, he did a wonderful work for years."


What impresses me about this early accounting of OT is that it even though it happened in 1914, it could have happened in 2014.

This makes me pause whenever I hear people saying that the occupational needs of people have changed and are changing so radically.  I don't know if that is really true.  Although some tools and systems change, the fundamental nature of occupational therapy does not.  In this sense it is nothing at all like medicine.  Medicine has changed.  Has occupational therapy?  In many ways we understand occupational needs the same way that Worcester did and the same way that Barton did.

So do we need more schooling, or just re-tooling?


Worcester, E. (1932). Life's Adventure: The Story of a Varied Career.  New York: Charles Scribner's Sons.

Wednesday, July 09, 2014


I sat on the witness stand, about 20 feet away from the parents that I had known and worked with for the last five years, and did my best to answer the Judge's questions as accurately as possible.  I think that I was more uncomfortable than the parents were and they did not seem to have any ill will and did not seem to be upset about my testimony.  They knew that I was just telling the truth, I think.

I told the Family Court Judge that I knew the family for several years because several of their children had been assigned to me for early intervention occupational therapy.  I was asked about one of my therapy sessions on a specific date and I told the Judge that as I sat and played with the child the fleas were jumping out of the carpet and onto little Jenna's legs.  And onto my socks and pants.  Jenna's legs were covered with bites and streaked blood from all the scratching.  The week prior to that session I taught the parents how to use commercially available 'flea bomb' products safely in order to address the problem.  It seemed to work for a day or two, but they had difficulty getting all the fleas and eggs vacuumed up.  I spent part of one of my therapy sessions repairing their vacuum cleaner that was clogged and had a broken belt so they could vacuum, but I think that was part of the reason why the flea problem persisted.  The fleas were just everywhere, and the problem probably needed to be solved with a professional exterminator.  I know it was not my job to fix a vacuum but I was trying my best to help.  I had some small fear that I would be criticized for stepping outside of my role in taking that action.  They don't often talk about this kind of stuff in OT school, which is a shame, because it is a reality.

The family sat there, unphased by my testimony.  It was all true, and I tried to help them.

I explained that at one point in time a municipal social worker determined that the children needed to be removed from the home, so the children were sent to another family except for the baby, who the County allowed the parents to keep.  I worked with little Jenna and she thrived in her new home and with her new family.  The fleas were really just a tipping point that activated a system.  Although I believe that the parents loved their children they did not have the resources to care for them.  They did not have the knowledge, capacity, understanding, or money.  In some bizarre bargaining session between County officials and the parent's appointed lawyers and the children's Law Guardians, the children were traded back and forth like poker chips, and the parents decided to relinquish custody of the older children if they were able to keep the baby.

After the Court decision and the change of custody it was a challenging situation to navigate.  I knew the family for several years, and then I was subpoenaed to participate in the County's efforts to remove the children, and then I was the therapist when the children moved to their 'new' family.  Throughout all of this the County adoption workers discouraged care providers from sharing information about the 'old' family with the 'new' family because of privacy concerns.  Then it got even more complicated when the baby was approved for early intervention and the 'old' family requested me.  It was all clearly an example of having Too Much Information.

Society has an interest in the well being of its members, and actually takes on some rather aggressive stances when there is documented threat to the well being of children in particular.  This is legally known as the parens patriae functions of the State.  A lot of people who work in child welfare contexts bemoan the slowness of this system to respond, and people on the receiving end of State intervention bemoan the powerlessness that they perceive when these systems are activated.  I think both of those perspectives are correct at the same time.

The 'new' family wanted little Jenna to continue receiving therapy, based on history and perceived needs and objective data.  They were surprised when the child's case came up for discussion regarding EI to CPSE transition because the County and the School District decided that the child did not require special education supports.

This was interesting to me as a person who had Too Much Information, because I knew the 'old' family and the intellectual disabilities of the parents.  I knew the intellectual and developmental disabilities of the older siblings.  I also knew about the intellectual and developmental disabilities of little Jenna.  Now it is true that once she wasn't raking her skin raw in an attempt to alleviate the itching from flea bites that she was able to direct more energy into development.  It was simply true that she made a lot of progress after she was removed from her 'old' family and placed with her 'new' family.

Society believed that there was such a threat to little Jenna's well being and development that they removed her from her family, but that same Society also believed that maybe it wasn't so bad after all and that she didn't need special education.  These are relatively incompatible beliefs, but as they are two totally distinct County agencies with separate bureaucracies that there will be no accountability for the discrepancy.

I tried to talk to the Education bureaucracy within the boundaries of what I am entitled to discuss, but it was evident that there was an intransigence there based on a different and competing set of realities.  On one hand you have the reality that Society is very interested in doing what is in the best interest of children, to the point where people have started to cynically identify that whenever a politician wants to accomplish something they will use the catch phrase 'for the children.'  On the other hand is the reality that people who are comprised into larger units that we call 'Society' are beginning to decide that they do not have endless resources and that there have to be limits to what they want their governments to do.  So although they are emotionally tied to doing things 'for the children' they have taken pragmatic steps by implementing property tax caps that then cause Education bureaucracies to limit things like special education services.

The bureaucracies, functionally ignorant of what drives broad policy and competing emotional sentiment at the level of the family and individual child, just looks kind of stupid as it takes such dramatic action to 'save' children from danger and then does little to nothing to actually promote a more functional outcome once they are removed from the 'danger.'

From a current day news context, this is why people line up in Murietta, California and block busloads of children who are illegal immigrants.  They care about those kids, but not when the caring means that they have to open their wallets and accept higher property taxes.  People legitimately have some outrage, because the apparent answer is to use Federal tax money to make more detention centers and to hire more bureaucrats to process paperwork, but the localities would be stuck with the real cost in health and human services costs over time. Local people can't afford it, or don't want to afford it.  That causes some people to say that the people blocking buses hate children, and it causes the people blocking buses to be in a ridiculous situation of having to explain that they do not hate children. 

Meanwhile, kids sit on buses.  Or perhaps closer to home you might notice that they are yanked out of their families to save them, but not always provided services that they probably need to really save them.  The families who take these children into their homes often don't realize this.  Sometimes the children are lucky and the mere change in environmental context and the structure and support of a resource-privileged foster family makes up the difference.  Sometimes it doesn't.

In the Early Intervention to CPSE transition meeting where I had to shut my mouth and not talk about everything I know the County agency who did not talk to the other County agency told the partially informed foster family that they could come back to the Committee in case there are concerns in the future but that they didn't want to "burden" the child with too many services all at once.

They actually said "burden" as if providing help to a child was somehow a burden.

There have been a lot of impactful verdicts in little Jenna's life.  The 'old' family had no power over the last verdict.  The 'new' family turned to me and I suggested that they advantage a loophole in early intervention eligibility that would allow her to receive special education supports through the EI system until the end of the year and delay her transition into the preschool system.

So little Jenna will get her services, because her OT knows the loopholes and tricks.  It kicks the can down the road another six months, when there will have to be another meeting and another determination made in a room by a bunch of people who know the truth and can't speak it and others who don't know the truth and are not incentivized to seek it out. There will be another verdict, and I will mash up the details with other situations and probably report on the typical outcome of such situations.

Between then and now, if people are inspired to do so, I hope things like this get read so there can be some improved understanding of our very confused priorities and policies around the needs of children.