Friday, August 29, 2014

Patient vs. Client - What could go wrong? Look around and see...

Thirty years ago there was an important philosophical debate in the occupational therapy profession.  That debate had to do with whether or not use of the term 'patient' or 'client' was more appropriate for occupational therapy.

Reilly argued that a move away from the term 'patient' would equate to abandoning the moral base of the profession and in fact changes the entire purpose of the profession.  She considered the change as abandonment of our ethics around patient care, and without those ethics we would no longer be in a position to help people because we would instead have to focus on contractually serving the needs of our patron clients.

Yerxa and Sharrott were also deeply concerned about abandoning patient-based ethics.  They outlined several problems with client-based ethics (my numbering for organization purposes):

1. A legalistic or rights-based medical ethic is untenable for several reasons. First, it would require that requests for medical care be allotted on a preemptory basis...

2. Second, the patient-health professional relationship would forfeit its compassion and trust for the adversarial relationship of legal ethics.

3. Third, a right holder (in this case the client) must be a competent adult capable of self-directed choice, with adequate understanding of the provider's knowledge.  However, the recipient of health care often is not capable of an equal relationship.

Their prescience is actually quite incredible in consideration of where we currently stand in our health care context.  Yerxa and Sharrott warned about client-based ethics:

This could result in a normative, restrictive view of health, which robs patients of their liberty. The patient's role in developing goals pertinent to his or her concerns- and not necessarily consistent with those generated by health practitioners - could be adversely affected.

We are now living out the warnings that were given to us thirty years ago.  Here is evidence of our philosophical drift where we no longer have an ethical rudder:

1. Social justice, also termed distributive justice, was inserted into the Code of Ethics and occupational therapists were told it is a MUST FOLLOW rule (Slater, 2011).  We have been told that we must advocate for the highest principles of social justice, which relegates professionals into the role of determining who has 'more' or 'less' in order to guide advocacy and decision making.

2. Some within the occupational therapy Academy take it a step further, and actually promote radical change to rights-based ethics based on a new morality of resource distribution.  Autonomy is simply lost in this new ethic, a fact pointed out by Durocher (2014).

3. As a practical example, in pediatric practice occupational therapists now provide services to SCHOOL SYSTEMS instead of CHILDREN and the professional association promulgates resource allocation and staffing based on WORKLOAD instead of a CASELOAD (AOTA, APTA, ASHA, 2014).  There is no patient morality here and in fact this is the deepest example of how we have lost our professional souls in service to the municipal patrons that govern the educational system.

There is a beginning of an awakening to this as a problem.

Some therapists are championing a debate about the appropriateness of social justice as a guiding ethic.

Some therapists are questioning whether or not occupational science as a discipline has any authority to dictate a new morality that shatters the social contract that occupational therapy has with the public.

Thirty years ago Mary Reilly stated

In the history of our discipline there is probably no more important policy decision than this one, which changes the focus of service from patient to client. The astounding aspect of the decision is not that it was made, but that it was made outside the awareness of most of the membership.  Because this policy forces a radical transformation of the nature of occupational therapy, it threatens the survival of the discipline.  A greater danger, however, lies in the disinterest or lack of attention the membership has paid to the issue... It is both an individual and national association shame that occupational therapists do not seem to know how and when to engage in a public debate on an issue so critical to the membership and the society in which the service is embedded.

Many people missed the opportunity to engage the debate thirty years ago.  The new debate on our Code of Ethics and on promoting a rights-based service ethic is dragging us further off the path that represents our social contract based on our founding moral philosophy.

Don't miss the chance to participate this time.  Join these debates.  Read, discuss, and engage the issue.  The future of the profession depends upon it.


References:

AOTA, APTA, ASHA (2014). Workload approach: A paradigm shift for positive impact on student outcomes.  Downloaded 8/29/14 from http://www.aota.org/-/media/Corporate/Files/Practice/Children/APTA-ASHA-AOTA-Joint-Doc-Workload-Approach-Schools-2014.pdf

Durocher, E. (2014). Occupational Justice: Future Directions.  Journal of Occupational Science, 21:4, 431-442.

Reilly, M. (1984). The importance of the client vs. patient issue for occupational therapy. American Journal of Occupational Therapy, 38(6), 404-406.

Slater, D.Y. (Ed.). (2011) Reference guide to the occupational therapy code of ethics and ethics standards. Bethesda: AOTA Press.

Yerxa, E.J. & Sharrott,G.W. (1985). Promises to Keep: Implications of the referent "patient" versus "client" for those served by occupational therapy.  American Journal of Occupational Therapy, 39(6), 401-405.

Monday, August 04, 2014

Comments re: recent RCT on sensory integration


I received several emails asking me about the dialogue that was recently published in the Journal of Autism and Developmental Disorders regarding the Schaaf, et. al (2013) study.  A kind colleague forwarded the comments to me and I had the chance to review them.

Ashburner, Rodger, Ziviani, and Hinder (2014) made some comments about the original research.  They basically outlined concerns with the parent report measures, lack of blinding, and confounding impact of invested time for the parents.  They also expressed concerns with dosage and non-equivalent treatment conditions between groups. 

The original authors (Schaaf et al, 2014) thanked them for their comments and expressed that a treatment manual would be published later this year that might help others replicate the interventions.  They also expressed that they are following a step-wise method of progression from case study to feasability study to RCT.  They state that future studies will address some of the concerns raised.  The authors defended the non-blinded and non-equivalent design, stating that using blinded evaluators was enough to address concerns and that treatment effects were large.

The concerns raised by Ashburner, Rodger, Ziviani, and Hinder are very similar to what was posted in this blog in December, right after the original study was published.  There really are not any new concerns.  Now they are just formally published concerns.

As I indicated in December, if there are true differences to be measured because of sensory integration treatment we will find them after we design studies that are not so vulnerable to criticism.  I blogged about the design as soon as I read it because the problems seemed rather obvious.  The fact that a group of academics and researchers bothered to write formal comments to the journal would seem to validate the concerns.

References:


Ashburner, J.K., Rodger, S.A., Ziviani, J.M., Hinder, E.A. (2014). Comment on "An intervention for sensory difficulties in children with autism: A randomized trial by Schaaf et al. (2013)." Journal of Autism and Developmental Disorders, 44, 1486-1488.

Schaaf, R. et al (2013). An intervention for sensory difficulties in children with autism: A randomized trial. Journal of Autism and Developmental Disabilities, published online at http://link.springer.com/article/10.1007%2Fs10803-013-1983-8/fulltext.html

Schaaf, R. et al (2014).  Response from authors to comments on "An intervention for sensory difficulties in children with autism: A randomized trial."  Journal of Autism and Developmental Disorders, 44, 1489-1491.