Wednesday, March 18, 2015

On 3D printing technologies and The Nature of Gothic

We want one man to be always thinking, and another to be always working, and we call one a gentleman, and the other an operative; whereas the workman ought often to be thinking, and the thinker often to be working, and both should be gentlemen, in the best sense. As it is, we make both ungentle, the one envying, the other despising, his brother; and the mass of society is made up of morbid thinkers and miserable workers. Now it is only by labour that thought can be made healthy, and only by thought that labour can be made happy, and the two cannot be separated with impunity. - John Ruskin, The Stones of Venice.

3D printing technology is a new fad that is capturing the attention of occupational therapists.  The technology is disruptive, primarily because of cost factors, but as is often the case there are important considerations lying underneath the alluring new technology.

During the Industrial Revolution society developed technological solutions that made mass-produced items readily available.  People seem to enjoy showcasing achievement, and I can't help but notice the similarities between our celebrations around 3D technologies and the mid-century celebrations of the Industrial Revolution.  YouTube and Facebook are our new Crystal Palace at The Great Exhibition.  I am not sure that much has changed in the last 150+ years.

Reading Facebook testimonials on the use of 3D technology is a descent into feel-good hashtag exaggeration.  We spend 3 minutes oohing and aahing as an outsider technophile delivers a neon-pink prosthesis to a child whose limb has been blown off by a landmine, but what happens when those cameras stop rolling and the video is over? 

Cost is undoubtedly a disruptive factor - but is all this really as inexpensive as is typically touted?  There are rampant claims about prosthetic hands that can be made for $50 as compared to a standard hook prosthesis that might cost hundreds or thousands of dollars - or as compared to a myolectric prosthesis that can cost tens of thousands of dollars.  Is the new technology really only $50?  Who pays for the printer?  Does the third world country littered with landmines have electric power in remote villages in case a part breaks?  Does the third world country have an outsider technophile at the ready in all the remote villages to print and then assemble and then custom-fit the device?  So is it really just $50?

The allure of the technology causes people to overstate its utility - as has always been the case.  

The mass production of goods in the Industrial Age caused people to yearn for a time when artisans were responsible for the creation of their own products.  Ruskin and then Morris believed that aesthestics were lost in the sea of mass production.  They argued that this was not just a loss of beauty but that it was also a loss of humanity.

So how aesthetic and human is this?

I fully understand that function matters, but functional alone is not enough.  History has taught this lesson rather clearly.

Where is the Nature of Gothic in our new technologies?  We should look at our technologies as a first and faltering step toward improvement.  However, if we fail to address aesthetics, and if we fail to consider that machines will not replace the artisan skills required to deliver help to humans in need, then we will have lost much more than we have gained.

Tuesday, March 17, 2015

Occupational therapy and case management

There is an RA Motion for consideration that charges the RA Speaker to appoint an ad hoc committee beginning the summer of 2015 to delineate the role in case management for occupational therapy in primary care and mental health.

The rationale for the motion states that "The practice of occupational therapists (OTs) allows for the role of case managers, however, the profession recognizes the need for OTs to better define their role in the new model of care which is primary care and in mental health."

I would like to have a discussion about whether or not the core premise behind this rationale is valid.  I believe that someone trained in occupational therapy may have the requisite skills to serve as a case manager, but I am not convinced that the activities of a case manager constitute the practice of occupational therapy.  This is an important distinction.  If it is determined that this is not the practice of OT, then we should consider whether we should be allocating resources to supporting this employment pathway.

Based on my understanding of the literature on this subject, the role of 'case manager' has recently been pursued more in international contexts than it has in the US.  In fact, several articles have appeared in international journals debating whether or not case management was a legitimate role for the profession. (Krupa and Clark, 1995; Lloyd and Samra, 1997; Culverhouse and Bibby, 2008; Michetti and Dielman, 2014).  Based on a reading of this literature, it hardly seems settled that this is a legitimate role of OT practice.  There is less evidence for this role in the US literature.

AOTA published a statement on this topic in 1991 but I couldn't find anything updated since then.  For a long time OTs have served in case management roles.  The AOTA statement says that OTs might serve as case managers but that many other professionals do as well.  In a response to a letter about this issue, Mary Jane Youngstrom (2000) stated that it was difficult to discern  what was the 'practice' of OT vs. what was 'using OT skills and knowledge.'  It is an old theme and has been repeated many times throughout our history.

The question remains pertinent today.  

Case management, per se, is not a recognized domain of concern in the OTPF.  There have been changes to the Scope of Practice documents and the OTPF that support the concept of advocacy, but these have been controversial - particularly in context of the ongoing debate about social justice/occupational justice.

I do not see adequate justification that case management is OT practice.  I see that it is definitely something that someone may do with their OT skills and knowledge.  Delimiting our practice is critical, particularly if we are interested in re-engaging and defining our roles in mental health.  

Unfortunately, OTs are not doing a good job at explaining their proposed role in mental health.  Case management is a distinct role.  Consultation to systems (trauma informed care) is another distinct role.  Treatment of patients is a distinct role.  I don't get the sense that there has been a well thought out strategy about what will delimit our practice as we re-engage.  That is a problem in my perspective.

Rather than pursue another half-baked strategy that confuses stakeholders about what OT is and what it does, I believe that we should all get on the same page and make coherent internal decisions before we approach others about how we will define our practice.


AOTA (1991). Statement: The Occupational Therapist as Case Manager. American Journal of Occupational Therapy, 45(12):1065-1066.

Culverhouse, J., & Bibby, P. (2008). Occupational therapy and care coordination: the challenges faced by occupational therapists in community mental health settings. British Journal Of Occupational Therapy71(11), 496-498.

Hafez, A., & Youngstrom, M. (2000). Case management practice. American Journal Of Occupational Therapy54(1), 114-116.

Krupa, T., & Clark, C. C. (1995). Occupational therapists as case managers: responding to current approaches to community mental health service delivery. Canadian Journal Of Occupational Therapy. Revue Canadienne D'ergoth√©rapie62(1), 16-22.

Lloyd, C., & Samra, P. (1997). Professional issues. Occupational therapy and case management in mental health rehabilitation. British Journal Of Therapy & Rehabilitation4(2), 91-96.

Michetti, J., & Dieleman, C. (2014). Enabling occupational therapy: moving beyond the generalist vs specialist debate in community mental health. British Journal Of Occupational Therapy77(5), 230-233. doi:10.4276/030802214X13990455043403

Saturday, March 07, 2015

Daylight savings time and temporal contexts and stuff

Sometimes concepts all just pile on at once.

This morning I was putting together some lecture material for a class where I will be discussing contextual factors and why they are important to occupational therapists.  Ironic.

Contextual factors are defined as interrelated conditions that are within and surrounding the person.  We generally break them down into personal, cultural, virtual, and temporal categories.

The reason why it is ironic is because someone told me today that it is my Dad's anniversary.  Not really.  It is the anniversary of his death - five years ago now.  I never consider that it is his anniversary.  The five years since that event is an important example of temporal context, or maybe it is supposed to be.  Temporal contexts refer to stages of life, times of day or year, duration and rhythms of activity, and even history.  Basically, they provide a backdrop of time for the way that we consider things.

I don't always process time in quite the same way as other people, I notice.   I have a picture on my desk of when I was 4 years old and my Dad is holding my hand as we are walking down the steps of my grandmother's house.  It could have happened yesterday, by my reckoning.  It is kind of a timeless photo to me and it represents something that I don't want to ascribe time to.

Same goes with the way that I perceive some of my friendships.  I have been friends with a couple guys in my hometown since we were all kids.  I don't see them often, or even have contact with them on any social media.  But when I go down there, no matter how long it has been since we have seen each other, we just pick up as if we had all seen each other yesterday.

Today is also the beginning of Daylight Savings Time.  It is a concept that I have abhorred my entire life.  I can wrap my brain around some pretty heady concepts, but don't ask me to interpret what has been lost or gained around Daylight Savings Time.  I just don't get it.

Thoreau said "Time is but the stream I go a-fishing in.  I drink at it; but while I drink I see the sandy bottom and detect how shallow it is.  Its thin current slides away, but eternity remains."  I read that when I was 15 years old, flying across the country for a visit to family in Washington State.  Up until that time, I don't think I can recall a quote that made more sense to me.  That is why I remember reading it for the first time so vividly.  I can't even express how tickled I was to learn how transcendental concepts worked their way into the thinking of some OT founders.  Seriously, in consideration of all things that can happen in a person's life, how likely is it that one of the first quotes that ever made sense to me also happens to form the basis of a philosophy of self-reliance and autonomy that people built a whole profession around?  That's pretty amazing.

Anyway, I don't do time jumps.  I don't know what Daylight Savings Time means.  I don't forget history or say, 'The past is the past' because to me it just isn't - it is all a part of the eternity that we are floating in.  And five years ago is the same as yesterday.

That's about all I have to say about temporal contexts.