Productivity measures should include quality and quantity. Insight from APTA EJC

(upbeat music) - Welcome to this APTA Podcast. - I'm Lois Douthit. In this episode, host Becca Dittweiler will talk with Dolly Swisher about everyday ethics, incorporating ethical considerations and practices into your daily life. And now, Becca Dittweiler. - Well, hi, I'm Becca Edward Dittweiler. I'm a member of the Ethics and Judicial Committee of the American Physical Therapy Association, and I'm here bringing you this podcast today, and we're hoping to increase our outreach to members and bring relevant information about ethics directly to you. Thank you, Dolly Swisher, for joining us today. How are you? - I'm good, Becca. How are you? - I'm doing wonderful. And I'm so happy to have you on our podcast today for our first podcast ever as the EJC. This is super exciting to have you here. And in case you don't know who Dolly Swisher is, she's a Catherine Worthingham fellow, long-standing history of service at the APTA, including she helped us revise our code of ethics in 2009. She's published three textbooks, about 30 manuscripts. I don't know how many speeches at this point, but she was our McMillan lecturer in 2022 and our Sarasota lecturer in 2021. She is a great faculty member, emeritus faculty at USF, a mentor and an awesome friend. And thank you so much for joining us today, Dolly. - Tulling my pleasure. And I appreciate everything that the EJC and you are doing to bring ethics to the practitioner. - Well, it's great to have you here. So, you know, I want to start by just getting your perspective. You've done so much work in ethics and physical therapy, and so much has changed over the last several decades. So what do you think are the biggest ethical issues facing the profession of physical therapy? - I think someone in nursing said that they thought that organizational pressures, really, and the fact that we are dealing with bigger and bigger healthcare entities and the amount of, the amount of organizational constraints on practitioners may turn out to be one of the primary issues of our day. And I think when I look back on how things have changed, I do think that one of the things that attracts many people to physical therapy is the ability to work one-on-one and really put that patient first. And I think that still drives physical therapists, but I think that we have to be more savvy about how we can address organizational constraints and things that affect the relationship that we have with the patient, because that's always been one of the strongest things for physical therapists is the amount of care that they bring to the patient and the therapeutic alliance, now we'd call it, but the way that we're able to convey to the patient, we're with them, we're in their corner. - Yeah, I think you're totally right. It's so interesting to look at some of the, more recent literature around workplace ethics and the things that are maybe even affecting physical therapist satisfaction with their jobs. So can you give me some specific examples of things that you think workplace ethics has to do with how physical therapists experience every day, ethical issues? - Well, I think one of the common things has to do with the amount of time and how we can select patients, the amount of time that we can spend with individual patients, what are the things that we can do? And I think some common issues are productivity issues and billing issues. And I know, but this goes way back too, I can remember long ago, someone in a working situation say, I had this really, I had something happen that was quite disturbing because one of my patients brought in a bill and they said, "I don't know why you charged me for this." And I looked in the bill and I realized it wasn't really the charges that I had made. So I went to the coding office, which was really appropriate ethical followup. And I said, "What are these bills about?" And I found out that everything that I billed was being up coding. And I will say that since that, and that's been a long time ago, but since that time I've had other people say to me, I really realized I needed to make a change because my organization's billing practices were unethical. They were charging wrong codes, they were maximizing codes, and I wasn't in charge of my billing. And of course, as you know, one of the things in the code of ethics says, it doesn't say that we can't really control all of the bills in organizations, but we are in charge to make sure they're accurate and that they reflect what was happening. - So that's a really great point. And I think that's a really good example of something that people to be aware of how their charges are going in. And I wanna go back to something you said about productivity and the pressure for productivity. So do you think to, aside from organizations having kind of this potential negative billing practices, do you think there are individual temptations for physical therapists to up code themselves, to maybe charge this code 'cause I get paid more or charge this because the organization says I should do that? How do you think that boils down to the individual level? - Well, I think you're onto something really important, which is there are productivity expectations and that's what the minimal that the organization may say that you need to charge in order to get a satisfactory. But one of the things that happens is that there are bonuses that people get for productivity. And I think that one of the things that people could do, and I think that we should encourage is that bonuses should be based not just on the amount, but on quality. And that's a lot harder for organizations to do. So productivity bonuses or raises also advancement. So those sorts of things should be, there should be dual considerations, not just how much you do, but how well you do it, and then also including patient input. Now that can be tricky as well. So ideally, I think it should be based in part on what the patient is experiencing. I was very satisfied with Becca's care or gosh, Dolly could really communicate better. And I'm really tired of hearing about ethics, those sorts of things. So you all, you want to take into account what's the on the ground experience of the patient, but you also want to take into account maybe X, only your colleagues really know whether you're good at manipulation perhaps. Your patient can say what their experiences is in terms of the comfort and all of those sorts of things. So both things are important, but ideal productivity measures have to do with how much you do, how well you do, from the patient standpoint, perhaps from expert standpoint, and also softer measures like about, do you convey care to your patient, therapeutic alliance, relationships? And then another factor is, do you communicate well with other providers? So on that score, let me say a couple of friends of mine and relatives have recently had physical therapy experiences. And I have to say it was a little bit discouraging to me. The one person fell off her, you know, she had an accident and she went to a physical therapist and she had very strict country indications about movement because of the really delicate fracture. So her doctor recommended several physical therapists and she went to somebody and immediately the physical therapist started doing these things that she had been told not to do, like take off the brace and all this stuff. So of course they always call you and it's hard for you to get context. I think context is so important in these things. And so I asked her some questions and when she said, well, the doctor told me X, she said in her words, the physical therapist just blew her off and it was very worrying to her. So finally I said, you know, I would really, I would do two things. I would call your doctor to see what was, and I would think about finding somebody that would communicate a little bit better to you. - Yeah. So I say that in terms of looking at quality. If we think about quality, you know, and I have no doubt that that therapist was meeting their productivity expectations. So, but were they delivering quality care? I'm not, I wasn't there, so I don't know, but you know, that's another thing is the competence. You know, why were the prohibitions, the contraindications not being guarded? Perhaps I digress, but that was. - No, I think it's a good story. You know, I think it's something that, you know, really demonstrates the variety in practice and maybe the way that people see, you know, what is excellence and what is evidence-based care? What's good communication? And maybe some of that is bogged down by this pressure for productivity and that's one of those competing things to our excellence is this organizational workplace ethics that you're talking about. You know, what advice would you have to maybe a physical therapist or PTA who's in a situation where the expectations really exceed what they think is possible, while also providing excellent care? You know, what are some things that somebody could do if they felt that they were in that situation? - So first of all, I think that all healthcare professionals are in difficult situations with organizations. And one of the things that physical therapists have had going for them is the scarcity of physical therapists. And that can tend to be the case in some practice settings. But in other practice settings, people, you know, may be afraid to lose their jobs. So one of the things I would say is first of all, communicate concerns. And I think that depends in part on how your practice is set up and what kind of practice. In a larger setting, there may be some, you may be able to go to your department head and talk about, I have the following concerns. Can your department head convey it? And in those same larger situations, there may be other healthcare providers that you could partner with. Like, you know, a lot of times in a larger organization, things are organized more by floor or by practice focus. So, you know, maybe it's in a rehab setting. Then in the larger group, you can say, you know, I feel like we're being pressured and then you may be dependent in part on people's, on people's bringing those forward for you. But a lot of times I will say that those call on deaf ears. I think that people can point out in their code of ethics. So we did in the last iteration, I know now that we're trying to freshen up our code of ethics. I'm totally supportive of that effort. But I think our code of ethics has to be robust enough that people can say, you know, I can't just, I'm prohibited from working just on productivity or some of the things that are in there that really concerns them. On some level, people have to recognize that this is kind of a mini conflict of interest. We think of conflict of interest a lot of times from the standpoint of politicians or we like to think about doctors' conflicts of interest. But, you know, when we have bonuses on the line, when we have promotions on the line, you know, based on not giving optimal care, we do have to recognize that for ourselves as a conflict of interest. So then we have to think, well, how do we do that? - You know, one of the things that really strikes me about what you just said is really this falling on deaf ears. And in your McMillan lecture, you talked about creating moral spaces where people can have dialogue about things just like this, you know, things that are problematic from a moral perspective. You know, how would you recommend organizations open, you know, their ability to listen to people and have dialogue about some of the issues that might be presenting in their clinics? - Well, I know, especially in Europe, they have started, oh, by the way, I would want to think that sometimes patient stakeholders should be involved in those things. So I don't know that we're set up, but recommending how it is that we would do it, first of all, you have to notice that it's going on. You have to bring it forward. And a lot of times it will take time to do it, but making the request, could we talk about some of the ramifications? You may not be successful, but in bringing it forward, at least you're not just burying the issue. So requesting time. Hey, can we talk about what are the alternatives? You know, are the productivity, we feel patients aren't also finding examples of how patients were injured, but maybe not, you know, it wasn't, they were overtly injured, but what's the damage that's being done by strictly focusing on productivity and what aren't people getting? So meeting with each other. And the other thing I would talk about, I think, you know, sometimes people talk about this, you know, Walker I think talked about this, or as creating moral space, or some people have talked about this, is creating moral space. But one of the things that we do unconsciously, there's this kind of taken for granted nature to clinical practice. We're kind of in our clinical mind, and we have to make sure we keep ethics there and ethics in our mind as well, with regard to relationships and communications, but also the ways that organizations are constraining that. There was a great article that Zeezo et al wrote about everyday ethics. And first of all, I'd say we don't really totally know what everyday ethics means in physical therapy, but it has more to do with everyday ethics, you might say, are the non-sexy parts of ethics. They're not high tech, they're not organ transplant, they're what happens day to day, they're common, they're not exotic, they don't get a lot of attention always. But one of the recommendations that the authors made, well, they pointed out that everyday ethics has a lot to do with relationship, virtue ethics, pragmatic ethics, feminist ethics, not the four principles kind of approach, like autonomy, beneficence, non-moleficence, and just that we might be used, the abstraction. And they said, one of their recommendations was to avoid viewing ethics as something that was extrinsic to clinical practice, which evacuates ethics from everyday practice. And I say that because I think that the organizational constraints are hard to approach. We love being in our clinical selves. I know I do as a practitioner, I'm fascinated with what's going on with the injury, and also trying to make sure that the patient makes good progress. But we also have to think, are we really looking at the ethical dimensions of practice, or do we just say, well, there's not much I can do about that? So the other recommendations that the authors had were to avoid not making time to integrate the relational dimensions. So they recommend reflecting on, how do you think the patient was receiving what was going on? What was their experience? And then the example I gave you, the patient was acutely aware that there was no therapeutic alliance. They weren't making the connections. And that's one of the things, you know, that's been so powerful for physical therapy. If we're not making a good relationship with the patient, we know we're not going to succeed. And people need to talk about our productivity constraints at the point where we're not making that critical connection. Really, really awesome advice. And it's one of my perspectives and some of the things that we've worked on together that people don't always recognize when an ethical issue is occurring, especially in an everyday ethical scenario, where it's not something like, do I put the person on a ventilator or take them off a ventilator? When things are being challenged in their own moral code and the things they think are important, you know, they may feel something, but they may not always acknowledge it or know what to do about it. So what would be your perspective on, you know, helping people to recognize, maybe stay current on what are common issues that people are experiencing and know when to recognize when it's happening to them? Well, I think you're onto something really important, which is that I do think as we have different special interest groups, there should be, people should understand what are the most common kinds of issues and challenges that occur in their practice area and be aware of them. So first of all, even if it were informal ethics literature, which would be good to have, we don't have it in every area, but what are the things that most people would anticipate? So there's some educational dimensions to that. When we teach, we tend to teach it more as a global thing. These are the ethical issues that physical therapists encounter in general. But you know, there are a lot of differences from what people in outpatient experience and maybe what people in rehab care experience and certainly maybe a people in home health. So I think first of all, having an awareness of that and talking about that. The other thing that has been successful in some areas is having kind of ethics grand rounds. If you feel like you don't have time day to day to reflect on that, you know, having somebody bring a case study, someone do a literature search and see what other people are finding and can we talk about it? And I think that would be helpful. And also on the level of the chapters, the state chapters or the districts, you know, it wouldn't be wrong to have an ethics forum in a professional meeting where people just talked about, "Hey, what are people seeing out there?" Because one of the things we know is that ethical issues have changed. Now COVID-19 was a great educator to us of how quickly ethical issues could change because I think that physical therapists during the COVID-19 pandemic suddenly found, not everyone, but suddenly found that their ethical issues were quite different, you know, challenges with communication, but also that organizational constraints and pressures were actually heightened in that case. - Yeah, I think, you know, based on some of our work we've done together, interviewing PTs and PTAs during the pandemic, it was really clear that the organizations had to really shift and change and respond to these new challenges, which I think will continue to occur in healthcare. You know, it may not be COVID-19, but it may be the next thing that is a major challenge. You know, maybe it's telehealth or, you know, one of the things that comes to my mind too is social media. You know, that's something that really is pervasive across practice settings. You know, and you've written a couple of things about social media. And I'm curious what your thoughts are about the ethical challenges related to engaging with patients via social media. - Well, that's really a good point, and there are a lot of levels to the question. So one has to do with just focusing on the relationship with the patient. And that's changed dramatically. And I know there was a good article about professionalism and social media, but those tend to be a little bare bones in terms of the general recommendations. And one of the things is how to communicate with the patient. There are a lot of issues there. Patients want to be communicated with by text, but oftentimes there are constraints on that. How do you handle that? There are a lot of patient satisfaction issues and also, you know, patient autonomy issues. So how do you deal with that? But also there are issues about the line between where do I as a professional, where's the line between my personal and my professional self? What should I be posting online from a professionalism standpoint? What shouldn't I be posting online? And a whole variety. And again, those issues would vary by different practice settings. So I do think it deserves a lot more attention. I don't know if in the revision of the Code of Ethics, they're gonna address that more because actually since the last, I think it was 2010 that the last revision was implemented. I think there have been so many changes in social media issues. Also, what another everyday ethics issue that people have pointed out is bullying and discrimination. And one of the things that social media does is it broadens the context of what's happening in my clinic because someone may perceive if somebody is posting things that are bullying or harassing in their personal context, this is a spillover into the clinic perception. - Yeah, well, it sounds like we have a lot of things to sort out in that sort of new frontier of ethics and how we relate and use social media to connect with patients, be more available, but still maintain professional boundaries. In fact, myself and Deborah Gordon-Bader wrote a column in the upcoming PT Magazine Ethics in Practice column about boundaries and social media and kind of bringing attention to that very topic of we have a lot of things to sort out here and professional boundaries and the way that we engage with patients responsibly and the things we put out on social media I think is gonna be a really important thing for us to tackle in the future. I think also what you said about learning from things that have happened in the past and kind of how we can look to the future, I think having dialogue and this kind of dialogue we're having today is a really great place to begin to think about things that are important and to help inform members and non-members and people who are interested in these areas and really just keeping current with issues I think is really useful. So I appreciate your remarks on that. - So- - Can I make another comment about social media too is that I do think there's some generational issues and if my PT is very tech savvy and I'm maybe elderly and not very tech savvy do I feel in the loop or out of the loop and how does that affect therapeutic alliance? Also the opposite is true. People like to text people they like to text their physical therapist but there are aspects to which you can feel like you're in the in group or the out group whether you're a texter or a non-texter. - Absolutely and I think just navigating how we form relationships with patients or potential patients on social media can be challenging. So one of my final questions for you is you just have had so much great advice and your career's been so amazing to watch and the things that you've produced. If you could give a piece of advice about how we can approach ethical situations that come up that maybe are everyday things that happen in everyday life what would you give us a suggestion for how to approach something when you realize it's happening? What are things that we can do to kind of process that and figure out how to make a decision? - Well you already talked about the one piece which is you're gonna address zero of the problems that you don't identify. So creating an ethical awareness with yourself and it helps to not walk that journey by yourself. So it's nice to know that you have a trusted colleague. Personally I've always found that helpful to have somebody that I can talk to about something. You're not, you're trying not to breach confidentiality and all of those sorts of appropriate things but it really helps to have somebody who is a sounding board that you can trust and that respect that helps to have a mentor. So having someone who can help you with those and in my experience on Ethics and Judicial Committee I discovered that there were a lot of really great ethics mentors out there in the States that they were the go-to person in the state. You would find out that in ex-state they always called so-and-so when someone wanted advice. At the same time it's difficult for someone that's not aware of the contextual issues to give a relevant advice. And I can say that I've been approached at a number of meetings where people say, well they have this horrible problem, their organization is disregarding the needs of the patient, they're doing horrible things, they're really not doing what they need to do. Can I help them? That's one of the hardest things 'cause you can ask a lot of questions and then you're making the kind of general recommendations that we have but oftentimes that's not helpful. So getting some clarification by having a sounding board and a mentor is really important and then deciding what your options are. Unfortunately, I think by and large what I've found is that a lot of people have been unable to make the kinds of changes. I can't tell you how many people end up leaving organizations instead of trying to help them make changes. Now maybe that says more about healthcare organizations in general that they're just not a pair to dress those and there's plenty of literature that suggests we do have some challenges in healthcare in that regard. But I do think that having strategies of coming together. So finding people that you can work with that would address it. Now sometimes the problem doesn't do that. It doesn't lend itself to addressing banding together to bring the issue forward. So then, like I said, having mentors and talking to people. So then at the end of the day you have to kind of decide with yourself what you're gonna do. Now that has to do with the really hard stuff, the really difficult situations where it's kind of you either you have to decide, can I stay in this organization if this is what their stance is? The other thing I think is that it's you have, I would give the advice that it's not always, I know some people may perceive some as what I've said as being about doing the right thing. It's not always about doing the right thing. It's often about being the right person who can do the right thing. So developing, some people would call this a virtue-based approach or some people might call it a care approach, but developing the qualities and then other people might call this moral agency. It's about developing the ability and the situation to do the right thing and have those strategies. So in a way this is investing in yourself, creating the qualities of doing the things that you think are important to do. Because I think that if people stay in situations and don't act over time, this does result and you're writing about this, others are writing about this moral distress and moral injury. It takes a toll. So part of developing moral resilience is dealing with yourself, developing those qualities that allow you to persevere, but also doing that with others in sync within organizations to create more resilient physical therapy departments and clinics and those sorts of things that are more able to deal with these problems so they don't take such a big toll. Well, Dolly, that is such great advice. And I think there's a lot to unpack there, but I think the most important things is that you have a process, you have people that you're using as mentors and you're kind of talking through that. So if I could summarize some of the main things that you've talked about today, you've really talked about organizational ethics and how the context in which we experience ethical issues is so important and how we resolve those issues in that context, I think is really valuable. Now, I think a couple of the other things that really stuck out to me is just kind of becoming a person that can recognize and work through issues that arise, finding people that can support you as you're experiencing some of these everyday issues and just being more aware about the things that we're dealing with, whether it's our practice setting, our specific organization and finding ways that we can combat some of those issues and also to protect ourselves and our mental health and well-being in long term. Do you have any final comments you'd like to give us, Dolly? - Gosh, that's a hard question. I think that there's so many great therapists out there that are really working on these issues. And I know there's been quite a bit of work done and I'm just encouraged people to go forward and I appreciate the opportunity to be involved in the podcast because I know this wouldn't be my way of getting word out there because I'm one of the old dinosaurs, I suppose. So I think it's great we're using the new media to do that. - Well, thank you so much for spending time with us today. We really appreciate it and your wisdom is very valuable to us. And I would just like to encourage everyone to look for the APTA Ethics and Digital Committee resources on the webpage. We're also again, putting out the ethics and practice column and we look forward to continuing the dialogue with everybody and we really appreciate this time. - You can find more APTA podcasts like this one on Apple Podcasts, Google Play and Spotify or by visiting apta.org/podcasts. Thanks for listening. (upbeat music)