You’re 10 times better than the clinic next door and twice as good looking!

Chances are that if you are reading this blog, you will also have noticed that our Advertising Standard is up for review.

Do you know that it is likely our most breached Standard? And I’m sure that you did not know that as soon as the new Standard is finalized, we will begin to actively scan the internet and other advertising sources looking for those in breach and addressing the problem.

Why the fuss?

Many of you tell us that your colleagues advertising make the profession look, well, unprofessional.

Sometimes it’s misleading. Sometimes it makes downright false claims (like the one in the headline). Since patients use advertising as a source of information when they are choosing a physiotherapist, it’s got to be truthful. And since you want them to take you seriously as a legitimate health profession, it’s got to be professional.

But we need you to tell us what you expect in terms of truthfulness – we are particularly interested in what you think about advertisements that make comparisons between practitioners.

Is it right to say that the data suggests that you are in the top ten percentile of physiotherapists treating knee problems or is this data capable of manipulation?

If we have a requirement that any such claims be truthful and verifiable, do you think that you could provide evidence to verify those claims?

Or are we working too hard on this? Do patients need the sort of protection that we are trying to offer or have we moved into an era of ‘buyer beware’ that applies to health care just as much as the knives that we see for sale on the Shopping Channel?

We are on the threshold of pursuing those who breach our advertising Standard and holding them accountable to it. Now, more than ever, we really need your help to ensure that we capture the Standard appropriately.

Tell us what you think – take 10 minutes to comment on the proposed new Advertising Standard now.

 

Let’s Get Strategic

Whoever first said ‘time flies’ could have been talking about the strategic planning cycle.

Four years ago—a month after I had started working at the College― Council met to develop a strategic plan. They set three goals that we’ve been working hard to achieve, goals to ensure that physiotherapy regulation in Ontario focussed on things that matter—things that contribute to delivering safe, competent and ethical care. You may be familiar with the goals that Council set as you’ve read about them here and in Perspectives over the years. I hope you’ve seen the impact in new Standards, new communications activities, our work around clinic regulation and changes to our registration processes. We’ve also been working to improve our technological infrastructure—that may be a part of our strategic plan that isn’t as obvious (so far). We have one year left to reach our goals in the current strategic plan, and now it’s time to set the path for the next three or four years to come as we start strategic planning once again!

WE WANT TO HEAR FROM YOU.

We’ve already talked to a group of physiotherapists who attended our breakfast at OPA InterACTION 2016, as well as Academic Practice Leaders. We’ve received input from our Citizens Advisory Group.

And now it’s your turn. This link will lead you to a list of things that could be the most important things for the College to focus on over the next several years. We’d like you to rank them so we know where you think we ought to focus. Or, if we haven’t identified something that you think we should pay more attention to, we need to hear that as well. Your input will be shared with Council when they meet to set the priorities and you’ll get a chance to read about the results over the summer or in the early fall.

What are you waiting for: weigh in now!

 

STOP IT BEFORE YOU GET IN TROUBLE! A RANT.

I am receiving more and more reports about physiotherapists sending patients for personal training or Pilates and enabling patients to submit receipts for these services under the physiotherapist’s registration number. Guess what? In many cases this is inappropriate and you could get in serious trouble.

The ONLY time that your credentials can be used to bill for physiotherapy is when the treatment is truly physiotherapy and it has been provided by you or by someone acting as your assistant.

There are cases where a patient presents with a health problem that requires a supervised exercise problem as part of a physiotherapy treatment plan.  In such situations, the exercise program can be a legitimate element of the physiotherapy care.

The physio might manage the exercise program directly or might have someone else manage that part of the patient’s care. The minute that someone else is managing a part of a physiotherapy treatment plan on behalf of a physiotherapist, they are acting as a physiotherapy assistant.

It doesn’t matter if they are a registered kinesiologist, an athletic therapist or a personal trainer: all of the requirements of the standard for Physiotherapists Working with Physiotherapist Support Personnel apply.

Does the College really take these cases seriously? Ask the three physiotherapists who’ve been to Discipline in the past 14 months for failure to meet the standard of care for the use of assistants in their work with personal trainers or athletic therapists. Ask the handful of physiotherapists who are presently under investigation for referring their healthy patients to gyms and Pilates classes and billing their sessions as preventative physiotherapy.

Every one of you who uses your credentials as a way of getting free non-physiotherapy services for your patients is undermining the credibility of the profession.

I know that your patients ask for it. That doesn’t make it right.

Council approved a new draft Standard for consultation called Physiotherapists Working with Assistants at its last meeting.

Read it.  Think about it.  Let us know if you think it needs to be changed before it’s made final. Watch your inbox and the website for a chance to tell us what you think about the changes and additions over the coming weeks.

And if you know a physiotherapist who is not meeting the Standard – do them a favour and send them the link or make them a copy of it – get them to read it before they read their name on the Discipline page of our website.

When Breaking Up is Hard to Do

You’ve been seeing Janet for several months. She’s an elderly widow who first came to you following a knee replacement. She recovered quite well and is ready to be discharged.

The problem is, Janet really likes you and wants to continue coming for therapy. She makes weekly appointments for the treatment of back pain. But, you are aware that your treatment is not having a particular therapeutic benefit, except perhaps for a placebo effect.

Janet doesn’t need physiotherapy: she needs company, caring and some gentle exercise.

You know that the Professional Misconduct Regulation makes it an offence to continue treating a patient where treatment is unnecessary, but when you try to persuade Janet to stop coming, she gets tearful. The last time you saw her, she brought you a tray of homemade brownies to thank you for keeping her as a patient. You feel very guilty about hurting her, but you don’t feel comfortable carrying on with her care.

What do you do?

Our Practice Advisor, gets calls about scenarios like this pretty frequently. I’ve written before about the physiotherapist’s obligation to maintain professional boundaries.  It’s worth acknowledging that often it’s patients who wish to step over that line. They want care they don’t need, they want to be your friends, they want to set you up with their sisters or brothers, and this can put you in an uncomfortable situation. You worry about hurting their feelings. You worry that they’ll make a complaint about you if you discharge them.

Let’s be clear.  You are entitled to discharge patients, who no longer need your care, even if they don’t want to go.

The regulation says that you must not discontinue needed professional services except in certain circumstances. A physiotherapist is entitled to discontinue care in a variety of circumstances, including situations where the patient is abusive or non-compliant with the treatment plan.

You can read more detail in the regulation itself, but the bottom line is that if the patient is in need of ongoing treatment, you should help them to find an alternative physiotherapist, or at least make sure they have time to do that for themselves.

But in Janet’s case, she no longer needs treatment.

As in all interactions with patients, you will want to be respectful in your communications and you should always note the conversation in the patient’s chart.  But when the time comes for you to end the relationship, whether it’s because they are violating boundaries or for any other reason, you are entitled to do so.

You are responsible for the therapeutic relationship, and sometimes that will mean you need to end it.

We’d love to hear from you about how you handle patients who are having a hard time letting go or manage challenging relationships.

 

Resources:

Therapeutic Relationships and Professional Boundaries

Guide to Therapeutic Relationships and Professional Boundaries

Managing Challenging Interpersonal Situations When Providing Patient Care

Guide to Managing Challenging Interpersonal Situations When Providing Patient Care

 

Are Great Practitioners At Risk of Losing Their Reputation?

There was a BBC headline that caught my eye not too long ago: “Athletics doping: What happens if trust goes out of sport?”* It was about the results of an independent commission set up by the World Anti-Doping Agency, but it could have been about your profession. It could have been physiotherapists.

I have to quote the next part, because it resonated so loudly for me: “… sport is not getting the governance it deserves. Governance is a dull word…. (but) it is critical, and it is critical that it is done right, because otherwise we are all being cheated. Sportspeople are being swindled of their careers, of their reputations, of their future. Us sports lovers are being defrauded of our trust, our emotional energy and our financial largesse.”

This is exactly how I feel about regulating physiotherapy.

So many of you are amazing. You put your patients first. You work extremely hard to fit one more person into your busy schedules. You assess carefully and you reassess regularly. You bill fairly. Your advertising is truthful and classy. You keep on top of new developments in treatment options and other knowledge. You don’t advise patients to come in for sessions that you know that they don’t really need.

You care.

And then there are the few who cut corners in treatment, breach the standards and break the law.

It’s true that governance is a dull word (not to me, but I understand how you might feel that way), but it’s critical that that we do it right because those of you who are great practitioners are at risk of losing your reputation.

Our standard setting, quality management and professional conduct activities are your insurance against encroachment of the swindlers.

As we hear more and more stories about overuse of physiotherapist assistants, failure to engage in continuing professional development, insurance fraud and new grads who can’t find jobs where they are not expected to break the rules, good regulation is more important than ever if you want your profession to retain its reputation as a caring discipline with a unique and essential skill set and body of knowledge, stand behind regulation.

Do something about it. Report colleagues you honestly believe are failing to meet their professional obligations. Participate in public consultations. Get involved with the College Council or join your professional association.

Participation is another way that you can protect patients because if they don’t feel like they can trust your profession, they will stop coming to see you.

One more quote I want to share – let me know if you see the parallel to physiotherapy:

“Sport only survives if we all keep coming back. We come back because we believe in it. If that trust goes, everything else falls with it.”

[1] http://www.bbc.com/sport/34767962

 

How Will You Stay Inspired in 2016?

Shari Hughes, Associate Registrar—Practice, College of Physiotherapists of Ontario

Shari Hughes, Associate Registrar—Practice, College of Physiotherapists of Ontario

Guest Blogger: Shari Hughes, PT

I just read something inspiring—so inspiring in fact, that I want to share it with my fellow PTs. Here it is:

“Our quest [as health care providers] is clear…It’s a search for meaning in the value of the person who has come to honour us with his or her quest for some help. And we think to ourselves, is this a [prime minister]? Is this a hero? Is this a mother? Is this a father? An artist? A craftsman? An honest labourer? A climber of hills? A singer of songs? Who is this person who honours me with their presence, and what can I do to help them?”

I read this paragraph in an article describing the closing keynote speech delivered by Don Berwick at the Institute for Healthcare Improvement (IHI) 27th Annual National Forum on Quality Improvement in Health Care.

I read the article because it was about Don Berwick—a powerful thought leader and an engaging speaker committed to sparking bold, inventive ways to improve the health and health care.

This is not the first time Berwick and the IHI group have inspired me.

The first time was in 2005 with the 100,000 lives campaign. I’ve also turned to IHI to learn about rapid response teams and care bundles and PDSA improvement cycles and the Triple Aim initiative—I could go on and on but you should check them out for yourself at www.ihi.org.

Maybe it’s because I’ve heard and have been impacted by Don Berwick before. Maybe it’s because it’s a new year filled with new possibilities. Or maybe it’s because I can so easily apply his words to the profession I love so much.

In this latest speech he also talks about a new era in health care and nine steps to take going forward.

  1. Stop excessive measurement: I don’t mean that we should stop measuring. Indeed, I celebrate transparency in every form. How else can you learn? But we need to tame measurement. It has gone crazy. Far from showing us our way, these searchlights training on us, they blind us. We can’t find Sean in that glare. I vote for a 50 percent reduction in all metrics currently being used.
  2. Abandon complex incentives: We need a moratorium, I think, on complex incentive programs for individual health care workers, especially for doctors, nurses and therapists. If a program is too complicated to understand, too complicated to act upon by getting better, then it isn’t an incentive program. It’s a confusion program. It’s a full-employment program for consultants.
  3. Decrease focus on finance: This could be impossible. I feel naïve, almost, suggesting it, but for just a while, wouldn’t it be great if we could step off the treadmill of revenue maximizing? …If leaders really did care about profit, they would concentrate unremittingly on meeting the needs of people who came to them for help, but they aren’t. We aren’t.
  4. Avoid professional prerogative at the expense of the whole: From Era 1, we clinicians, doctors, nurses, we inherited the privilege. It’s still there. We can still use it. It’s the trump card of prerogative over needs, over the interests of others. ‘It’s my operating room time.’ ‘I give the orders.’ ‘Only a doctor can.’ ‘Only a nurse can.’ These are habits and beliefs that die very hard, but they’re not needed. They’re in our way.
  5. Recommit to improvement science: For improvement methods to work, you have to use them, and most of us are not. I’m trying to be polite, but I am stunned by the number of organizations I visit today in which no one has studied [W. Edwards] Deming’s work, no one recognizes a process control chart, no one has mastered the power of testing PDSA (plan-do-study-act), Nathaniel’s Method or the route to the top. You can see the proof of concept. This is beyond theory now.
  6. Embrace transparency: The right rule is really clear to me. Anything we know about our work, anything, anything we know about our work, the people and communities we serve can know too, without delay, without cost or smoke screens. What we know, they know, period.
  7. Protect civility: With the self-satisfaction courted by Era 1, with the accusatory posture that’s at the heart of Era 2, civility and, therefore, possibility have been in much too short of supply. I don’t lack a sense of humor, although I may sound like it right now, but in my opinion, jokes about herding cats or green eyeshades or soulless bureaucrats or the surgical personality, or the demanding patient—these are not funny.
  8. Listen. Really listen: These terms—coproduction, patient-centered care, what matters to you — they’re encoding a new balance of power: the authentic transfer of control over people’s lives to the people themselves. That includes, and I have to say this, above all, it has to include the voices of the poor, the disadvantaged, the excluded. They need our mission most.
  9. Reject greed: For whatever reason, we have slipped into a tolerance of greed in our own backyard and it has got to stop … We cannot ask for trust if we tolerate greed. The public is too smart.

As insightful and thought-provoking as the nine steps are, what resonates so much for me is the powerful reminder of my role as a physiotherapist in the simple question: “Who is this person who honors me with their presence, and what can I do to help them?”

History is full of little sayings that inspire big outcomes.

I’d love to hear more about what inspires you—what makes you get up every day and love doing what you do. Tell us, please!

Shout, Shout – Let it All Out!!!

You Talk. We Listen. 

By now you know we’ve been working hard to consult about the potential for clinic regulation in Ontario. The one and only thing about the consultations that has disappointed me is the suspicion I’ve encountered about the consultation process itself.

It appears that many people seem to think that our working group has already made a final decision.

That is not true.

We actually do listen to you and the more thoughtful and well-researched the information you provide, the more useful it is in shaping the final product.

The clinic regulation consultation has been and is intense – there’s an opportunity for input through a dedicated website, ontarioclinicreguation.com, by email, phone calls, commenting through the blog, in-person at town halls or in writing. You are welcome to reach out to me or any of the other 12 Colleges involved in the project.

What I am about to say applies equally to the smaller consultations we hold, like when we ask your opinion about a Standard or when we invite you to take part in a website survey.

The response you provide helps to create whatever we are working on. When we get responses that tell us that something won’t work (our definition of clinic is too broad or we shouldn’t include sole practitioners for example), we are likely to change it so it makes better sense. The more specific you are in your feedback, the more helpful it is to us in identifying the weaknesses.

Sometimes your feedback might tell us the item we are consulting about is confusing or ambiguous— if this happens, we head back to the drawing board and try to make it clearer.

If the response to a consultation was overwhelmingly negative, with lots of information about how we had made a mistake, this would drive us to do further research.

Public consultations are not popularity contests.

Frankly, it’s easier to scare up negative feedback than thoughtful input, so sometimes a high number of negative responses does not persuade Council not to move forward with a decision.

It is the quality of your input that matters the most.

Consultations are not just with the profession. We ask other regulators how they approach things. Sometimes we ask special interest groups for their input —like employers or physiotherapist assistants.  And, whenever we can, we try to get the opinions of patients and their caregivers too. Help us by telling your friends, family and even your patients to check out our website and get involved.

I promise you that what you tell us does impact the decisions made.

And that’s how the profession really makes rules for the profession.

It’s a little wee thing, but maybe you could add it to your list of New Years’ Resolutions? “In 2016, I will participate in self-regulation!

Shhh! The Registrar’s TOP SECRET FORMULA for Avoiding Complaints!

Amanda is a young woman in pain. Mr. McBean is an experienced physiotherapist who achieves excellent clinical outcomes. So how come she’s complained about him?

  1. Because he reached his arm across her chest, coming into contact with her breast
  2. Because it really hurt when he moved her arm through the full range of motion
  3. Because she didn’t get better after two treatments
  4. Because she found out that Ms. Lee, who was providing her treatments, was a PTA when she thought Ms. Lee was a physiotherapist who worked in partnership with Mr. McBean

If you answered all of the above, you got it right.

So what went wrong for Mr. McBean?

  1. Amanda was surprised by the physical contact with her breast, which she did not expect. Without an explanation of what the injury was and what the treatment would look like, she interpreted the events as intimate violations. She complained about sexual abuse.
  2. Amanda was surprised by the pain. She didn’t tell Mr. McBean it was OK to move her arm and he didn’t tell her what to expect. She complained that he assaulted her.
  3. Only a miracle would have resolved Amanda’s issue after two treatments, but she didn’t know that. She didn’t know that she should expect to go for six. She complained that he was a bad clinician.
  4. Amanda booked an appointment with a physiotherapist. She assumed that the person touching her was a physiotherapist filling in for Mr. McBean. Nobody told her that she could or was receiving physiotherapy from an assistant. She complained that Mr. McBean lied to her and provided her with inferior care.

The bottom line is that in each and every case, Amanda did not give consent.

There is no science to this, my friends. Informed consent means that you talk to your patient. You give them all the information that THEY might think relevant and you let them decide if the next step is OK with them. And if you aren’t sure how much information to give them, give them a little extra to be on the safe side.  If something changes along the way, talk to them about the change and what you propose for next steps and let them decide if that’s OK. And for Pete’s sake, before you start treatment, tell them what you think is wrong, how you propose to address it and how many visits it might take…AND ASK THEM IF IT IS OK TO PROCEED.

Don’t take shortcuts when you discuss treatment and don’t assume you know best. Sincerely ask every one of your patients for permission to proceed.

The secret formula for staying out of trouble? Talk to your patients. Start immediately and never stop.


Video: Did You Get Consent?


Additional Resources
7 Things You Should Know About Consent
Briefing Note: Health Care Consent Act
The Health Care Consent Act (HCCA)

 

Regulating Clinics – Your Turn to Talk!

We know physiotherapists are sometimes compelled by their employers to provide services in a way that does not meet the profession’s clinical or ethical expectations.

And sometimes business operators engage in behaviour that physiotherapists aren’t even aware of, but can still get the PT in trouble: they use the physio’s name for bad advertising or billing practices, for example.

A bad work environment can lead to poor quality care, safety issues or misuse of health system resources—and that’s no good for patients.

The problems that we see at our College are shared by many other health professionals in Ontario. As you know if you’ve been here before, our College is working with a group of partners to advocate for clinic regulation in Ontario. This is not a government-directed initiative, but came from the desire of Colleges’ to protect patients.

Of course, lots of clinics are already regulated by other regulators or other entities, but many places that deliver health care are not regulated in any way.

There are currently thirteen regulators, including us that may join in the next little while. Together, we have developed a draft proposal about how clinics could be regulated.

Clinic regulation would mean that businesses would be held to the same sorts of standards and expectations as individual health professionals.

At this stage, our proposal is aimed at YOU—do you think our proposed regulation would work? What are its strengths and weaknesses? Most of all, would it protect the public?

You should have received an email recently from the College inviting you to check out the clinic regulation consultation website.

The website has videos and lots of detail about the proposal and is set up to let you share your thoughts on the idea. Your are invited to webinars and town halls too.

Please pass this info along to your friends. Post it on Facebook, tweet it. Hey, tell your mom—I hear her Instagram is legendary.

All kidding aside, we need to hear from as many people as possible to refine our proposal so we can get it right before we take it forward to government and ask for a new law.

Physiotherapists, this is your moment!

Use the expertise and wisdom you’ve developed as health professionals to protect patients in a whole new way—by helping to shape meaningful change to the health system we all live with.

Check out the website, share your comments online, come to a town hall and let us know what you think.

Webinar (Please Register Here):

Wednesday, November 18, from noon until 1 pm

Upcoming  Consultation Dates (Please Register Here):

November 23
*Kitchener-Waterloo
6pm – 8pm

November 25
*Sudbury
6pm – 8pm

November 26
*Windsor
6pm – 8pm

December 1
*Ottawa
6pm – 8pm

December 2
*Toronto
6pm – 8pm

December 9
*Brampton
6pm – 8pm

Friend not Foe: A PT Student Experience

Lauren Quinn, PT Student – Clinical placement at the College of Physiotherapists of Ontario

Lauren Quinn, PT Student – Clinical placement at the College of Physiotherapists of Ontario

When I learned that I would be completing my clinical placement at the College of Physiotherapists of Ontario, I was apprehensive. In the world of PT students, I have found that the College is often misunderstood and sometimes negatively perceived.

From creating standards to performing practice assessments, aka “audits,” to discipline hearings, my impression was that the College would be disciplinarian-like…but I could not have been more wrong. Within hours of working there, I quickly learned how supportive the College is to its members and how valuable a resource the staff are to all.

Some people may see the College as an enemy to PTs because of its duty to protect the public. What might not be clear to all is that the College protects the public by actually working with physiotherapists to make sure they are ethical, competent and safe practitioners.

Being self-regulated is a privilege.

Why would I spend my time and my resources to become a trained physiotherapist if anyone could call themselves a PT and open their own practice?

As a future PT, I am comforted knowing that the College is there to maintain the reputation of the physiotherapy profession and ensure the competency of practicing members.

Practice Assessments

When a PT thinks of the College, they most likely think about—and dread—the possibility of being selected for a practice assessment. That dread comes from a lack of understanding.

I believe many PTs aren’t aware of the true nature of these assessments. Assessments are not designed to trick and punish PTs, but instead the College’s goal is to have members improve their practices based on their own reflections and a structured discussion with a peer.

The assessment questions are available on the website and PTs can choose their own charts for discussion. Using this approach, the College hopes that PTs will be able to identify and correct any behaviour that may not meet the standards of practice before the assessment.

I was pleasantly surprised to learn that after the assessment is complete, members are allowed to make a submission to the College to share how they have improved their practice if there were areas for improvement. If the member was unable to show that the assessment gaps have been addressed, the College then works closely with that PT to help them to meet the standards by giving them resources or setting them up to work with a peer coach.

Concerns, Complaints and Investigations

Similarly, investigations into concerns about health professional’s behaviour follow a fair and objective process. The College always assumes its members are professional, ethical and competent until there is evidence to prove otherwise. Complaints are thoroughly investigated and the members are encouraged to make a written response to share their side of the story.

Typically, very few complaints are referred to the Discipline Committee, with most issues requiring no action or some form of remediation.

It’s all about the College’s desire to protect the public by coaching physiotherapists to improve and making use of remediation. The College reserves strict disciplinary action for the most serious cases, where the protection of the public is a grave concern.

I wrote this blog post—independent from the College—because of the discrepancy I noticed between the professional perception and the College’s objectives.

College staff believe in the profession the members and is committed to helping members be their best professional selves.

They are available to help PTs in any area of their practice, registration and professional obligations. You can also contact the Practice Advisor.

As I transition into independent practice, making use of the College’s resources and knowledge will help me to be a better physiotherapist and deliver the best care to my patients.

Because isn’t that why we all went through years of school and continuing education—to ultimately help rehabilitate our patients and improve their quality of life—so shouldn’t we support their protection as well?

Sitting in My Castle, Making Up the Rules…

Judging by some of the comments to some of my blogs, some of you must think I sit in my office, scheming to write rules that make the lives and jobs of physiotherapists harder than they need to be.

When I wrote the blog “My support person hurt someone. Am I in trouble?” one person responded that PT supervision of support personnel has always been adequate and “the College just wants to keep changing things for no reason.”

Several of you suggested the College had created a new rule to make PTs responsible for the actions or omissions of the support staff with whom they work.

When I wrote that it’s a PT’s professional responsibility to report colleagues with physical or mental conditions which may impair their ability to deliver safe and effective care, you responded saying this was a “witch hunt” and that physios don’t have the skills to decide whether a colleague has cognitive dysfunction.

In my last blog, when I wrote about the sensitivities of having personal relationships with patients, one of you said, “Thank you for making our social world even smaller and the bubble in which you prefer we live in even larger.”

I didn’t make any of those posts up. In fact, none of these blogs were about new rules—I was describing expectations that already exist.

The expectations are found in standards on our website and in the practice of your colleagues. I was just writing to remind you about them, or maybe to point out a rule where the evidence at the College suggests a certain percentage of PTs may be slipping a little (or sometimes a lot).

The fact is I have no authority to make up the rules. But you do.

If you feel that the College’s expectations are wrong or out of touch with reality, step up and take part in changing them.

Self-regulation means the rules about physios are set by physios. There are legal and governmental requirements sometimes, and legislation requires that any decisions about practice standards make patients’ needs the first priority—but the specific content of standards and regulations is determined by College Council.

Council considers all of the research before it makes any decisions. They might look at things like worldwide standards for physiotherapy, the expectations for other professions, trends in regulation and the viability of enforcement and costs of implementation.

Once they have an idea of how they might want to proceed, they consult with members of the profession and the public in Ontario to determine whether there is an Ontario-specific expectation.

Council’s responsibility is to capture in writing the expectations of the majority of the profession so everyone practicing physiotherapy in Ontario shares the same understanding of right and proper professional behaviour.

Since Council is required to put the patients’ needs at the centre of every decision, the decisions do not always create the easiest path for physiotherapists, but they do ensure that the integrity of the profession is maintained.

Based on some of your feedback, there are physiotherapists who think that the College is getting it wrong.

If we are, then we want to do better.

We have begun reviewing every one of our standards to update them and make sure they capture the realities of modern practice: that’s one of the College’s strategic goals.

You can be as involved as you want to be. Watch the website and your email for opportunities to contribute your opinion. Your perspective will always be considered by Council, and I promise that we will report back in Perspectives or on the website about how Council responds to the feedback it receives.

In the meantime, keep the comments coming to the blog—although we don’t respond individually, we read every one and take them into account when we are deciding about what to focus on, preparing materials for our website or updating our standards. Even when you don’t like us, we’re listening.

 

College Standards 

Consultation

Patients or Friends—Does it Have to Be One or the Other?

Your patient asks you to play on her softball team. There’s nothing romantic and you have lots of common interests and a couple of common friends. Should you join the team? I’ve written in my blog about boundaries before—we are pretty clear that dating patients is a problem and that sexual relationships are forbidden. But what about when patients become friends? What are the boundaries then?

I’m not going to tell you that there is a clear answer to this question. This is one of those situations that highlights what sets professionals apart from other sorts of workers. The clerk at the local hardware store does not need to second guess whether it is appropriate to become friends with a customer, but a healthcare provider does: therapeutic relationships entail a level of trust, power and closeness that don’t arise in other situations.

There are at least three reasons you need to be careful. You must be able to remain objective about your patients’ care. You have an obligation to put your patients’ needs ahead of your own, which includes avoiding conflicts of interest. And you have to protect your patients from harm—physical, mental, financial—any possible harm, as much as you can. When your relationships with your patients become too close, it can be difficult to maintain your professional perspective.

I asked Shari Hughes how she would explain this issue. Shari is a PT, Associate Registrar and wise advisor and she said that, “a PT gets to see the patient undressed, gets to ask lots of personal questions (but doesn’t have to answer any) and has control over whether the person gets to go back to work or sport (just to name a few). I think it’s natural to try to equalize that differential by the PT sharing stuff about themselves or by the patient offering their accounting expertise at tax time. I think friendship with a patient is a possibility. However, I think the greater likelihood is for the patient to misunderstand a kindness and to potentially be harmed or for the PT to lose his or her objectivity and for the patient to be harmed.

So, you join the softball team. Now your patient is asking for your advice about her aching Achilles at a game. She trusts your therapeutic skills. Do you give her advice? If you do, are you insured? Do you charge for the advice? Wait a minute—did you do a full assessment or did you make clinically inappropriate assumptions based on the casual environment? Maybe there is something in her history, unconnected to the ball game that led to the problem. You missed it because you were offering advice outside your usual clinic setting. And you were in that position because you were friends. It gets even more complicated if she is a WSIB patient—can you be objective about evaluating her work readiness?

In another example, several of your patients are your Facebook friends. You share a post about your sister’s direct marketing business that sells health and beauty supplements. Your patients take this post as clinical advice and buy things they otherwise never would. After all, they trust your judgement about health-related things. But your sister makes money off of your patients and that could be a conflict of interest for you.

Our best advice? Use your good judgement, but it’s probably safest to avoid all personal relationships with patients.

If you are in a small community, this will be nearly impossible and we understand that. In your case, you will have to take special care to ensure that you do everything you can to remain objective, put your patients’ needs first, and to protect them from harm.

I’ll let Shari have the final word, “I wonder whether what we are talking about is treating everyone the same so that the likelihood they’ll misunderstand or be hurt or taken advantage of (whether intentional or accidental) is lower? And by treating everyone the same I don’t mean EXACTLY the same, but within the same general limits or boundaries. I guess you could call it keeping appropriate patient-specific professional distance. For example, the prim and proper 86-year old Mrs. Smith will always be “Mrs. Smith” but the 17 year old skateboarder can be “dude” (do they still make skateboards?) And maybe it’s okay to go to Sally’s first violin recital after her wrist fracture rehab, but you definitely wouldn’t accept Johnny’s mom’s invitation for dinner…”

Records, Consent and How to Stay out of Trouble

I’ve blogged about consent before (What do you call uninformed consent? Punchline: No consent at all). In that post, I reminded you that your job in getting consent is to make sure that the patient fully understands his or her options and makes his or her own decision about how to proceed.

Too often, the physiotherapist is sure he or she knows what is best for the patient and the exchange looks more like instructions and less like a dialogue. Let’s say the conversation with the patient is like a journey to a particular treatment: even if you are sure that you know the destination, this is no time to take a shortcut.

So let’s assume you DID have the appropriate conversation—what did you put in the patient record?

I’ve been sitting in with the Inquiries, Complaints and Reports Committee quite a lot recently. You might be surprised how often the issue of consent arises.

At every meeting there are one or two patient complaints where the patient says that the physiotherapist did not get consent for the treatment he or she provided. Sometimes the patient says the treatment hurt and he or she would never have consented to something that hurts. Once it was someone who said that the risk was too high and she did not consent to that. Other times patients say that they would not have consented to treatment by assistants or that they would not have consented to a treatment plan that required too many visits. Over the years, some of the complaints have been that the patient did not consent to be touched in a particular place on their body.

In almost all of these cases, the physiotherapist responds to the complaint, writing to the Committee that he or she did get informed consent. When there is disagreement like this, how can the Committee determine whose report is more accurate?

Because physiotherapists have an obligation to keep patient records, the Committee knows it can look at the patient record to clear up the dispute. As one of the Committee’s lawyers once advised, “If it’s not in the record, it didn’t happen.”

Unfortunately, all too often, not much is in the record. This can mean that the Committee may be forced to draw the conclusion that the conversation didn’t happen, or was too brief to provide the “informed” part of the informed consent.

If I were you, I would make sure that I never took a shortcut to informed consent.

I would ask the patient for consent to conduct the assessment and then, after that, I would explain the treatment plan and ask for specific consent for treatment. I would have that conversation with the patient myself, eyeball-to-eyeball, and I would make a note in the chart (something more than ticking a box, or including a consent form obtained by the receptionist).

My notes would be especially thorough if there was something unusual about the conversation (for example, Did the patient have an unusual risk profile? Or did he or she seem particularly confused or demanding? Was the treatment being discussed a controlled act?).

So I ask you, how do you manage the consent conversation? What information do you record? What makes it challenging and do you have ideas or tips for your colleagues of things they can do, to do it better?

I hope you will post your thoughts and let’s have a conversation about consent!

 

Perspective is Everything

Peter Ruttan, President, College of Physiotherapists of Ontario

Peter Ruttan – College Council President and Guest Blogger

 

 

 

 

 

Shenda’s Peter’s Blog

If the saying “perspective is everything“ holds true, then I got my fair share of ‘everything’ earlier this month at World Confederation for Physical Therapy (WCPT) in Singapore.

It was an excellent conference with more than 3,500 PTs from around the world coming together for three days of presentations, discussions, courses and networking.

Canada was well represented at WCPT, with well over 50 participants from Canadian universities, regulators and our national association.

Singapore is a grand location and the conference itself was very impressive, but I want to focus on the small, two-day conference called INPTRA, which preceded WCPT.

The International Network of Physiotherapy Regulatory Authorities (INPTRA) was started 15 years ago by CPO past-Registrar Jan Robinson, to give regulators an opportunity to share resources and experiences.

Sixty-fix people attended INPTRA, representing 16 countries and Shenda and I had a chance to present on how regulation works in Ontario and Canada and hear about the successes and challenges of different models in other countries.

Here is some of what I learned:

Australia

  • In Australia, all health professions are regulated by one agency and there is a common code of conduct and standards that apply to everyone.
  • Complaints from the public for all health professions go to this same agency.
  • There is one, national registry and PTs are free to move about Australia. Mobility to New Zealand is very straightforward.

United Kingdom

  • In the UK, there is a national registry of PTs and all health professions are governed by pooled standards.
  • Complaints from the public are also pooled, but profession-specific in how they are adjudicated.
  • Mobility is seamless between England, Ireland, Scotland and Wales.

Other Countries

  • USA has a state run licensure system with different standards for each state.
  • Singapore and Southeast Asian countries have good mobility and common standards, but the public does not have direct access to PTs.
  • Kenya, Croatia and Sri Lanka are in the fledgling stages of national PT regulation.

While having lunch with the Australians, it was a somewhat embarrassing to admit Canada has only 20,000 PTs, yet we have 10 separate PT Registers and PTs do not have the ability to move freely across Canada with one registration.

Without pooling of standards in Canada, there are 10 slightly different versions of the same standard.

Do we really need 10 record keeping standards for PTs?

I left Singapore with a new perspective on PT regulation in Ontario and with many questions. We are fortunate to have regulation of any kind to protect the public, a luxury many nations do not have. We also have the added privilege to have the opportunity for the profession to regulate itself.

However, we also have an obligation to learn from other countries and consider if it will work in the Ontario/Canadian context.

Would common standards work for all PTs across Canada?

Would common standards work for all health care professions in Canada?

Should one board adjudicate all complaints for all health professions?

Can we still have provincial regulation but at least have a national PT registry?

I think national standards for Canadian PTs would bring efficiency, clarity and may add to public confidence. I also think a national registry for PTs would efficiently give all provincial colleges access to one database and allow PTs in Canada to be more mobile.

Thanks to Shenda for letting me take over her blog this month. I’ve given you my perspective and now I’d like to hear yours. Tell me what you think below!

The Best Thing About Being A Professional…

Might be the worst thing too—you are accountable for all elements of your professional life.

When things go right you should feel great—you helped a patient through a tricky problem, you contributed your time to a charity event, you had a successful business year. Well done!

But you are also responsible for anything to do with your practice when things don’t go so well, for example, if your practice number is used for fake billing or if a support person to whom you assigned patient care progresses a patient too fast. The Ontario Divisional Court recently had something to say about this. They were considering an appeal by two doctors from a decision made by the College of Physicians and Surgeons of Ontario.

The advertising regulation at that College is similar to our Standard. The doctors argued that the company they worked for published testimonials and other advertising in which their names and faces appeared without their knowledge. The Judges found that even if the doctors did not know about these advertisements, they knew their employer had created inappropriate ads in the past and they failed to show that they had taken reasonable steps to remove improper advertising bearing their names. The doctors were held responsible.

If this sounds familiar, you might remember a decision by our own Discipline Committee a few months ago, when two physiotherapists were held responsible for billing personal training as physiotherapy, even though this appeared to result from business decisions made by their employer. How far does your responsibility go?

Besides being accountable for yourself, you also have to watch out for your colleagues. If you see someone you believe cannot safely provide care due to a health problem, you are required to report it to their College. Likewise, you have to report if you have reason to believe that a health professional sexually abused a patient. And if you are the facility operator (say a clinic owner) then you must report incapacity due to health problems, suspected sexual abuse and incompetence.

It’s not enough to be a great clinician. You are a custodian for the profession. This is the burden that comes with being a professional—you are accountable.

Luckily, we know you are up to it. The vast majority of you are outstanding professionals. Each year, we receive substantiated complaints and reports about fewer than half a percentage of the profession, and our peer visits to your practices result in practice enhancement only three per cent of the time.

So keep up the good work, and remember to always expect the same from your colleagues.

P.S. No matter what I blog about, many people comment about the need to regulate clinics. We heard you! The CPO is working hard on this project with 8 other Ontario Colleges. We are at the research stage. Regulating clinics would require a change in the law but we are hoping to make a proposal to the government in the winter this year. Stay tuned!

Let’s talk about S*X

Sharon’s young. Ali’s great looking. She’s treating the rotator cuff he tore playing ultimate Frisbee. They both like House of Cards. The next thing you know, Ali is offering to meet Sharon at a local pub and teach her how to play pool. She finds him attractive, can she say yes?

Joan is recovering from a bad car accident. Chaitan provides home care and sees her alone in her bedroom. She’s afraid she’ll never walk again and she’s in a lot of pain. Chaitan helps relieve the pain and gives her the hope and the therapy that lead to her recovery. Because of Chaitan, she is able to return to work when she never thought she would. The next thing you know, she’s planning to leave her husband for him. He finds her attractive. Can he pursue it?

What do these two situations have in common? They both cross the appropriate border of the physiotherapist-patient relationship.

Physiotherapists need to remember how special they are. Your expertise gives you an exceptional position in patients’ lives. Patients are likely to trust you more readily than they would trust someone they met in a different way. They are likely to feel grateful to you for helping them. They may feel intimidated by you because you have skills and knowledge they need but don’t have themselves. You spend time with them in treatment, you touch them, you see them alone and outside of their street clothes. All of these things can lead to a feeling of closeness that would not likely develop if you were to meet elsewhere.

I know that we all think we can tell when it’s “the real thing” but the law says that Ali is not himself in that relationship—Sharon has a position of power over him that makes her more desirable or compelling than she would otherwise be. Maybe this is even more apparent with Joan and Chaitan—who wouldn’t fall in love with someone so kind and important in their life? In both cases, the law says that if the couple were to have sex, it would be abuse and the physiotherapist would lose his or her licence.

Does the law go too far? Maybe. But the law is meant to protect the most vulnerable. When a doctor trades sex for drugs, it is easy to see he has taken advantage of a weak patient. But the patient is nearly always a little bit vulnerable. That’s why I want to remind you that you are special and powerful: you help patients to get better. But you must also hold the patient-therapist relationship sacred, by keeping a clear professional distance and remembering that they are your patients, not your friends.

Related Resources:
Standard: Therapeutic Relationships and Professional Boundaries
Guide to Therapeutic Relationships and Professional Boundaries

Is It Health Care Or Is It A Business?

Does it have to be this way?

I think that the difference between a health care profession and a business is simple: it’s in your motive. If you do this for a living to take care of patients, you are a professional. If your top priority is profit, you are a business person.

Before you post angry comments—I don’t mean that health care professionals can’t make a profit. Of course I don’t! I am talking about your primary reason for going to work in the morning. I hope that your first goal is to help patients and the gorgeous consequence of your good work is a healthy income.

The problem arises when patient care is secondary to the bottom line.

When Council was brainstorming business practices that are unacceptable, they quickly came up with the following examples: sales of products or services that do the PT’s profit line more good than the patient; advertising that is misleading or false; using too many support personnel to adequately supervise; using support personnel who aren’t properly trained; telling patients they need care or devices that won’t really do them any good; offering services that are not really physiotherapy but billing patients or third party payors for physio; inadequate, false or incomplete records; false billing. The list went on from here.

Last year Council adopted a policy of zero tolerance for inappropriate business practices. That means that if you are engaged in one of the practices listed above (or something not listed but equally offside) then you are doing a disservice to your profession and to your patients and the College will not accept it.

When the College learns about such a situation, the appropriate College Committee will consider it (that is, you will be evaluated by your peers and appointed members of the public—not by staff, and never by me) and the outcome could be anything from a meeting with the Committee, to compulsory education or could lead to a revocation of your certificate of registration.

We have heard from you: You deplore businesses that put profit before patients and Council agrees with you.

Physiotherapy CAN be a profession and a business—it’s just a matter of putting first things first.

My support person hurt someone. Am I in trouble?

Scene 1: You assessed your patient and made a plan that included having her walk with a walker. But one day, in your absence, your support person independently decides that the patient is ready to use a cane instead. This was really bad judgement. Now the patient has fallen and broken her hip. Are you responsible?

Maybe. One of the questions we would ask is whether you knew that your support person might make an independent treatment decision.

Scene 2: Your support person sexually abused a patient. Are you responsible?

Maybe. The College would want to know whether there were any hints that the person was likely to behave inappropriately and whether you had taken the right actions to correct it.

We know that you want clear answers from us, but in these situations it’s impossible. Our investigation would involve the questions posed above and more. Every situation has to be evaluated in its own context. The bottom line is that you, the PT, are responsible for decisions or actions taken by a support person acting under your authority. And, patients have a right to expect to receive care that is just as good as if you had delivered it yourself.

So, if you aren’t sure whether your support person has the knowledge, skills and judgement to carry out your treatment plan, you’d better train that person and supervise them until you are sure.

If your employer hired someone whose work you would not want carried out under your name, make your objections loud, clear and official. If you have observed any questionable ethical behaviour on the part of someone working for you, take steps to ensure it doesn’t happen again. If you think your PTA shows questionable clinical judgement, you must give very clear instructions, including direction about the limits of their decision-making authority.

On the other hand, if you are thoughtfully and appropriately using support persons to make certain that you can deliver safe and effective care to as many patients as possible, thank you on behalf of all of us PT patients across Ontario.

You may be aware that Council approved putting more information about PTs on the Public Register at its meeting in December 2014. One of the things that will now appear on the Register, starting July 1, 2015, is whether you work with support personnel. This was a tough decision for Council and the subject of a long debate. Ultimately, they decided to go ahead because patients are entitled to know who is delivering their care and because Council is hopeful that having the information on the Public Register may help to remind all PTs that this is another area where quality practice is very important to the College.

We know that support personnel are a necessary and often a valuable addition to PT practice today. We will be putting lots of background information on our website so that patients understand more about these practitioners and what to expect from a PT who uses support personnel.

In the meantime, you should use your good judgement to determine whether the support personnel that you work with need closer supervision, better training or a narrower range of assigned tasks.

Do you use support personnel? How do you ensure that they deliver the same quality of care as you would yourself? We want to hear from you.

Bad Start to a New Career

I’m not kidding you, this was a conversation that one of my colleagues overheard recently on a train.

Student 1 (let’s call him Jason): I’m going to start my own business.

Student 2 (let’s call him Mateo): Me too—I’m never going to work for someone else.

Jason: I know, right? And here’s what I’m going to do—I’ll get all my friends and family who have extended benefits plans to come to me and then invoice them for the maximum for each of their plans.

Mateo: Right. You don’t even need to treat them.

Jason: You don’t even need to see them!

(Both laugh)

I hope this conversation makes your flesh crawl a little. I hope that you think, like I do, that there is something terribly wrong when newcomers to the profession are planning to use their education and credentials to make as much money as possible without thinking one thought about patients.

I know that the financial pressures continue to grow year after year, and that it’s much harder to earn a good living as a physiotherapist today than it was in your parents’ time. And yet, I want to believe that physio students go through the incredibly competitive process of getting admitted to a university physical therapy program because they truly want to treat patients, to make people well, to keep people mobile.

Shari Hughes and I met two amazing groups of PTs at the Ottawa Hospital last month. They told us that there aren’t enough hours in the day, or dollars in the budget, to provide the care that they want to provide for their patients—and it’s breaking their hearts. I would trust that group of PTs with my mom or my children without a doubt.

It’s hard to imagine that with the kind of attitude those soon-to-be health care professionals displayed on the train, that they will make caring for patients or quality care a priority. I hope my children or mom doesn’t see one of them: What a waste of time and money that would be.

I’ve spoken with many of you who are able to balance making a nice living with providing high-quality care. So this blog is addressed to you: Make those students on the train understand that even if they were only joking, every time someone acts or talks like that it makes the profession look bad. A patient’s access to care depends on a pool of worthy, qualified and ethical physiotherapists.

Showing my age, and (mis)quoting The Jackson Five: Don’t let one bad apple spoil the whole bunch.

How about you? What would you say or do if a student or colleague said something like this to you?


College of Physiotherapists of Ontario
Standard for Professional Practice—Fees & Billing

Your Mom’s Nurse Was Just Convicted of Drug Trafficking—Do You Need to Know?

How much information about their health care providers should patients and other members of the public be able to see? Where’s the line between the public’s right to know and the professional’s right to privacy?

All of the health care professions in Ontario have Public Registers on their websites. These Registers all have some information about health care providers. For example, you can find out where your doctor went to university or whether your dentist has been disciplined by the College. But should these Registers go farther?

As a member of the public, should you be able to see exactly why your optometrist was referred to a Discipline hearing? Should you have the ability to find out whether the Ontario College of Pharmacists’ Inquiries, Complaints and Reports Committee ordered your pharmacist to take training courses or work under supervision? Should you be able to look up whether there are criminal charges outstanding against your mom’s favourite nurse?

You may have read in the news recently that the Minister of Health told all the Colleges to make transparency a priority. It is Dr. Eric Hoskins’ opinion that we need to ensure that as much information as possible is shared with the public. View the Minister’s letter and the College’s reply to it.

As it turns out, our College has been considering these important issues in partnership with the professions mentioned above for more than a year. All of these Colleges have been taking steps to make more information about our members available to the public. In September 2013, our Council approved Transparency Principles and at its last meeting, Council tentatively approved changes to the by-laws that will add information to the Find a Physiotherapist feature of the website such as criminal findings, bail conditions, the status of hearings for PTs referred to the College’s Discipline Committee and whether physiotherapists use support personnel.

We are asking for your input about these changes, please provide your thoughts. Once Council has received your feedback, they will make a final decision about whether to publish these pieces of information on the Public Register.

But that is only phase one. The second phase of the transparency project will consider what other types of information should be made public – in particular, criminal charges and Inquiries, Complaints and Reports Committee decisions. You’ll be asked for your opinion again about those things in the new year.

If these changes are approved at all the Colleges, you’ll see more information about health care professionals which may help you choose between practitioners. On the other hand, if you are a physiotherapist, it also means that the public may soon have additional information about you.

This is important.

Tell your friends to check it out and have your say. In the world post WikiLeaks, are there barriers to the amount of information that should be available about health professionals? Where is the line between the public’s right to know and the professional’s right to privacy?

I’m listening…

 

Joke: What Do You Call Uninformed Consent? Punchline: No Consent at All!

OK. I know, that was a lame joke. I hope you aren’t coming to this blog for humour.

Let me tell you about something that happened to me a few years ago, before I was Registrar of the College of Physiotherapists of Ontario.

I called a sports rehab clinic where I’d been before, to see a physio for treatment for lower back pain. I was assessed and received treatment three times over a two-week period. It wasn’t until then that the clinic asked for payment. After I paid, I was handed a receipt signed by a PT who wasn’t the person I’d seen. I thought it was an error, so I asked the receptionist about it. She told me not to worry because the guy I’d been seeing was a support person and the PT whose name appeared on the receipt was happy to have the billing go out under her name and registration number.

What’s this got to do with consent? Well, I was not informed that the person treating me was not a PT. It was reasonable for me to assume that he was, since when I called to make the appointment, I asked for a PT. When this fellow talked to me about my treatment plan and when I signed the form, I was consenting to receiving treatment from a physiotherapist, not a support person. So, in fact, he did not have consent to treat me at all. There are other problems with this arrangement, including the fact that it’s inappropriate for support personnel to conduct assessments, but that’s a subject for another day.

Sometimes we regulators can make the idea of consent sound tricky, but I don’t think it really is. As a patient, I can only give my informed consent if you have given me all of the information that I need to make choices about my care. The Health Care Consent Act outlines some of the things that patients need to know, but it’s really common sense. You need to give the patient all of the information that a reasonable person would need to know to make a decision about treatment (that includes things like what the treatment plan will look like, what my options are, whether there is support personnel involved and how many visits I can anticipate will be needed).

Signed consent forms are the icing on the cake—they are a good way for the PT to demonstrate that he or she had the consent conversation with the patient. But what if there is no conversation: what if, instead, the patient fills in a form on a clipboard at the reception before even meeting the PT? Without a detailed conversation with the physiotherapist immediately, that’s probably not consent.

In 2007, a researcher looked at how physios in private practice understood informed consent.[1] She found that the PTs thought of informed consent as part of their routine clinical explanations, rather than a process of providing choices. The PTs were more concerned about ensuring a good outcome than enhancing the patient’s ability to make a choice. On the one hand, that’s great—I speak on behalf of all your patients when I tell you how much we appreciate your focus on our well-being. But on the other hand, it’s my body and what happens to it ought to be my decision.

Perhaps it seems like I am oversimplifying. Maybe you work in a place with a number of other professionals on a team and the administrative requirements are for one consent form to be filled out at the beginning of the treatment. As long as there is a real conversation, that’s OK. One team member can obtain consent on behalf of the other care providers. The test is whether the right information was provided and understood by the patient.

Think about this like any other task you might assign to someone else. You may assign obtaining consent, but only if the person who is having the conversation with the patient is appropriately trained and knowledgeable.

Did the patient know who was going to be treating her? Did she understand any potential side effects? Did she know what options she had for treatment? Did she understand her treatment plan and, if it involved support personnel, when she would be reassessed by a PT?

If the answer to each of these questions is yes, it sounds like you got consent. And if the treatment changes as the patient progresses, you should get fresh consent and that doesn’t have to be a form—it can be a conversation and a note in the file (please don’t forget to document that you got consent—there are so many ways it can go badly if you don’t). Remember, the conversation is about offering the patient choice: it’s not about telling them what will happen next.

I have another story about consent. My daughter was delivered by emergency C-section. There I am, with six hours of labour behind me, being rushed to an emergency room. Around me, a battalion of nurses and residents running along beside me. “Do you consent to a C-section because your baby is not getting enough oxygen?” frantically asks a stranger in a mask. And my nod is recorded on my chart. No way was that informed consent. But my fantastic 13-year-old daughter is a good reminder to this regulator that in emergencies sometimes even the most sensible rules need to bend.

Your turn. Have you had consent conundrums? What are your challenges?

___________________________
[1] Clare M. Delany, “In private practice, informed consent is interpreted as providing explanations rather than offering choices: a qualitative study,” Australian Journal of Physiotherapy 2007, Vol. 53: 171-177.

Related resources:
Briefing Note: Health Care Consent Act
E-Learning Module: Consent

What if Your Colleague Made a Mistake But You Got Punished?

A few years ago the British Parliament was considering how they could improve patient safety after a series of crushing hospital incidents. And here is what the members of parliament said, “Doctors could risk losing their licence if they fail to report fitness to practise concerns about their colleagues.”[1] Do you think about that for physiotherapy? Do you wonder about your obligation to report your colleagues?

Maybe you watched while Susan, who was teaching Mrs. Hall to climb the stairs on crutches after hip surgery, left her alone to take a phone call. Or you think that Claire may be showing signs of age-related cognitive decline. Perhaps you know that Joe down the hall sometimes asks his pretty patients on lunch dates. Maybe you heard your boss offering patients invoices for PT services when the service was really personal training.

Here’s the thing: if self-regulation is built on the belief that physiotherapists are in the best position to set the standards for physiotherapy, then physiotherapists are also in the best position to identify when those standards have been breached.

I am sure that most of you believe that if a PT’s functioning is impaired due to substance abuse, mental health problems or incompetence, patients may be put to risk. And your feedback to the College has been clear—you hate dishonest business dealings. And yet most health professionals do not report their colleagues. In one study only 37% of nurses who have experienced working with impaired colleagues reported them.[2] It’s no different for physiotherapists: in a study from Australia, only 19% of the participants indicated they would report to the Board if they were aware of sexual misconduct by a colleague.[3]

Your partnership with your colleagues and your membership in the profession creates bonds of loyalty that can make it very difficult for you to step forward. We understand that. Maybe it would help you to know that we will never take any action without proof and where there are health concerns we will always take great care over the well-being of the physio.

But if you believe in physiotherapy as a true self-regulating profession, you can’t turn your back. Sure, there are legal obligations to report in some cases, but I am talking about more than that. I am talking about making sure that the people that you work with meet your own expectations for your profession. And when they don’t, I am talking about taking action. First line might be to speak with your colleague directly, but in cases of true patient risk or legal responsibility you will need to take stronger action. Tell your supervisor. Call the College. Call the police or Children’s Aid if you need to. Because as much as offering therapeutic care, monitoring your colleagues is part of being a physio.

What do you think: Should physiotherapists be investigated for failing to report concerns? Have you ever reported a concern? What happened?

 

___________________________

[1] Helen Jaques, “Doctors should to be held to account for behaviour of colleagues, say MPs,” BMJ 2011;343:d4794.

[2] J.W. Beckstead, “Modeling attitudinal antecedents of nurses’ decisions to report impaired colleagues,” Western Journal of Nursing Research, 2002 Aug;24(5):537-51.

[3] I. Cooper and S. Jenkins, “Sexual boundaries between physiotherapists and patients are not perceived clearly: an observational study”, Australian Journal of Physiotherapy 2008;54(4):275-9.

Why is the College such a lousy advocate for PTs?

Hi Everyone—the headline is a trick question. We aren’t advocates for physiotherapy or physiotherapists at all. We aren’t even allowed to be.

The legislation that creates the College of Physiotherapists (and all the other health colleges in Ontario) gives us our power but also limits our power. It creates the College for the purpose of regulating physiotherapists in the public interest. There is nothing in there about assisting the profession to ensure that more patients receive public funding, nothing about assisting PTs to obtain a broader scope of practice, and there isn’t anything that says that we can stop other health professionals from delivering physiotherapy.

It’s understandable that people get confused about the role of the College. Historically, when people began to train to deliver specialized skills, they established guilds. The point of the guilds was to set standards to keep quacks out because quacks stole business from the real professionals. The best way to protect the business was to make sure that the real members of the guild met entry standards to get into the guild and then met performance standards in their work. A person who needed a bricklayer, for example, could count on a guild member to build a house that would not fall down and squish the babies in their sleep.

In a way, we are not so far from that today—the College still sets entry requirements and ensures ongoing quality—but the promotional aspects of the guild (that is, the advocacy part) have been separated from the rule-making activities and now belong to the Association.

There is sometimes overlap in our activities. A recent example is the work we did together to provide webinars about the practical application of the funding revisions. From the College’s perspective, we needed to educate physiotherapists about the rules and expectations surrounding the delivery of care under the new model. From the Association’s perspective, they wanted to offer support and education so that PTs could make the most of the new model.

So does the College do anything to help the profession? We think that we do. First, we collect information from you to establish what you expect of your peers. From this information, we set out standards and guidelines for all PTs. We educate and advise about the standards and, in worst case scenarios, we investigate and prosecute their violation. And what does that do for you? It ensures that a patient who needs a physio can count on a College registrant to offer safe ethical care. And that preserves and promotes the profession. But that’s as far as we can go.

Sometimes some of you make comments on the blog, or e-mail me (thank you, I am always happy to hear from you) and you are disappointed because we do such a lousy job of advocating for you. I’m sorry about that—sometimes I wish that we could do more because I believe so strongly in the value of the profession—but that’s not our job.

Clinic Regulation: Now What?

Two posts ago, I asked you whether you thought that the College ought to regulate clinics in addition to the physiotherapists who work in them. The overwhelming majority of comments favoured this idea. You told us that College regulation would mean higher quality care in the clinics and that it would make them safer places for physiotherapists to work. You also told us that regulation by the College would reduce inappropriate business practices. We heard you loud and clear. Although we regulate you individually, and although there are standards that speak to both care and business practices, these are not enough. You confirmed that business owners who are not regulated can be an impediment to physiotherapists being able to meet the College standards.

Physiotherapists, as a self-regulating profession, are in the best position to determine how best to regulate the profession in the public interest. That’s why you elect representatives for our Council. As you may recall, Council directed that we explore clinic regulation, but at every step along the way, your feedback will be absolutely necessary.

So now what?

The next steps will be slow (perhaps painfully so). It is not within the College’s power to begin to regulate clinics. Everything that we are allowed to do is set out in the Regulated Health Professions Act and its associated regulations. These are Ontario laws and may only be changed by provincial parliament.

Our next step will be to gather and collate hard evidence of the problems that arise in the present (non-regulated) clinic environment. Then we need to develop proposals for legislative change that would address these problems. During the course of developing these materials we will need to consult with many stakeholders—you, the public, other health care professionals who work with physiotherapists in the clinics and the clinic owners. We will be reaching out to you through Perspectives, this blog and in other ways to get your input.

We will need to identify a regulatory solution that does not cause more problems than it solves (for instance, physiotherapists and massage therapists often work together in the same clinics—should we be considering a regulation that requires clinics to have any type of regulated health professional at the helm, or would it have to be a physiotherapist? Would the clinics need to be owned by physiotherapists or would we require a physio (or another regulated health professional) to be designated as responsible for decisions made there? What would be the financial implications for working physiotherapists?).

Once we have done the data collection and have developed what appears to be a reasonable legislative approach, we must ensure that our stakeholders support it. The government needs to see significant support before it will consider new legislation and, of course, many stakeholders will have suggestions for change that we would need to incorporate.

After all our homework is done, we will make a submission to government. If government supports the change, then the parliamentary process begins.

I hope that this long list of activities does not sound like an excuse for foot dragging. I wanted you to understand the complexity of the decision-making and reassure you that even if you don’t see or hear much about this issue, we will be pursuing it. The process could take several years.

In the interim, you are always welcome to check out our Council materials (or come by and observe a meeting) to get an update, or contact me through e-mail or a phone call.

And by the way—happy spring!

Advertising and Physiotherapy: Where Do You Draw the Line?

Some of you are familiar with the Advertising Standard. Among other things, it prohibits endorsements, testimonials, superlatives and anything that could be interpreted as promoting a demand for unnecessary services.

I know some of you hate it. I have heard from you that it is not fair that you must compete with unregulated clinic owners who freely use these very advertising tools. I understand that. When the College is publishing standards it is important to know that the standards are based on feedback that we receive from the profession as to what the expectations should be. In the fall of 2013 we advised the profession that the advertising standard was up for review and we sought feedback from all of you. The feedback we received was that the expectations defined in the standard were reasonable. So unless new evidence arises, it seems as though the standard is set at the right place. In addition, the government has been requiring the new Colleges to have advertising regulations (a higher level of accountability) that address just these issues.

The goal of the advertising standard is to ensure that members of the public can rely on the information provided by physiotherapists to make a decision when they are choosing a physio. We, as a society, expect to be able to trust our care providers. We all know that there is enough information out there to suggest that you shouldn’t believe everything that you see or hear but patients in pain or family members seeking care for loved ones may not be as skeptical of advertising by health care providers as they would be if they were looking at a used car ad. The nature of self-regulation is to protect the public from undesirable or unprofessional behaviours by those few members who might engage in them. These are the reasons that physiotherapists are held accountable to an advertising standard.

So I don’t want to talk too much about what’s wrong with the standard. I would rather talk about how we should apply it. You are the profession. These are your standards. Tell me what you think.

Scenario One

On its website, a physio-owned clinic has a beautifully produced video done by a well-known television personality talking about how the clinic keeps him active. This meets the definition of advertisement in the standard. Seems like an endorsement, or do you disagree?

Scenario Two

A WagJagTM (or LivingSocial or Groupon) promotion offers 10 physio sessions and a 50% discount on orthotics for a low, low price. The advertisement doesn’t say anything about what happens if the first assessment does not demonstrate that physio is clinically indicated.

Do you think this intends to promote unnecessary services?

I would love to hear from you about whether these situations breach the standard. Are they professionally appropriate? Do they mislead the public? What other advertisements have you seen or used that you want to talk about?

Tell me – tell your colleagues – what you think.

 

Thank You For Your Feedback About Whether the College Ought to Regulate Physiotherapy Clinics

Thank you for all your input on the issue of whether the College ought to regulate clinics. We left the blog post up for longer than usual because new comments kept coming in.

The College will be exploring the potential for clinic regulation over the next few years. Watch Perspectives or the website for updates on our activities and opportunities to continue to be involved in conversations about this topic. Please be patient, though, because regulation of clinics would require change to the legislation itself and that process can take many years.

 

Should the College Regulate Physiotherapy Clinics?

I have been thinking about fraudulent billing practices a lot lately. Not such a cheerful way to begin the New Year, I know.

This won’t come as much of a surprise to you if you have been following the College’s activities over the past 18 months: one of our strategic goals is to improve the protection of the integrity of the title physiotherapist and the College registration number. What Council intended when they developed this goal was to ensure that all physiotherapists uphold the good reputation of physiotherapy in their billing practices.

Why did Council feel such a goal was necessary?

We see cases where new physiotherapists are pressured into inappropriate billing or where unwary PTs fail to audit the billing practices of their employers. We also know that some physiotherapists are billing for services they did not provide, or billing for things that could not reasonably be called physiotherapy.

Our neighbours to the south also see such cases and they’re taking a hard stand with heavy penalties for health care fraud. Just recently a physical therapist in Michigan was sentenced to 10 years in prison for filling in blank insurance claim forms and a New Jersey coach is now facing 10 years in prison for falsely billing insurers for physical therapy.

Despite evidence that some PTs are not behaving appropriately, we believe that clinic owners who are not physiotherapists orchestrate the vast majority of inappropriate or fraudulent billing that takes place under your names and registration numbers. Since it is your responsibility to audit all billing and prevent misuse, it is you who are ultimately accountable for the wrong-doing of others. And, as I said, it makes all physiotherapists look bad.

Perhaps you have had some personal experience that connects you to this problem. Many of you participated in the professional credential tracker (PCT) pilot that we did last year. The PCT is an electronic tool developed by the Insurance Bureau of Canada (IBC) to support regulatory colleges and help their registrants stay informed about how their professional credentials are being used in Health Claims for Auto Insurance.

Some of you no doubt learned that facilities you had never been affiliated with used your registration number, or that your registration number had been used to process payments by a clinic long after you had stopped working there.

So what’s a College to do?

Council has proposed that we begin to explore regulation of the clinics themselves. Just like pharmacies are regulated by the College of Pharmacists, our College could regulate clinics that offered physiotherapy. If this were the law, physios would work for physios: that would allow you to feel comfortable in the knowledge that your employer would be held to the same high standards as you are yourself.

Changing the law would be a slow process and not entirely within our control. At this stage, we are just starting the conversation. Please, let’s start here.

What do you think?

Do You Know What Physiotherapy Is?

As some of you may know, I am a lawyer. But that doesn’t mean I am practicing law when I am acting as the College Registrar. I am not, although I believe my legal training helps me to perform well.

When our Practice Advisor, Shelley Martin, is talking to you on the phone, she isn’t providing you with physiotherapy even though her expertise as a PT is critical to her role.

How about you? If you are a physiotherapist, does that mean you are delivering physiotherapy whenever you deliver any sort of care or service?

At the College, we’ve recently been asked whether physiotherapists can assign Zerona® therapy to physiotherapy assistants. Have you heard of this therapy? It is a cold laser fat reduction therapy that was featured on the Dr. Oz television show. The question assumes that Zerona® therapy is physiotherapy, but I’d like to explore that a little more.

The scope of practice in the Physiotherapy Act refers to “the assessment of neuromuscular, musculoskeletal and cardio respiratory systems, the diagnosis of diseases or disorders associated with physical dysfunction, injury or pain and the treatment, rehabilitation and prevention or relief of physical dysfunction, injury or pain to develop, maintain, rehabilitate or augment function and promote mobility.”

If someone seeks out Zerona® to treat their back pain or improve their ability to walk, is it physiotherapy? If a person wants the therapy to look better in a bikini would you still call this physiotherapy? (I know that someone who wants it for cosmetic purposes might benefit from a mobility perspective, but is it really right to use this as a justification for calling it physiotherapy?)

It’s hard to define physiotherapy because practice constantly evolves and because, as in the Zerona® example above, the same activity may sometimes be physiotherapy and sometimes not.

The Canadian Physiotherapy Association has a Description of Physiotherapy in Canada which provides lots of examples of activities that may be included as part of physiotherapy. It also says, “Physiotherapy services are ‘those that are performed by a physiotherapist and any other trained individual working under a physiotherapist’s supervision and direction’”. I think this is incomplete because it doesn’t say what services are not included.

Here are some other examples of treatments we have recently had questions about. What do you think?

  • supervision of an exercise program for weight loss
  • acupuncture for plantar warts or fertility or smoking cessation
  • desensitization techniques for children with autism

Which of these things is physiotherapy? What happens when they are performed by personal trainers, kinesiologists, traditional Chinese medicine practitioners or psychologists? Are they still physiotherapy?

As a health care provider and a caring professional, the services you provide may be no less valuable whether they are technically ‘physiotherapy’ or not. Many things that are not physiotherapy may be included in your practice because they are for the benefit of your patients. Maybe we could say that if quality performance of the activity does not rely on the knowledge, skills or judgement that come from physiotherapy training, it’s not physiotherapy.

This isn’t just a question of semantics. Patients are entitled to rely on the title “physiotherapist” as a guarantee that you will deliver safe and effective physiotherapy, but not that you will be good at other things, like cold laser fat removal or psychotherapy. It is important your patients understand that when you deliver a service that is not part of the knowledge, skills and judgement you have acquired as a physiotherapist, they are assuming a different kind of risk.

There is another group that is entitled to rely on your invoices as affirmation that the services provided were physiotherapy and not something else. They are the payors who have entered into agreements to pay for certain therapeutic treatments, but not, for instance, for cosmetic interventions.

All the same, if you happen to have tried this Zerona® therapy, let me know if it worked!

What Kind of College Should We Be?

In Ontario, the College of Chiropractors exempts new graduates from paying a registration fee in the year their first certificate is issued. New dentists pay a proportion of the fee depending on the month they enter practice. Respiratory therapists, whether they are new grads or returning to practice after an absence, pay a proportion of the fee depending on the time of year in which they register. Nurses, doctors and midwives all pay the full annual fee no matter what.

Your College has changed its approach to registration fees a couple of times over the past decade. Most recently, members could either pay the full fee or choose to obtain a four-month certificate. This meant that if you were just beginning your career, or returning to work after starting a family, you could obtain a short-term certificate that would bridge the period between when you wanted to enter practice and our annual renewal date of April 1. This could save you several hundred dollars.

But here is what happened: time after time, some physiotherapists failed to renew these short-term certificates. At the College, we spent a great deal of time and money trying to remind them and track them down, yet year after year we discovered many who practiced without a certificate for months at a time. The College’s prime directive is to register physiotherapists to protect the public interest: the four-month certificates undermined our ability to do this and we could not permit this to continue. In June, Council eliminated the four-month certificates.

But now what?

Should we be like the regulators for nurses, doctors and midwives? We would charge the full fee for everyone. In this way, we would know that everyone was duly registered and the public interest would be protected.

Or should we be like the colleges for chiropractors and dentists and offer reduced fees for first time registrants but no one else? If we did this, we would give our newest members a head start and welcome them to practice.

Or should we be more like the respiratory therapist college and permit all registrants to pay prorated fees so they pay only for the portion of the year remaining at the time they register? This would enable new grads, and physiotherapists returning from educational, health or parental leave, to equally benefit from a fee reduction.

Council struggled with this question at its meeting in September: there were passionate arguments for all positions.

The one-fee-fits all approach is simple to administer, simple to enforce and fair because everyone pays the same fee every year. Some would argue it also more aptly reflects a professional commitment to self-regulation than the other options. When a PT takes a break from practice, he or she is still a physiotherapist. Unless you are retiring or turning to a new career, you continue to benefit from self-regulation even when you are not practicing. While you are away for a year or two, the College continues to work on your behalf to ensure the ongoing quality and guidance of your colleagues so that you return to an ever strong profession.

Also, while you are away, if you are not contributing to the cost of running the College, the rest of your colleagues must each contribute just a little bit more until you get back.

On the other hand, applicants who are just beginning their careers are likely to need all the financial support they can get and it might start them off on the right foot in terms of their relationship with the College. A more engaged professional population leads to better self-regulation.

And what about Moms and Dads returning to work after a period of staying home with babies? Or daughters and sons who have taken time off to care for aging parents? Or PTs returning to school for specialty training? The most compassionate regulator would offer assistance to these groups while their earnings were reduced. And the College has been doing this up until now with the four-month certificates. Can we take this benefit away?

Council needs to hear from you—should every registrant pay an equal annual fee or should we offer reduced fees for new members? And how about leaves of absence—should we offer fee reductions for people who need time off from practice for personal reasons?

You can weigh in the comments below, or you can click over to thecollegeasks.com and let us know what you think. If this is important to you—tell your friends to visit the website and provide feedback too.

I am looking forward to a passionate debate.

P.S. Thank you to those of you who offered comments on my last blog. And welcome, if you haven’t dropped in before.

A word about the College’s response to your comments on the blog: we read every one and we learn from you. We welcome your contribution whether you agree with my remarks or disagree. There are a few rules on the side bar that indicate that we might remove comments if they are inappropriate, but otherwise, we won’t censor you. Please don’t expect a reply to your remarks—I already had my chance to express myself, now it’s your turn.

Click here to comment

Funding Changes to Physiotherapy—Where’s CPO in all of this?

Thanks for stopping by to read my first blog. I am hopeful that you’ll stay long enough to leave a comment and tell me what you think about this issue. The purpose of Shenda’s Blog is to generate discussion around things that matter to patients, the public, physiotherapists and anyone touched by the regulatory world, so don’t be shy.

This summer there’s been lots of conversations about the government’s announced funding changes for physiotherapy. One of the conversation threads in an article that ran in the Toronto Star suggested that the College should take action against those people who had been allegedly billing OHIP excessively up until now.

Here’s how that conversation unfolded. On July 25, the Toronto Star reported, “Letters aimed at recovering $104,600 were couriered to 45 clinics Wednesday after a three-month OHIP audit found more than half of the records did not support claims…”

In the comments section on the Star website, jimmydgp wrote: “I will call the College of Physiotherapist’s [sic] of Ontario today and enquire as to why all of the PT’s who have contributed to this scheme are not suspended…”

And then on July 26, james58 wrote, “Why isn’t the College of Physiotherapists who are supposed to protect the public investigating these bogus clinics?“

On July 27, Dave U. randomly emailed me directly to ask, “Where is the CPO on this? Why are they so quiet?”

Where are we indeed?

Personally, I stand in the ranks of the outraged, if as the Star reported, 58% of billings made by designated OHIP clinics were unsupported. (Please be clear, I don’t know if that’s true, I am only quoting what the paper said).

What do you think?

Were the billings appropriate if the government had created a loophole that permitted them to flow the way they did? Should we accept that individual physiotherapists were merely employees and not responsible for the way the companies for which they worked billed OHIP? Do group exercise classes really equal physiotherapy? Do you think that the OHIP billing allegations, together with the Auto Insurance Anti-Fraud investigation from last year, have irrevocably tarnished the professional reputation of physiotherapists?

It seems to me that many of you are likely uncomfortable with the old funding model and the billing activities it led to. Let me tell you why I think this.

Last fall and winter, I went around the province with John Spirou, College President and a practicing physiotherapist. We spoke with groups of physiotherapists about a day in the life of the College. We presented a couple of real life scenarios of cases where PTs had inappropriately billed insurance companies. John would always ask the assembled group of PTs, “How does this make you feel? Are you embarrassed that a physiotherapist would do this?” The physiotherapists we met with were universally appalled by this conduct. In fact, in many of the examples that we shared, PTs thought the College response was far too lenient.

I formed the impression that the majority of physiotherapists have pretty strict ideas of what’s appropriate in terms of billing. If that’s correct, how are PTs feeling about the newspaper coverage of this issue?

And, back to the question of where is the College on the allegedly inappropriate OHIP billings?

We are not like the police force. We cannot undertake investigations without receiving a formal complaint or having solid evidence that an individual has committed an act of professional misconduct. And we don’t have the power to investigate clinics or businesses, only individuals—but let’s talk about that in a future blog post.

So where is the College on all of this?

We’re watching and waiting—just like you are.

By the way, jimmydgp, you never called!