Clinical Decision Making

Clinical Decision Making

 Standard familiar decisions: The PT’s knowledge and experience make these
decisions almost automatic.
 For example, 85% of a PT’s caseload may be made up of children with developmental
delays. Patient management decisions for these patients are standard and familiar
 Standard unfamiliar decisions: The diagnosis and treatments for a condition are
well known or at least supported by research but are not commonly encountered.
 For example, the same PT as above may be assigned a patient with torticollis; the PT is
able to make decisions about the child’s therapy but may feel less comfortable with or
confident in patient/client management decisions for this new patient
 Open familiar decisions: These are familiar decisions that involve some
idiosyncratic (distinctive)element, such that further investigation or new
strategies are required.
 For example, the pediatric PT may be assigned a new patient with developmental
delays who also has visual and hearing impairments; the PT must therefore modify
all the components of patient/client management to work effectively with the
patient
 Open unfamiliar decisions: These decisions involve confusing or conflicting
information that requires longer and more careful consideration.
 For example, the parents of a child with developmental delays may request that the
PT incorporate aromatherapy into the treatment sessions; otherwise they will take
the child to another PT. Later the same day, the father of another patient tells the
PT that he has lost his job and no longer has insurance to pay for the physical
therapy services his child has been receiving regularly for over a year. In each case
the PT must decide what action would be in the best interest of the patient.
Referral relationship

 More than 30 states have passed legislation allowing the public direct
access to PTs (and in 48 states PTs can perform initial examinations
without a physician’s referral)
 Most physicians now refer a patient for physical therapy without
prescribing a detailed program; the referral simply reads, “Evaluate and
treat.”
 The skills of the PT in all elements of patient/client management may be
examined much more closely by individuals who are self-referring than
they are by patients who are referred and who assume that the referral is
in their best interest.
TECHNOLOGICAL ADVANCES
Interpersonal Relationships

 In the 1977 Mary McMillan Lecture, Mary Clyde Singleton reminded

the physical therapy profession of the importance of its human side,
seen in PTs’ devotion to human welfare and in the need for PTs to be
compassionate, loving, understanding
FACTORS IMPORTANT TO SUCCESSFUL PHYSICAL THERAPY
TREATMENT

1. The physical therapist’s treatment method is the most decisive (quick decision) factor in the
patient’s recovery.
2. A physical therapist should not become too involved with the patient’s personal or social
problems; these are the responsibility of other health care professionals.
3. Patient motivation is a vital component of successful therapy.
4. The interaction between the patient and therapist is crucial in physical therapy.
5. Physical therapy should promote the patient’s health rather than emphasizing the diagnosis.
6. The physical therapist’s knowledge and technique are what make physical therapy work.
7. The physical therapist should not simply treat a part of the body part, but rather should be
interested in the whole person. (holistic approach)
8. Physical therapy should be oriented toward the patient’s resources rather than the person’s
problems.
9. The patient’s own capacity for recovery is a major factor in the success of physical therapy.
10. Physical therapy is above all an aid to self-help; it works by eliciting the patient’s own ability
to change and improve.
11. The interaction between the physical therapist and patient that makes physical therapy
successful begins during the first therapy session.
12. The physical therapist should place less emphasis on the patient’s diagnosis and more
emphasis on enhancing the individual’s coping skills.
13. The interaction that occurs between the client and physical therapist has no bearing on a
successful treatment outcome.
14. The patient’s diagnosis should be the central focus of attention in physical therapy.
15. Many patients can be treated successfully without the physical therapist necessarily having a
holistic view of the individual.
Ethical and legal issues

 Legal issues in patient/client management are addressed in state statutes, or

practice acts, that regulate the physical therapy profession.
 PTs must be knowledgeable about the practice act in each state in which they
intend to work, because the components of patient/client management and
the factors that affect it may differ from one jurisdiction to another.
 Code of Ethics and Guide for
Professional Conduct

 As the term patient/client management might suggest, ethical issues related to this
role of the PT focus on the relationship between the therapist and the patient, as
well as the context in which these issues arise.
 For example, the APTA’s Guide for Professional Conduct (GPC) includes sections
on confidentiality, trustworthiness, or fidelity, respect for the individual’s rights and
dignity, and the autonomy of the patient .
 A physical therapist shall place the patient’s/client’s interests above those of the
physical therapist. Working in the patient’s/client’s best interest requires knowledge
of the patient’s/client’s needs from the patient’s/client’s perspective.
 Patients/clients often come to the physical therapist in a vulnerable state and
normally will rely on the physical therapist’s advice, which they perceive to be
based on superior knowledge, skill, and experience. The trustworthy physical
therapist acts to ameliorate(make better) the patient’s/client’s vulnerability, not to
exploit it.
Informed Consent

 Beauchamp and Childress describe informed consent as having

five elements:
 Competence,
 Disclosure,
 Understanding,
 Voluntariness,
 Consent.
 Managed Care and Fidelity

 In an attempt to put the brakes on escalating health care costs, managed care
organizations have established financial incentives for providing fewer
services.
 Morreim describes this as a “balancing act” in which health care providers
must balance fidelity to the patient with accountability to society and financial
self-interest. In this regard, Morreim argues, conflict of interest is inherent to
the managed care system.
Thanks