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Switching From Autopilot

jules-rothstein@attbi.com

Every commuter knows the feeling. You gaze out the window, recognizing the familiar surroundings, but suddenly it occurs to you that you don't know how you arrived. You are where you think you should be, but you can't recall taking the turns and making the decisions that led you there.

Unfortunately, this commuter experience may be all too similar to how we function in other aspects of our lives—including how we practice.

Despite an increased focus on patient-specific functional goals, physical therapists (and other health care professionals) lack a general consensus about what constitutes "clinical success." Like commuters who navigate their way to work unconsciously, we often find ourselves functioning on automatic pilot in the clinic, gravitating toward measurements of impairment or classic measurements of function as indicators of clinical success. For any given patient, however, these types of measurements might not be relevant, particularly when it comes to interventions designed for preventive purposes or to the patient who has a unique lifestyle and values atypical tasks.

This month in the Journal, Beattie and colleagues (page 557) discuss the development of a patient satisfaction instrument that they offer as another way to determine whether we have a successful outcome with a given patient. Although the results are somewhat preliminary, the data indicate that patient satisfaction is often influenced by factors not directly controlled by physical therapists. For instance, certain aspects of patient satisfaction may be determined more by the skill of the architect who designed the clinic than by the clinical competence of the physical therapist. Beattie and colleagues suggest that such factors are not as important as professionalism and adequate time spent in patient care; however, based on this study and others, such as those mentioned by Beattie et al, patient satisfaction clearly is associated with a variety of factors, only some of which may be under the direct control of the individual physical therapist.

Members of our profession need to discuss the role of patient satisfaction in the assessment of both physical therapist performance and clinical benefit, and some of the discussions should include other interested parties, such as payers and patient groups. There is no doubt that we prefer having satisfied patients to having dissatisfied ones—but there also is no doubt that legitimate concerns exist regarding the use of satisfaction as an outcome measurement.

Treatment beyond what is necessary or justifiable, physically ostentatious offices, and a variety of creature comforts may result in "satisfied customers," but does that indicate that the physical therapy was successful or that an intervention meaningfully changed a patient's life? Another critical consideration is whether patient satisfaction compromises payer satisfaction. A balance must be struck, taking into account what is important for the patient and what is feasible under the payment system. In short, although patient satisfaction measurements seem to have a place in practice, we have yet to adequately define that place.

In stark contrast to the use of satisfaction scales in assessing the outcome of interventions, Martin and colleagues (page 566) focus on a more traditional measurement, one based on neural control and biomechanics. They examine the use of the distance measurement between the vertical projections of the center of mass and the center of pressure in people with Parkinson syndrome, contending that this measurement may be useful in the assessment of intervention outcomes. At one time, this type of measurement would have been welcomed by physical therapists as a scientifically based impairment measurement that could demonstrate, in an incontrovertible manner, whether we achieve something through physical therapy. I believe that time is past, however.

Just as the proponents of patient satisfaction measurements have to develop underlying concepts and arguments, so too do the proponents of the type of measurements that Martin et al identify. The authors describe a well-conducted study in which technologically impressive instrumentation was used to examine what they believe is an indicator of neurological control. But a question remains for researchers: Should this measurement—even if it reflects neurological control, particularly in people with Parkinson syndrome—be used to assess the outcome of an intervention? Or does this type of measurement have more value as an indicator of the nature of underlying impairments, and, if so, would it be of greatest value as something that guides a treatment strategy?

These two uses of a measurement—to measure outcomes and to guide interventions—are not mutually exclusive. The problem is that we often assume without evidence that a measurement used for one purpose can be used equally well for another. I would argue that, until a measurement is shown to predict some meaningful benefit to a person's ability to function, we cannot assume that the measurement is a meaningful outcome measurement. Nor can we assume that seemingly desirable changes in variables justify specific interventions or physical therapy in general.

Regardless of the types of measurements we use (eg, patient satisfaction or variables that reflect biomechanical or neural control), we need a firm theoretical foundation before claiming that the measurements can be used to judge the benefits of interventions or to justify our services. That theoretical foundation preferably should arise from the accumulation of data and the synthesis of ideas that are tested through research—not from the comfort that we feel in using familiar interventions and familiar outcome measurements.

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This Article Submit a response Alert me when this article is cited Alert me when Rapid Responses are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Rothstein, J. M Search for Related Content PubMed PubMed Citation Articles by Rothstein, J. M Related Collections All Editorials Jules Rothstein Social Bookmarking                      What's this?