Submitted by: Jeremy Nelson MPT
If its our job to make a plan of care, to orchestrate changes over a period time that will cause the structure of our client to be able to perform better, why not look to the knowledge bases and skill sets of other makers to see if we can learn something. Music composers, strategic planners, choreographers, architects, and other professions of the arts. In particular the training they receive in the being professional makers or creators. All develop arrangements of interrelated parts that give rise to specific results, whether the medium for the artist is sound, light, space, or color.
The subject matter that the rehab and sports performance professional works in is that of human motion. What is there to be learned by the professional artist that consistently produces specific works of art, sometimes requiring weeks, months or years to complete the work. How do they organize their work and change efforts? Is it something that can be applied to the work of improving human function and performance? A little background on the on going investigation of producing specific results in the realm of physical therapy is presented in the following paragraphs.
Many years ago, as a shiny new PT I worked for one of the big rehab providers that were dominant in the rehabilitation market during the 1990’s. This was the time of Managed Care and by the late 90’s providers, regulators and the consumers were beginning to push back having been pushed around by the often indisputable decisions of HMO’s and other managed care organizations. The whole focus was on reducing costs, which was coming from a focus on the problem of increasing health care costs. Make the system more efficient because of the problem of waste. Too much out of control costs were threatening to ruin the future. The action was to rope in these out of control costs or bad things would happen.
As a result, this general policy was being applied in large generalizations based on diagnoses, DRG’s and other attempts to find accounting hand holds will deciding how to allocate the healthcare dollars. The principle was that pathology could be categorized and the patient assigned to a general category of pathology that would be associated with best practices, care paths, and reasonable costs. Certainly a logical consideration when working from within the problem solving structure. However this was to set up a conflict based on values that change healthcare as we know it today.
What they were seeing was through bottom lining each diagnoses, patients could be categorized and treatment plans standardized to off the shelf pathways. What myself and my colleagues were seeing was something different. What we collectively understood was that each patient is unique and their circumstance more than just their diagnoses. Often times patients with the same diagnoses presented very differently in terms of their needs for functional restoration and the services of a rehab professional. As a result, pathways were unsupportive in providing guidance. More categorization on a sub categorization level was prescribed and diagnoses were divided again and again adding to the complexity.
This was all taking place within the context of one of the few remaining centralized hospitals for rehab services. At one time, novice rehab professional, the land was full of rehabilitation hospitals, dedicated to restoring function over weeks to months. Today, the goal of full rehabilitation before returning to the community is unlikely. The pressures were immense for a large organization to try and manage the limited reimbursements from patients that required reasonable resources. But again we were up against a system that was grouping patients by diagnoses.
The FOR – Functional Outcome Report
With support from my colleagues in the rehab department we started to develop a tool, a communication tool, to provide information to the insurance adjusters that presented the patient unique situation. Using the Nagi model as a basis, the report sought to demonstrate the unique levels of function of the patient and in relation to the needed levels of activity to return home. With this slingshot we took on Goliath. Well it didn’t turn out the way I thought it would, namely the development of the tool as an on-going part of the medical record. But it did clarify in my mind that as a patient advocate, the place to start was with an honest assessment of the current capacity of the patient and trying to describe it within the context of the physical demands that would be required to re-enter the community.
In this way, perspective was developed that could assist in decision making. No longer would I be focused on the diagnoses as the primary organizing data point to my plan of care and actions. Now don’t get me wrong, I am not anti pathway, nor do I rail against the evils of protocols. These are valuable and necessary tools. What has changed with most pathways is that the sequentially organized outcomes are defined in a way were they can be measured. For it’s the assessment of current reality that changes the pathway from route process to a tool for clinical decision making. However, event this addition of a clear current reality and what the outcome is supposed to look like will not be enough to support the long term change efforts associated with most rehabilitation and sports performance improvement. For that we need to understand what the professionals who work for weeks, months, and years in producing a work of art, a composition, a software project or other structure that is interacted with.
Better Forms of Problem Solving.
After I changed organizations, I was involved with the task of improving efficiencies for an organization I was employed by. It seemed simple again, build a better system of patient care and the world will beat a path to our door. Before I began studying structures, patterns and the dynamics creates by structural relationships, I continued with experimenting with various classifications systems, now with the power of relational databases. However as I would learn later, classifying is not creating nor is classifying the same as clinical decision making. I now had a more robust system of sorting data and repeatable logic in the form of a computerized database.
This type of “If Then” thinking seemed like the approach to take at the time. But again I bumped up against my preoccupation with the specific. No classification system could encompass all possibilities, given that all patients had unique circumstances, desired outcomes, capacities and environmental constraints. And even if it could, the data structure would not be able to handle the human element of values. Within the context of the specific, one element of the decision may outweigh all of the other considerations. It seemed that trying to produce a better problem solving approach was limiting what we could provide and was working against the customization and patient focus that we were telling our community that we valued as an organization.
It’s worth repeating that the practice of improving and restoring function is an act of making, of building. There may be some tasks that require the elimination of something but it’s always in support of some sort of specific outcome or behavior. You can eliminate the pain in a joint and still not have an arm that can throw a ball. You can restore the flexibility of the lower extremities and still not have someone who can walk safely. I think Robert Fritz has said it best, “You can get rid of all of your problems, and still not have what you want.”
Although I could see the need to be able to make things and my role as a PT as a maker of body structures that would give rise to functional patterns, I was not very good at it. I came by that poor performance honestly as I was simply applying the wrong causal structure to produce the changes that I wanted. Most of the time the pattern was to make a big effort, see change in my patient, and then have that patient return in a few months with the same problem and then to take massive effort again in dealing with the crisis. I understood bio mechanics but faced with the multiple data points and complexity of moving parts it was difficult to organize the information into a narrative of actions taken over time to improve function. Often time, the patient and myself would know that an outcome was wanted in terms of returning to the golf course after the back injury, or beginning tennis after the shoulder pain, but the action would sort of run out of steam.
Over the years I have been amazed at the complexity of functional movement. When the hierarchical arrangement of the body and the smaller movements that support the larger functional patterns are superimposed on the complexity of movement, it becomes much less complicated. As I continued to study the different fields of art and the knowledge base and skill sets of composers, painters, and other makers, I learned that the highly complex is an arrangement of simple relationships. These simple relationships act as a basic unit of measure that can be organized in higher levels of hierarchical arrangement.
Whether it is a Bach fugue or a Picasso, the fundamental relationships are present. It wasn’t until I began studying system dynamics and structural dynamics that I began to learn that the cause of the problem is not always at the site of the symptoms. Also, I learned through the study of Structural Dynamics, that the arrangement of outcome and the current reality assessment of the outcome can produce a new dynamic to restore momentum when the energy had gone out of the project. This was a tool of the trade for professional makers, as they would step into their work, producing and making, and then step back to get a clear perspective of how it was progressing in relation to the vision of the work.
Structure is found also in the subject matter of artists. Musicians work in a world of proportionally related sounds. This scale of sounds and their internal relationships provide the foundation for the development of music. Music includes rhythm, melody and other observable behaviors. If the sounds were not prior related, it would be impossible to produce music. For these scales hold in them the ability to produce tensions, tensions that come from the arrangement of opposite but complementary musical notes.
The human body also contains proportions and a hierarchy of arrangement. The body is a series of interrelated components of a whole, each with a supportive function towards a functional outcome. We can use this underlying proportional structure to produce intensification of functional movement we call therapeutic exercises. Not all therapeutic exercise are created equal. Just as a wrong note to ruin the momentum and capacity for expression in a piece of music, so can including an exercise that undermines the function of the component as it supports the COG BOS primary relationships.
Artists and other makers have specific skill sets and knowledge bases. They have unique sets of knowledge, however they have the commonality of organizing their workflow to produce long term change over time. With an understanding of how to make things, the rehab and sports performance professional can add this skill to their change efforts, providing more opportunity for the change that clients and patients want to be involved in their lives as they desire.