In Part 1 of this series, I presented the first pillar of an EPIC solution for health care reform: Evidence. In short, the application of science-based approaches of assessment and treatment would decrease costs and improve outcomes.
The US is spending a lot of money to insure fewer people and provide less adequate care. Our current system of health insurance is based on a pooled risk. The insurance company effectively rations care simply by making the decision to pay or not, based on the risk factor involved. Don’t forget: the insurance company is doing whatever it can to minimize payments because, imagine this, they are a business trying to make money. We shouldn’t necessarily hold that against them.
What people want their health insurance to do – and what it is actually designed to do – are two different things. If you have auto insurance, for example, you don’t expect it to pay for the maintenance of your vehicle, do you? You would only utilize it in catastrophic situations. There is nothing wrong with that thinking – but a pooled risk system isn’t designed very effectively for the health care world. So let’s build it a little differently from the ground up.
Health care reform has become a red hot topic that has inspired the wrath of Republicans and Democrats alike. Both groups, much like Nero, are playing the fiddle as Rome burns and health care costs skyrocket. Some have gone so far as to say that health care reform may even be unconstitutional. As the debate is waged, facts are lost in the vitriol and diatribe.
One fact that everyone agrees on is the cost of health care in this country. We are currently spending 17% of our GDP annually to pay for health care. Projections are close to 20% over the next decade. That is not something that can be maintained. Simple. Rome is burning and needs a fire extinguisher, and a big one at that.
As Einstein once said, we cannot solve problems using the same thinking that we used to develop them in the first place. And this becomes all the more apparent in health care.
This four part series is about exactly that – solutions to the health care woes in this country. It will require an EPIC solution for an epic problem.
Effective treatment should be more than just throwing a bunch of interventions at the wall and hoping that one of them sticks. It should consist of an evidence-based intervention defined by a sound clinical reasoning process.
Clinical reasoning skills are as important as (if not more than) patient handling skills or manual techniques or clinical prediction rules. But “learning how to think” isn’t typically a college course, and the task of acquiring these skills is typically under-appreciated in both the practicing clinician and student clinician. Why spend time learning how to think when I need to spend time learning how to do?
Clinicians will often neglect the impact of their beliefs on their clinical reasoning skills. It is terribly easy to introduce a number of errors into the clinical reasoning process, and in doing so, create a situation in which “logic” and “evidence” fight a battle with “anecdote” and “beliefs”. This in turn severely limits the clinician’s ability to formulate clear hypotheses, consistent mechanical and medical diagnoses, and evidence-based treatment interventions.
It has become a reality in the political arena, regardless of the issue – be it the environment, immigration, or health care. There is always an 800 pound gorilla in the room that nobody wants to talk about for any number of reasons. Taking a hard line with the gorilla - “playing hardball”, if you will – can be a perilous task indeed.
It is pretty tough to play hardball with that 800 pound gorilla in the room. The gorilla has a strong fastball, throws a great curve, and has lots of power behind it. It has a cute smile, that gorilla, just before it decides to tear your head off.
The health care system has historically had physicians in the role of “gatekeepers”, in which the physician directs all care for the patient. But the health care world is changing. Patients want access to care, and they want to do so with any number of providers. They want direct access to chiropractors, advanced nurse practitioners, and physical therapists, among others.
Enter the 800 pound Direct Access gorilla, known as the American Medical Association, and it’s Scope Of Practice Partnership. George Orwell would be proud: if you are a non-physician health care provider, Big Brother is watching your every move.
The numbers are a little staggering. Eighty percent of the population will eventually suffer from non-specific low back pain. Most of those people will have back pain that presents with no apparent mechanism of injury.
The reality of most clinical practice guidelines for the treatment of low back pain is pretty simple – don’t do the things that aggravate it, do the things that make it feel better, stay active, and do not take any more than a couple of days of bed rest (if any). Though that doesn’t appear to be any sort of rocket science, the majority of the research on low back pain leads us to these simple conclusions.
Wouldn’t it be great if there was a solution that would be successful with a large number of people, provide consistent results, and focus on self care strategies? Better yet, let’s make that solution cost-effective as well, if at all possible.
How does a $29.99 solution sound to you?
With this in mind, let’s look at three simple strategies and principles that can be used on a daily basis to decrease low back pain.
In my last post, I discussed how the bell curve could put a lot of training myths and fallacies to rest. But if you think that the outliers dominate training and fitness, wait until you look at their effect on health care.
In health care, and most certainly in the sports medicine world, clinicians continue to believe that symmetry and alignment are critical in the discussion of injury rehabilitation and prevention. In the same breath, there are countless clinicians (be they physical therapists, chiropractors, massage therapists or physicians) that go on to describe biomechanical mal-alignments and “imbalances”, and then spend their lives trying to treat patients that present with these “syndromes”. In their minds, it is obvious: that which is not symmetrical must in fact be a cause of your _____ pain (insert any typical musculoskeletal complaint here).
I never cease to be amazed that the human species has survived thousands of years with the scourge of the dreaded biomechanical mal-alignment. Wow. It is hard to believe how we, as a species, could ever survive a quarter inch difference in leg length as we ran through the jungle, or how we didn’t die of neck pain given that one shoulder was higher than the other.
For many, the bell curve might be a faded memory from a college statistics class. It might be a painful memory at that! But it can also serve as the foundation for many discussions in the health and fitness world.
For those who may have forgotten, S.E. Smith notes that “a bell curve is a graph which depicts a normal distribution of variables, in which most values cluster around a mean (average), while outliers can be found above and below the mean”. A bell curve indicates that the variables are within normal expectations and behaving in a predictable manner.
Although the context and relevance of a normal distribution are well known, it is amazing how these can be selectively forgotten in the health, fitness, and sport worlds. We could put a lot of training myths and fallacies to rest, once and for all, by rigorously testing our assumptions and using what we know about the bell curve.
First, we need a brief refresher class in statistics. Then, with bell curve in hand, we will dive headlong into myth-squashing and envelope-pushing.
Allan Besselink, PT, DPT, Ph.D., Dip.MDT has a unique voice in the world of sports, education, and health care. Read more about Allan here.