The Value of Telehealth

The following are some thoughts combined with an excerpt from an email conversation I had with Mike Studor, PT, MHS, NCS, CEEAA, CWT, CSST, FAPTA.   His question are likely on the minds of many of our colleagues.  

The novel Corona-virus, COVID 19 Pandemic of 2020 has dramatically changed how we do anything and everything. It has plunged us into an existence that is contrary to the human condition: isolation.  As humans, we are not designed to be isolated. We are social animals equipped with nervous systems specialized to connect, interact and create within a social network (family, tribe, clan, etc.). Yet, at this historic moment, we are asked to perform “social distancing” to protect ourselves and others from the spread of the virus.  I strongly pronounce that “Social distancing” is the wrong phrase. Truly, the intent and behaviors we need to exhibit should be physical distancing. We need to be physically distanced from each other, not socially. This is not a “thought virus”, this is a physical virus that only spreads through physical contact with physically contaminated objects.  The wrong kind of distancing as significant consequences to our health.  

For new readers, I am a physical therapist whose Mission is to explore the science of relationship to improve healthcare.  Read more

Question: As a physical therapist, what value do I provide?

I'm gonna use this and the following questions to geek out a bit.  My field of study is the neuroscience of the relationship between the patient and the provider.  I think that most would agree that an "outcome" is more than the technique we perform on a patient.  We as physical therapists (and medicine as a whole) strive to get "better outcomes", but are not exactly sure how.  I do not believe that we fully understand all of the "attribution factors" that create a successful outcome. And until we have additional empirical research to firm it up, we are relying on ideas and theories.   For now, I believe that the best investment in understanding how to optimize clinical outcome is an N=1 model where the outcome is determined by the therapeutic alliance between the PT and the patient. 

Questions: I am compelled to ask myself, if the building, the equipment, the milieu of our clinic went away – where is the value?  

Answer:  Value to who?  The obvious answer is "to the patient", but I would also suggest that there must be value for the provider.  We must move beyond the myth of a “patient-centered” model of care. It must be relationship-centered. The success is in the provider “showing up” fully for the encounter to listen, to connect, to synthesize the patient’s experience into her own and to co-create a treatment plan.  The provider must be fully invested or she is relegated to being a technician performing a procedure. The clinic space, the equipment and the milieu are all a part of the treatment experience, both for the patient and the provider. When you take those elements away, what remains is the relationship, maintained in whatever way possible.  In my opinión, the value can be described to what happens between the patient and the provider in a therapeutic alliance.  

Question:  More importantly, “where WAS the value?” in the mind of the patient [during the in-clinic appointment].  

Answer:  That depends on the mind of that patient (N=1). As mentioned, we have brains fully equipped to connect with others, and circuits dedicated to “mind reading”.   However, the challenge we face is thinking that we know the "minds" of others; when in reality, we are constantly making assumptions about the minds of others (I explain the neuroscience of this part of the nervous system in my courses).  This assumption process is important and efficient for high-paced human interaction, but not always accurate. To truly understand the value in the mind of the patient, we have to ask. 

Question:  If I or we did not convey an experience that was valuable beyond the tangibles of the in-person visit (my hands, our equipment, etc) then what value did the patient take from the experience?  

Answer:  YES, this is critical!  I believe strongly that the physical therapist is more than a proceduralist!  PT’s improve function by getting people moving. We offer essential "mechanical" interventions (moving a patient's body part manually and through activation of nerves and muscles), but I maintain that is only part of the "value".    Although we are trained as mechanics and we facilitate movement, the patient must ultimately be the one who integrates the movement into their lives. A physical therapist, at his or her best, is guiding the patient in a process of integrating mobility into his or her life.  The saying I commonly use "The best surgeon cannot heal a cut." The patient does the healing, we have a specific role in that healing process. A successful relationship between the patient and provider activates a bunch of neurological processes that affect "healing".  

Question: In the in-person clinical setting, was our interaction personally valuable enough to them that they feel that I can give them some value when we are physically removed?  

Key phrasing is "personally valuable enough". This captures the essence of "patient-centered", although I think that patient-centered does not actually work.  The question might better be, "what does this patient 'personally value', and can I give them enough of it so that they actually perceive it and stay engaged in a treatment plan?"  When I know that, the next questions are easier...

In summary, if a PT has already established a meaningful relationship with the patient, then that engagement can continue in telehealth, but will require some additional skills to maintain that relationship.  If not, then the perceived value, by both, may not be worth the effort.  And a New Patient to the practice can also have a valuable experience, when it's done "properly". 

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