When I was in college, I worked at a summer camp in Maine for 2 summers. When a group of adolescents from the age group I was assigned to as a counselor was going on their first overnight climb with a full backpack, I, along with other counselors, was assigned to that adventure. Approximately half way up the mountain, one of the campers threw her backpack to the ground and proclaimed that she was not going to carry her backpack any longer. I told her that while it certainly was her choice to make that decision, that included in the contents of her backpack was her lunch and snacks for that day and that she was not going to be allowed to ask for food from any of her friends. Well, after approximately 20 yards she stomped back to where she had dropped her backpack, put it on her back, and proceeded to make it to the top where she was able to appreciate the beautiful view from Mount Jefferson, one of the Presidential Mountains in New Hampshire, while she ate her lunch. The moral of that story is that sometimes one has to be pushed to reach the top of a mountain and that kicking and screaming are just a waste of energy.
A few years ago I decided that I wanted to climb Mount Katahdin, which is the mountain in Maine that has the highest elevation (5269 feet). I had planned to initiate a good training program by first climbing a few 1000 footers, then a few 2000 to 3000 footers, and then a couple 4000 footers. Well, somehow the summer got away from me and I had not been able to follow through with most of the training plan. But, I had reserved a camping site in Baxter State Park and so, one day in August, I began my ascent at 6:30 in the morning along with 3 friends. We listened to the weather that morning on the local station and heard that it was predicted to be 70°F with 15-mph winds. We were pleased with that because it was not going to be too hot and the mild wind meant that the black flies would not be as menacing. However, we later learned that we should have sought out the weather prediction specifically for Katahdin. Unfortunately for us, the temperature approximately one-half way up decreased to 40°F and the wind increased to 55-mph gusts. For much of the climb I had to flex my trunk and push into the wind, which required more energy than I had planned to expend. The punch line is that although we made it safely up and down in 12 hours, my final 2 hours were really kind of ugly. Without my hiking poles to plant so that I could swing my legs forward, I would have been in real trouble as my knees did not want to hold me up for the eccentric contractions that were required to prevent my rolling down the very rocky mountain. I had not made the time to complete the training required to accomplish the task and now I was paying the price for that. When we finally made it into the car, I requested a bottle of the electrolyte drink we had, and I know that it took me about 30 minutes to get enough energy to take off the cap of the bottle and another half hour before I could get the bottle to my lips. For the next 2 weeks, my patients/clients had to wait approximately 10 minutes when I had to stand up from a chair or a stool, and if someone knocked on the door to my house I had to yell out, “I'll be there in 10 minutes” (and they could see me through the window).
I am telling these stories as they come to my mind because we, as physical therapists, are now being pushed to climb the “G-code” mountain. We are being pushed to become more accountable about quantifying the effectiveness and efficiency of what we do to assist our patients/clients toward their goals. Although I have wanted to stomp, kick, and scream when writing therapy goals, I have been pushed to write them so that I would have a job so that I could purchase my daily lunch. At the end of some days, I am tempted to write only 1 goal, which would be “to get my patient/client better.” However, I think that my employer would not be too happy with my abbreviated plan. Now the writing of goals is not enough. We have to document that we have a valid and reliable and measurable way to evaluate whether we have accomplished each goal. We must prepare by having appropriate functional outcome measures at our fingertips even before we meet our patients for the first time.
As I assembled a binder for my coworkers that included 1 to 3 functional outcome measures for each joint and impairment, and how to score the tests, and the statistics for each of the tests (reliability, validity, sensitivity, specificity, minimal detectable change, and minimally clinically important difference) I found that many of the outcome measures had been developed in the 1970s, 1980s, and 1990s. It appears that we (and I am included in that “we”), as physical therapists, did not train ourselves (or were not trained in our schooling) to seek an objective and measurable way to document the effectiveness of what we were doing for our patients/clients. We simply were walking along the comfortable path of saying, “I know that I am getting my patients better.” Our push for measuring progress did not come from internal motivation to quantify progress. The push has now come from the external source of the Centers for Medicare & Medicaid Services. I am going to do my best not to stomp, kick, and scream up “G-code” mountain. I invite you to join me (for both endeavors).
Anyway, I have now set a goal to climb Katahdin again in the fall of 2013. Last week, I began properly by climbing a 1000-foot ascent on the Cutler Trail in Hiram, Maine. I hope to climb Katahdin in a much “prettier” way this time. Although I still will bring my hiking poles, I am hoping that my well-being does not depend on them. I hope to be able to enjoy both the ascent and the really awesome view at the top. It is such a privilege to be able to experience breathtaking views of my environment during my days off from work, and it is also a privilege to have the experience of assisting my patients/clients as we train together to accomplish their “functional” goals. Now, with the external push, I am going to be able to proclaim, with objective data to support me, “we did it.”
Nancy C. Donovan, PT, PhD