Physical Therapy telehealth lessons learned mistakes made

Physical Therapy telehealth lessons learned mistakes made

 

 

My perception of my abilities providing telehealth video conferencing Physical Therapy or Physical Therapy service online follows the Dunning-Kruger effect.

 

 

The Dunning-Krueger effect is a process of overestimating and underestimating our abilities and competence.

 

When I began offering telehealth Physical Therapy in 2017, I initially overestimated my abilities. Over the past seven years, I have progressed through the four stages of the Dunning-Kruger effect.

 

• Unconscious incompetence – didn’t know what I didn't know.
• Conscious incompetence – became aware of what I didn't know.
• Conscious competence – gained more competence.
• Unconscious competence – haven’t quite mastered it yet.

 

Unconscious incompetence – didn’t know what I didn't know.

When I started providing Physical Therapy services online my confidence was high. I believe 80% of diagnosis is a result of listening to what the patient tells me. I had decades of listening to patients. In my area of expertise, I felt confident at providing not only effective assistance but efficient service as well.

 

Then the COVID pandemic hit, I thought great I’m already set up with providing Physical Therapy online. I was ready.

 

Conscious incompetence – became aware of what I didn’t know.

Eventually I realized that:

• My confidence was higher when I could physically guide patients – a luxury telehealth does not allow.
• I also struggled with verbally directing movements, a skill I needed to refine.
• My skills in telehealth did not work for everyone.
• There are frustrating ambiguities regarding statutory limitations providing telehealth services. For example, one of my patients sent me an email request for assistance while she was on a cruise in the Caribbean Ocean. I reached out to the Physical Therapy Virginia license board for guidance. The guidance was that statutes and regulations did not address this issue.

 

Conscious competence – gained more competence

I gradually accepted that in-person Physical Therapy is generally superior, but I also recognized that telehealth Physical Therapy has distinct advantages in certain situations.

 

When the available times because of commitments of the patient, telehealth can be a good alternative for in-person visits. For example, work hours and time commitments to take care of aging parents or children make it difficult to find time for travel and waiting for in-person medical appointments.

 

When the costs for the patient are prohibitive because of a lack of health insurance coverage, high deductibles on health insurance plans, the cost for the patient for a telehealth visit should be less when self-paying versus in person visits. There are a limited number of studies showing costs for telehealth visits is lower than in person visits.

 

When obtaining optimal medical services is difficult because of geographic distance barriers telehealth can be a good alternative or supplement for in person visits. I have been able to provide second opinions regarding Physical Therapy to patients living more than 2 hours car drive from Richmond Va, and patient’s living in Georgia US. Telehealth services benefit individuals with chronic pain by reducing the need for painful travel to in-person visits.

 

Another benefit is a telehealth visit may allow the healthcare provider to see the real environment the patient is dealing with. This facilitates intervention involving movement pattern training.

 

Unconscious competence – haven’t quite mastered it yet.

With more time and practice, I learned how to become more effective with the telehealth mode of Physical Therapy service.

 

My standard practice during in-person Physical Therapy visits is to provide the patient with real-time visual feedback on how they are moving using 2D slow motion video.

 

A prevailing belief is that Physical Therapy is known to provide hands-on interventions. Telehealth Physical Therapy is not hands-on interventions.

 

Physical Therapists are movement specialists.

Physical therapists examine and evaluate the movement (system including diagnosis and prognosis) to provide a customized and integrated plan of care to achieve the individual’s goal-directed outcomes.  Physical therapists maximize an individual’s ability to engage with and respond to his or her environment using movement-related interventions to optimize functional capacity and performance.

If there is pain with movement then observation of movement is important. Observing painful movement occurs during telehealth visit.

Recording of telehealth video conference and screen shots sharing of visual data with patients can occur during subsequent sessions.

As my understanding of telehealth evolved, I also explored different ways of delivering remote care, including synchronous and asynchronous methods. Synchronous telehealth is a real-time interaction between the patient and a healthcare provider.  Whereas asynchronous telehealth also known as “store-and-forward” is communication between parties that is not live. The tactic of using video recordings is well suited for asynchronous telehealth.

Here is an example of assisting a patient to move in a more optimal way during a telehealth session to manage rib pain that was accomplished during the COVID pandemic.

Having the patient capture a real-world selfie video while moving during a painful activity has proven valuable and is amenable to use during synchronous or asynchronous telehealth visits.

I learned that some of the shortcomings of telehealth visits can be overcome by providing a hybrid of combining follow-up with in-person visits with telehealth visits.

My hope is to continue progressing through the uncertainties and ambiguities of the competencies of providing Physical Therapy services using intellectual humility.

 

"Real knowledge is to know the extent of one's ignorance” – Confucius

 

 

Keywords: Telehealth, Physical Therapy, PT Online, competency, Georgia, Virginia, Dunning-Kruger, Movement specialists, Selfie-Video, chronic pain, second opinion  

In-person Physical Therapy is generally superior, but telehealth Physical Therapy and hybrid combination of telehealth and in-person Physical Therapy has distinct advantages in certain situations.