Resolving the Issue of Unwanted Variation in Clinical Practice with Dr. Tara Jo Manal

Welcome back to the Healing Pain Podcast with Dr. Tara Jo Manal

Today, I’m broadcasting the second interview I recorded live at the Physical Therapy NEXT Exposition & Conference back in June. I want to thank the APTA for arranging this great interview on what’s a very important topic for the profession. Each year at the convention, the John H.P. Maley Lecture Award is presented to an APTA member who has demonstrated clinical expertise and a significant contribution to the physical therapy profession. The lecture is considered to be one of the highlights at the APTA’s NEXT Conference & Exposition. This year’s lecture was awarded to Dr. Tara Jo Manal. It’s titled Strike While the Iron is Hot.  I really love that topic.

Dr. Manal was a Founding Co-Chair of APTA’s PT Now initiative, is Director of Clinical Services and Residency Training at the University of Delaware’s Physical Therapy Department, as well as an associate professor at the DPT program at the University of Delaware. She is board certified in orthopedics as well as sports physical therapy. Her focus is translating the evidence and how it could be implemented into clinical practice. I spoke to Dr. Manal about the importance of standardized practice and how we can prevent the unwanted variation, which can be such a challenge when there’s so much information and a variety of treatments available to us today. This is an important topic whether you’re a clinician, an administrator or a patient. Settle in and take a listen and of course make sure to share it with your friends and family on social media.


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Resolving the Issue of Unwanted Variation in Clinical Practice with Dr. Tara Jo Manal

Tara, welcome to The Healing Pain Podcast. It’s great to have you here.

Thank you very much. I’m glad to be here.

Congratulations on receiving the John H.P. Maley Lecture at this year’s PT Exposition & Conference. It’s a great honor that you can present that. This year, you’re advocating the implementation of standardized procedures in physical therapy. I guess the biggest question is why should a physical therapist be concerned or why should we be moving in that direction?

HPP 055 | Unwanted Variation
One of the biggest risks that we have to best practice is unwanted variation in care.

One of the things that we know in healthcare in general, not just in physical therapy but all healthcare, is that one of the biggest risks that we have to best practice is unwanted variation in care. What that means is not that you can’t have anything that varies because each of our patients are individuals, so absolutely everything should be precision tailored to the individual. However, what you don’t want to do is be below a standard. You don’t want to give below standard care. What’s really important is that we identify, are we standardized? If there is a best standard out there, are we implementing the best standard practices that we have? When we do, it is always better for the patient and cheaper. It’s actually the way in which we hit that Triple Aim of improving healthcare, improving patient’s lives, and reducing costs.

When I first started practicing in 1997, I remember there was this term that was used frequently by a therapist that there’s no cookbook for patients. I think we all understand that patients are individuals, but I think we also understand especially now with the amount of research out there, that there is inefficiency to doing certain things, especially for certain diagnosis that is a best practice. There’s also probably inefficiency within the healthcare system as far as saving dollars. Can you talk further about that a little bit?

I think they come together and that’s what I think is so great. When you mention that cookbook approach, the idea is that parts of cookbooks are good. The idea that if I want to make something, I can make it again and everyone will like it as much as they did the last time is actually a good thing. My family does not want me to stray from a cookbook. When we think about medicine or care, what we’re saying is not that everything can only be done a specific way. What we’re saying is, what are the best standards for that intervention or that condition? If we’re not doing that, we are denying the patient something that they actually mean. If we’re doing things that are unnecessary, we’re over utilizing and so we’re wasting their time and healthcare resources. It’s that really nice balance between the need to’s and the nice to’s and figuring out where are we on that pathway for the specific condition that you’re treating or the specific intervention that you’re providing. What are the guidelines for the specific intervention? What are the guidelines for the specific condition? Either way, are we making sure that all patients are getting best practice in every setting across every environment every time? That’s really what standardization is about. It’s not about taking something away.

We are at the PT NEXT Conference and there are new practitioners here, new physical therapists, as well as those that have been around for decades like therapist like me. Let’s talk first to the new therapist, who’s been out maybe one or two years or maybe a new grad. Why is this important to their practice?

One of the things I think is super important to think about and I actually try to lump us all together because I’m an old practitioner, I’ve been practicing longer than you have either, but I would be a new practitioner tomorrow if I got an acute stroke come in to the clinic that I’m treating. If a patient walked in who had acutely been discharged after stroke, that for me would be a stretch. That would be no different than had I been a new grad because quite honestly, I have not kept up to the level that I would want to, to provide care for that patient. I think we’re all new practitioners at any one moment. It just depends on what walks through our doors.

Truly to the new practitioner, one of the things that I see standardization as and to me in the conditions that I don’t treat very often, I see it as a gift. It’s like my fast track to get to the right answer quickly. If this really did happen and I had a patient after an acute stroke come in and none of my neurological therapists were available or there, I would run over to one and say, “Just get me through the eval. What tests and measures do I need to do? What do I need to look for to stratify for emergency risk? Give me the five-minute tour of what I’ve got to do.” That is standardization. If I could just go and pull that and say, “I know how to do that, that, that. I never heard of that test. Give me two seconds, I’ll pull it up. I can do that test. That’s a great test. Someone invented that. How smart.” I now do that in my evaluation. I have now raised myself up to best practice. Even though literally fifteen minutes before, I might not have known what to do. That’s what standardization is and that’s the gift it gives to new grads as a new therapist and also to the rest of us when we have to stray outside of our practice area, expertise. More and more, we have to do that. We have patients sometimes that come in with a wound and that is not something I do on a regular basis. We consult with a wound therapist and we follow them for a few visits, and we get that person back in there again. I can’t pretend that I have maintained my skills in every possible thing that could walk through my door over 25 years. That’s just not going to happen.

Our profession is we have a breadth of information and specialties, subspecialties. We become quite large as far as a healthcare practitioner goes. We treat a lot of different types of things so what you’re saying makes perfect sense. If I own a private practice and my eye is on let’s say quality care, I want to make sure every patient that comes in my door is treated so they’re happy, they come back, and they tell their friends and family and people in the community. I’m also looking at the bottom line because nowadays in healthcare, reimbursements have dropped so we have to pay attention to our finances in private practice. How might this benefit the private practice owner?

Let me give you a specific example about that and then we can take it in a positive and a little bit in a negative direction. Let’s imagine we’re dealing with blood pressure. For best practice in your private facility, you as the leader have decided that you should really check blood pressures on people before you exercise them and that that’s the smart thing to do. It improves your liability and it’s also right. You implemented that in your practice but you haven’t really standardized how you do that. You just said, “Everybody, we should do it.” You have therapists that are doing it. Maybe they’re not doing it in the best procedure that they could so some of their data’s not very good. They have a blood pressure but it’s not actually very accurate. They’re actually making decisions based on that. Maybe they sent someone away today because their blood pressure was too high. It turns out they have white coat syndrome. You’re always going to have a high blood pressure. A patient missed out the ability to be treated, but you missed out on a patient because you didn’t have a standardized way that you decide to attack this really simple and important thing which is, is this person even safe to be treated?

Someone got anxious. They realize the blood pressure is a little bit high but why is it high and can I work with that?

If you had a standardized approach to how you did that, then you would be sure and confident that all of the therapist would be making the same decisions given the same scenario. As a private practitioner, I run my own clinic although it’s a university clinic. I don’t have the financial responsibilities on my shoulders other than budget. In our clinic, I have students, I have residents and therapists of varying levels of confidence and length of participation and specialization, etc. I need to know that no matter who sees that patient when they walk through the door that they get the same care they would get if they got it from the top person in the room. What that means is when you standardize, you bring everybody up to the level of the best practitioner you’ve got. In my world, that’s at the level of the nation. We, by using standardized protocols, re-evaluation guidelines, etc., clinical practice guidelines, are saying, “Let’s bring us all up to what the best of us know how to do.” As a private practitioner, I want to know that that’s what’s happening in my clinic. I don’t want to hope. I want to know.

I think it’s brilliant because so many practice owners spend time training new practitioners. People come from different schools. They have different professors with different schools of thought or their affiliations maybe were stronger in one area versus the next. What we are saying is they might be able to arrive at your clinic even more trained than you thought they would and you have to invest less in them, which could be beneficial for a private practice owner.

That’s right or you’re investing a significant amount in getting them used to the idea that this is how one practices. That the training in getting everyone up to speed with your rehabilitation guidelines you’re implementing within your facility is teaching that therapist that they cannot be all knowing at all moments, of every time, on every condition that could possibly walk in the door. That is impossible. What you’re saying to them is, “That isn’t how we do it. We go and find the best evidence and we implement that in our practice here. We do it systematically and we all do it together.” That’s a very different environment. As a patient, that’s the one I want to be treated in.

On this podcast, we talk to practitioners as well as patients that are interested in pain. Obviously, the patients are interested in healing their pain. Right now, studies show that the average person with chronic pain sees upwards of ten to fifteen different types of practitioners before they usually land with one practitioner who helps them on their path toward healing. What might standardized care do for that patient who has struggled and searched and really had a problem finding the care they need?

HPP 055 | Unwanted Variation
There are some nice standardized guidelines and screening tools that you can use with patients so you can stratify their risk for chronic pain.

Pain is a great example of that. There are some nice standardized guidelines and screening tools that you can use with patients so you can stratify their risk for chronic pain, as an example of that, to avoid unwanted variation. With that, there’s evidence to suggest that there’s best matched treatment interventions for that stratified risk. The idea that you could go to a clinic that uses standardized care in the case of pain is a great example. They call it in a global sense, psychologically informed care. The idea is that certain patients actually benefit from additional resources aimed at them as your patient. There aren’t resources that every single patient needs but certain patients, if they score on certain levels of screening tools, actually says they would benefit most from matching this. As a patient, I know with their using that standardized practice, I’m going to get the thing I need. If I don’t match for meeting it in order to improve, they aren’t going to waste my time doing it. I can ensure that the experience I have is going to be excellent and it’s going to match me personally. The idea that standardize is one size fits all is exactly the opposite of what it is. It’s those who need what, get that. That’s a very different way of one size fits all.

This is a big project and it’s one that you’re starting to lead as a leader. Where does this exist right now in the physical therapy profession? There had been seeds planted where we see this come up right now.

We’ve been talking about this for a long time and we’re not the only ones. It’s been about twenty years, has been a push in medicine to standardized care. It’s just that physical therapy, we’re a little bit smaller. We don’t have as many deadly procedures so we get away with being under the radar a little on this but it’s been going on for a long time.

Just to touch on that, when you say a deadly procedure, something like a spinal surgery is more likely to be standardized because if it’s not, someone may die from it.

I would love for that to be true. I think if you look at the Dartmouth Atlas of Healthcare, which their job is to track variability in practice in medicine, you will see hugely wide unwanted variation in spinal surgery across the country, which cannot be explained by the patient’s condition or their preferences. That variability is not based on anything that we can concretely recognize as related to the condition that the surgery is for. That variability is related to a lot of other factors that are physician preference, availability on schedules to be filled. There are a lot of reasons for that. That’s why this is so important. For physical therapy, we’re going to be pushed in those same pressures as pay for performance increases. It’s more about how excellent your outcomes are. If they’re not, they will pay for the ones that are and you will not get the same reimbursement and that’s the minimum. The maximum is you get pushed off the ladder.

We can’t have this conversation without talking about how this might impact a physical therapist’s interaction with an insurance company or a third party payer. There are direct cash-based practices but a lot of practices are still working through insurance. What kind of impact might this have on payers?

I’ll give you a positive example. I actually see only positive, quite honestly, with the payers. Some of it is going to be renegotiating what it means for us to care. Let’s think of clinical practice guidelines in muscular torticollis in pediatrics. That clinical practice guideline came out in 2013. They said, “You need to intervene earlier. You’re too slow.” They actually use that data and the data that the CPG, the Clinical Practice Guideline was built on, to get payers to pay for physical therapy when they didn’t use to reimburse for it. That’s a win for the patient, for the baby, for the family, and for the therapist. Using that data can help with third party payers to say, “If you treat it now, we don’t have to treat it and it’s not more expensive later,” and they are listening to that. They are absolutely listening. The negative side is that there had been some arbitrary rules. Not a lot of them don’t all make sense. It might hinder the way you would treat a patient that you think would be the best practice because you can’t be reimbursed if you’re not the one doing the very specific thing. We need to teach them but we can really make that argument when we’re all doing the best practice and we’ve raised up that care, then you can go in and demand something more. When the variability is so all over the place, we can’t point to how that’s best practice. You can’t actually measure the innovation that you try to do if your base is unstable and variable. You can’t see how the treatment that you did was so innovative it actually made the person better faster and was less expensive because your baseline is too variable. We have to standardize and bring everybody up to here then we can innovate.

We’re pretty big as a profession. If I think about just the amount of back pain we treat that’s across the country, very, very common musculoskeletal pain syndrome, all of us would have to start doing similar types of procedures for us to get the data to then take to the insurance company and say, “Right now, you’re giving me nine visits and really I need twelve visits.”

HPP 055 | Unwanted Variation
What we probably need to do more importantly in the short-term is at least measure the same things at specific intervals.

You’re right about that. What we probably need to do more importantly in the short-term is at least measure the same things at specific intervals. We might not have to do the same treatments. What sometimes we find is that there’s a variability like this that’s all acceptable. Unwarranted variability doesn’t mean the same. It means not arbitrarily different. It may turn out that you like to do exercise primarily. Someone else does some manual therapy but then they also incorporate a lot of more home exercise or home program. Another one does it in a step down fitness center but in the end, if all of those get to the same place, then all we start arguing about is which one was cheaper, fast, or best. You’ve got all to the same place but that meant we measured something on all of those people at the same time so that we could compare. I think our first hurdle is to do what they call a standardized data set. We measure that on our patients at some specific time always, every time at that time. That’s how we can start looking at those large cohorts and find out who the superstars are out there. For me, if I find out you’re doing what I’m trying to do but you’re doing it faster, better, I’m done. I’ll just start doing what you’re doing. I am not so invested in anything I do today that I wouldn’t change it for the benefit of my patients.

As you’re talking, I’m seeing numbers fly past my vision because I’m thinking, “We need to start collecting data.” I think we have done a really good job in the last probably ten years in PT of collecting more and more data. Is there any one part of the physical therapy profession whether it’s inpatient, rehab or outpatient where we’re closer to having data that would help a cause like the one you’re backing?

I think that there’s such a push in health services research. They’re almost all in big medical centers because they can really control the costs and they can see the total cost of care. When you have fragmented care like we do in an outpatient environment, they see so many different practitioners. Sometimes it’s really difficult to actually follow the numbers. I think that there’s a lot of innovation that’s happened in those environments. I see that that will probably continue being one of the major pushes. Those systems are doing work in outpatient environments, we just needed to pick up what they’re demonstrating to be improved and start applying it in our environments as well.

This is a fascinating conversation. I think it’s one that’s really important to the profession. I’ve been speaking with Dr. Tara Jo Manal. If people want to learn more about you and more about this topic, where can they find you?

I’m at the University of Delaware. We have our website which is or you can just go to the University of Delaware and type in physical therapy or PT and it will end up in our area. I am there full-time. My primary responsibility is to run a clinic and clinical services as well as teaching the program.

Thank you for being on The Healing Pain Podcast. It’s been a pleasure speaking with you. With every podcast, please make sure to share this with your friends and family and give us a five-star review on Amazon and iTunes to help us out. We’ll see you next week on The Healing Pain Podcast.

About Dr. Tara Jo Manal

Physical therapy cannot move forward as a profession until those who practice it resolve the issue of unwarranted variation in practice. Tara Jo Manal, PT, DPT, FAPTA, in her delivery of the 22nd John H. P. Maley Lecture, was unequivocal in sending this message to the profession. “The greatest challenge to the value of physical therapy is unwarranted variation—situations in which wide variation of care is not explained by the type or severity of the condition or by patient preferences,” she said to a capacity audience on June 23 as part of APTA’s NEXT Conference and Exposition.

Dr. Tara Jo Manal was a founding co-chair of APTA’s #PTNow initiative, is director of clinical services and residency training for the University of Delaware’s Physical Therapy Department, as well as an associate professor in the entry-level DPT program at the University of Delaware is a board-certified clinical specialist in both orthopedic and sports physical therapy, and her focus on the translation of evidence and how it can be implemented in those specialties has resulted in the publication of 15 monographs and chapters, 22 articles, and more than 150 national and international invited and accepted presentations.

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