About Debora Davidson, PhD, OTR/L

Debora Davidson, PhD, OTR/L, has practiced OT since 1979. Her clinical career initially centered on children and adolescents with behavioral and emotional problems. For 20 years she served as an OT faculty member at several nationally ranked universities. In 2011 Debora left academia to initiate Bright Futures in Focus, a private practice serving young adults with disabilities who want to achieve a satisfying transition to adulthood. From 2011-2015 she was the OT Clinical Editor for OnCourse Learning. She is a clinical occupational therapy blogger for TodayinOT.com. Debora initiated Authentic Occupational Therapy to inspire OTs who want to regain their clinical mojo. Join the conversation at www.facebook.com/AuthenticOT.

Facing facts about race is essential to patient-centered practice

Patient-centered care is as essential to quality healthcare as is technical expertise. A while back I wrote a column explaining the values and actions comprising patient-centered care. Here, I will explore a requisite task to becoming a patient-centered practitioner, regardless of your profession. That task is learning to face the reality that a racial difference between the practitioner and client can affect the work, and that it is our responsibility as professionals to proactively prepare for and respond effectively when working with clients we do not look like. Claiming color-blindness has been demonstrated not to work, so please keep reading. Do you feel uncomfortable? Join the club. The topic of race is always sensitive and there’s high risk of hurting feelings or being misunderstood even in the most ordinary of times. Current events have inflamed many of us to the point of anguish or anger. However, to look away from the influences of race in the delivery and receipt of healthcare is not an option if one is to be evidence-based and competent. Research has demonstrated that African Americans as a group have experienced significantly substandard quantity and quality of healthcare in our country. The patterns of disparity are deeply dyed into our systems of care and our national culture. By acknowledging them and by making each professional interaction a good one, we can contribute to their solutions. As a white woman I have often felt that perhaps I had no right to talk about the issue of race. I cringe to recall how, as a small-town Midwesterner interviewing for my first OT position (a community mental health center in Boston), I explained that my lack of history with people of color and urban settings [...]

Professional pride and prejudice

As college students in healthcare education programs across the country celebrate their graduation into professional careers, I can’t help but think about all it takes for them to transform from bewildered first-year students to competent young practitioners. When I was a professor, each fall I looked out at a classroom full of fresh faces and wondered how such young-looking people could be prepared for what lay ahead. Some of them were wondering the same thing, I am sure. There often is struggle on the way to earning that degree and credential. Rigorous curricula are unforgiving and not everyone makes it through. There are surprises about what the career path really entails, and some of these are unpleasant. To work in healthcare, young people are expected to mature quickly and balance empathy with professionalism. Students must be dedicated, determined, humble and hardworking as they acquire a new language, a new work culture and an avalanche of information they must quickly assimilate. This is true in every health profession. Success also requires abiding by the rules and social mores of our professions and settings. One of the great joys of professional education is seeing students starting to transform. It’s delightful to overhear them conversing in their new language. The excitement and affirmation they feel when they attend a professional conference and realize they can understand and fully participate in the discussions of seasoned professionals and students from other schools is a joy to behold. It’s then that they recognize they have earned the opportunity to be accepted into a very special, elite club. Such feelings can inspire learning and help fuel effort as students work hard to succeed at challenging curricula and clinical internships. Feelings of pride in their chosen [...]

The Tao of patient-centered care

"Tao (pronounced "dao") means literally "the path" or "the way." It is a universal principle that underlies everything from the creation of galaxies to the interaction of human beings. The workings of Tao are vast and often beyond human logic. In order to understand Tao, reasoning alone will not suffice. One must also apply intuition." — Derek Lin Patient-centered care (aka client-centered care, patient-directed care, patient-driven care, etc.) has infused the published descriptions of today’s healthcare industry and professions.  National and world health organizations include patient-centered care as a hallmark of best practice. A casual medical database search of this term immediately yields articles in journals of nursing, dentistry, medical devices, surgery, social work, hand therapy, health management, primary medicine, behavioral medicine, rehabilitation, emergency medicine, mental health, occupational therapy, and many more. Yet, according to the same body of literature and my own observations, truly patient-centered care remains largely unpracticed. It consists of attitudes and actions that can be a challenge to live up to, an ideal to be ever sought and only attained through practice and diligence. True story:  A 17-year-old girl was admitted to a hospital psychiatric unit with terrifying hallucinations and delusions. She wept copiously and had not slept for days. She continuously prayed aloud or ruminated about having brought the Zika virus into the world. Her parents, immigrants from South America, were distraught, and asked to have their priest perform a rite of exorcism as soon as possible. The patient and parents were counseled about the neurobiological nature of schizophrenia and importance of medication, but remained firm in their request. The psychiatrist and team made this possible by providing a private area for the ceremony to take place, and interacting with [...]

Our productivity is based on patients, not the bottom line

“Productivity — the amount of output delivered per hour of work in the economy — is often viewed as the engine of progress in modern capitalist economies. Output is everything. Time is money. The quest for increased productivity occupies reams of academic literature and haunts the waking hours of C.E.O.s and finance ministers.”  - Tim Jackson, ecological economist and professor of sustainable development at the University of Surrey I am an occupational therapist and six years ago I also became a small business owner. My parents were hard-working entrepreneurs, so I had lots of early exposure to the ways of business. Our dinner table conversations often included discussions about bills of lading, sales reports, delivery dates and inventory. I learned the essential nature of a sustainable business: more money coming in than going out. I understand that healthcare is an industry. Whether the hospital, outpatient clinic, rehabilitation center, skilled nursing facility or home health agency is set up as a not-for-profit or as a traditional business, if it runs at a deficit it is unwell and ultimately unsustainable. In my parents’ business the main measure of success was selling goods at a profitable rate, while maintaining low-as-possible overhead costs. Each quarter they would hope to do a little better than the one before. Some years were better than others, but over time they became skilled at figuring out how many lawn mowers or hedge clippers to order, and ways to keep their employees productive even in the Midwestern winter (answer: sell snow shovels and Christmas trees instead of lawn equipment). Healthcare professionals typically view our main measure of success as the degree to which we help those we serve. The organizations we work for usually highlight [...]

 Interprofessional healthcare is a big deal

The World Health Organization has been pushing interprofessional healthcare delivery for more than 50 years, and is not alone. Almost every major professional association has endorsed IP team approaches, including the American Nurses Association, American Speech and Hearing Association, American Occupational Therapy Association, American Physical Therapy Association, American Academy of Physician’s Assistants and American Academy of Family Physicians. In the past 10-15 years many universities have developed courses or curricula to infuse interprofessional practice into entry-level medical, nursing and allied health education. The young practitioners coming out of these programs are better prepared than ever before to engage in interprofessional teams, given the opportunity. If you were educated prior to 2010, you may be confused by the relatively new emphasis on interprofessional teamwork in healthcare. Patients pretty much everywhere receive care from an array of different professionals within each setting, so you may think that a bunch of care providers all working alongside one another equals an interprofessional team. Not so. What is this unicorn of healthcare delivery? Authentic IP teamwork looks like this: There is an IP Plan of Care for each patient that is negotiated and decided by the team. Roles of care providers are fluid and determined by the patient’s current key needs. Team members are both experts in their disciplines and knowledgeable about others’ skills and roles. Everyday work is coordinated and often shared. Communication is regular and frequent. "...you may think that a bunch of care providers all working alongside one another equals an interprofessional team. Not so." If your everyday work experience resembles this model, you are lucky! Despite universal agreement regarding the desirability and effectiveness of IP practice, the majority of clinical practitioners have yet to achieve this ideal. [...]

My views on the ‘McDonaldization of medicine’

E. Ray Dorsey, MD, and George Ritzer, PhD, published a Viewpoint article in JAMA Neurology a year ago that has repeatedly resonated with me. These writers — a neurologist and a sociologist — recognize healthcare can be delivered in an individualized way, given the right conditions. The writers describe how fast-food management principles have been applied to healthcare and the results of using this style. Four qualities define the McDonaldization of medicine, and each has its benefits and costs. Here is my interpretation of Dorsey and Ritzer’s table, depicting the effects of the fast-food approach on therapy services and therapists. Dimension - Efficiency Presentation - Use brief sessions and pre-set frequency/duration of treatment.  Use questionnaires rather than observations. Focus on productivity standards. Provide fewer OTs and OTAs to produce more billable units. Benefit - More patients are processed at a lower cost. Cost - Patients receive decreased client-centered and holistic care, reduced interpersonal rapport and suboptimal outcomes. Therapists experience burnout. Dimension - Calculabilty Presentation - Count and record actions and easily measured outcomes. Evaluation, intervention and outcomes are measured numerically. Benefit - Data can guide future practice and research. Cost - Practitioners’ attention and time is diverted to recording data. Reduces care to small, discreet values, losing the big picture view. Dimension - Predictability Presentation- Utilize protocols, checklists and templates, plus scripted interviews. Benefit - Ensures attention to a standardized set of critical factors and actions. Cost - Can result in rote, automatic care that ignores unique needs and client motivations. Can obstruct building therapeutic relationship. Clinical judgment and creativity are stifled. Dimension - Control by nonhuman technology Presentation - Use electronic medical records that dictate clinical reasoning, billing codes and utilization review. Benefit - Provides systematic, [...]

Break away from behavioral modeling and dare to be different

“Be the change you want to see in the world” - Mahatma Gandhi Some years ago my mother, sisters and I traveled to London together. It was my first transcontinental flight, and I was excited and a bit nervous. As I sat next to my older sister, I saw her remove her shoes and put on some little sock slippers. I took off my shoes and put on slippers, too. Soon after, she reclined her seat; I did the same. When asked if she wanted a beverage, she ordered green tea. I also ordered green tea, but soon regretted my decision. You see, I truly hated green tea! Why on earth did I, a grown and very independent woman, imitate my sister even to the point of ordering (and yes, choking down) a beverage that tasted like grass? I had to laugh at myself, even as I sipped the nasty stuff. Once a kid sister, always a kid sister, I guess. If you recall your psychology courses (social learning theory), you know that it was more than just family dynamics; it was behavioral modeling. The hard-wired tendency to unconsciously copy one another is arguably the foundation for all human bonding, grouping and the evolution of cultures. The things we do and the choices we make every day are influenced by many unconscious perceptions. Going with the flow is great for keeping harmony and ease. However, it becomes a problem when we sacrifice things we value such as integrity, originality, improved performance — or a good beverage, for example. Unless we deliberately elect to stay attentive and course-correct as needed, we probably end up navigating our days on imitative auto-pilot. I sense that behavioral modeling is one [...]

My vision for an OT practitioner’s Bill of Rights

Writing is one of my coping strategies. One year ago, I got fed-up-to-here with pain-filled stories of suffering and injustice among my colleagues, so I responded by drafting a list of “Basic Rights for Healthcare Professionals.” Then I proceeded to record a pretty awful video of myself talking about them. I brought the video back out today as a kind of private anniversary moment, and it was painful to watch. I was in my backyard and my neighbor was using a deafening chainsaw, but I was too stubborn to just hang it up for the day. I had to laugh at myself and was glad that not too many people had viewed it. Despite its technically flawed delivery, I remain passionate about the Bill of Rights idea, and I still want your feedback. This time I’ll just let you read it and skip the video with the chainsaw soundtrack. Basic Rights of OT Practitioners (a work in progress) All certified/licensed occupational therapy practitioners deserve to be treated with respect and to practice with the autonomy conferred by our accrediting agencies and licensing boards. They have the right and responsibility to routinely and consistently: 1) Follow the standards of practice and codes of ethics of our profession. 2)  Follow state and federal laws, such as those that mandate reporting suspected abuse and neglect of vulnerable clients, including fraudulent practices or documentation of services. 3) Work in conditions that routinely support basic physiological needs (i.e. flexible time to eat and use the restroom). 4) Be paid for their professional services, including documentation, evaluation interpretation and reporting, communicating with team members on behalf of the clients, and treatment planning. 5) Make clinical decisions in the service of their [...]

Permission to speak freely

Occupational therapists and assistants are more than my colleagues. They are my former students from the classroom, fieldwork and internships. They are passionate about our profession. They are my co-learners at professional conferences. Today they are my readers, and people whose words I may read one day. They are my pals and partners in crime, as we’ve invented the just-right challenge therapy group or a lab activity. They are the people I can call on at a moment’s notice and who have always responded with hands-on help, words of encouragement and ideas for how to get things done. They are my role models -- the people I never want to disappoint or let down. I see them as compassionate, smart, hardworking and generous to the point of giving until it hurts. I love them all. I really want to write blogs that inspire and energize OT and OTAs. The rub is that I know how very difficult practicing real occupational therapy can be right now. For years, I have been hearing from therapists all over the country and in many different practice settings (SNFs, acute care hospitals, rehabilitation centers, public schools and non-profit agencies, to name a few). They have been warned against providing any services short of or beyond what has been predetermined as billable. Many are threatened with sanctions or termination if they are caught documenting after-work hours, although there are not enough minutes allotted in the day for this. The very notion of providing client-centered, occupationally-focused and holistic care is frustrating and foolish, in these workers’ worlds. I have witnessed the acculturation of my students to this reality, when they would come to my classrooms after their Level I fieldwork experiences looking [...]