Clinical Assumptions versus Clinical Hypothesis

In today’s healthcare system it has become quite difficult to find an answer to your medical problems. This is partially due to the dwindling dollars provided to healthcare providers by third party payers. This decline in reimbursement is evident especially with regards to the provision of Physical Therapy services. Healthcare providers now create a Clinical Assumption versus a Clinical Hypothesis to solve your health care issues. I will be discussing scenarios based on Physical Therapy because that is my field of interest; however, the same thought process can be extended to other healthcare professions.

In an insurance based system, regular Physical Therapy treatment sessions are usually in thirty minute increments. In this thirty minute session the patient needs to update the therapist on his/her progress, the therapist needs to perform a set of tests and measures in order to guide the treatment and there maybe the need to perform a manual intervention followed by exercise.          Is twenty-five to thirty minutes enough time to perform all of these functions?  Just imagine you as the patient or even you as the therapist, it is an anxiety driven process. Before the therapist can complete the patient’s examination/treatment, the next patient is waiting and the therapist has to leave the first patient unattended to perform exercises with verbal instructions. What I have found to be the problem with this system is that it is all rushed and doesn’t leave enough time to understand your patient’s pain and movement dysfunction. The patient has been left alone to do their exercise??!! But the patient has a movement dysfunction!! I believe that the patient’s exercise must be monitored. I also believe that if the patient has dysfunction with his/her daily movement it will be carried over into the exercise resulting in a rebound effect with regard to any pain being experienced. Consequently, the patient’s goal has not been met.  The therapist doesn’t have enough time to figure out if the exercise is appropriate or not, assuming that if the exercise worked for patient A, with the same diagnosis that it will work for patient B. This is an assumption we cannot make as the exercise prescribed to patient B may actually exacerbate the injury. Patients should always feel as though their functional goals have been met every session. This can happen if the correct hypothesis was created. With improvement in the patient’s condition the hypothesis should continue to change.

Another example of a Clinical Assumption (true story): Patient goes to the doctor because of dizziness. The doctor asked a few questions and assessed her lungs, heart and ears. The patient was prescribed high dosed steroids diagnosing her with a vestibular neuritis. This was all of a 10 minute visit. What was the clinical hypothesis? Where is the differential diagnosis? Low and behold the diagnosis was wrong and steroids were not required. This is one of many errors made based on quick Clinical Assumptions. How much did the patients healthcare dollars pay for this?

My past and current experience reveals that in the Physical Therapy practice with an hour one-on-one session you are able to solidify a clinical hypothesis and treatment and patients, at the end of the session, feel as though their functional goals have been met. This is especially important for the more complicated treatments. For example, I have treated an ankle sprain in both the insurance based and fee for service settings; in the first setting it can take 2-4 sessions to reach meaningful outcomes and in the latter setting only 1-2 sessions. The difference is that I had more time to form an extensive clinical hypothesis to drive a meaningful treatment.

This blog is not to push everyone to go into a fee for service system but rather to push the healthcare system to increase reimbursements. With improved reimbursements we as Physical Therapist become more efficient and will reach functional outcomes sooner, in turn spending less resources and medical dollars.

We need a healthcare system that spends enough time to format the appropriate Clinical Hypothesis versus a Clinical Assumption.  We can spend less time with the Clinical Assumption but our outcomes suffer. On the other hand, we can spend more time with the patient and form the appropriate Clinical Hypothesis and improve the overall function and quality of life of the patient.

It is unfortunate that the healthcare system has become a business and has lost the personable nature of medical care. Your insurance card (some people think it is for free services) does not buy you better healthcare but rather places the patient in a system of inefficiency where executives of insurance companies and healthcare systems get paid 6 million dollars a year, and where the patients who have been paying their premiums for years cannot pay for their cancer treatments.

Just some food for thought. Your health is important and the best treatment should be available to all.

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