Another ethical dilemma: Clinical competency

By October 7, 2014 Ethics 10 Comments

SNF Ethics

The ASHA Code of Ethics states:

  • “Individuals shall provide all services competently. Individuals shall use every resource, including referral when appropriate, to ensure that high-quality service is provided.”
  • “Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence and performance.”
  • “Individuals shall engage in only those aspects of the professions that are within their scope of their professional practice and competence, considering their level of education, training, and experience.”
  • “Individuals shall engage in lifelong learning to maintain and enhance professional competence and performance.”

APTA Code of Ethics states:

  • “Physical therapists shall demonstrate independent and objective professional judgment in the patient’s/client’s best interest in all practice settings.”
  • “Physical therapists shall make judgments within their scope of practice and level of expertise and shall communicate with, collaborate with, or refer to peers or other health care professionals when necessary.”
  • “Physical therapists shall achieve and maintain professional competence.”
  • “Physical therapists shall take responsibility for their professional development based on critical self-assessment and reflection on changes in physical therapist practice, education, health care delivery, and technology.”
  • “Physical therapists shall cultivate practice environments that support professional development, lifelong learning, and excellence.”

AOTA Code of Ethics states:
Occupational therapy personnel shall

  • “Provide occupational therapy services that are within each practitioner’s level of competence and scope of practice (e.g. qualifications, experience, the law).”
  • “Take responsible steps (e.g. continuing education, research, supervision, training) and use careful judgment to ensure their own competence and weigh potential for client harm when generally recognized standards do not exist in emerging technology or areas of practice.”
  • “Refer to other health care specialists solely on the basis of the needs of the client.”
  • “Take responsibility for maintaining high standards and continuing competence in practice, education, and research by participating in professional development and educational activities to improve and update knowledge and skills.”

While we are looking at the ethical dilemmas in the prevailing model of healthcare and how it impacts our patients, we should also take some time to look at our clinical skill. We are bound by our code of ethics (and likely your state licensure) to continually improve clinical skill and practice only in areas where we are competent. Improving our clinical skill and competence is great way improve elder care.

Social media is good, but not great

Social media is a good thing, but I am concerned that it may be the easy way to solve some of our clinical dilemmas. It is almost too easy to hop on social media and ask a clinical question. But are you getting a clinical answer? Sometimes yes. Other times you are getting people’s experiences and opinions.

Experience is really important. In fact, when we look at great therapy we are considering two types of experience – patient and clinician – along with evidence based practice. What’s missing on social media is other people don’t know you (and your skills) and your patient (and their specific presentation).

So we really need to make sure that we are becoming better clinicians. We need to feel competent and confident in our services. Our patients deserve the best.

What if you aren’t competent?

No sweat. I’m not competent to treat every SLP patient either. If you are referred a new patient that you aren’t competent to treat, you can do a few things:

  • Refer them to another therapist that is competent in that specific area.
  • Contact a therapist (or clinical specialist) in your region (employed by the same company) and negotiate to have that person coach you through the treatment. This is someone you can share those HIPAA protected details (unlike social media).
  • Seek education via webinars, online courses, textbooks, journal articles, etc. This is especially important if you see a specific condition, etc. often.

There are some things that I am not competent in treating. Voice is a big one. I have always been uncomfortable with my own voice. My voice class in graduate school was rushed. And I’ve only had a handful of voice patients. Honestly, I am not good at voice therapy.

Thankfully, I’ve got an awesome colleague, who is also a vocalogist, who loves voice. She sings, performs, and has done an impressive amount of continuing education to hone her craft as a singer and therapist. My voice patients go to her, always! They get better treatment from her. She refers to me for my own specialties. She wrote a guest post for us to help us understand vocal changes with aging.

There should not be any shame in not being an expert in all areas of our field or asking for help. As therapists our scopes of practice are diverse. Due to medical advances, our patients are becoming more complex.

How to improve your skill

This month, Gray Matter Therapy will focus blog posts on this very question. We will look at why CEUs are so expensive, recommendations for accruing CEUs as a new clinician (this comes up over and over on forums), assessing education opportunities for usefulness, and more.

In addition, newsletter subscribers will receive a tracking sheet I use to track professional education. It doubles as a record for ASHA and state intervals and an expense report for tax deduction purposes.

References
American Physical Therapy Association. (No date). Code of Ethics for the Physical Therapist. Available from www.apta.org/policies.
American Occupational Therapy Association. (2010). Occupational Therapy Code of Ethics and Ethics Standards. Available from www.aota.org/About-Occupational-Therapy/Ethics.aspx
American Speech-Language-Hearing Association. (2010r). Code of Ethics[Ethics]. Available from www.asha.org/policy.

Rachel Wynn
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Rachel Wynn

Speech-Language Pathologist at Gray Matter Therapy
Rachel is a speech-language pathologist and creator of Gray Matter Therapy. She started making noise as a patient-centered care advocate in 2013. She believes great care happens when patients are informed and engaged.
Rachel Wynn
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  • Dean Metz

    this is one reason I’m a big fan of having a professional mentor. Someone one can bounce ideas off of, can guide one through difficult situations, and can offer solutions in a variety of situations like this one. Find someone who embodies the professional you’d like to be, and ask them to mentor you. It’s a lifelong process, as all learning should be.

    • http://www.graymattertherapy.com Rachel Wynn

      Dean- Thanks so much for your comment. Professional mentors can be amazing! SLPs have a mentor during their clinical fellowship. Some of these mentors are amazing and lead to long relationships, but some do the bare minimum. Even if your employer provides you with a mentor, that person may not be the right mentor for you. You suggest finding someone “who embodies the professional you’d like to be”; I think that’s a perfect suggestion!

  • http://speechadventures.com/ Mary

    Great post Rachel. You bring up some very valid points that social media is a fantastic resource; however, social media – like CEUs – must be looked at careful. All too often, people take the easy way out and rely and on the experience of others. Many times this is fine…but there are some times that it truly is not okay. I’ve seen many situations where what’s recommended is blatantly not EBP and even though it’s been pointed out that there is no EBP to support it, people still insist on using it.

    One element that you’re post didn’t click on is the ethical consideration of offering advice on social media. As you pointed out, the person offering advice doesn’t know the clinical expertise or the client. Wrong information can be potentially harmful. While it would clearly be an ethical violation for the SLP to provide services that would harm a client, it is just as wrong for an SLP on the side line to offer therapeutic advice without knowing all of the history. Obviously, due to HIPAA and FERPA considerations, that information should not be shared on social media. Unfortunately, I’ve seen many posts on social media where although names haven’t been shared – personal information including diagnosis has been. Some of these have been blatant violations of HIPAA/FERPA as they could easily trace back to the client in question.

    While I believe social media has a place – and we all need a place to be able to share information – it takes a great deal of care to do so carefully, respectfully, and ethically.

    • http://www.graymattertherapy.com Rachel Wynn

      Mary- Great point! Wrong information can be potentially harmful. I try to offer responses in the shape of “have you thought about…” or “in my experience…”, because I don’t know this patient.

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  • http://www.mitpressjournals.org/doi/abs/10.1162/jocn.2009.21261#.VE3VEfnF-BI Dr. Whitney Anne Postman, Ph.D.

    Rachel Wynn, you propose that one’s clinical education can be continued/enhanced “via webinars, online courses, textbooks, journal articles, etc.”
    All good!!
    May I please add some more indispensable resources? They are:
    -ASHA Special Interest Groups: http://www.asha.org/Sig/
    -ASHA Practice Portal: http://www.asha.org/practice-portal/
    -For those working with neurogenic populations, the ANCDS Practice Guidelines & Practice Resources: http://www.ancds.org/index.php/practice-guidelines-9 & http://www.ancds.org/index.php/practice-resources
    -Mayo Clinic: http://www.mayoclinic.org/
    -National Institutes of Health: http://www.nih.gov/

    I myself don’t know how I survived before becoming an affiliate of SIG-2 and a member of ANCDS. Involvement in both communities is well worth the investment, and *highly* recommended to all of my noble SLP colleagues who read Rachel Wynn’s superb blog post!

    Yours in scholarly SLP solidarity,
    Whitney Anne Postman, Ph.D./CCC-SLP

    • http://www.graymattertherapy.com Rachel Wynn

      Thanks for the comment and additional resources!

    • https://www.facebook.com/EdgarVincentClark Edgar V. Clark

      Thanks…. good resources!!!

  • https://www.facebook.com/EdgarVincentClark Edgar V. Clark

    So, here is my two cents worth… by what measure do we judge who is clinically competent? Who defines that for us? Someone can complete a graduate degree, follow ASHA guidelines for competency in an area (like MBBSs or FEES for example), but never really “get it”. On the other hand, someone else may have a natural affinity for an area and be an awesome therapist straight out of the gate.

    Another way to look at it is – If a client were hurt or mistreated in some manner how would you prove or disprove that the clinician was “competent”? What minimum standard beyond the Masters Degree or CCCs should they have (which CEUs are the “right” CEUS and what experience is the “right” experience)?

    I’m very much coming from my “my world” of swallowing dx/tx where I feel most comfortable… I see clinicians everyday that dx/tx and have done “all the right things” on paper, but just don’t get it. They consider themselves great dysphagia therapists, but they aren’t… are they “wrong” for treating?

    I guess in a way I’m thinking that as our scope expands and our knowledge base expands, much of what we need to know should be shaped during the acquisition of a degree so that when we enter the workplace, we have a broader understanding of what’s going on… think about it, a CF is potentially working with the same type of patient as a PhD with a specialty certification in swallowing! Maybe in some areas of our profession an advance level of knowledge (particularly in areas where we can do physical harm) should be mandated upfront vs searched for after the fact.