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Disagreement with employer over foot orthotic prescription

Discussion in 'Biomechanics, Sports and Foot orthoses' started by lynnb, Mar 10, 2010.

  1. lynnb

    lynnb Member


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    Hi, I know what the answer to this question before I ask but here goes as I think I am going insane.

    I have just started working in a biomechanics clinic where there assessment is similar to my method but there end result always seems to be the same. From the little time I spent there all patients get the same or similar device issued. I have reviewed numerous prescription forms and files and this is what I have found.

    1. all patients get about a 2 to 4 degree intrinsic forefoot posting only
    2 subtalar and limb length measured but the rearfoot is never posted always left at 0 degrees with no heel cup.

    I have questioned the method and the only answer i get is that only posting the forefoot works and that they get great results according to physio's and patients. However according to the patient files not everyone is happy.

    I have tried to put my point across but no one is listening. Anyone got any ideas's how I can approach this?
     
  2. Griff

    Griff Moderator

    Re: Advise please

    Lynn,

    I can't quite work it out from your post - is this a private practice where you work in an interdisciplinary team? Are you the only Podiatrist amongst a team of Physio's? Who prescribed/issued all of these devices prior to you working there?

    Ian
     
  3. DaVinci

    DaVinci Well-Known Member

    Re: Advise please

    Leave. Stop working there. You will not be happy there long term if this is what is going on.
     
  4. lynnb

    lynnb Member

    Re: Advise please

    Sorry wasnt sure how to write this post or if I should even. It is a private practice that gets referrals from physio's, osteo's etc. The podiatrists have always prescribed insoles from the forefoot measurments only, that i have seen so far.
     
  5. Griff

    Griff Moderator

    Why does the prescribing habits of the other Podiatrists at the clinic affect what you do in any way?
     
  6. lynnb

    lynnb Member

    It doesnt, I have not prescribed these. I dont understand why they do an indepth assessment gathering all the data we require but only post the forefoot. I am newly qualified and just want make sure that I am right in my understanding so I am able to stand up for my methods.
     
  7. Griff

    Griff Moderator

    Sorry - they way you worded it sounded as if there was pressure on you to prescribe in the same way.

    Ask them for their rationale. And stand up for yourself. Ask them how they would cause a STJ pronation moment in an individual with a severly medially deviated STJ axis. Ask them how they would reduce stress on the peroneii. Ask them why they give the same prescription to whoever they see irrepsective of their pathology. Challenge them - I expect you will then soon find out what the real answer to the above question is...

    In all honesty if you are a new graduate who is enthusiastic about biomechanics then this may not be the best learning environment for you. If your colleagues prescribe exactly the same devices for literally any pathology they see then you will learn nothing from them and find it difficult to grow as a clinician. Surround yourself with people you respect professionally, and who challenge you daily.
     
  8. lynnb

    lynnb Member

    Thanks for the advice but I think I already knew to start looking for a new job! I know if I ask anything about the method all I will get back is well it works and that the runners and other sportsman/women we treat have great results and the physio love the insoles. Thus we get more and more referrals!!

    I still cant figure out why they prescibe orthotics this way.
     
  9. Griff

    Griff Moderator

    Don't waste your time trying to figure it out if those are the only answers you are getting.

    There's only one smart move from here: see post #3 by DaVinci...
     
  10. lynnb

    lynnb Member

    Just found this in my notes from my induction days.

    Most patients have a forefoot varus and if you aligning the forefoot you then establish the optimal position for each stage of gait.

    But going from the evidence in the presciption forms/other staff its the only adjustment they ever make.
     
  11. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    That is absolute nonsense. Forefoot varus is extremely rare! Like the others said - leave.
     
  12. Griff

    Griff Moderator

    There is not much about any of that sentence I agree with, but thats probably for another thread...
     
  13. Here's the rub. The kind of devices being advocated here may be more beneficial to the patients they are prescribed to than any other device prescribed using another protocol. They might not be either. But can anyone point to the evidence? Personally, I would not leave my job over it. If you want to try this approach, try it and see what your outcomes are like. If you don't want to prescribe your devices this way, prescribe them how you want to, audit your outcomes and educate.
     
  14. stevewells

    stevewells Active Member

    I agree with Simon - I wouldn't leave over it - but at the end of the day you are a clinician and you have to use your clinical judgement and prescribe how you see fit - it would be a poor defence in court to say you were prescribed as you were directed by others in the practice. You alone are responsible for your patients if only you treat them.
    Good Luck - DLTBGYD
     
  15. Griff

    Griff Moderator

    Spooner has nailed it with this paragraph. Can't disagree with any of that.

    In hindsight and having slept on it I think Simon and Steve are probably right. Maybe I was a bit hasty saying you should leave. I was merely thinking back to my first ever job as a graduate and how much it moulded me as a practitioner (and how much I learnt from the colleagues I worked with - most of whom I still respect and have kept in touch with). I still really dislike the idea of a new graduate being in the situation you describe yourself in - particularly as often they lack the confidence to challenge their colleagues.
     
  16. Steve got to ask what does DLTBGYD mean ?
     
  17. Fraoch

    Fraoch Active Member

    LynnB

    I've been in a similar situation to yours; if you cannot get these people to understand and you are not able to prescribe the way you wish then consider finding another job.

    I would recommend you try the evidence based approach first though - it just might work if your boss is reasonable.

    I used to work for a couple of out-dated dinosaurs and was not allowed to use a decent orthotic company hence we had a standard "one shape works for nobody" CFO upon which I would be sticking numerous pads and wedges.

    The writing was on the wall for that one. Some years later I'm running my own show and having a great time. And great results.

    Wish you the best of luck, it sucks for now but you'll get where you want to some day.
     
  18. stevewells

    stevewells Active Member

    Don't Let the Bastards Grind You Down
     
  19. blinda

    blinda MVP

    Ahhh....that`ll be it.
     
  20. toughspiders

    toughspiders Active Member

    I agree, the patient is seeing you and you are responsible for your own decisions. Let the others do as they wish. You do as you know best,
     
  21. Atlas

    Atlas Well-Known Member

    Doesn't matter who your boss is, how well educated he/she is, nor the reputation; this quote of yours takes precedence.


    Look at Simon's response. Try something different and take note of subjective/objective changes short, medium and long term.

    The problem though is the political nature of a workforce. No senior clinician would appreciate a younger one coming in and doing things differently and having better results etc. Its called wounded pride. So my advice is to tread carefully if you value your job.




    It is rarely what is in the patient's best interest unfortunately.




    Ron Bateman
    Physiotherapist (Masters) & Podiatrist
     
  22. healthyfeet

    healthyfeet Active Member

    prescribe according to own assessments!
     
  23. Via what protocol?
     
  24. Yeah, don't read too much into that.

    Nobody gets good results 100% of the time. Sometimes resolution is not to be had. And the patients who come back to you, or someone else, will tend to be the dis-satisfied ones. So whilst I'm sure there is more that can be done for many of them do be aware that the patients you see will not be a representative sample of the method's success rate.

    Unfortunatly our successes disappear into the sunset, our failiures stay around!


    Don't bother trying to argue with that. You can't. "because it gets good results" is the END of a conversation. The only rational comeback is "no it does'nt which they will never in a million years accept.

    My advice is to start looking for another job. Oh sure, you can get by in an environment like that, but you will not be happy there. I'm guessing you're fairly new to biomechanics, you need a job where you will be stimulated, tested, mentored and assessed. What can you learn from these people besides to do what they do?

    You will ALWAYS disagree with people around you on what you prescribe because we all have different ideas. But you should be able to have a good enjoyable row about it based on the rationale and the evidence.

    And If I can gaze into my mystic Bob crystal ball for a second, I see a time where they start resenting you for your upstart ways and your radically dangerous ideas about rearfoot posting. At that point there will be bad feeling as you challenge their insecurity.

    I've worked in a clinic where someone prescibed only one prescription for all ills. * Its utterly soul destroying. Every time they see one of your patients, take your device out, tell the patient its rubbish and replace it with what they use, a little piece of you dies inside.

    So my advice is to find another job. You might cope where you are, but you'll never be happy there.

    Regards
    Robert

    *Freelan with 14mm medial heel wedge extended to sulcus.
     
  25. Lab Guy

    Lab Guy Well-Known Member

    Since you are new there, perhaps you can just do what you are told for the time being. During this time, you may wish to write a paper on a subject relating to Biomechanics and submit for publication to show that you are an expert and take your profession very seriously. I am sure your employer will look at you with new eyes and be more willing to give you the freedom to practice your biomechanics the way you wish.

    Also, as others have wisely said in prior posts, it is very important to choose your words carefully so that you do not deflate or wound the egos of the other practitioners. If you do, you will most likely be asked to leave.

    I do think you have a good chance of overcoming your challenge if you are patient. You have an opportunity to enlighten them as well as bringing improved care to the patients being referred there. Perhaps that is why you are there in the first place.

    I worked for a Podiatrist where I did not agree with a lot of things that were being done. In time, I was able to gain his respect and a lot of positive changes came forth.

    Good luck,

    Steven
     
  26. Songs to do with this dilemma.

    The clash - should I stay or should I go
    young gunz - same s**t, different day

    regards
    Robert

    *if you go there will be trouble...
     
  27. DrBobJ

    DrBobJ Welcome New Poster

    go for itd
     
  28. efuller

    efuller MVP

    Hi Lynne,

    I did the biomechanics fellowship at CCPM in 1988-9. I can tell you that I had plenty of disagreements with the rest of the members of the biomechanics department. This was a year after Kevin left, so I didn't have many people to agree with me. You can learn in your current job if you have time to think, do outside reading, and have the ability to experiment on your and your employer's patients. As long as the patients come back to see you, you can see how well they do with your treatment regimen. They aren't making you do everyting exactly the way that they do it, are they? I can tell you that I did not convert any of the faculty from the neutral position paradigm to the tissue stress paradigm.

    Learn from your employers what you can while you solidify in your own mind how you think the foot works and what appears to be the best way to treat various things. After having taught at podiatry school I've seen the whole range of how confident people are in their decision making. There are those who unquestioningly do what they were taught. There are those who question everything they are taught. Sometimes patients like someone who is absolutely sure about what they are doing. Other times patients need someone to go through the whole thought process in making a treatment decision. The more times you go through the thought process the quicker it will come. Know why you do what you do.

    Eric Fuller
     
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