A Problem with Protocols

Rehabilitation protocols are an important part of physical therapy. They provide guidelines and standards of care to assure appropriate progression after injury or surgery. Protocols communicate expected time-frames for recovery and facilitate the most efficient, high quality healthcare. 

Reading a protocol gives me a sinking feeling. At such and such time, restore this and stop that, this is contraindicated and ensure that you get to that. It sounds so helpful and simple. In practice, protocols are a weight that one person, a mere physical therapist, cannot carry. It feels like juggling 5 bowling pins when your limit is 3.

I understand that "feeling it out" and "let's see how it goes" doesn't cut it when you want to standardize stress applied to surgically repaired tissue. It's no way to define and justify evidence-based practice. But during my 14-year PT career, there have been no ACL or rotator cuff tears or re-tears. There were no broken pins or loose screws. Zero joints have dislocated under my watch. And my offices have thrived as privately owned, independent businesses.

Protocols easily become mindless dictators. Don't answer. Don't ask. Don't try to make sense.

"Okay. Got it. Follow the protocol."

These days, protocol power comes not from surgeons or medical advisory panels, but from accounting departments. Calculated patient encounters, reimbursement rates, and discharge dates drive services rendered. Woe to the patient (and healthcare provider) who doesn't achieve the standard goals within the defined parameters. Protocols give the least credit for the resources invested in people who need care the most.

Protocols are no respecter of persons. There's no formula for our entire system and being. Protocols coldly march forward, day by day, paying no mind to unique body structure and function much less motivation and perspective on what it means to live well. Protocols don't care about your fibromyalgia, stressful workplace, leg length discrepancy, or recently deceased spouse.

And yet protocols are simply one small instance of the health care tail wagging the dog. It's happening everywhere and has effected you already.


As much as I hate what the Affordable Care Act is doing to health care and especially to small businesses, I will resist blaming protocols on President Obama. I know so little, just enough to be aware that the big picture is not so cut-and-dried.

Imagine a time when the patient and provider decide if, when, and how they can be treated. -Sigh-

Nah. That would never work. That would require honesty, transparency, and mass selflessness on behalf of all parties. It would require hope and change from the achievers, the lazy, and everyone in between. This country needs Jesus. No, really.

So this holiday season, encourage your diabetic uncle to find the time and support for an appropriate diet and exercise program. Tell your wayward niece that she really should get out of the house and get a job. And then wish them "Happy Holidays." I'm kidding, of course. Well, kind-a. 

Now where were we? I mean, according to the protocol...