Let’s face it. Clinicians are tired. Tired of paperwork (electronic or othrwise). When I’m out and about training–which is every week by the way–and encouraging therapists to monitor and measure outcomes in their daily work few disagree in principle. The pain is readily apparent however, the minute the paper version of the Outcome Rating Scale flashes on the screen of my PowerPoint presentation.
It’s not uncommon nowadays for clinicians to spend 30-50% of their time completing intake, assessment, treatment planning, insurance, and other regulatory forms. Recently, I was in Buffalo, New York working with a talented team of children’s mental health professionals. It was not uncommon, I learned, to spend most of two outpatient visits doing the required paperwork. When one considers that the modal number of sessions consumers attend is 1 and the average approximately 5 its hard not to conclude that something is seriously amiss.
Much of the “fear and loathing” dissipates when I talk about the time it usually takes to complete the Outcome and Session Ratings Scales. On average, filling out and scoring the measures takes about a minute a piece. Back in January, I blogged about research on the ORS and SRS, including a summary in PDF format of all studies to date. The studies make clear that the scales are valid and reliable. Most important, however, for day-to-day clinical practice, the ORS and SRS are also the most clinically feasible measures available.
Unfortunately, many of the measures currently in use were never designed for routine clinical practice–certainly few therapists were consulted. In order to increase “complaince” with such time consuming outcome tools, many agencies advise clinicians to complete the scales occasionally (e.g., “prime numbers” [5,7, 11 and so on]) or only at the beginning and end of treatment. The very silliness of such ideas will be immediately apparent to anyone who ever actually conducted treatment. Who can predict a consumer’s last session? Can you imagine a similar policy ever flying in medicine? Hey Doc, just measure your patient’s heart rate at the beginning and end of the surgery! Inbetween? Fahgetabotit. Moreover, as I blogged about from behind the Icelandic ash plume, the latest research strongly favors routine measurement and feedback. In real-world clinical settings feasibility is every bit as important as reliability and validity. Agency managers, regulators, and policy makers ignore it at their own (and their data’s) peril.
How did the ORS and SRS end up so brief and without any numbers? When asked at workshops, I usually respond, “That’s an interesting story.” And then continue, “I was in Israel teaching. I’d just finished a two day workshop on ‘What Works.'” (At the time, I was using and recommending the 10-item SRS and 45-item OQ).
“The audience was filing out of the auditorium and I was shutting down my laptop when the sponsor approached the dais. ‘Scott,’ she said, ‘one of the participants has a last question…if you don’t mind.'”
“Of course not,” I immediately replied.
“His name is Haim Omer. Do you know of him?”
“Know him?” I responded, “I’m a huge fan!” And then, feeling a bit weak in the knees asked, “Has he been here the w h o l e time?”
Haim was as gracious as ever when he finally made it to the front of the room. “Great workshop, Scott. I’ve not laughed so hard in a long time!” But then he asked me a very pointed question. “Scott,” he said and then paused before continuing, “you complained a bit about the length of the two measures you are using. Why don’t you use a visual analog scale?”
“That’s simple Haim,” I responded, “It’s because I don’t know what a visual analog measure is!”
Haim described such scales in detail, gave me some examples (e.g., smiley and frowny faces), and even provided references. My review on the flight home reminded me of a simple neuropsychological assessment scale I used on internship called “The Line Bisection Task”–literally a straight line (a measure developed by my neuropsych supervisor, Dr. Tom Schenkenberg). And the rest is, as they say, history.