Key Characteristics of Rehabilitation Quality Improvement Publications: Scoping Review From 2010 to 2016
Tiago S. Jesus, PhD,a Christina Papadimitriou, PhD,b Ca ́tia S. Pinho, BSc,cHelen Hoenig, MD, MPHd,e
From the aGlobal Health and Tropical Medicine & World Health Organization Collaborating Center for Health Workforce Policy and Planning, Institute of Hygiene and Tropical Medicine, NOVA University of Lisbon, Lisbon, Portugal; bSchool of Health Sciences, Oakland University, Rochester, MI; cISVOUGAeSuperior Institute of Entre Douro e Vouga, Santa Maria da Feira, Portugal; dPhysical Medicine and Rehabilitation Service, Durham Veterans Administration Medical Center, Durham, NC; and eDivision of Geriatrics, Department of Medicine, Duke University Medical Center, Durham, NC.
Objective: To characterize the peer-reviewed quality improvement (QI) literature in rehabilitation.
Data Sources: Five electronic databases were searched for English-language articles from 2010 to 2016. Keywords for QI and safety management were searched for in combination with keywords for rehabilitation content and journals. Secondary searches (eg, references-list scanning) were also performed.
Study Selection: Two reviewers independently selected articles using working definitions of rehabilitation and QI study types; of 1016 references, 112 full texts were assessed for eligibility.
DataExtraction: Reported study characteristics including sutdy focus, study setting, use of inferential staistics, stated limitations, and use of improvememt clcles and theoretical models were extracted by 1 reviewer, with a second reviewer consulted whenever inferences or interpretation were involved.
Data Synthesis: Fifty-nine empirical rehabilitation QI studies were found: 43 reporting on local QI activities, 7 reporting on QI effectiveness research, 8 reporting on QI facilitators or barriers, and 1 systematic review of a specific topic. The number of publications had significant yearly growth between 2010 and 2016 (P=.03). Among the 43 reports on local QI activities, 23.3% did not explicitly report any study limitations; 39.5% did not used inferential statistics to measure the QI impact; 95.3% did not cite/mention the appropriate reporting guidelines; only 18.6% reported multiple QI cycles; just over 50% reported using a model to guide the QI activity; and only 7% reported the use of a particular theoretical model. Study sites and focuses were diverse; however, nearly a third (30.2%) examined early mobilization in intensive care units.
Conclusions: The number of empirical, peer-reviewed rehabilitation QI publications is growing but remains a tiny fraction of rehabilitation research publications. Rehabilitation QI studies could be strengthened by greater use of extant models and theory to guide the QI work, consistent reporting of study limitations, and use of inferential statistics.
© Archives of Physical Medicine and Rehabilitation 2018;99:1141-8
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1. So here I would say why/how this pub is a good resource (in a short sentence) Then give attribution to author... Winant writes.....
2. For your blog, I would try out how the comments will work. So ask readers to what they think? Do they have anything more to add? ....
3. Then the article gets appended here:
Barbara Ehrenreich's radical critique of wellness and self-improvement
By Gabriel Wiant
Ehrenreich has long been willing to question professional givers of advice. Born in 1941, she had her formative political and intellectual experiences in the Women’s Health Movement of the 1970s, in which women sought to create their own knowledge about and control over their bodies. In these efforts, they encountered endless patronizing hostility from male professionals. Doctors discouraged the Lamaze method of childbirth, which focuses on breathing and relaxation techniques, and instead favored anesthesia during labor and delivery. They were outraged at the movement for cervical self-examinations and they warned of the dangers of unsterilized speculums. (Ehrenreich cites feminist writer Ellen Frankfort’s cutting retort: “Yes, of course, anything that enters the vagina should first be boiled for at least ten minutes.”)
In her own telling, Ehrenreich became a self-conscious feminist when, pregnant with her first child, she asked about her dilation, and her doctor replied, “Where did a nice girl like this learn to talk like that?” Decades before Silvia Federici examined the politics of early modern witch hunts in her now widely beloved Caliban and the Witch, Ehrenreich published with Deirdre English Witches, Midwives, and Nurses—a work that traced the tradition of women’s healing knowledge and the history of endless attacks on it from men, culminating in the power of the modern medical establishment. The book was an unexpected hit, and the two followed up with For Her Own Good: Two Centuries of the Experts’ Advice to Women. So you can tell she gets some pleasure from saying no to doctors.
Natural Causes opens with her decision to reject a series of medical interventions. Ehrenreich is in her seventies and has survived breast cancer but, “in the last few years,” she writes, she has “given up on the many medical measures—cancer screenings, annual exams, Pap smears, for example—expected of a responsible person with health insurance.” She describes making this choice after a series of troubling experiences: First, her primary care doctor talked her into a bone scan, then diagnosed her with osteopenia—thinning of the bones—“a condition that might have been alarming if I hadn’t found out that it is shared by nearly all women over the age of thirty-five.” Bone scans, though, have been heavily promoted by the manufacturer of the osteopenia drug, which itself turns out to cause bone thinning. Next, she got a false positive on a mammogram and decided never to get another.
Even though she showed no signs of sleep apnea, her dentist wanted her to get a test for it, “after which I could buy the treatment from her: a terrifying skull-shaped mask that would supposedly prevent sleep apnea and definitely extinguish any last possibility of sexual activity.” The risk of sudden death in her sleep, she decides, is tolerable. She turns down colonoscopies, certain that she’ll die of something else before colon cancer kills her anyway. She fires her doctor after he suspends his ordinary practice and offers “concierge care” instead—pricey, constant access and a heightened testing regime.
Ehrenreich, who has a Ph.D. in cell biology, isn’t opposed to scientific medicine. But she is alert to the power dynamics that characterize a patient-doctor relationship and the ways those dynamics can influence patients’ decisions: Some will seek or accept treatments that won’t help with their condition, simply because so much power is invested in the doctor. Ehrenreich quotes at length from a 1956 article titled “Body Rituals of the Nacirema” (“American” backwards), which describes an American hospital through an ethnographer’s eye:
Few supplicants [patients] in the temple are well enough to do anything but lie on their hard beds. The daily ceremonies, like the rites of the holy-mouth-men [dentists], involve discomfort and torture. With ritual precision, the vestals awaken their miserable charges each dawn and roll them about on their beds of pain while performing ablutions, in the formal movements of which the maidens are highly trained. At other times they insert magic wands in the supplicant’s mouth or force him to eat substances which are supposed to be healing. From time to time the medicine men come to their clients and jab magically treated needles into their flesh.
Stripped of the authority of Western medicine, the treatments the article describes sound like cruel rituals. “The fact that these temple ceremonies may not cure, and may even kill the neophyte,” the article goes on, “in no way decreases the people’s faith in the medicine men.”
A bit wryly, Ehrenreich points out that she’s not the anti-empirical one in this debate. Doctors have been quite resistant to so-called “evidence-based medicine”—the disbursement of treatment according to quantitative evidence rather than medical discretion. And, accustomed to the present system, many patients now worry that anything less than constant testing and maximal intervention would leave them at risk: “An internist in Burlington, North Carolina, reports that when he told a 72-year-old patient that she did not need many of the tests she was expecting in her annual physical, she wrote a letter to the local paper about him as an example of ‘socialized medicine.’ ” Doctors and hospitals use these expectations to drive up demand and prices, and patients, afraid and intimidated, submit.
The way Americans assent to such treatments fits more broadly into a culture of arduous self-improvement regimens. Here, Ehrenreich speaks as an inveterate gym rat, a participant in the astonishing rise of the workout since the 1970s. She sees the ascent of exercise culture in part as a continuation of women’s reclamation of their bodies in the 1970s, and in part as an example of the retreat from public concerns and move toward individualism that many of her peers made around the same time. “I may not be able to do much about grievous injustice in the world, at least not by myself or in very short order, but I can decide to increase the weight on the leg press machine by twenty pounds and achieve that within a few weeks,” she writes. “The gym, which once looked so alien and forbidding to me, became one of the few sites where I could reliably exert control.” What was a consolation, however, quickly evolved into a prize. Working out became a status symbol, a form of conspicuous consumption for a professional middle class bereft of purpose; and it became a disciplinary device, part of a culture that inflicts “steep penalties for being overweight.”
Once associated with play, exercise is now closer to a form of labor: measured, timed, and financially incentivized by employers and insurers. Like any kind of alienated labor, it assumes and intensifies the division between mind and body—indeed, it involves a kind of violence by the mind against the body. Ehrenreich is tired of being told to “crush your workout,” of being urged to develop “explosive strength” through a “warrior” routine. She cites the copy from an advertisement for a home fitness machine: “A moment of silence please, for my body has no idea what I’m about to put it through.” Exercise, for some reason, has become a struggle to the death. As Oscar Pistorius—the amputee and Olympic runner convicted of murder in 2015—has tattooed on his back, “I beat my body and make it my slave / I bring it under my complete subjection.”
While workout culture requires the strict ordering of the body, mindfulness culture has emerged to subject the brain to similarly stringent routines. Mindfulness gurus often begin from the assumption that our mental capacities have been warped and attenuated by the distractions of our age. We need re-centering. Mindfulness teaches that it is possible through discipline and practice to gain a sense of tranquility and focus. Such spiritual discipline, often taking the form of a faux-Buddhist meditation program, can of course be managed through an app on your phone, or, with increasing frequency, might be offered by your employer. Google, for example, keeps on staff a “chief motivator,” who specializes in “fitness for the mind,” while Adobe’s “Project Breathe” program allocates 15 minutes per day for employees to “recharge their batteries.” This fantastical hybrid of exertion and mysticism promises that with enough effort , you too can bend your mind back into shape.
“Whichever prevails in the mind-body duality, the hope, the goal—the cherished assumption,” Ehrenreich summarizes, “is that by working together, the mind and the body can act as a perfectly self-regulating machine.” In this vision, the self is a clockwork mechanism, ideally adapted by natural selection to its circumstances and needing upkeep only in the form of juice cleanses, meditation, CrossFit, and so on. Monitor your data forever and hope to live forever. Like workout culture, wellness is a form of conspicuous consumption. It is only the wealthy who have the resources to maintain the illusion of an integral and bounded self, capable of responsible self-care and thus worthy of social status. The same logic says that those who smoke (read: poor), or don’t eat right (poor again), or don’t exercise enough (also poor) have personally failed and somehow deserve their health problems and low life expectancy.
Of course, the body cannot really be mastered this way. For Ehrenreich, in fact, the body is not even a single thing, but rather a continuous, contradictory process. Immunology—her academic specialty—hinges on an essentially military metaphor of distinction between self and nonself: The immune system protects the homeland by destroying invaders. What, then, are we to make of routine episodes of intrabody conflict? There are obvious cases, such as cancer and autoimmune disorders. But Ehrenreich points out that even something as ordinary as menstruation appears to be the product of the adaptive struggle over resources between mother and fetus, an “arms race ... between the human endometrium and the human embryo/placental combination.” The body, like the body politic pictured on the frontispiece of Hobbes’s Leviathan, only gives the appearance of unity: It’s made of a “collection of tiny selves.” And for that matter, there’s not really a king to impose order.
In the intriguing, somewhat curious later chapters of Natural Causes, Ehrenreich explores the agency of cells and other “tiny minds.” Macrophages—immune cells that destroy pathogens—also abet the spread of cancer and instigate potentially catastrophic inflammatory diseases. They may even, Ehrenreich suggests, be responsible for aging itself. They seem to decide to do this, as it were, on their own. The “immune self,” a shadow entity that lives within the human body, sometimes cooperates and sometimes pursues its own agenda.
From there, it’s agency all the way down. “From cells to molecules and from molecules to atoms and subatomic particles—the level of spontaneity only increases until we reach the wild dance party that goes on at the quantum level.” Ehrenreich is not asserting that macrophages or particles have consciousness, but that they can initiate action unpredictably. Human consciousness can partly grasp but cannot fully master this spontaneity. Indeed, consciousness itself—the unitary Cartesian mind—is a megalomaniacal fantasy, misbegotten by the rise of bourgeois society. “The process of thinking involves conflict and alliances between different patterns of neuronal activity. Some patterns synchronize with and reinforce each other. Others tend to cancel each other, and not all of them contribute to our survival.”
Ehrenreich offers a vision of a nonmechanistic physical and biological world, one we’ve lost track of in the modern effort to measure, manage, and exploit nature. Her account of its working can at times feel bleak. Ehrenreich knows this and teases the reader for registering it with a dust-to-dust litany. “The muscles that have been so carefully sculpted and toned stiffen when calcium from the dead body leaks into them ... the organs we nurtured with supplements and superfoods abandon their appointed functions. The brain we have tamed with mindfulness exercises goes awry within minutes after the heart stops beating.” Soon, your brain liquefies and “just pours out the ears and bubbles out the mouth.” So much for the sovereign mind.
But Ehrenreich’s universe hums with life and activity. It’s warm, not cold. She wants to join it in her final years, not leave it behind by cloistering herself in the clinic, the gym, or the spa. For the elderly today, “the price of survival is endless toil” to keep fit, along with incessant trips to the doctor and avoiding all good food, right up till death. She’s not interested. She still works out, though less intensely than before, and she stretches every day—some of it even “might qualify as yoga.” “Other than that, I pretty much eat what I want and indulge my vices, from butter to wine. Life is too short to forgo these pleasures, and would be far too long without them.”
Ehrenreich’s political agenda goes largely unstated in Natural Causes, but is nonetheless central to her argument. Since at least the mid-1970s, she has been engaged in a frustrated dialogue with her peers about how they choose to live. In her view, the New Left failed to grasp that its own professional-class origins, status anxieties, and cultural pretensions were the reason that it had not bridged the gap with the working class in the 1960s and 1970s. It was this gap that presented the New Right with its own political opportunity, leading to the ascent of Ronald Reagan and fueling decades of spiraling inequality, resurgent racism, and the backlash against feminism.
The inability of her contemporaries to see themselves with enough distance—either historical distance or from the vantage of elsewhere in the class system—is the subject of some of her best books: Fear of Falling, a study of middle-class insecurity, and Nickel and Dimed, her best-selling undercover report on the difficulties of low-wage employment. At some level, it’s what all her work has been about. In the final pages of Natural Causes, Ehrenreich stages a version of this lifelong dialogue with her peers. She tries to convince them, in the last act, to finally concede that the world does not revolve around them. They can, she proposes, depart without Sturm und Drang.
Two years ago, I sat in a shady backyard around a table of friends, all over sixty, when the conversation turned to the age-appropriate subject of death. Most of those present averred that they were not afraid of death, only of any suffering that might be involved in dying. I did my best to assure them that this could be minimized or eliminated by insisting on a nonmedical death, without the torment of heroic interventions to prolong life by a few hours or days.
It’s a final, existential version of the same argument she’s made forever: for members of her generation and class to see themselves with a touch more perspective.
Despite Ehrenreich’s efforts, this radical message hasn’t resonated among them as widely as she hoped. She has, meanwhile, worked on building institutions that may foster a different outlook in the years to come. In 2012, she founded the Economic Hardship Reporting Project, an impressive, foundation-backed venture to support journalists reporting on inequality. Ever alert to the threat of social inequality and the responsibility of middle-class radicals, she served until just last year as honorary co-chair of Democratic Socialists of America—that renewed organ of radicalism for the millennial precariat. She is not giving up. “It’s one thing,” she writes, “to die into a dead world and, metaphorically speaking, leave one’s bones to bleach on a desert lit only by a dying star. It is another thing to die into the actual world, which seethes with life, with agency other than our own, and at the very least, with endless possibility.”
It takes a special kind of courage to maintain such humility and optimism across a whole lifetime of losing an argument and documenting the consequences. Barbara Ehrenreich doesn’t meditate. She doesn’t believe in the integral self, coherent consciousness, or the mastery of spirit over matter. She thinks everything is dissolving and reforming, all the time. But she’s not in flux—quite the opposite. She’s never changed her mind, lost her way, or, as far as I can tell, even gotten worn out. There’s the tacit lesson of Natural Causes, conveyed by the author’s biography as much as the book’s content: To sustain political commitment and to manifest social solidarity—fundamentally humble and collective ways of being in the world—is the best self-care.
NOTE: Gabriel Winant is writing a book on care work and the Rust Belt.