Ep 181: The ethics of your clinical decisions, with Dr Nathan Vannatta

[00:00:00] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research

[00:00:10] to quality practice. I'm Claire Ardern, the editor-in-chief of the Journal of Orthopaedic

[00:00:15] and Sports Physical Therapy. It's great to have you listening today.

[00:00:18] So today on JOSPT Insights, we are talking about ethical frameworks and how that applies

[00:00:27] to return to sport decision-making. We are joined by Dr. Nathan Vanetta. Dr. Vanetta

[00:00:32] currently serves as a staff physical therapist in Gundersen Sports Physical Therapy Department.

[00:00:37] He's also instructional faculty with the Sports Physical Therapy Residency Program and adjunct

[00:00:41] graduate faculty with the La Crosse Institute for Movement Science at the University of

[00:00:45] Wisconsin-La Crosse. My name is Dan Chapman. I'm a US-based physical therapist and owner

[00:00:49] of Summit Physical Therapy and Performance in Baltimore, Maryland.

[00:00:53] And I'm Chelsea Kuhnment, a physical therapist and athletic trainer at Stanford

[00:00:56] University Athletics. Dr. Vanetta, thank you so much for joining us today on JOSPT

[00:01:01] Insights. We are so excited to dive into your paper surveying the moral landscape, how ethical

[00:01:06] frameworks influence the structure of return to sport decision-making.

[00:01:10] Thanks. I'm excited to be here, honored to be here chatting with you.

[00:01:14] Return to play decisions can be so difficult, especially when we're we add the sports

[00:01:19] realm to it. It's a typical person out living their life like there's there's no

[00:01:24] timeline, but just adding all of the factors in sports rehab that need to be

[00:01:29] considered can make it such a hard decision.

[00:01:31] It's not just like you pass these tests and you're good to go.

[00:01:34] So I love that you laid out great ways to think about it.

[00:01:37] I want to just hit first, what was the goal of this viewpoint?

[00:01:40] Yes, there's actually kind of multiple layers to why I felt motivated to write

[00:01:45] this article. One of them, obviously, to be help people guide people through

[00:01:49] making super complex decisions on return to sport as a lot of factors.

[00:01:54] The way health care providers manage various scenarios and complex ones in

[00:01:58] particular, that we don't all manage them the same.

[00:02:00] And that probably sounds like stating the obvious.

[00:02:03] But when you see enough variation across practitioners and especially when it's

[00:02:07] between people who you know, you've worked with, you respect their their

[00:02:10] reasoning process and their decisions.

[00:02:12] But yet sometimes the final decision that they arrive at can be different than,

[00:02:17] say, what yours would be trying to understand what kind of underscoring

[00:02:21] those differences and why people are disagreeing has been something I've

[00:02:25] been thinking about for a while.

[00:02:26] And it seems to me that those differences stem from deeper, a deeper

[00:02:30] disagreement than just what is right in the particular situation in front of us.

[00:02:34] I think these disagreements are coming as a natural outworking from different

[00:02:38] underlying conceptions of morality and ethics itself.

[00:02:42] So I wrote this article to try and articulate why these frameworks matter

[00:02:45] and then how they impact our reasoning.

[00:02:47] So not only in the specific context of return to sport, even though I think

[00:02:51] that that's a really helpful way to look at this and think about it, but also

[00:02:55] just to help people navigate broader disagreements in clinical situations.

[00:02:59] I want to go into what those four approaches are that you outline and how

[00:03:03] we can apply them in the clinic.

[00:03:05] One of the ways that I found helpful in thinking through this is sort of

[00:03:09] like this hierarchy of concepts when you're trying to think about an

[00:03:12] overarching theory of morality.

[00:03:14] And so what constitutes right?

[00:03:16] So each of the frameworks that I describe in the article are probably most

[00:03:20] appropriately categorized as applied ethics, but I don't really think it's

[00:03:25] possible to disentangle the applied aspect of any ethical framework from

[00:03:29] sort of its underlying foundational ideas.

[00:03:32] So to help us see that, I think starting at the top of that hierarchy

[00:03:36] is the concept of metaethics.

[00:03:38] So what metaethics is, is that deals with questions like, what is it that

[00:03:42] we consider to be good and right?

[00:03:44] Like as a concept, what defines that?

[00:03:47] And then what is the source or the foundation of good?

[00:03:49] So then along with that, apart from defining what is good in its essence,

[00:03:54] if you will also metaethics deals with, and how do we know that?

[00:03:58] How do we acquire moral knowledge?

[00:04:00] How do we know what something, what is something that we would consider good?

[00:04:04] Then from there, we move into normative ethics.

[00:04:06] And so once you've landed on what you consider to be good and how

[00:04:10] you know what that is, you have to have a way of evaluating how behaviors,

[00:04:14] how, what people do and think align with that underlying idea, that

[00:04:18] underlying theory.

[00:04:19] So in other words, what norms of behavior, hence normative, what norms of behavior

[00:04:24] are consistent with your conception of what is good and what is right?

[00:04:29] So at least from a secular perspective, there are three primary theories that kind

[00:04:33] of get the most attention historically.

[00:04:35] So those would be deontological theories, consequentialist theories

[00:04:38] or virtue theories.

[00:04:40] So a quick summary of the normative theories.

[00:04:43] So deontological theories would say that there are certain rules that we live

[00:04:46] by and those rules are found in the duties inherent in us as people, or

[00:04:51] because of the rights inherent in us as people.

[00:04:53] The consequentialist theory would say that there may be rules that we are to

[00:04:57] live by, but if those rules exist, they are established by things that

[00:05:01] maximize the good of people, however that's defined.

[00:05:05] And then virtuism would say, ah, but the rules, they're only helpful

[00:05:09] in so much as they aid us in understanding the types of people we

[00:05:13] ought to be.

[00:05:14] And then comes the applied aspect of these theories.

[00:05:18] OK, and that's kind of that's where we live as clinicians is how do we make

[00:05:22] decisions? So moving into the framers, the first one I describe is

[00:05:25] principalism. So the main idea that's really important in their theory is

[00:05:28] this idea of common morality.

[00:05:30] So they postulate that there exists some degree of moral agreement among

[00:05:33] people. What principles are in common across people ultimately arrive at four

[00:05:39] principles. So respect for autonomy, beneficence, non-malfeasance and

[00:05:43] justice. Respect for people because they're people and then aim to do to

[00:05:48] benefit others, help others, try your best to avoid harming others and

[00:05:52] then do that to all people regardless of race, sex, culture,

[00:05:56] class. So in applying this framework in the clinic, we have to ask

[00:06:00] ourselves how do these principles bear on whatever situation we're facing?

[00:06:04] So how do we respect this person?

[00:06:06] How do we make a decision that's for their good?

[00:06:08] How do we avoid causing harm to them?

[00:06:11] And then how do I do that for all of my patients?

[00:06:13] So that's principalism in a nutshell.

[00:06:15] So the difficulty here is oftentimes when any of those principles come into

[00:06:19] conflict, you have to have a way to resolve those conflicts in frequent

[00:06:23] many situations, allowing a person to make their own independent decision

[00:06:28] is a is a very convenient way to resolve a dilemma.

[00:06:32] So in our case, talking about ACL return to sport, we have an

[00:06:37] independent adult who's been given information.

[00:06:41] She's borderline as far as being being ready.

[00:06:45] But ultimately, if we're not in a position to override her choice,

[00:06:51] I think unless we can specify that this is a condition where we would

[00:06:55] override her choice, principalism probably largely would defer to her

[00:07:00] independent judgment.

[00:07:02] If she were to choose given like principalism would introduce that

[00:07:07] she's educated, we give her all of the resources and she she decides.

[00:07:10] So now number two, another approach to this is professionalism.

[00:07:15] So what does that go into?

[00:07:17] Professionalism.

[00:07:18] So in the way I'm using this isn't like an adjective about like how you

[00:07:22] should compose yourself or, you know, in a patient interaction.

[00:07:24] So this is referring to a specific set of rules and guidelines that are to

[00:07:28] guide behavior.

[00:07:29] So this framework, the main idea is that they object to the idea of

[00:07:33] common morality. The argument goes like this as a professional, we're bound

[00:07:38] by more stringent duties than everyday interactions.

[00:07:43] So this theory contends that that the duty of a health care provider has

[00:07:48] to patient confidentiality is far more stringent than the duties that we

[00:07:52] have to one another, say, as as neighbors.

[00:07:55] Right. So the breach of the in the former case could lead to fines and

[00:07:59] loss of your license, whereas a breach in the latter case, you know, you

[00:08:03] just might have your neighbor mad at you for a couple of weeks.

[00:08:07] The flip side of that. So not only do we have more binding

[00:08:09] responsibilities, but then we have special privileges.

[00:08:11] So as a profession, we're allowed to do things that normal people

[00:08:15] aren't. So, for example, in an exam, it's not uncommon for us to

[00:08:18] ask a patient to remove a piece of our article of clothing in order to

[00:08:22] examine the area.

[00:08:24] But it would be amazingly inappropriate for you to do to ask people to

[00:08:28] disrobe and just day to day interactions.

[00:08:31] So the idea is, is that within a profession that the duties that we have

[00:08:35] as professionals is not the same as the duties that we have as normal

[00:08:41] citizens, common, common people.

[00:08:44] So the main argument is that a theory of common morality is insufficient to

[00:08:48] guide health care ethics.

[00:08:50] What should guide health care practice and ethical decisions should

[00:08:55] come from within the profession itself and in some cases should even be

[00:08:59] determined by the members of that profession.

[00:09:02] Now, currently I'm not aware of any agreed upon set of principles, but

[00:09:07] some of the ones that are listed, at least in the article that I cite,

[00:09:10] things would be like seek trust and be deserving of it.

[00:09:13] Use your medical knowledge, skills, powers and privileges and immunities to

[00:09:17] the benefit of patients in society.

[00:09:20] Be mindful in responding to medical needs.

[00:09:22] They have respective autonomy, respect the autonomy of patients on their list

[00:09:26] and be truthful in your, in your reports.

[00:09:29] But I think the way that the, that this theory kind of envisions the idea

[00:09:34] of a profession kind of positions it such that it would be more willing to

[00:09:39] override patients autonomy in largely because it conceptualizes itself as

[00:09:45] having a duty to utilize it's the, your specialized knowledge in a way to

[00:09:51] inform people in a return to sport decision, the person best suited to

[00:09:57] know the risks and the long-term outcomes is probably going to be the

[00:10:02] healthcare provider more so than Ellie and Ellie.

[00:10:06] So some better than others for sure.

[00:10:09] But here we would be more inclined to say we have a duty to use our

[00:10:14] knowledge or Ellie's benefit.

[00:10:17] It may not always work that way.

[00:10:19] I don't think professionalism inherently means you're going to just make your

[00:10:23] own decisions without regard to what patients think, but I think that there's

[00:10:27] a greater tendency for us to take that role and come into upon ourselves.

[00:10:31] When we view ourselves in that role as we have this knowledge, we have

[00:10:36] this training, we have all this experience working with us.

[00:10:38] We've seen more ACL recoveries than any one patient has.

[00:10:42] And then, so this theory of ethics would say this would perhaps be a case

[00:10:47] where we would say, I'm going to step in for your best interest and say no.

[00:10:52] Okay.

[00:10:53] There's a third one consequentialism.

[00:10:55] Yep.

[00:10:55] So consequentialism remember, so this is the applied version of the normative

[00:10:59] theory that says that which is right is which maximizes good.

[00:11:03] So in this framework, when we encounter a situation, we're thinking

[00:11:07] less about what are the rules, what are the principles that we need to

[00:11:10] follow unless you're a rural utilitarianism, but the emphasis is

[00:11:14] going to be what actions bring about the circumstances where good is maximized.

[00:11:19] So the challenging thing here is that we have to first identify what is

[00:11:24] the sphere of good that we're trying to maximize, so like, are we talking

[00:11:27] about an individual, a specified group or like all people everywhere for all

[00:11:33] time, but we'd have to answer that first and then we would then have

[00:11:37] to answer what is the good that we're trying to maximize?

[00:11:40] Is it happiness?

[00:11:41] Is it health?

[00:11:43] Is it overall wellbeing?

[00:11:45] And then how do we define and measure those things after we've reasoned through

[00:11:49] all of those things, we would then have to say what has the highest likelihood.

[00:11:54] But when we apply this to this case, let's say if we use happiness, Ellie's

[00:11:59] team is going to be happy.

[00:12:00] Ellie's gets certainly going to be happy.

[00:12:02] Probably coaches are going to be happy.

[00:12:05] Mom and dad may be happy, but a little bit nervous.

[00:12:08] And so you can easily see how it would be justified potential, at

[00:12:11] least according to this framework to say, yeah, you could probably utilize

[00:12:15] consequentialism to reason the other way as well.

[00:12:18] If we looked at overall wellbeing in the longterm, you could probably

[00:12:23] argue the opposite way that does again, the challenging thing with this

[00:12:27] sort of theory is you have to then you have to stipulate those.

[00:12:31] Those sorts of things.

[00:12:32] What are, what is it that you're trying to maximize?

[00:12:34] And then how do you put that into, into practice?

[00:12:38] All right.

[00:12:38] And then the last one, I mean, not that these are the final four things to ever

[00:12:42] think about, but the last one you outline is the last approach is virtuism.

[00:12:46] So again, so virtuism is the term that I use to apply it, to refer to

[00:12:49] the applied version of virtue theory.

[00:12:51] So again, another subtle shift in reasoning.

[00:12:54] So in virtue theory, we're going to be thinking less about rules and

[00:12:58] less about outcome, but more about what is my role, what is my role as

[00:13:02] the healthcare provider or in our case, the physical therapist.

[00:13:05] So we have to first kind of formulate a way to conceive the type of healthcare

[00:13:09] providers we ought to be.

[00:13:11] And then, so it places much more emphasis on our motives behind

[00:13:14] the actions that we do.

[00:13:16] So from that understanding, then we derive the behaviors that are

[00:13:19] consistent with those characteristics.

[00:13:22] Kind of using our return to sport example, like if we were to shift

[00:13:25] Ellie's case, like instead of being seven months, she's a year and they

[00:13:28] say, well, she's a year out and the physical therapist says it are.

[00:13:32] She's doing good in physical therapy.

[00:13:34] Let her go.

[00:13:35] Under a virtue theory, we would say, Oh, you can't do that.

[00:13:39] No, that that's not consistent with being thorough.

[00:13:41] That's not consistent with using skilled reasoning.

[00:13:44] That's not consistent with providing, you know, using best evidence.

[00:13:47] That's not consistent with the way we would conceive of

[00:13:51] excellence in our practice.

[00:13:54] So a virtue theorist would have a some beef with that sort of reasoning.

[00:13:58] Whereas under a consequentialist theory, motives under most don't even

[00:14:03] matter the way that you get to the decision doesn't matter.

[00:14:06] It's just did it, did it bring about the outcome?

[00:14:08] And then under a day ontological theory tries others allotment for.

[00:14:13] A motives and virtues in that sort of thing, but it gets a little bit

[00:14:16] harder because it was like, well, if there weren't agreed upon rules that

[00:14:20] the guy didn't, that that reasoning didn't break, how do we say it was

[00:14:24] wrong?

[00:14:25] Whereas virtue theory would have very, would be very, have no problem

[00:14:30] being able to tell you why we would disagree with the way that that

[00:14:34] decision was made.

[00:14:36] Going just to Ellie's case, what would be compassionate?

[00:14:40] Like we'd want to empathize with her in the sense of we understand

[00:14:44] that she wants to get back.

[00:14:47] We understand that she's been working super hard.

[00:14:49] We recognize all the effort that she's been putting in over the last seven

[00:14:53] months.

[00:14:54] But then we also want to think knowing what we know about the risks

[00:14:58] that she would be assuming.

[00:14:59] We'd want to inform her of that.

[00:15:02] Okay.

[00:15:02] So your strength isn't quite all the way back.

[00:15:04] We know that if you wait at least until nine months, you're going

[00:15:07] to have the risk of re-injury goes way down.

[00:15:10] We want to integrate you a little bit more gradually than just like

[00:15:15] throw you in there next week.

[00:15:16] So we want to at least inform her of that.

[00:15:19] But then given that she is an individual who we respect and who

[00:15:24] we care about, we would be very careful to impose what we think that

[00:15:31] she would do, but ultimately leaving it in her court because she's an

[00:15:37] adult risk as far as we know responsible and capable of making

[00:15:42] decisions.

[00:15:42] And so we wouldn't necessarily be able to tell her not to.

[00:15:49] Another way that this may play out where if you need an actual letter

[00:15:54] from a healthcare provider clearing you, and then if a virtue theorist were

[00:15:58] to say, I really don't think that you are then to be truthful, could they

[00:16:04] actually write that letter?

[00:16:06] You actually signing that because of that's a form of act of

[00:16:08] virtuosism and that's your purpose.

[00:16:11] And that's not aligning with our purpose.

[00:16:12] Cause we can see that she's still lacking a couple of those traits

[00:16:16] versus we can just provide a recommendation and we can say,

[00:16:19] here's why I don't think so.

[00:16:20] But it ended the day.

[00:16:22] Yeah, it's still her independent choice.

[00:16:26] We face this stuff all the time.

[00:16:27] Really, really hard.

[00:16:29] Nathan is going through Ellie's case extremely helpful to actually

[00:16:32] there's still just like, sometimes it's just hard for me to grasp

[00:16:36] all of those concepts.

[00:16:37] So putting it towards a case of super helpful.

[00:16:39] Can we do that again with something just a little bit different just

[00:16:41] to kind of drive home these points and put them into practice?

[00:16:44] So I've called this third party payers in the art of deception.

[00:16:48] So here we go.

[00:16:52] Yes, got to make it fun.

[00:16:53] But I think this will be another situation that all of us can readily

[00:16:57] at least relate to maybe not in a specific way in the case.

[00:17:00] So you just completed an evaluation of a 21 year old male who was

[00:17:04] referred you to begin physical therapy for a partial Achilles rupture

[00:17:08] located near the myotendinous junction.

[00:17:11] So he was just cleared by the managing physician to begin

[00:17:13] transitioning out of a walking boot and begin formal physical therapy.

[00:17:17] Really looking forward to working with the guy is highly motivated and

[00:17:21] you just kind of already envisioning all the fun that it's going to be

[00:17:23] to help them get back to basketball.

[00:17:26] Then a few days later, you get a letter from the young man's insurance company.

[00:17:30] And it says that his claim for physical therapy has been denied.

[00:17:34] Now you're pretty baffled at this because he clearly has multiple

[00:17:38] impairments he's hardly out of a walking boot.

[00:17:42] He's not functioning nearly at the level that he was prior to the

[00:17:45] injury and certainly not to the level that we would expect given his age

[00:17:49] and health and athletic capacity.

[00:17:51] You being a good clinician that you are taking upon yourself to advocate for him.

[00:17:55] You call the insurance company and she explains that the reason the care

[00:17:58] will not be covered is because your clinic is coded as an outpatient

[00:18:02] hospital, which indicates a higher level of care than a normal outpatient clinic.

[00:18:08] Now you're still confused because you actually do work at an outpatient

[00:18:11] physical therapy clinic, even though you're affiliated with the hospital system.

[00:18:15] But even after clarifying that she respond by saying that that may be the case,

[00:18:19] but nonetheless, that hospital affiliation makes a code for your clinic.

[00:18:26] That still places you in a higher level of care quickly begin to see that

[00:18:30] there's no way around this unfortunate coding system.

[00:18:34] So you ask what types of justification must be given for this level of care.

[00:18:38] She lists out a few reasons and you know, most of them right away are just

[00:18:41] not going to work, but there seems to be one option that might qualify.

[00:18:44] So the final option to justify care at your facility is that your facility

[00:18:49] provides a service that is necessary for recovery that is not otherwise available.

[00:18:57] So ultimately you come up short finding something that you know, that your

[00:19:00] clinic has that some other clinics in town don't, you're not absolutely

[00:19:06] confident that you can say that your facility has is absolutely necessary.

[00:19:11] For his care patient chose this facility, given its reputation and long

[00:19:17] standing history in the area for providing care to athletes.

[00:19:19] He wants his care here.

[00:19:21] You are arguably one of the most qualified people to give it.

[00:19:25] Do you lie or some may say bend to the truth a little.

[00:19:29] So let's go through our principles to get through that.

[00:19:31] So what would principle ism?

[00:19:32] How would that approach?

[00:19:34] Well, how do we think about it?

[00:19:35] Well, obviously, so we're going to identify our four principles, right?

[00:19:38] So the principles that we'd have in play here is respect for autonomy.

[00:19:41] So the patient wants care at this facility.

[00:19:43] Beneficence would say, how do you ensure the best care for this patient?

[00:19:47] Like we want him to get good care.

[00:19:48] He's certainly going to get good care at our facility.

[00:19:52] And then depending on your relationship with other facilities in town, you

[00:19:55] may or may not, you may have varying degrees of confidence at other facilities.

[00:20:00] And then justice, I would say comes in here and like, is the insurance

[00:20:04] company just in this weird coding thing?

[00:20:08] So then out of principle ism, they would also specify certain rules to

[00:20:11] guide patient provider relationships.

[00:20:13] And so they, these rules, they would say derive from multiple principles.

[00:20:17] And so the rules that guide behavior would be veracity, privacy,

[00:20:22] confidentiality and fidelity.

[00:20:24] So veracity is the fancy word for truthfulness.

[00:20:28] So we have that, that we'd have to consider.

[00:20:30] So the main issue before us is, is our duty to truthfulness just as

[00:20:36] important as those other, other principles.

[00:20:39] And we would have to specify that.

[00:20:42] So those are the things we would think about.

[00:20:44] Those decisions we'd have to make looking at it from the principles of view.

[00:20:49] There would be some situations where deception is permissible, but you

[00:20:53] would have to justify that.

[00:20:55] And then ultimately they would discourage any, any form of, of deceit.

[00:21:01] Right.

[00:21:02] Okay.

[00:21:03] So now we've made that decision, or at least we're still, we're,

[00:21:07] we're marinating on that.

[00:21:08] So now let's think about it from a professionalism approach.

[00:21:11] I have a duty to my patient to ensure the best care possible.

[00:21:14] This insurance company does not have the right to specify what sorts of

[00:21:19] facilities that patients can receive care at through their arbitrary rules.

[00:21:24] So sorry, they're a little cynical.

[00:21:26] That's a little sassy as you got so far here.

[00:21:30] So I am justified in advocating for my patient in this case, for him to receive

[00:21:35] the care he wishes and that has a good chance of being the best care for him.

[00:21:41] So in that case, I'm justified, I'm justified in a white lie.

[00:21:47] If we want to call it that to say that the insurance company is going

[00:21:50] to pay one way or the other.

[00:21:52] So what difference does it make?

[00:21:54] Yeah.

[00:21:54] Because based on their, their unique knowledge as a profession,

[00:21:59] they know that you, them seeking care there would be the best.

[00:22:03] Yeah.

[00:22:03] And then I think they would be, I think they would have legitimate

[00:22:07] argument to say that I know better than the insurance company as

[00:22:11] the healthcare professional, even though theoretically most insurance

[00:22:14] companies have peer reviewers.

[00:22:15] So hopefully, you know, there, there should be some degree of reasoning

[00:22:20] behind some of these, these rules that we encounter.

[00:22:23] How about consequentialism?

[00:22:24] How do we think about it from that?

[00:22:26] From a consequentialist lens.

[00:22:28] So one could argue that the patient wants to be seen at this facility.

[00:22:31] You are qualified to give that care.

[00:22:33] The insurance company is going to pay for the services no matter what,

[00:22:37] whether it's this facility or another.

[00:22:39] So really there's no one who suffers or suffers any kind of loss by a little lie.

[00:22:46] So in the patient can get to what they want.

[00:22:49] Yeah.

[00:22:50] Happiness already pretty easy to justify.

[00:22:53] All right.

[00:22:53] Last up thinking about it from a virtuous standpoint.

[00:22:57] So I think it'd be easy to recognize honesty or truthfulness as a virtue in

[00:23:01] this case, but then we'd also be thinking about things like compassion

[00:23:04] and kindness, faithfulness to your patient, benevolence and justice.

[00:23:09] We would still have that duty or that that we'd want to maintain our

[00:23:13] virtue of truthfulness towards the insurance company, our compassion

[00:23:17] and faithfulness to our patient.

[00:23:19] But then if we throw humility in here, one could ask, am I truly the only

[00:23:25] therapist in the area that could see this patient?

[00:23:27] Is this truly the only clinic that's qualified to give him care?

[00:23:32] Do I know any of the other therapists in town?

[00:23:35] Could I coordinate that connection for this patient so that I can

[00:23:40] maintain my integrity towards the insurance company and still be thinking

[00:23:45] about this patient who I really care about.

[00:23:47] I wanted the article to be thought provoking and I hope that

[00:23:52] people walk away from it thinking.

[00:23:54] Without necessarily a, you're going to get an answer out of this, but

[00:23:58] you're going to have a lot of things to consider and then you can

[00:24:01] come together on a decision.

[00:24:03] Well, I really appreciate you taking the time to lay all that out.

[00:24:06] I feel like I went to school for a little bit and then I played a

[00:24:08] really stressful game for a little bit.

[00:24:11] Um, but I really appreciate you taking the time.

[00:24:12] Just like really introduce a different way we haven't, we, I feel

[00:24:15] like we think about the tests so much and making, letting us, and these

[00:24:19] are clinical reasoning in that way.

[00:24:20] But like the ethical side of it is just a whole other thing to consider

[00:24:23] that I think is really important.

[00:24:24] So thanks so much for laying that out.

[00:24:26] Absolutely.

[00:24:27] My pleasure.

[00:24:27] Thanks for having me on.

[00:24:29] I really enjoyed the conversation.

[00:24:31] So we want to thank Dr.

[00:24:32] Veneta again for coming on the show and sharing his insights and

[00:24:35] experience with us and all of our listeners.

[00:24:37] And as always, we want to thank you for listening to JOSPT Insights.

[00:24:41] Thanks for listening to this episode of JOSPT Insights.

[00:24:46] For more discussion of the issues in musculoskeletal rehabilitation that

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