Rehabilitation providers experience ethical conflicts every day, whether they realize it or not. Just today, I was cruising through social media on my lunch break and saw a post (edited for autonomy) that posed an ethical concern, potentially without its author even knowing. We’ll refer back to this post throughout the blog so please read:

“We have a patient at my clinic whose partner called and scheduled the appointment for the patient. My colleague did the evaluation this morning and said the partner answered all questions for the patient. The partner was inquiring about decreasing posterior pelvic floor tension for anal sex. The therapist found it strange that the partner was answering all the questions for the patient. At this time, I'm really wondering if the partner is forcing the patient to come to pelvic floor therapy and participate. How would you all handle this situation?”

You know this stopped my scroll immediately. Yes, it is a patient care question. However, this situation also brings up so many other intricacies that we encounter as pelvic health providers. I gave my reply and then read others, and this experience made me glad that Herman and Wallace offered three ethics classes talking about ethics for pelvic floor therapists to attend and be able to collaborate on issues just like the one above.

As a healthcare professional, staying informed about ethical and legal responsibilities is not just a requirement, but a crucial aspect of providing the best care for your patients. I instruct a remote course that tackles these difficult issues - my course, Ethical Considerations from a Legal Lens is a comprehensive remote course taking place on November 17, 2024, that will delve into these important topics from the perspective of the pelvic health rehabilitation field.

Why does this topic matter?
Navigating the complex legal and ethical landscape can be challenging for healthcare providers, particularly in specialized areas like pelvic rehabilitation or even more niche subsets within pelvic health. This course is designed to help practitioners gain a deeper understanding of ethical decision-making while helping a provider feel more legal compliance to safeguard the patient’s well-being and the integrity of a provider’s practice.

During this course, you’ll interactively explore key concepts including:

Each profession has its own code of ethics to give guidelines for the professional to act. This is the case for lawyers, doctors, mental health therapists, massage therapists, and accountants to name a few. In pelvic rehabilitation, the APTA and AOTA make different guidelines for physical therapists and occupational therapists respectively.

For physical therapists, the Code of Ethics is built upon the physical therapist's five roles, the profession's core values, and the multiple realms of ethical action. For occupational therapists, the code serves the two purposes of providing aspiration core values in professional and volunteer roles as well as delineating ethical principles and enforceable standards of conduct.

There are many areas of overlap and differences between the roles of physical and occupational therapists in pelvic rehabilitation. This blog will explore the areas that overlap in the world of ethical decision-making. Pelvic floor therapists must complete tasks such as management of patients/clients, consultation, education, research, and administration. Ethical realms can be individual, organizational, and societal and there are various situations an individual can find themselves in when providing care including problems, issues, dilemmas, temptation, distress, and silence.

September is Ovarian Cancer Awareness Month. Ovarian cancer is the seventh most common type of malignant neoplasm in women and the eighth cause of mortality for women (Gaona-Luviano et al, 2020). In women who have died from gynecological cancers, ovarian cancer is the leading cause of death (Arora et al., 2021). This type of cancer can originate from any of the ovary's three main components, including the epithelium, stroma, and germinal cells. Per Gaona-Luviano et al., 2020, “epidemiology of this cancer shows differences between races and countries due to several factors including genetic and economic.” Detection of ovarian cancer is problematic because there is no standardized screening process and most cases of ovarian cancer are found in the advanced stages (Gaona-Luviano et al, 2020).

How is ovarian cancer diagnosed?
Sadly, the existing screening tests have a low predictive value. A gynecological evaluation, transvaginal ultrasound, and tumor marker testing (cancer antigen-125/CA-125 assay) can help with early detection strategies but this has not shown a significant effect on the morbidity or mortality of this cancer (Arora et al., 2021).

How is ovarian cancer treated medically?

If you saw Ethical Considerations for Pediatric Pelvic Health and thought “Why are they making ANOTHER ethics class?” please let me take a moment to explain its origin and purpose in the Herman and Wallace course offerings. I wrote my Pediatric Pelvic Floor Play Skills course when I had colleagues asking for ways to play with their patients. When I started teaching this class, some of the most common questions that came up seemed like ETHICAL questions. How do we handle pediatric care in different settings? How do we get consent from minors? If a child says no but their legal guardian wants the assessment done, what does the provider do?

Pediatric Pelvic Floor Play Skills is a class written to help providers take the pelvic health knowledge they have, and learn activities they can perform with different ages of children to help work on their pelvic floor function. One of the tricky parts of working with children is including the child in their care plan and coordinating with caregivers. In this course, talk about specific concerns and considerations by age, as well as strategies to bring to a provider's practice. This class is for the provider who does not have a lot of experience treating pediatric patients and wants to learn how to make sessions enjoyable and effective. While in Ethical Considerations for Pediatric Pelvic Health, we review the different overall milestones, as well as what age-appropriate expressions of sexuality may look like as children develop toward adulthood.

Let's talk about Pediatric Care
When we say “pediatric” this can span from infants to teenage age groups. Dealing with a crying baby will be different decision-making versus a toddler in a tantrum or a defiant teen. The pediatric population is a vulnerable group because they can’t advocate for themselves, their own interests, and their health to protect themselves from harm. When we consider decision-making with a child, a therapist should consider things like their development, family structure, competence, and education levels. Children develop in a variety of areas including their fine and gross motor skills, language, cognitive, social, emotional, and behavior.

When I was diagnosed with Thyroid Cancer, I’ll be honest, one of my first thoughts was “Thank goodness this won’t directly affect my pelvic floor.” I think as someone who has experienced pelvic floor problems in the past and worked in the pelvic health field for many years, this is probably a somewhat normal reaction, but it wasn’t the standard from my parents and other loved ones. They wanted answers and information and because Thyroid cancer didn’t fall into my niche knowledge of pelvic health, I had to do some research.

Let’s start by saying that thyroid Cancer is the most pervasive endocrine cancer in the world (Bray, 2018). It is the sixth most common cancer in females in the United States (Siegel, 2019). Thyroid cancer incidence and outcomes depend on where the patient lives with Ethiopia and the Philippines having the highest death rates (Deng, 2020). There has been a rise in the diagnosis of thyroid cancer which studies attribute to access to health care, ultrasound, training of those doing the ultrasound, use of fine needle aspiration biopsy, and changes in monitoring and management guidelines (Megwalu & Moon, 2022). The five-year survival rate for people diagnosed with Thyroid Cancer is around 98.5% (Boucai et al. 2024). There are a few types of Thyroid Cancer and Papillary Thyroid Cancer accounts for 84% of all cases (Boucai et al. 2024). There are also follicular, medullary, and anaplastic forms making up the remaining cases  (Boucai et al. 2024).

When I tell people I have Thyroid Cancer one of their first questions is “What were your symptoms, how did you know?!” The short answer is, I didn’t know. My cancer journey started when I found out I had a 3 cm nodule that had grown a “significant” amount since my last ultrasound. My endocrinologist said the growth was enough to warrant a fine needle aspiration biopsy. In reading about this diagnosis, it seems many cases of Thyroid Cancers are asymptomatic and detected during a routine physical examination or found incidentally with diagnostic imaging  (Boucai et al. 2024).

Imagine you’re a provider who has foundational information about the pelvic floor. Maybe you’ve just started taking coursework for adults, you may have taken a pediatric pelvic health class or maybe you’ve been treating adults for years. You know the anatomy, the physiology, and the general treatment practice guidelines.

• Your clinic gets a call about a baby with colic and your supervisor asks you if you could treat it. Do you accept the evaluation?
• You see a post on a “mommy Facebook group” asking for potty training tips for a child who is withholding stool during potty training. Do you tag your business/practice as a resource that can help?
• You have a family friend with a child struggling with voiding during the school day and they ask you for advice as a pelvic health provider. Do you have ideas on how to guide them?
• A patient you are seeing for pelvic floor issues asks you to start treating their teenager because they have “the same issues.” Does this seem scary to you?

Pediatric Pelvic Floor Play Skills is a class written to be a supplement to other pelvic health education classes a pelvic floor therapist has likely taken. This class helps providers take the pelvic health knowledge they have, and learn activities they can perform with different ages of children to help work on their pelvic floor function. The class shows videos of actual treatment sessions of different children in different age groups showing how to integrate stretching, strengthening, coordination, and other fun activities into a therapy visit.

One of the tricky parts of working with children is including the child in their plan of care and coordinating with caregivers. Pediatric Pelvic Floor Play Skills talks about specific concerns and considerations by age, as well as strategies to bring to a provider's practice. This class is for the provider who does not have a lot of experience treating pediatric patients and wants to learn how to make sessions enjoyable and effective.

Have you ever heard the phrase “In one ear and out the other?” I sure have, I have vivid memories of my grandmother scolding me for just that. She could never understand how when she said things to me, particularly a list of tasks to do, I could never seem to remember. Funnily enough, my grandfather’s nickname for me was “rabbit ears” because he swore I could pick up on a conversation from anywhere in close proximity so it wasn’t my hearing. Pretty conflicting and confusing, right? I had trouble processing things I heard or remembering them long enough to do them. Years of Catholic school helped to give me structure and tools to keep myself and my fun little brain organized and on task, and I ended up being able to keep up with the rest of my class. 

The older and more self-aware I got, the more I realized my brain doesn’t work the way everyone else’s does. The more I worked with kiddos with autism and ADHD, the more I realized my brain worked similarly to theirs. When I first heard the term “neurodivergent” I felt immediately like I had found the answer to a question I didn’t even know existed for myself. This was why I wasn’t the same as other people in processing all things! This is why I had to touch everything to learn about it. This is why I had to rewrite all my notes from professors instead of just being able to absorb what they said. This is why I needed mnemonics, stories, acronyms, and other little “hacks” to learn things. 

There are many different ways people can learn. The most common forms of learning consider if a person learns best through visual, aural/ auditory, reading/writing, or kinesthetic movement. Individuals can be any combination of these, which can vary as they grow through life. Someone may start out learning better kinesthetically and learn to process information better visually as they age. In our COVID era, a new format of teaching became more prevalent, bringing “at distance” learning in to save the day in many instances.

1. You took Pelvic Function Level 1 and you left with more questions than answers when it comes to consent, vulnerability, chaperones, safety, and clinical decision-making about how to deal with tough client situations.
2. Your state requires you to take an ethics class and you're looking for a new class that actually applies to your area of expertise. (The thought of taking another ethics class honestly makes you feel like you'll immediately fall asleep).
3. You'd love to be in a conversation with a small group of like-minded professionals in pelvic health with varying levels of experience about common challenging ethical scenarios for pelvic health providers.
4. You have a burning ethical concern that you would love help with and the ability to anonymously offer it up to a think tank of other pelvic health providers sounds like a dream. You feel icky about something and need to get it off your chest and find solutions.
5. You're looking to learn about what ethics is, why it matters, and how to apply these concepts to your clinical practice, whether you're a newbie or veteran to the therapist life.

In all seriousness, Ethical Concerns for the Pelvic Health Professional is an ethics class created to fulfill your state requirements, answer your clinical practice questions on this topic, and help soothe any situations that may be causing you stress (maybe just a little, maybe a whole lot). Every time it runs, it's slightly different because although there is a structured curriculum, there is also a lot of dedicated time for applicable case study situations and group discussion of real concerns of the providers attending. Join Mora on April 20th in her next course!

PARTICIPANT TESTIMONIALS:

Mora Pluchino, PT, DPT, PRPC is a Stockton University graduate with a BS in Biology (2007), and a Doctorate in Physical Therapy (2009). Mora's toolkit involves experience in a variety of areas and settings, including working with children and adults, including orthopedics, bracing, neuromuscular issues, vestibular issues, robotics training, and in 2016 she began treating Pelvic Health patients. Mora is active with Herman & Wallace as a Lead TA, faculty, member of the content team, and has written and instructs 3 of her own courses with HW including Pediatric Pelvic Floor Play Skills which is intervention-focused, and does not delve into specific pediatric diagnoses.

“I’m an expert at children’s behavior” said no experienced therapist (or parent or teacher) EVER. Working with kids is one of the most gratifying and frustrating, not to mention mystifying experiences I have ever had. What works for one child sends another into a temper tantrum. What one kid thinks is fun has another whining about how they may die of boredom. Ask the pelvic organ stuffies in my treatment what I’m talking about, they could tell you some stories!

Herman & Wallace has two amazing pediatric courses by Dawn Sandalcidi (Dawn Sandalcidi’s course Pediatric Incontinence and Pelvic Floor Dysfunction) that give such a great foundation to diving intro treating pediatric clients. I’ve taken them both myself and would not have been the clinician, teaching assistant or instructor I am without them. In these classes you can learn all of the diagnoses, latest research and treatment protocols from someone who has been a leader in pediatric pelvic floor therapy for years.