A Mary Reilly Moment
Yesterday I had what I call a “Mary Reilly moment.” Mary Reilly was a highly respected leader of the occupational therapy profession in the mid-20th century. A statement from her 1961 Eleanor Clarke Slagle lecture1 is one of the most widely cited quotations in the occupational therapy literature:
Man, through the use of his hands, as they are energized by mind and will
can influence the state of his own health.
Indeed, the title of Reilly’s Slagle was audacious: Occupational Therapy Can Be One of the Great Ideas of 20th-Century Medicine. It is now the 21st century and “healthcare” has at least partially replaced “medicine” as the inclusive term. Yet Reilly’s lecture contains many other profound statements which might yet guide the profession to being one of the great ideas of 21st century healthcare. My Reilly moment was related to two of those assertions:
“The wide and gaping chasm which exists between the complexity of illness and the commonplaceness of our treatment tools is, and always will be,
both the pride and the anguish of our profession.”
“We won’t be put out of business by any budget change or any malice from any other group or any kind of neglect on the part of society. It will be because we who are out practicing in the field fail to realize the enormous nature of the work that we do. Our failure to appreciate what we do for patients will be the cause of our disappearance.”
What happened yesterday?
Last week I did a home visit with a gentleman who is blind and mobility limited. His income is too high for him to be eligible for personal care/aide services, but much too low for him to afford private duty assistance. His home and personal care reflect this challenge. More significant for his health, he has no reliable assistance to manage either his medication or his insulin. The medical and nursing providers on the in-home care team had devised a system that seemed reasonable: once daily medications pre-poured in blister packs delivered from the pharmacy and pre-filled insulin syringes. These are set out for the patient weekly by someone from the care team. After much trial and tweaking, the team reported things were improving—he was missing his meds or insulin once or twice a week instead of nearly every day. But last week, when I joined two team members on a home visit, they were frustrated as the gentleman had missed almost all of his insulin doses of the past week and his blood glucose was high. Yet he was certain that he had been administering the insulin every day.
As the nurse and PCP provided their services and set up the insulin and medicines, I investigated the context of his medicine and insulin administration. I inquired about his daily routines and the time of day that he took his medicine and insulin. I assured him that I was not doubting his memory, but I wondered if anything had disrupted his usual routines associated with administering insulin or taking medicines. I discovered his sleep/wake cycle was unstable. Often, he slept through most daylight hours, but was wide awake in the early am and late pm. He had few daily “routines” as activities were often timed to when a friend might be able to stop by to help him with a task or run an errand. But he insisted he was up every morning by 5am and that was when he took his medicine and his insulin.
I suggested that maybe it would help if he had an audible alarm set for about 15 minutes after the latest time he usually got up. It could serve as a reminder to take medicine and insulin. If he had already taken it, the alarm could be ignored. But if he had been distracted, the alarm was a backstop. He agreed to a trial. We set up the alarm in his phone to repeat daily, with a particularly distinctive and annoying ringtone. We went over the plan until he could state it without prompting. We also verified that he could turn the alarm off each day without cancelling subsequent days.
Yesterday when I went to see him, the PCP met me at the door, a smile on his face; “he took his insulin every day this week!” I said that was great news and went in to see the patient. I commended him on taking his insulin every day of the past week. Then we worked on another task as the PCP filled a week’s worth of syringes.
When the PCP returned, he said to the gentleman, “I have to ask: What do you think made the difference that you took your insulin every day this week?” I knew what I was hoping to hear, but really wondered what he might say. He answered simply and confidently, “Dr. Carol’s annoying alarm.”
Mary Reilly was right. The commonplaceness of our tools—our interventions--is often the anguish of our profession. But the nature of what we do is enormous. Occupational performance does not happen in a vacuum. It happens in a context: embedded in routines, times, places, social spaces, and cultural expectations. In LIFE! In the 21st century, where management or mismanagement of chronic conditions consumes significant healthcare costs and resources, much attention has been paid to patient knowledge. Far less attention has been paid to how that knowledge of health management activities is operationalized successfully in daily life. In this case, the alarm was not the intervention. The intervention was identifying and implementing the right cue compatible with the gentleman’s routines (such as they are), abilities, and resources.
We’re just one week in—so I can’t claim this as a successful intervention or a successful outcome. But it is a start. For this gentleman, a start toward better, more consistent blood sugar management. For the PCP, perhaps a broader understanding of both occupation and occupational therapy. For me, confirmation that there are feasible options to support his participation and his health management. it was another Mary Reilly moment. Hoping for yet another one when I go back next week.
What are your thoughts about commonplace interventions and OT’s role in the 21st century? I’d love to know more about your comments and ideas.
Issues of the American Journal of Occupational Therapy from the 1960s are not available online. The only option to access the lecture that I am aware of is in this book: Padilla, R. & Griffiths, Y. (Eds.) (2017). A professional legacy: The Eleanor Clarke Slagle Lectures in Occupational Therapy, 1955-2016, Centennial edition, available from AOTA Press.