Although having only been a PTA for three years, I've found myself in conversations with many potential future SPTA candidates. Quite a few have been with bright and hardworking CNAs who I work with in skilled nursing and others have been with folks my age or older (that would be the 40+ set if you were wondering) looking into PTA as a second or third career.
For those seeking direction about entering the physical therapy field -- I say this: The accredited PTA programs available are incredibly challenging, so be prepared to study and be tested weekly for almost two years without a significant break. I don't mince words or sugarcoat the process because people need to understand the commitment level you take on as a SPTA. However, when you've earned your degree and pass the state board -- you'll be working in a vastly varied field where your choice of setting and patient type can range from the local gym with a 12-year-old soccer player to the hospital with a 90-year-old recovering from hip surgery.
Whichever setting and patient group they ultimately choose to work with, I tell them they have to love it. If you're passionate about orthopedic PT but working in a skilled nursing setting with little exposure to ortho conditions, maybe it's time to make a job switch. Patients will know if your heart's not "in it" and frankly, you've worked too hard to just "phone it in" at work daily. Having said that -- give each PT setting a try, whether job shadowing a PTA or when choosing your clinical affiliations.
Personally, I find discussing the PTA profession with other interested parties to be one of my duties as a licensed healthcare professional in this field. Physical therapy has given me a profound insight into the human condition as well as myself. Providing advice and mentoring future PTAs can only support the long-term strength of the profession.
Well, I'm finishing my first week at a new facility and still trying to catch my breath. For those readers not familiar with my professional exploits, I resigned from a PTA position that I held for three years and started working in a similar setting (skilled nursing, long-term care) just this past week. As I reflect on the past few days, I've come up with a short list of unsolicited advice for anyone thinking about or preparing for a new job.
1. Take some time off between jobs. I say this because I did not and I highly regret my decision. My last day of work at my previous place of employment was on a Friday and I began my new job the following Monday. Saying "goodbye" to close colleagues and patients was exponentially harder than I thought it was going to be. As well, meeting all my new coworkers and orienting to a completely different facility just a few days later was exhausting. Even a four-day weekend off between locations would have renewed my energy.
2. On your first day of work, come early and stay late. This is obvious, of course. Your first day on the job is overwhelming between learning the layout of a large facility or hospital and the (always) unfamiliar EMR system the rehab utilizes -- you'll need the extra time.
3. Introduce yourself to the entire facility/clinic staff. This is crucial in making a positive impression particularly with nursing, one of the most important groups in the facility. Whether it is the RN or housekeeper, you will be communicating with these hard-working folks on a daily basis. You want them to know you are a team player.
4. Spend extra time getting to know your new patients. Refrain from charting during the session and really begin a conversation with each patient. If you work full-time, you'll be visiting with this person almost every day. Again, make them feel comfortable with you on day one and you'll be building a solid foundation of trust, which will carry over each therapy session.
These are just a few of my initial thoughts on the "first week" at my new job. I'm sure there is much more sound advice that I welcome readers to suggest or comment on. Generally though, I was struck with how universally therapy can be applied in different settings and ultimately, how important our profession is to the healthcare of our patients -- at any age.
As we all know, maintaining our patients' personal and health information private is mandated by HIPAA laws and frankly, common sense. I would be less likely to disclose a patient's name to an unknown visitor than hand my credit card to a stranger on the street. Often though, I find myself abbreviating my own "history" to inquiring patients.
Having recently gone through a divorce, I shy away from discussing my private life with my patients simply because it can get awkward. Although I freely will discuss my children -- names, ages and interests -- to a curious patient, when the conversation naturally turns towards the topic of my "spouse," my description gets a bit vague. It's not that I think my patients "can't handle the truth" -- all of these people have seen their fair share of tragedy and triumph (some are WWII vets for goodness sake). I just do not feel my personal problems need to be unloaded on patients who are already vulnerable and often depressed.
As PTs/PTAs, our patients are depending on our therapeutic knowledge to guide them through their treatments each day -- knowing their therapist's personal life is a complicated mess is not exactly comforting.
As well, maintaining the therapist privacy is just as important. Recently, my fellow colleague suffered a serious illness in which he was hospitalized and required an extended leave of absence. Because he was widely respected by his patients and had been working full-time, many were constantly asking the PT department, "Where is my therapist -- is he coming back?" We fielded the questions by downplaying the severity of his illness and stating, "He is getting stronger every day." Again, the patients did not need to know the extent of this therapist's illness as they are dealing with their own health issues and the therapist deserved some privacy to heal without worrying about stressing out his patients on top of everything else.
Privacy is a two-way street, which should be respected by both the therapist and patient. This allows for the focus to be on the most important goal of all -- the patient's recovery. Do you have a "no-tell" policy regarding your personal life with patients? How do you field the "awkward" questions?
Last week, I resigned from my first PTA job. It was stressful and I was anxious about my director of rehab's response, but it was time. As I've blogged over the past few weeks, I was finding myself more frustrated than I've ever felt with the job and my morale was at an all-time low. After covertly interviewing in the early morning hours at a few different facilities, I had accepted a generous offer (above my asking hourly wage) from another inpatient setting closer to my home.
Having worked at this current facility for exactly three years now, when I sat down with my DOR to break the news, he was disappointed but not surprised. I stated the simple facts: This new opportunity would offer me an easier lifestyle as I would be cutting my commute time in half and I would have more time for my kids in the evenings. I also felt compelled to mention the significant pay raise they were offering. I prefaced the "news" with the positives of my current position with his company, which included the outstanding team of therapists I work with daily.
My boss was kind enough to state that he was losing a great therapist and that no matter where I go, I'll be an asset to that rehab department. As well, he offered to be a reference contact in the future. Before I left his office though, he also gave me this final pearl of wisdom: Change can be good in this industry. Although there are certainly many advantages to staying with the same facility/clinic for years, when you push past your comfort zone, you can only benefit as a therapist from the new experiences and clinicians you'll meet along the way.
So in two more weeks, I'll be heading off to greener pastures (closer to home, at least). Whether this new company is the right fit for me is to be determined. But I'm confident I'm heading in the right direction.
In the skilled nursing setting, many of the patients on my schedule have a dementia diagnosis. Whether displaying mild signs such as repeating a story or severe moaning and perseverating over mundane details, I try to keep the treatment focused on their functional goals. When it comes to touching dementia patients, whether during a transfer or giving tactile cues, I enter their personal space with caution.
After years of lifting, scooting and facilitating patients and their movements, I don't hesitate to touch my patients when teaching or in greeting. The patient's with memory impairments, however, can be impulsive and particular. Recently, I had one patient (with mild dementia) snap, "Don't touch me!" after I tried to lightly stoke her back to soothe low-back pain she was experiencing. Later on that day, as I was leaning forward to offer a moderate assist for a sit-to-stand in the parallel bars, the patient asked if he could kiss me. This is the same patient who tried to take a swing at a CNA and me when we tried to get him out of bed that morning.
Whether a confused patient becomes combative or "too friendly," my therapeutic tactic is to re-direct. At times redirection can only happen in a quiet, calm environment. And even then, redirection and focusing on the task can be futile. Although frustrating at times, I remind myself that this patient's therapy is just as important as the next patient's knee-replacement rehab as we are working on maintaining strength, function and safety during transfers.
It's also important to keep in perspective that these people have lived full lives, including marriage, raising children, having careers and surviving wars. I happen to be one of the last people they'll meet in their lives who is there to help ease their pain. Although aspects of their brain are now dying, they deserve the same respect as any other patient. It just can be a more delicate therapy session.
Do you have patients (with dementia or not) who are "more challenging" than others and if so, do you have any strategies that can assist other therapists (like myself) in helping these patients progress?
I'm coming up on my 3-year anniversary with the skilled nursing facility where I currently work. I remember vividly the phone call from my rehab director informing me that I was hired on as a PTA. It was an incredible high -- having just graduated from the PTA program not but two weeks before. Honestly, it felt like I'd won the lottery, having secured a position in a SNF, my therapy setting of choice and with a decent starting wage to match.
My first few years were brutal at times but amazingly informative. The lead physical therapists who I worked with utilized every opportunity to teach me and took me to task daily on the functionality and quality of therapy I was offering our patients. Through these rigorous mentoring years (at times I felt like I was back in a clinical affiliation), I grew into the therapist I am today.
With my mentors having left the SNF and moved on with their careers, I find myself with the unfamiliar feeling of job restlessness. Up until a few months ago, I felt comforted by the fact that my day (albeit filled with stresses) would run predictably into the next. My awesome group of colleagues would be there for support and help with a patient at a moment's notice, and my yearly paid vacation days smoothed out the high census months.
Then one day I just felt different about my future. Suddenly, I had a myriad of reasons why "change" sounded like a viable option. Having written more than a few of these blogs describing my growing unease, I finally took one reader's advice and decided to "diversify my options." To be completely honest, I'm not quite sure what that meant -- so I translated it into interviewing for other PTA positions.
The interview process, when one is not depending on the position presented, can be a fantastic learning experience. In the few interviews I've been on recently, absent is the nervous "pit-in-my-stomach" feeling. This has allowed for a more open conversation with rehab managers as to whether their facility or clinic can benefit from my experience and how I might grow as a therapist with them. Whether I accept a different position in a new facility or setting has yet to be determined. But I definitely feel more at ease as I'm setting my own course for the future and on my terms. Now, if only we could procure CEU units for the interview process...
A few days ago, I was preparing a patient for a slide-board transfer from the edge of her bed to the wheelchair. As she was a max-assist with two therapists for this transfer up until this point, we were attempting to progress to a one-person assist and increase her self-initiation. As I reached around her torso and gripped firmly onto the gait belt, she blurted quite incredulously, "How did you ever decide this is the line of work you wanted to do?"
I was so caught off-guard and amused by her question (as well as the timing), I had to abort the transfer attempt to chuckle. Without much of a pause, I simply answered, "I like to help people -- and this job is really rewarding." I explained to her that I was originally going to focus on sports medicine physical therapy until I volunteered in a skilled nursing facility for my observation hours and completely fell in love with working in this setting.
We completed the transfer with a beautiful minimal assist, which surprised us both considering her max-assist level just a day or two ago. I have no doubt she was more comfortable and trusting of my abilities after our impromptu conversation (as I'm sure she had her doubts since she has about 200 pounds on me and I'm a towering 5-foot-1 in my clogs).
Her question and my immediate response couldn't have come at a more pivotal time. I've been frustrated and disgruntled at work recently (if you read this blog on a regular basis, you've probably picked up on this vibe). As therapists, we have more than a few tough days. Between communication breakdowns with management, nursing and unmotivated patients, some days make me question whether I should make a major career change.
Ultimately, the rewards I gain from my job as a PTA far outweigh the lows. Watching patients go from barely being able to perform an ankle pump in supine to scaling stairs with a single-point cane, is frankly just awesome to witness. I realize now the stresses will never really go away and the focus should always remain on the most important factor of this job -- the patients and their goals. Sometimes those reminders come when you least expect and need to hear them the most.
When I arrive to work every day, I'm faced with a list of patients and expected therapeutic minutes to achieve for the day. What's missing on my list, you might ask? Scheduled therapy times. This translates to me knocking on many of my patients' doors in the a.m. to tentatively "schedule" my day of treatments. In many cases, because I've worked with the patients on a regular basis, I know which of them prefer morning to afternoon therapy sessions. This leads me to consult with the treating OT or COTA, as overlapping schedules have a tendency to happen frequently.
Most days, my schedule falls into place and I'm able to treat most of my patients. But more often than not, I'm chasing after a patient who left for the activity room or is being given a shower by nursing. If I sound frustrated, it's because I am. As a PTA in a SNF, every minute of my day will be measured toward my productivity. Not to mention the intense pressure to secure minutes to meet the patient's RUG level. A few years ago, our rehab department attempted an hourly schedule for each patient. Unfortunately, for the exception of one or two "appointments," the patients weren't able to keep their schedules due to fatigue, illness or simply to use the bathroom.
One of my colleagues mentioned how she enjoyed the "freedom" of having the flexibility of scheduling her patients vs. a "set time." Her point was that certain patients may require a 70-minute treatment session and others can only tolerate a 40-minute session. I see this advantage, but I would still prefer a more developed framework for my day. The responsibility would focus on patients' compliance with their agreed scheduled time compared to my open-ended question of, "What time would you like to do therapy today?"
If you work or have worked in a skilled nursing setting, are your patients given hourly therapy schedules? Is this system successful for you and your patient or do you find yourself constantly rescheduling throughout the day? I suspect the more staff supporting the patients' therapy schedule (nursing, CNAs, activity dept.), the chance of participation increases as well.
When a patient first arrives at a SNF from the hospital, typically he's in pain, ill and many times confused. Once the primary therapist completes the initial evaluation, that patient is quickly scheduled for PT seven days a week. The ideal situation would be to have the primary PT and a PTA treat the patient throughout the week, progressing treatments and meeting the goals of the established plan of care.
Unfortunately, this isn't a perfect world and skilled nursing PT can quickly "run off track" when it comes to providing an important component to a patient's recovery; continuity of care. As a full-time therapist, I'm lucky enough to be able to treat the same patients Monday through Friday with the exception of the primary PT's fifth visit, of course. However, there are weeks when my schedule of patients shifts daily due to a colleague calling in sick, PRN staffing, or the full-time weekend therapist's arrival (working Friday through Monday).
There are many times a patient, who I have treated for weeks, inexplicably "disappears" from my schedule only to resurface on another PTA's patient list. In such cases, my PTA colleague and I will make a "player trade" with someone off my schedule who that PTA has worked with before.
I've actually seen patients work with four or five different therapists in one week. This lack of continuity with just one main therapist is the least ideal for the patient. Despite the fact that every therapist who treats this patient is working toward the plan of care goals as set by the primary PT, it's difficult to progress when each therapist has a different there ex plan. The phrase "too many cooks in the kitchen" comes to mind during such a scenario.
Our rehab team has addressed this issue in the past and has made efforts to schedule patients with the same PT/PTA daily, but some patients do fall through the cracks when census is high and additional PRN staffing is necessary. When this is recognized, we advocate for the patient and keep the "player" on our roster.
My experience working in a skilled nursing facility has many advantages including autonomy as a therapist, a bustling team atmosphere and working with my favorite group: the tough-as-nails geriatric population. However, being a full-time PTA in a SNF has its drawbacks as well.
This could not be better illustrated than by the working day I just experienced. When I arrived to work today, one of my colleagues called in sick. Due to no available PRN staff, myself and the remaining therapists had an additional patient or two tacked onto our schedules. As well, the facility was experiencing a norovirus outbreak, thus therapy sessions were to be completed in patients' rooms under contact precautions. And then I found out one of my patients had passed away the previous evening.
This was just another Wednesday. Actually, that was a heavier day than my usual, but my work days have been running 8-10 hours long recently and often I find myself walking through my front door at 7 p.m. By Friday, I'm spent physically and emotionally, and ready for nothing but -- bed. My situation is a bit more unique living in the Great Northwest of this country, where daylight hours are amazingly short and the sun sets before 4 p.m. Having said that, I'll take the short days over the Northeast snowstorms any day.
As I was warned by many experienced therapists when I first began my career, "Eventually you'll burn out in a SNF!" I'm feeling the fatigue set in. So how am I trying to avoid this professional "burnout," you might ask? First, when I leave the SNF doors for the day, I also leave my job stress in my cubby. Somehow, I've found a way not to take it home with me. It helps that my life is just as frenetic at home as a single mom with two kids.
Secondly, I run. Correction, "jog fast," as a form of physical and emotional fitness (side note -- it took me nearly five years to enjoy running, but well worth the wait!). On many levels, exercise reduces my stress and cluttered thoughts. And finally, writing this blog has helped me "vent" my thoughts on the vast topic of my profession.
Trust me, I know I'm not unique. Whether you work in a SNF, hospital or private clinic, every one of us faces stress daily. What I want to know is how do you avoid the "burnout?" Are you able to find a balance between a stressful work environment and your sanity? Love to hear your thoughts.
Over the past few years, I've noticed my therapeutic style has changed subtly in some ways and drastically in other aspects. Due to self-preservation and the ever-present productivity demands, I've developed into a much more efficient therapist. From completing three full treatments in the morning without concurrent patients to communicating effectively with the nursing staff regarding pain medications for certain patients at specific times, my clinical timing skills have to be right on target for a successful day.
One major modification I've noticed since my first year as a PTA is my documentation style. When I first started working in the SNF a few years ago, my rehab director advised me to "keep it simple" when it came to my daily notes. Unfortunately, as a fresh new graduate of the PTA program, one-page SOAP notes were my reality and strength in school. I struggled with "editing" my clinical information, which all seemed "life-or-death" important to include. How will the next therapist know that the patient had a longer left-side loading response? Everything was relevant and everything went into those first notes.
Over time I realized my style, although informative, was mostly inconsequential and laborious for the rest of my team of therapists to read through. Most notably when trying to complete a progress note on a patient and coming across the page-long paragraph describing the gritty details of a THA patient's family visit, I knew I had to rein in the verbiage. I found I looked forward to reading the previous day's notes written by therapists who described the therapy session in a basic format with the important details clearly expressed -- without the flourish.
Gone are the days of my long narratives describing the therapeutic benefits of a toilet transfer. And with this change in my writing style, I find that I'm actually more efficient in my daily job performance. I have other colleagues who respectfully disagree with me and find the longer detailed descriptions of the session important to impart to the next therapist. However, I'll be keeping my notes short and relevant -- and save the extra time for the patients.
There has been much discussion recently about how much people earn. Whether comparison of PT/PTA salaries by region, such as on the ADVANCE website, or in politics regarding raising the minimum wage (don't worry, I'm not going to tackle that slippery slope), people want to know: What am I worth? It's timely though, as I've been perseverating over my hourly wage for more than a year now.
If you're unfamiliar with my history, here's a brief synopsis of my career so far -- I've been a full-time PTA for almost three years. Out of the "graduate gate," I was lucky enough to be employed in my preferred PT setting of a SNF, where I've stayed over these last few years.
When my 2-year "anniversary" came around last year, I felt I was in good position to ask for a pay increase as I'm hard-working, experienced (compared to when I started) and had the most seniority on the rehab staff; which is not much leverage, but it's something. When I finally sat down with my boss, the rehab manager, he was generous with his compliments on my therapeutic and interpersonal skills with the patients, but not so much with the inevitable raise request. As he informed me, the corporate policy of the facility only allows a 1% increase yearly.
I was deflated, to say the least. Without disclosing exactly how much I earn, let's just say 1% would not significantly change my paycheck amount. That was the exact moment the cold hard truth fell hard and unceremoniously in my lap. If I wanted to get a higher pay rate as a more experienced therapist, I would have to find a job somewhere else. If I stay, the new graduates coming out of the PTA program this spring will be earning the same paycheck. However, if I leave and find a different job elsewhere, I would be considered a more seasoned therapist and garner higher pay -- depending on the PT setting of course.
There are a few problems with this plan, however. In my county, we have an accredited PTA school producing 20 graduates a year, basically saturating the market in a 30-mile radius. PTA jobs are hard to come by and becoming scarcer each year. Secondly, I really enjoy working with my rehab team. Working alongside such considerate and talented therapists makes my job easier and less stressful. And finally, with the aforementioned lack of jobs in the area, I'm lucky to have mine, including benefits. As a single mother, I don't have a lot of wiggle room in my budget for a part-time job either.
So what does a quasi-new therapist do when she seeks a higher pay rate than that of an entry-level new grad? Well, as you can see -- I don't know. I'm currently reviewing my options on employment-finding websites without much success. Have you ever been in this professional situation and what did you do? Any feedback and advice will be appreciated here at the crossroads of "do I stay or do I go?"
As a new PTA grad a few years ago, I was lucky enough to be mentored by two very talented physical therapists. Both PTs, who happened to be married to each other, took this petrified/inexperienced PTA and taught me the essentials of SNF rehab and more. After two intense and lesson-filled years, this PT couple left our therapy team to work in an orthopedic outpatient clinic.
Since their departure, our rehab director has valiantly attempted to fill the large void left on our rehab team. Specifically, looking for a strong PT willing to take the helm of our caseload. To be clear, we have two other capable PTs on staff, both of whom work part-time during the week and are new "mommies" with vested interest to leave work as soon as possible. The bulk of our rehab staff is made up of full-time PTAs (including myself) with varying degrees of experience but more importantly, patient advocates and devoted team members.
Over the past year, myself and the rest of the PTA staff have watched talented contract physical therapists and disinterested PRN PTs come and go with a varying sense of disappointment or relief. Having such a cohesive PTA staff and having lost such strong PT leaders, we were optimistically hesitant to bring on a new "captain" to our team. We waited patiently and hoped for a viable candidate to apply for the job.
There's a reason skilled nursing has one of the highest pay rates for physical therapists. The days are long and the patients complicated, coupled with grueling documentation demands, not to mention the productivity expectations -- you will be deserving of your paycheck. A PT has to carefully consider the SNF setting compared to the laid-back outpatient clinic. I've personally been told by one PRN PT (at work) that she "hated" skilled nursing. As you can imagine, she wasn't tapped for many more shifts.
Just when we thought we'd have to get to know one more "traveling-contract" PT, we were informed a local therapist accepted the position. As luck would have it, this PT is refreshingly "normal." She works well with her patients and staff, possessing the most important attributes to being a successful SNF therapist: clinical skills, compassion and a keen sense of humor. Having only just started the job two weeks ago, my PTA colleagues and I are crossing our fingers that she'll rise to the challenge of being our fearless leader. For now she'll have our support in every way and we'll all hope for the best. To be continued...
Recently, a coworker of mine introduced me to a quote by Albert Einstein and how appropriately it relates to our patients in the SNF setting: Life is like riding a bicycle. To keep your balance, you must keep moving.
For that matter, this quote can be applied to most patients in any PT gym, whether outpatient clinic or post-op acute in the hospital. Most of my patients are "out-of-balance" -- literally, in many cases as a result of inactivity. As we all know, sedentary lifestyle and poor diet choices are causing an epidemic of younger, diabetic patients with co-morbidities, who never exercised a day in their life.
As a result, many of my patients look at me like I have two heads when I remind them that physical therapy sessions are every day during their stay at the skilled nursing facility. And yes, they are expected to participate each and every day. These are, of course, extremely low-level patients and we begin their treatment with the most basic of exercise: supine in bed. As my patients, I educate them on the importance of exercise not just with building strength and joint ROM, but in the psychological benefits including reducing stress and depression.
With no surprises, I've had the "just keep moving" talk with more than one patient on my schedule who refused to get out of bed due to fatigue/pain/drowsiness/nausea. It's frustrating for us both. They're very ill and feel terrible and I know they won't start getting stronger until they get out of their bed. Unfortunately, sometimes this standoff doesn't get resolved and the primary therapist has to give it his best attempt, which can ultimately result in the patient being removed from therapy for non-compliance.
Once in a while though, I'll be given a patient who starts therapy so weak he can barely walk in the parallel bars. Even through the pain and fatigue, he participates in therapy every day and begins to progress. Whether limited by obesity or an amputation, he gives 100% effort and surprises even himself with his accomplishments. In turn, these patients inspire me to not give up when this job gets insanely stressful or even when I set a personal goal for myself.
Please share how you motivate your patients to "keep moving," whether in an inpatient or outpatient setting. Better yet, how do you keep moving? Because I'm always open to tips, bicycle or not. ;)
When I started my journey into the physical therapy field, I found myself surrounded by eager SPTA students, like myself, beginning a new career. Nearly half the people in my graduating class from PTA school were over the age of 40. Many had children and degrees in other fields, but all of us were unwavering in our mutual goal to become PTAs.
I now find myself working with more than one of my fellow "older" students on our SNF rehab team. In fact, there is currently no therapist under the age of 35 in the PT department. Although I have worked with plenty of talented "20-something" therapists over the past few years, I find the most successful therapists in the SNF setting are those with a bit of life experience of their own.
One of these therapists is my colleague Fred, who I've talked about in a past blog or two. Fred is unapologetically 61 years old, white-haired and has been a PTA for as long as I have. In fact, we sat next to each other in class during the entire PTA program. Nicknamed "Dr. Fred" by the staff due to so many patients mistaking him for the facility MD, Fred has the ability to charm even the toughest patient.
Fred and all of my fellow therapists on the team bring a quality to their work that cannot be taught or earned in a degree; and that's wisdom (along with a large dose of compassion). Does this make Fred or I more successful at the job than the newly graduated 27-year-old DPT? Of course not! But years of working in vastly different jobs, raising kids and experiencing the effects of aging personally can only assist in being more relatable to our patients.
In three short months, I'll be turning 40 myself. A few years ago, I would've cringed at the thought of this milestone because (as I would tell myself) 40 is middle-age -- it's the beginning of being "Old." Today, I embrace the number. My age has only helped me become a kinder and more patient therapist. And if Fred is any indication, my future looks very promising. Did you enter PT as an "older" therapist or do you have a "Fred" type in your office or gym? Have you found age (whether old or young) to be a benefit in regard to patient relatability during treatments?