I work full-time at one facility and help out at another. The second facility is an hour drive away by highway. It fell to me because I'm the only one willing to go there. I burn a tank of gas if I make two round trips. My company pays me drive time to the facility as an enticement to go there. Sometimes I've gone on Saturday if I thought Monday was going to be awful. I never intended for Saturdays to become a regular thing because it wore me out and my weekend was shot.

Last Friday, the second facility got three Medicare Part A admissions. The program director was put out with me when I told her I'd be there on Monday. She told me I needed to come on Saturday and not only see those patients but also provide complete treatments. For the rest of the day, I received text messages asking me if I'd changed my mind.

I finally received a call from the area manager. She, too, wanted me to give up my Saturday. Her main concern was getting those evaluations completed and in the system. She never asked me why I didn't want to go nor did she offer me any incentive. She simply told me somebody needed to go there this weekend.

Now, in my mind if it was about the patients, someone would have offered me an incentive to go. If patient care was the priority, a little extra money to get the job done wouldn't have been a problem. I've seen several other companies to that. If the goal was to treat the patients, it wouldn't have mattered if they had to pay me, or someone else, a little more for the inconvenience. But paying someone something extra makes a big difference if all you're looking at is the bottom line.

The continued pressure only strengthened my resolve not to go. I felt no reason to help someone who only saw dollar signs. None of the people who thought I should give up my Saturday were willing to give up theirs. For my company, the only difference between Saturday and Monday was an extra day of billed services. There was nothing patient-centered about the situation.

Last week I described being warned not to make trouble by reporting the nurses watching the baby camera while at work. I've been thinking about that. Why would I be the troublemaker for reporting someone else doing something wrong? Shouldn't it be the other way around? You would think the person bringing it to attention would be thanked.

I worked at one SNF where I was considered a bad employee for complaining the CNAs weren't cleaning residents regularly or getting them out of bed. I was told to leave it alone. They were overworked and couldn't be expected to do everything. I was fired for reporting someone to the state board for consistently not writing notes. I've since found out he was the best friend of the owner of the company that fired me. I earned the wrath of the emperor's flunky in the evil empire (a former place of employment) for daring to report dangerous behavior with ICU patients of another therapist.

In each case, the problem I reported directly affected safety and care of patients. Across the board the reaction was the same. Leave it alone. If I didn't leave it alone, that would require someone higher up the ladder to take some action. It would mean changing an established practice or creating conflict with an employee. It would take someone's time and effort to ensure the CNAs were performing their job duties as required. In simpler terms, it would be inconvenient to make changes.

It's sad that in today's healthcare, inconvenience dictates how problems are solved. Solving problems takes time no one has to spare. It's easier to let things slide or take some token action because it requires less time. Nothing will change because the guilty know there will be no follow-through. The last thing a manager or supervisor wants is someone complaining and demanding action be taken.

It's easier to silence the complaint than fix the problem. After a while, no one complains. They recognize that not only will the situation not change, but the person who complained becomes the problem. This creates an ongoing cycle of frustration. I know how it feels to have a target on my back. I just didn't know it was there at the time. I'm sure I'm not alone. Ultimately the ones who suffer the most are our patients. Unless they have a family member or other advocate present, care can be less than stellar.

So I complain. I'm getting used to the fallout from creating conflict. I continue to hope that causing some changes to be made will ultimately improve the facility as a whole. I don't think anyone else will say anything.

There has always been some conflict between therapy and nursing. Each complains about what the other does or doesn't do. Last week I saw something that floored me. I went into the nursing office looking for a chart. I didn't find the chart. I did find three nurses watching someone's grandson through a web cam feed at his day care. It was on the computer screen. They'd apparently been watching a while. They were talking about things they'd already seen him do.

OMG! This is a facility that makes me account for almost every minute of my day. Employees aren't allowed access to the WiFi. Yet these three nurses were watching the kiddie cam on a computer only they have access to. If I want to look something up on the web, I have to use my phone. Therapy has one computer in our office. None of the therapists have access. If I want to download a Tinetti or Berg, I have to ask the secretary to do it for me.

This is the kind of double standard that creates conflict between the two disciplines. It can lead to resentment and distrust. I wasted several minutes looking for that chart only to find it sitting unused in the nursing office. Those were minutes I could have spent doing something else, not to mention the added aggravation of having to look for it.

I brought it up to my supervisor and was told to let it go. It would just get me labeled a troublemaker. The logic of the situation escapes me. The nurses were doing something no one else is allowed to do on equipment no one else has access to but I'm a troublemaker if I bring it up. I think I'm safe in saying no work was being done in that office.

I'm sure this happens everywhere. There's no telling how much time is wasted in the "evil empire" where I formerly worked and everyone has computer access. Although I doubt anyone there has the time to sit and baby-watch for more than a minute or two. There's a huge difference in work production between watching a few minutes every so often and devoting 10 minutes at a time to the viewing. The same is true of any activity that takes away from work time. A certain amount of wasted time is expected. The baby cam took wasting time to a new level.

The positive influence of animals on healing is well known. Caring Critters now make regular visits to various facilities within the Houston area. Dogs can be certified as therapy animals. Horses are used for hippotherapy with great results. Now I'm going to try to combine the two.

Last Friday, my horse Expsychment (pronounced "excitement") made a visit to the SNF where I work. For me it's the best of both worlds. I get paid to play with my horse. But something more important also happens. The residents get to play with him. I bring bags of chopped carrots so everyone gets a chance to feed the horse. I've forgotten the simple joy of interacting with an animal because I do it all the time.

It's been several days and they are still talking about it. Several of them have proudly told me how they fed him a carrot. Others talk about how he didn't bite when he took the carrot from them. I think almost everyone in the facility has thanked me for bringing him. Even the residents who didn't get all that close seemed to have enjoyed it.

But something else happened. He was there for nearly two hours. Toward the end, as the novelty wore off the residents started going inside. That's when therapy started bringing out the residents who wouldn't normally have come. These were the ones not so cognitively intact or pretty much limited to one extremity. They don't interact so much with others, until the horse came over to visit.

Every single one of them lit up. Carrots were carefully placed into hands which I held up to him. They laughed and giggled. They smiled. A couple moved more in those few minutes then they had in weeks. Those residents couldn't thank me in the hall but they didn't have to. Seeing them was enough. We talked about it the rest of the day.

I'm going to start working with him. He's going to learn to be more patient and how to greet everyone. I hope to get him to put his head close enough for some extra petting, or at least a nose rub. This time we only had carrots. Next time I'll bring some other treats for those residents who need a little more than average. He may not be an official therapy animal but he got the job done.

This week a patient was referred to therapy because of neck pain. I quickly determined she had a mechanical derangement of her cervical spine. Something was locked in the upper cervical region that prevented her from rotating. Her complaints were inability to sleep and turn her head.

Once a manual therapist, always a manual therapist, I guess. There were several things I could have done, modalities included. Instead I laid her on the mat, positioned her head off the end and did what I used to do once upon a time. Within a few minutes, I had increased her ROM in all planes and abolished her pain.

The next morning, I was reminded why I disliked manual therapy. I expected to find her somewhere similar to where she left me. I was wrong. She ignored all the education and warnings. She went right back to what she'd been doing and came back in worse shape than when we started. All of my questions were answered with either a description of how much it hurt or with excuses. It was obvious she hadn't been listening. None of the excuses covered what actually happened.

It seems she loves to solve puzzles. As soon as she got back from dialysis, which she blamed for all the problems, she spent several hours bent over working on a puzzle. It was all I could do not to get up and bang my head on the wall next to her. It took three more sessions to regain everything again.

I was amazed at how much I remembered. As soon as I started repetitive motion testing, it all came back. I visualized how everything was moving. I instantly knew what to do and how to do it. I guess once you learn something it stays in your brain. That's a pretty good argument for cortical reorganization following skilled learning. Years later the motor pathways are still there.

As soon as the pain stayed gone she stopped coming to therapy. I'm glad she's better. I'm also glad I can go back to what I normally do, counting reps and writing notes. This job is nothing if not easy and mindless.

No matter where I am, I hear the old school/new school discussion. In simplest terms, it's a comparison of how we did something years ago compared with how we do it now. In more unkind terms, it can become a condemnation of those who went to school back in the day or new graduates. It came home to me how different the thinking is last Friday.

I made a comment about how being slow in writing evaluations results in lower productivity. This was meant with a stunned silence followed by a question. Why aren't you writing them during the evaluations? That way it is billable time.

Now I admit I'm seriously old school. The people I was speaking to were new school. Back in the day, we were taught to devote our attention to the patient for the duration of the treatment session. The patient, or rather his payer source, was paying for our time and expertise. You don't take time out for prolonged documentation. You write test results. You note prior functional and living levels. You discuss goals and therapy expectations at the time of evaluation.

My understanding of new school teaching is that it's acceptable to write evaluations during the evaluation period. The same is true of progress notes etc. The reasoning is improved efficiency and less downtime. In theory, this would mean more patients can be seen in the same amount of time.

This discussion is a minefield I'd rather avoid. I simply use this as an example of the differences between the two schools of thought. I often write parts of my evaluations when I perform them. It's hard to remember details. What I don't do is complete the document. After I complete the evaluation, I begin treatment.

My new school colleagues complete the evaluation, write the evaluation and then begin treatment. I think the time is about the same. The difference is they charge for the time spent writing. For as long as I can remember, I've been told not to charge for documentation time. Things have changed. We complete the same process but in different ways.

I'm not comfortable with this new definition of what is chargeable time. Unless you discuss the evaluation item by item, I don't see it. Sooner or later I'm going to hear about my productivity. My options appear to be get with the program, document off the clock, learn to write very quickly or something completely different. I guess I'll see what happens.

For the last few months I've been doing something new, teaching. I'm teaching for one of the larger continuing education providers for physical therapy. I teach what I love, how to treat stroke patients. I just finished a four-day tour of teaching. It was long and tiring and gave me the opportunity to decide if this is something I want to do.

Now that I'm home and not rushing to airports, I've had time to think about it. I've found something else I love to do. And fortunately it's not at the whim of someone else. I finally found a direction for myself. I've been wondering what I'd do when the physical demands of the job became too much. Now I know. I will somehow be teaching. Teaching as a second career means more topics than stroke rehab but I think I can make the transition.

There have been times over the last year, today included, when I've questioned whether I wanted to remain in this occupation. Now I have an answer. I'm not sure how I'll manage the change but once I identify a goal, I can begin to work toward it. Step one is figuring out the process.

This revelation makes me wonder about other therapists who are beyond halfway in their careers. What will they do? My solution won't work for many others. And given the way experienced therapists are being treated in the job market, I doubt they'll continue working until retirement. There are lots of experienced therapists out there. We should take advantage of them and learn from their experiences.

I hope I'm able to convey my knowledge and skills to others in a meaningful way. I hope I'm able to help people become a little bit better at what they do.

Those arguments are flawed in so many ways. I don't know where the belief that everyone should have as much therapy as possible comes from. It simply isn't true. Anyone who has worked in rehab or long-term care knows our patients have limitations. The facility wanting three hours of therapy doesn't always translate into the patient tolerating three hours. The same is true in a SNF. Patients who can barely maintain alertness are routinely scheduled for 50 minutes of therapy per session.

The truth is that every patient is different and what is enough for one might be too much for another. Setting arbitrary therapy levels for reimbursement isn't ensuring optimal therapy. It means someone will spend the required amount of time trying to get the patient to do something so she can charge for her time.

Sadly the person I had the discussion with was a clinician who recently moved up to management and should have known better. The same person told me we must spend adequate time with our lower-level part B patients. That's fine. Just realize by definition, "lower-level" means not able to do as much so less time is necessary for a treatment.

Everything revolves around how much time I spend with a patient. Very little is said about what I do during that time. Allowing someone to rest for half of the session isn't very therapeutic. If the patient needs that much rest, the session is too long.

Until someone figures out a way to calculate reimbursement by means other than how much time the patient spends in therapy, this isn't going to change.

There's just one thing missing. Where is the evidence? Nowhere on the form, or anywhere else, is there a blank requesting evidence to support what the speaker is saying. I don't know if this is unique to Texas. When I teach in other states, I've been asked to provide a list of references. One even wanted a list of my prior teaching experience. Texas asks for none of that.

I think this is how courses get approved that shouldn't be. A few weeks ago, I received an approval for a topic I know has no evidence to support it. I did a literature search when I got the form. As much as I wanted to, I couldn't deny the approval for that reason. That isn't a criterion we use for approval. It should be.

If we're going to say everything we do is based on evidence, then the continuing education we attend to renew our licenses should be evidence-based. Asking for an explanation of how the topic relates to physical therapy doesn't cut it. One course claimed that a happy brain would enable it to learn better. Another person submitted a personal training program. Those are pretty easy to dismiss. But some of the evidence-less stuff is more mainstream.

I overheard someone spouting such nonsense at a horse show. She used the technique in her clinic and was working on one of the show kids who was having cramps. She said relaxing her back muscles would relieve the cramps. When she finished, she recommended the course to me. Later I did a search. No evidence for the technique and even less evidence for what she was doing. And that course was approved for CEU credit in Texas.

I think a list of references, no older than 10 years, would be sufficient. In fact, we could say the five most recent. That would certainly cut down on the requests I receive for approval. It might not improve the quality of the program, but at least it would be evidence-based.

When the nurse said she didn't lift because she hurt her back, I had to fight the urge to ask her what she was doing at work if she couldn't perform her duties. This is an SNF. Lifting is an everyday part of the job description. If she wasn't able to assist with moving patients, she wasn't performing a regular job duty. In this case, that meant three people were at greater risk of an injury because the necessary fourth person wouldn't assist.

I've lost count of the times I've heard that excuse from someone. Usually it's a nurse, not a CNA, who you would expect it from. Once in a while, PT techs have been unable to lift, but in my experience they try anyway. I don't think I've ever heard a PT or OT say they couldn't lift.

What is the problem with nursing? Is that something they're taught in school? There's always some friction between rehab and nursing about who is responsible for lifting. I worked in one hospital where PTs were considered a lifting service. Not only would nursing not help, they wouldn't stay in the room. Lifting heavy people is so much easier with more staff.

I don't doubt this nurse had a back problem. If she had a lifting restriction, she should have been on light duty or not been working. I don't understand how this is acceptable for one group of employees and not another. This wasn't an instance of being sore from a specific activity with recovery in a few days. This nurse stated she didn't lift at all.

I wonder what would happen if I did that. I don't think it would last very long. Even if no one questioned me, I wouldn't be able to work because my patients would stay in bed.

I don't know what was funnier. She was appalled that I'd even suggest therapy on the weekend. She was also shocked that I didn't immediately understand that her daughter coming later was more important than therapy could ever be. I didn't say anything to her but wanted to. It amazes me how some people arrange their priorities.

This was a SNF. Patients are admitted there specifically for therapy. That implies they are expected to participate in therapy. I guess no one explains that to patients before they're admitted. The same thing used to happen when I worked in inpatient rehab. Patients were routinely shocked when we came to get them for therapy on Saturdays.

These are the same patients who refuse because a television show is on or they want to take a nap. I've been standing patients in the parallel bars only to have them let go of everything to answer a ringing cell phone. They're then shocked that I want to continue therapy. I had one woman who wouldn't leave her room without her cell phone. Later I'd hear her complaining that she was trying to talk on the phone when I wanted her to try to walk.

Research with animals is showing hundreds and hundreds of repetitions are needed for motor recovery. It's a given we aren't able to do enough with our patients. We don't get enough visits. We don't have enough time in the day. Entire courses are devoted to getting more out of our patients in the limited time we have with them.

I long ago realized there's nothing I can do to motivate these people. They'll do what they want. Sometimes they aren't able to go home because they didn't make enough progress. I've yet to hear one of them admit to any responsibility for that happening. So this morning I had a good chuckle to myself. I don't know if she did therapy today since she wasn't on my schedule. I'm sure whoever did have her heard how ridiculous therapy on the weekends was.

Recently I took on another challenge, writing a CEU module. When I agreed to do it, I thought no problem. This is what I teach. I already have an outline and references. I can just fill in the words. After I started writing, I realized something. When I teach, I have lots of material to cover so spend little time on any one thing. The CEU module is only one thing.

Back to the references I went. Since I hadn't researched the topic in a while, I found a few newer ones. Then I went through the articles I've saved. Some were detailed, others not so much. Now I'm stuck. The problem isn't the actual writing. I don't know what to include. I've read CEUs that were so far over my head I was surprised I got any questions correct at the end. I don't want that to happen.

For my first effort I chose something I was interested in, neuroplasticity. I'm fascinated by that. Even without consulting references, I'm able rattle off information when needed. I want to know more about it, how it occurs, what I can do to influence etc. What I don't know is how much other therapists know and how detailed my module should be.

I've done enough independent study CEU modules to be familiar with the format. There's also a word limit. The challenge is deciding which words to use. I want to talk about synapses and neurotransmitters. I want to talk about developmental proteins. But I think that would be boring to the majority of readers. I'm not sure that many people care about how it happens so much as how to make it happen.

Could I do what I do without knowing that? Probably. But knowing how the processes work makes it easier to figure out what to do next. To put it into perspective, I've tried to think of it in terms of something I don't know. What if I were reading an orthopedic CEU? How much would be familiar? Or better, sports medicine. I know very little about that. Just about anything would be new information. I'd probably have difficulty with those questions as well.

I'm going to be struggling with this for a while. I think I'll write it and then ask someone who isn't so neurologically driven to read it for feedback.

The responses to that post made some good points. First, impaired cognition is a need for skilled therapy. Usually that falls under the scope of practice of STs and sometimes OTs. Other than safety and family training, it isn't directly addressed by PTs. Second, safety must be addressed no matter what the level of cognition. Even the most confused person must be safe.

Maybe my question should have been, "When is therapy no longer skilled?" It only takes a few visits to rearrange furniture. Appropriate fall measures should be completed. Addressing balance issues is a skilled service but sometimes the only deficit is failure to remember to lock the wheelchair or RW. How many visits does it take to determine whether or not learning will occur? The same is true of way-finding in a facility. It's necessary but not something usually addressed by PTs.

This brings me back to the original question of, "What is skilled therapy?" Or my new question, "When does it reach a point that enough is enough?" Special training isn't required to remind someone to lock a wheelchair or warn of obstacles. CNAs do it all the time. Those patients need skilled therapy to address cognitive deficits but it isn't the purpose of physical therapy to provide it. Keeping patients on caseload month after month to ensure they remain ambulatory isn't a skilled service. It needs to be done but not by physical therapy.

Maybe we hang on to them because they're elderly. TBI patients are frequently referred to as walking wounded. They generally regain physical mobility but remain confused, impulsive and very unsafe. No one expects PT to keep them on caseload once they are walking with supervision. I've had much more confused TBI patients than the elderly patients I've been describing, who I discharged while OT and ST remained involved. It's the same problem, just a different population.

I'm looking forward to the responses to this post.

I've been noticing a disturbing trend lately. More and more facilities are considering the need for supervision as a need for skilled therapy. Back in the day, patients referred to SNFs and outpatient had an obvious need. They had trouble walking. They couldn't transfer. They'd recently undergone total joint replacement. The knowledge and skill of a therapist were needed to treat the impairment.

Last weekend, I worked at a different SNF than usual. I had nine people on my caseload. Six of those were ambulatory with supervision. They didn't need help to transfer. They didn't need help to walk. They weren't falling all over the place. They all had a diagnosis of dementia and required supervision for safety. For two of them, dementia was the admitting diagnosis. I'm not talking about facility residents who've declined in function. I'm talking about people admitted because they can't be left alone.

Physical therapy addresses physical problems. Impaired cognition that prevents the learning and retaining of new information isn't going to respond to physical therapy. No amount of safety training is going to make someone who can't form new memories remember to lock a wheelchair or rolling walker. Admitting someone with the expectation that a PT can improve cognition is ridiculous.

It doesn't require skill to walk with someone like that. Anyone can do that with minimal training. These are people admitted because they can't go home for some reason. They don't need PT, or at least not very much. They need to have someone with them at all times for safety. Training the caregivers would be skilled therapy. Caregivers might come to visit but rarely attend therapy sessions. They have to work.

I don't have a problem with admitting those people. They do qualify to be in the facility, just not on therapy caseload. Medicare A only pays for the stay if there are skilled needs, which usually means therapies. And therein lies the crux of the situation. This is a common situation with TBI patients. Their mobility improves but they can't be left unsupervised. We refer to them as walking wounded. I think that definition needs to be broadened.

The APTA is characterizing us as movement specialists. We are the muscle experts. So please tell me how an elderly walking wounded fits into that description. I don't see it.

Someone was fired last week. The rumor is going around that she was fired because she didn't smile. I don't know if that's true or not but in Texas it is legal. Here an employer can fire an employee for any reason, even if they make it up. Nor do they have to prove it's true. There are no laws preventing it. Maybe the woman smiled. Maybe she didn't. She's still fired.

Last year I was the victim of something similar. I've become very familiar with Texas labor laws. When I've brought the topic up with lawyers, everyone gives me the same answer. It might be legal but it's very unethical. Those same lawyers tell me there are no laws against unethical behavior. You're just supposed to know better.

I looked through the Texas practice act. It covers every kind of professional behavior; charging, documenting, conflict of interest, interaction with patients etc., except ethicality. It says PTs are to behave in a professional manner. The APTA does have a code of conduct. It touches on ethical issues although it's somewhat vague. Nowhere could I find anything concerning enforcement of ethical behavior.

I don't know who acts as the ethics police for physical therapy. Physicians have a process in place. I couldn't find anything specific for nursing but they spell things out much more clearly. Apparently we're just supposed to know better. I'm here to tell you, that isn't true. Some people either don't know, don't care or don't think it applies to them.

Maybe ethicality falls under professionalism. I can see that argument. A professional should behave in an ethical manner. I can think of a few PTs I've worked with over the years who did nothing overtly wrong but didn't behave in a professional manner, although I'd say they were ethical. I worked under a manager who was blatantly unethical but was professional in appearance.

We need a better definition of both for our profession. Which brings me back to my original question of who functions as the ethical police for physical therapy? To whom do we report unethical behavior? More importantly, how do we enforce it? I have no clue. I think we're generally a very ethical bunch but there's always someone who takes advantage of a position for personal gain or wrongly uses information.

This is going to become a larger problem as we continue to grow as a profession. The more responsibility we take on, the more careful we must be.