For the past few weeks, I've been writing about problems facing the physical therapy profession. These include tunnel vision focused on direct access and practice without referral. Another is the public perception of who we are and what we do. Still another is poor membership in the APTA and why most PTs don't see the benefit of being a member.
Based on the comments I've been receiving, I'm clearly not the only one seeing these things. I'm not the only one who feels these are serious problems facing our profession. Usually I receive both positive and negative comments. Lately most comments have supported what I'm writing.
I know from teaching in various parts of the country these problems are nationwide. I see it. Others see it. What I want to know is why the leaders of the APTA don't see it. And if they do, why don't they address it, even if to redirect focus onto their issues.
I've yet to read anything from the APTA addressing these issues. The closest thing talks about rebranding the profession as movement professionals. They might be working on that but I'm not seeing it in mass media. Nor am I hearing it from our leaders.
Why is this not happening? Why aren't these issues important enough to address? Every year the Foundation for Physical Therapy has an auction as a fundraiser. One of the things you can bid on is lunch with the president of the APTA. I wish I could afford to bid on that. I would love to ask these questions. Granted, afterward I might be stripped of my membership and barred from further participation in APTA activities. It would be worth it.
Last weekend was another horse show. During the downtime, I was involved in two conversations that illustrate some of the points I frequently make. The first occurred between two women who didn't know I'm a PT. The second occurred with a high school senior who did know.
The two ladies were discussing a recent hospitalization following an orthopedic procedure. The woman who'd been in the hospital wasn't happy with her doctor. He told her he couldn't predict the outcome. When he asked her if she wanted therapy she said no. It wasn't anything she couldn't do at home by herself. He agreed with her and told her to save her money.
The high school senior told me she had been considering becoming a PT but changed her mind. She had specific reasons. There aren't enough jobs. It's too expensive compared to the salary earned. It takes too long to finish. And my personal favorite, the title doctor is misleading.
I didn't bother to say anything to the ladies. It would have gone over their heads. I did talk to the senior. She made valid points. Her perception is that other senior students feel the same way about the profession.
I think the APTA has some work to do. They don't seem to be improving public perception of the profession. Direct access isn't going to do anyone any good if patients don't think they need the therapy and don't want to pay the co-pay. Who is going to provide that care in the future if students continue to perceive PT as they do now?
There was one other conversation I should mention. One of the parents was complaining about back pain. He said he needed to get home to his chiropractor. He didn't want to go to the doctor. That would just waste time. He didn't want a massage. That wouldn't help. He thought he hurt it at the gym so was laying off exercise. But one trip to the chiropractor and he'd be as good as new.
Yes, I did ask him why he didn't ask for physical therapy. He didn't realize we treat back pain. Besides he'd already been to his chiropractor and gotten therapy before. He didn't see a need to change.
Last weekend I had dinner with some friends. One of my newer acquaintances knew what a physical therapist does. First he wanted to know what clinic I worked at. When I told him I work in a hospital, he wanted to know how I liked working with shoulders and knees after surgery.
I finally had to explain in detail what I do each day. This included an explanation of the difference between orthopedic patients and neurological patients, and my preference for the latter over the former. I don't know which he had more trouble believing: that I actually do what I do or that I wasn't searching frantically for something orthopedic.
Given some of my comments about lack of brand identification for the profession, you might think I would be happy he knew what a PT is. His knowledge didn't make me all that happy. His concept of PT was so narrow it excluded the majority of what we do and where we do it. At least he didn't ask for a massage.
This is an example of another divide in our profession. The divide of how we are described. The information that is out there focuses on outpatient, orthopedic therapy. To the uninformed that is the impression being issued. With the exception of pediatrics, I have yet to see anything that shows PTs doing anything that isn't orthopedic.
The ads for local PT schools feature orthopedic settings. Whenever PT is discussed as a career, the accompanying picture is some kind of outpatient setting. I don't think I've ever seen a picture in a catalog depicting anyone with any visible impairment. Everyone looks like they're at a clinic receiving therapy.
This misconception isn't doing us any good. The promotion of PT should be all of PT, not just a special interest group or featuring generic pictures that could have been taken anywhere. I lay this problem at the feet of the APTA as well. They are so driven toward direct access and practice without referral, the rest of what we do seems to have been forgotten.
At the end of the evening, I asked my new friend about his PT experience. As I suspected, he'd been to an outpatient clinic for back pain. But he only went one time. The co-pay was too expensive. He went to a chiropractor instead and feels much better.
"I need therapy. Refer me to someone who knows what they're doing."
This was an actual request to me last week. One of our CNAs has an Achilles tendon injury. She has been wearing a moon boot for a few weeks. Last week her physician ordered physical therapy for her.
I wasn't much help for the request. I'm not in the loop of people who would have information like that. The other PT at my facility is very strong orthopedically. I told her to ask him. He couldn't help either. It is very hit-and-miss in a clinic. It all depends on who works with you. He named a clinic in her area that has a good reputation but couldn't promise she would work with someone good.
This is sad. Obviously skill level will vary by practitioner but you would assume everyone has a basic knowledge level. Apparently this is not the case. I could treat someone with an Achilles tendon injury. I wouldn't be the best at it but I believe I would be adequate. I hate to think a PT working in an outpatient clinic has no better knowledge than someone who hasn't treated orthopedic patients in years.
True or not, that is the perception of our CNA. It is also the impression of my coworker. What is happening in these clinics to make people think this way? I've had other people tell me they went for therapy but it didn't help. Those same people will later report improvement following a chiropractic visit or getting a massage.
What is the problem? Some of it may be inappropriate referrals in the first place. Sometimes patients are sent to therapy because the physician doesn't know what else to do with them. Some of it may be passive patients who want things done to them rather than doing it themselves. Is it a lack of education on the part of the PT?
I really have no idea. But it must be addressed. This reflects poorly on the profession as a whole. There is a segment of the general population who believes not every PT is good at what they do.
Two weeks ago I attended a Texas Physical Therapy Association meeting. The speaker was Mike Conners, president of the TPTA. Last week I discussed my belief the APTA is too focused on issues, such as direct access, that do not affect the majority of PTs and PTAs. Mike made another point that needs to be considered.
We all know that physician's orders are required for PTs to treat patients. Mike pointed out that none of the other disciplines competing for the same patients have that restriction. Anyone can be seen by a massage therapist, an athletic trainer or a personal trainer without having to see a physician first. None of these have the education we have but all practice without restriction.
In Texas, as in other states, there is stiff resistance from the physicians to remove the physician referral from the equation. They have described PTs as skilled technicians who require the direction of a physician to know what to do. Obviously some of this is financially driven. If they control the therapy, they control the money.
In the hospital setting, I need the physician to tell me the patient is medically stable enough to begin mobilization. This isn't true in skilled nursing. The majority of those patients are stable. In the school setting, it is easy to recognize those children who require intervention.
This problem is larger than the conflict between therapists and physicians over referrals. It is a mindset problem. There is a large scale belief that physical therapists are incapable of treating patients without first having the approval of someone else. Part of that belief arises from lack of understanding about what physical therapists do.
Once again we circle back to the APTA. Educating the public about who we are and what we do falls under their umbrella. I don't see anything out there on a large scale. Individuals and small groups are doing this but we need a large-scale, national educational push over a long period of time.
For example, the elder former President Bush is known to have Parkinson's disease and other chronic health problems. Somewhere along the line he received physical therapy. An ex-president would be a wonderful spokesperson. What about Gabrielle Giffords, the ex-congresswoman who was shot? She received inpatient rehab at a facility in Houston. She could speak firsthand as to the difference therapy made in her life. Somebody missed the boat.
Here's the problem. Neither received therapy for orthopedic problems, which is what drives the push for direct access. I hope there were other reasons not to approach those people rather than tunnel vision as to what physical therapy is and does.
Last week, I went to a meeting of the Texas Physical Therapy Association Southeast District. Mike Conners, the TPTA president, was speaking. His topic was the future of physical therapy and increasing awareness of legislative action in the Texas congress.
He touched on all the usual topics: direct access, reimbursement for outpatient services, the therapy cap, concussion management and defining the brand of physical therapy. The APTA wants us to be known as movement specialists. He cited examples of other disciplines trying to infringe on our area of expertise.
Those are important issues. But as I sat there, I realized they have little direct effect on me. With the exception of the therapy cap, every issue Mr. Conners touched on concerns outpatient therapists. I say except the therapy cap because that contributes to limitations my patients face after discharge. Had a non-therapy person been in attendance, that person would never suspect PTs do anything but outpatient therapy.
I work in a hospital with sick patients. I need physician input as to whether my patients are ready and able to tolerate therapy. The same is true for PTs who work in SNFs, AFLs and the school system. I lack adequate medical knowledge to make that decision.
Restructuring the reimbursement system for outpatient treatment also means little to me. It is a problem. So are flat salaries, increasing therapist-to-patient ratios in facilities and shorter lengths of stay. Reimbursement for what I do comes out of a chunk payment the facility receives.
Everyone agrees our healthcare system is broken. Nowhere is it more evident than in hospitals and long-term care facilities. Reimbursement cuts have taken their toll on every aspect of patient care and care-providing. I'm not going to get a raise this year. I'm just happy my pay isn't going to be cut. I always have more patients on my caseload than I can treat if I spend just 30 minutes with each one.
Where are the APTA and TPTA on those issues? Why aren't they lobbying legislators to fix the broken healthcare system? They spend hundreds of thousands of dollars lobbying for things that affect only a fraction of our practitioners.
If those laws ever come to pass, therapists who work in outpatient settings will benefit. What about the rest of us? Salaries aren't keeping up with the cost of education. Adequate staffing has long been a thing of the past. I could continue. The list is long. One of the reasons given for not being an APTA member is not getting anything out of membership. Maybe this is one of the reasons why people feel that way.
I have a new thing to be upset about, mechanical lifts. Yes, they've been around awhile. Yes, we've all used them. It's pretty much a given that any transfer performed with one is not a functional transfer. Still, as therapists we managed to avoid their use and perform functional transfers.
No lifting rules require a device of some kind. More and more this is becoming some version of a standing lift. They are easier to use and can be performed by one person. They also allow patients to be placed on the toilet, something that could never have been accomplished using a hydraulic lift. There are pluses. There is also one huge minus.
Transfers using a mechanical lift are not functional transfers. By definition the patient is a passive participant. There is no opportunity to practice transferring. They also put the patient into a non-functional position. I can't think of any functional activity that is performed in the stand-lean required by those lifts.
Facilities like them because they are cost-efficient. They don't particularly speed up patient care but they do prevent injuries and loss of work due to injuries. For the cost of a $3000 or $4000 device, they cut down on employee injuries and associated costs. To management that is a winning combination. I just returned from teaching in California, which is a no-lift state. It is state law such a lift must be used by everyone.
I pulled the literature on these lifts. The articles are to the point. All find a reduction in injuries and associated costs. All also state the transfers are not therapeutic or functional. A few looked at patient outcomes and found no significant difference. None specifically looked at transfer skill as an outcome measure.
I have a simple question. If we're using those lifts, when are our patients practicing transfers? They aren't. Sure we get bariatric patients who can't be moved any other way. And we get train-wreck patients in the same situation. I've had stroke patients who could only sit in a neuro or cardio chair. But the end goal has always been improving transfer skills.
No one wants to get hurt moving a patient. At the same time, we want to help our patients become more independent and gain important skills. I hate the things. The only thing I hate more is the electric scooter. We want to promote independence and the ability to care for oneself. These lifts do the opposite.
Lately I've been getting comments on my blog posts from people seeking advice about entering the PT profession, and asking how or why I became a physical therapist. The answers to both of those questions are complex. The medical environment today is significantly different from when I went to PT school 30 years ago.
I like to joke that I went to school "back in the day." I earned my bachelor's of science in physical therapy in 1984. That was so long ago I've had to relearn things at least twice. We don't even do most of the cutting-edge stuff from back then anymore. Reimbursement was different. Patients stayed in hospitals and rehab facilities for weeks at a time. No one complained about going home too soon.
The practice was different. The expectations were different. We had the time to work with patients. We had the opportunity to use our skills. No one entered PT school determined to only work in outpatient orthopedics or own his or her own clinic. You treated whatever came to you. I had the opportunity to watch my patients improve and build relationships with them.
The dynamics between patients, families and therapists were also different. On one hand, therapists were seen as important to the recovery process. On the other, there weren't that many of us. The conflicts between therapies and other disciplines weren't as pronounced. More importantly we charged for individual services performed. This was before the onset of DRGs. The rehab department was considered a revenue-generation source. No one counted minutes except on rehab.
I'm not going to try to describe how things are now. I hope people enter physical therapy programs for the same reasons as 30 years ago. I don't know that I would still become a PT if I had to do it all over again. Most of the reasons I entered the profession have been lost in transition. Back then I could never have afforded three years of graduate school after four years of undergraduate study. The option wouldn't have existed for me if that were the case.
I feel like I make a difference when I work with my neuro patients. That keeps me going. I love teaching others how to do what I do. That makes me feel good. Sometimes I feel like I'm working only to support my horse habit. I've been doing this for 30 years. I must be doing something right.
Bob (not his real name) was one of our facility frequent fliers. His diabetes was out of control. His circulation was terrible. He had a BKA on one leg and the other leg needed one. He refused to wear his oxygen so was always SOB. Nonetheless he was always in a good mood. He joked around with us. He made therapy fun.
The first time I met him, Bob couldn't even sit edge of bed. He was dependent to transfer. Once he got into his power chair, he zoomed around the building. I could always find him sitting outside in the sun smoking. We spent a lot of time together.
We also struggled with his new prosthesis. Twice daily I would make him stand and weight-shift. I brought tears to his eyes by stretching his hamstrings. Two months ago when he left us, he was walking over 100 feet with CGA and a RW. I don't know which of us was prouder.
The Bob who was readmitted two weeks ago wasn't the Bob I remembered. He was lethargic. He was confused. He recognized me but couldn't remember why. He was so SOB he needed BiPAP at night. He was still a trooper. He agreed to get up every day. I knew he was in trouble. He wasn't fussing about going outside to smoke.
Last week he had a rapid response and went to ICU. The next day he coded and they couldn't bring him back. I wasn't shocked that he had passed. It was probably the best thing for him. But I felt it inside. I try to keep a distance from my patients for my emotional well-being. Bob got to me. We were friends.
I can think of a handful of other patients whose death touched me. One was a woman who knew she was dying and insisted on therapy until the very end. Another was a heart patient who died the day before he was discharged to a rehab facility.
Goodbye Bob. You'll be missed.
Last Friday our facility cell phone policy was clarified. There is to be no cell phone use at work except while on break or at lunch. Anyone caught using a cell phone will receive a written warning. Cell phones should not be seen on the nursing units unless you're using the phone for work.
I don't know about other facilities. Where I work there is someone on a cell phone almost everywhere you look. Some of our CNAs and housekeepers have ear buds and listen to music while working. I constantly see people texting and standing outside having phone conversations. I would be willing to bet others are playing games. Obviously someone decided to do something.
The first part of that is very clear. We can have our phones with us but only use them at specific times in specific locations. The second part bothers me. Who is going to decide what is work-related? I use mine to compute patient ages, days since admission and look up medical terminology. To me those are work-related uses. From across the room, I could just as easily be texting or on Facebook.
The only way to know what I'm using my phone for is to look over my shoulder. While that is intrusive, I'm fine with it. I'm not going to be doing something else. The problem is there's no guarantee a supervisor will make the effort to investigate before writing someone up.
The problem is explaining doesn't equate with innocence. It won't take people too long to come up with convincing excuses. So either everyone is given the benefit of the doubt or everyone is considered guilty with no action taken. It might keep phones out of sight but not out of use. But if no action is ever taken, the ban won't last very long.
It would have been simpler to ban the things from the nursing floor period, no exceptions. If you're doing your job, you're not hiding somewhere playing on the phone. If you're trying to avoid work, you're going to do it whether you have your phone or not.
For now I'm going with the simple approach of keeping mine out of sight. I can find a way to make a call or answer a text if I need to. I can do my simple math with pencil and paper. I want to see how this plays out before engaging in any risky behavior.
People who work in healthcare are familiar with the term "frequent flyer." It refers to patients admitted over and over to the same facility in a short period of time. We have our share where I work. Most of them have chronic medical problems that are difficult to manage. I've watched these individuals deteriorate over multiple visits.
But there is another group. These people are admitted, recover and go home to do exactly the same things that brought them to the hospital in the first place. I have two of them right now. Both have chronic respiratory problems. Both are oxygen-dependent. Both have continued to smoke. One is on his third or fourth trach. The other complains about not being able to walk to the bathroom without becoming short of breath.
It is almost ridiculous. They come to therapy but only do what they want to do. Nonetheless they improve enough to return home. Two months later they are back. They admit they smoke and state they will continue as soon as they're discharged. Neither of them follow their recommended diets. It's no wonder they keep coming back.
I've asked our doctors. They say there's nothing they can do. Once the patients are discharged, it isn't their responsibility. The docs say even if they say something, the patients ignore them. They provide education. We provide education. Everyone provides education. Nothing changes.
I can't help but wonder what would happen if these individuals would make even a few small changes. I suspect the periods between hospitalizations would be longer.
It is frustrating for us. We provide the best care we can. We get them well enough to go home. And still, back they come. I'm sure this isn't a unique situation. It's happened at every facility I've worked at. The only difference is now the patients are sicker.
While I was teaching last week, it dawned on me that I have a unique perspective on continuing education courses. I've been on both sides of the projector. When I teach, I'm not listening. I'm trying to remember to say everything I want to on a topic. I have set examples I use every time but no two courses are the same. If I get distracted, I sometimes forget what I meant to say next.
I can see everyone in the room when I'm up there. I see who is listening, and who is doing a crossword, reading the newspaper or sleeping. I don't mind the sleeping. I get paid whether or not you learn. I prefer you learn but that's your choice. I also prefer the sleepers to stay in the back. It throws me off when you're in the front row.
Once I had a woman spend the first hour solving a crossword. Later she wanted to debate me on something I had said. I didn't give her much opportunity. If you want to correct me or object, at least be paying attention and I'll be much more willing to hear the differing opinion.
Even though I spend the day looking at the class, I remember nothing about the people in it when I finish. With rare exceptions, I couldn't tell you if you were paying attention or not. I try to look toward everyone but I never focus on any one person, so I don't store anything in memory.
Room size makes a difference. The larger the rooms, no matter how many are in attendance, the less I perceive about the class. Larger and very small classes are harder to connect with. I try to look around the room while I'm talking. It helps me gauge how I'm doing, if people are listening, etc. I know no one cares about everything I say.
I have evidence to support what I'm saying. You may not agree, but I can support my opinion. This means I have to introduce the evidence into the course. I know going over specific articles is boring. But sometimes I have to do it to bring in the evidence.
I try to learn from other courses I've attended. The worst one so far was the stroke course prior to CSM last year. They read from the slides. They offered no examples. It was biased toward individual interests rather than providing all viewpoints. I spent most of the time sitting on my hands to keep from causing trouble. Worse, one of the main speakers talked more about herself than the material. If I ever fall into any of those ruts, I hope someone slaps some sense into me immediately.
Last weekend I was at a horse show, which means I was off on Friday. One of the things I do is manage our list for who gets out of bed over the weekend. We start the list on Monday, adding names as the week progresses. We have a tech who works the weekend, getting patients out of bed. Sometimes he gets to everyone and sometimes he doesn't.
This morning when I started this week's list, I noticed some patients were marked as priority for last weekend. We normally don't do this. I was somewhat shocked when I read the list. None of the patients I would have made priority were on the list. Instead there were two patients with difficult families. The rest had out-of-bed orders, which are standard admission orders for one of our physical medicine docs. Everyone gets that order whether it's appropriate or not.
Yes, out of bed is important. It would be great if everyone could get up. But when only a limited number of patients can get up, I prioritize those who will either lose ground or need to practice transferring. Just because a family is difficult doesn't mean the patient will get the most benefit from being out of bed. The same is true of standard out-of-bed orders. Some people will benefit more than others.
Maybe this is an old school, new school thing. I'm frequently told I'm very old school. When I teach, I can easily divide my classes into old school and new school. I base my decisions on what I believe are best for my patients and nothing else. New school people take other things into consideration.
The person who made the list bases everything on what is best for her and avoids conflict. I'm not sure when avoiding conflict became a criteria for necessity of therapy, but I guess now it is.
This isn't something major. Someone made bad decisions. It worries me because if you do something like that once, you can do it again. If you keep up the practice it becomes the norm. I can see that happening very easily here. I don't have any more shows for a few months so I don't have to worry.
Many years ago there was a television show called "Kids Say the Darndest Things." I think the same could be true of our patients and families. Over the last few weeks I've heard many things that make me want to shake my head.
I was trying to help a man stand in the parallel bars. He was rather large and non-weight bearing on one leg. After several attempts he informed me he could do it just fine at home. He has one of those rocker recliners. He parks and locks his four-wheel walker in front of it, rocks and back forth until he gets up some steam. Then he can pull himself up.
A few days ago I was evaluating a woman who'd been on hospice at home but was now in the hospital. Her daughter was concerned about the hospice agency. Her mother was getting sicker and sicker and they weren't doing anything about it. Finally she took her mother to the emergency room because no one at the hospice agency would do anything.
This morning I assessed a 90-ish woman who was not arousable. My plan was to get her into a neuro chair to work on arousal and provide stimulation. Her daughter requested we wait until after lunch to get her mother out of bed. She said her mother liked to sleep late and she didn't want us to disturb her.
The list could go on. I'm not even considering all of those family members who have unrealistic expectations of therapy, overestimate the patient's ability to participate or expect me to singlehandedly lift someone who weighs at least twice as much as I do and is dead weight. I wish I had a tactful way to explain to obese people that obesity is the problem, not the diagnosis that admitted them.
A few weeks ago, I expressed my frustration with our capital budget process. While I was gone, my coworkers submitted a request for, among others things, a stand lift transfer device. To say I was shocked was an understatement.
Since that time I've campaigned against the thing. It doesn't promote functional transfers. It doesn't allow patients to practice transfers. There are so many things we need more, like gel cushions for our wheelchairs. In the literature it's touted as a time saver that prevents back injuries. Every article I read started out by describing the transfers as non-functional. But no argument that I made worked until today.
I pointed out that it would be used for a month or two. Then it would be pushed aside because it will create more work than it saves. We will have spent several thousand dollars on something gathering dust and getting in the way. Last year our manager bought us two electric, bariatric neuro chairs. They've been used twice since they arrived and now are in the way and gather dust.
So it turns out the strongest argument I could offer wasn't promoting functional mobility. It wasn't promoting independence. It wasn't quality of care. It wasn't even the cost. The strongest argument I had was pointing out the same mistake had been made the previous year and it didn't need to be repeated.
Granted there are many things wrong with the whole situation. I wasn't saying anything they didn't already know. I guess they just didn't want to hear it. Maybe it was easier to refute my argument by ignoring it. Then again, I convinced them by citing cost versus usage, not quality of care or any of the other things that are supposed to matter.
I keep asking for wheelchairs and cushions, which we would use on a regular basis. Still haven't gotten any more of those. Oh well. Score one for the good guys.