I didn't know exactly what to do when that happened. I didn't want to correct her in front of the patient and family. It wasn't like that particular piece of information mattered in the big scheme of things. Still, it was incorrect which bothered me. I'm not about to say I know everything about strokes or pushers. However, I had just completed a paper examining pusher syndrome with 17 references. In this case, I know my information was accurate. Given the circumstances I made the decision to let it go for the moment. Still, it bothered me.

I'm sure I'm not the only one who has run into this. It's happened to me a few times, though never in front of a patient before. No matter when it happens, it's difficult to know what to do. Sure, I could just let it slide. But that really isn't a good idea. All that does is perpetuate incorrect information being spread. Just because it doesn't make a difference this time doesn't mean there won't come a time when incorrect information will effect a treatment decision. I've done that a few times. Most recently it involved a relatively new grad who didn't want to put ice on a TKR post-op day one. Her reason was the ice would accelerate formation of scar tissue and therefore impair therapy.

I just finished a class project that involved looking at available health-related information and rating it on accuracy. The point of the assignment was to make us aware of how much of what's available to people is incorrect, biased or out of date. We were made aware of this to help us with patient education and assist with finding information for our patients. PTs and OTs are one of the few healthcare disciplines that actually spend meaningful time with patients. As a result, we're often asked questions about things unrelated to therapy. We need to be able to provide accurate and truthful information in return. That's why this situation bothered me.

The solution to my problem was simple. I pulled the OT aside and explained what my research had found. She was surprised but glad for the new information. My problem was solved. I've also heard doctors give incorrect information, almost always about something therapy related, or, and this really kills me, telling someone who isn't ready for gait therapy I will be by to get them up to walk. I'm not suicidal. I'm obviously not going to correct an attending physician. I realize the doc meant well but it just made my job more difficult by setting up an unrealistic expectation. Which is another reason accurate information is important. Part of my job is educating the residents who pass through the unit. This is one of the areas I stress.

It's never easy to tell someone they're wrong. Yet, because we provide so much education and do so much teaching it's important we be correct in what we say. Not everyone takes it well when told they were wrong.  Just like not everyone handles confrontation, though mild, well. This may be another example of me being picky. It wouldn't be the first time. Nonetheless, while no two situations are exactly the same, there are times when something needs to be said. I have one piece of advice for those, like me, who have to do something.  Say it with a smile. Negatives are easier to take when presented nicely and in a friendly way.

Obesity is defined as an increase in body weight beyond the limitations of skeletal and physical reinforcement. Morbid obesity is defined as excess body fat that has an adverse effect on health.  (The Free Dictionary, 2009)  There is a general consensus that the rate of obesity is continuing to climb in America.  Obese patients are a common part of practice today.  Research concerning PT and obesity is necessary to determine evidence for the best practices.  In this case, though, I think the researchers asked the wrong question.

PTs are trained health care providers.  They view obesity as just one of a multitude of possible co-morbidities.  It would be expected that their opinion as a whole would be neutral.  I think a more telling question would have been to ask how those PTs felt about treating obese and morbidly obese patients.  I think the answers would have been somewhat different.   It's already been established that obesity is associated with poorer outcomes and longer length of hospital stays.  The same relationship is probably true between obesity and PT. 

For example, an obese person s/p a total joint replacement is going to be at a disadvantage. The increased weight on the joint will increase pain.  More muscle strength will be needed for the limb to move so the limb will require additional strengthening.  The extra weight will cause fatigue more quickly.  The overall therapy will take longer to get the same results.  The added days will cause the insurance company to pay more.  Progress in therapy will be slower.

The problem is more acute in an inpatient setting.  Whenever I have an overweight or obese patient I know I'm going to have to work harder to mobilize that patient.  I usually don't have help so I'm going to have to do it myself and my fatigue level will decrease.  Two weeks ago I worked with a CVA patient who tipped the scales at 534 pounds.  I had orders to mobilize her.  With the assist of the CAN, I got her to the EOB.  She had right-sided weakness and fell to the left.  Even with my whole body weight sitting on the bed I couldn't keep her from falling over.  I had to elevate the HOB as high as possible and have her lean on a bed rail.   We never got beyond sitting EOB. 

Let me be clear.  I'm not complaining about that patient.  Working with patients like that is part of the territory.  What I am doing is using her as an example of the difference in treatment the extra weight made.  I would be very interested in the opinions of PTs concerning the actual provision of care to an obese person.  I would also be interested in knowing how many facilities have purchased bariatric equipment in adequate numbers.  In my experience as soon as someone goes into the bariatric w/c you will need another one.  The rest of the time the chair will sit and gather dust.  I would also like to know if facilities have changed staffing patterns to accommodate the obese.  Finally I would like to know how many therapists who work with obese patients are concerned about potentially injuring themselves while providing therapy.   I worry about that all the time because I am a single income person.  If I don't work, I'm out of luck so to speak.

The research in this article is a good start.  It answers one question but asks dozens more.   Clearly more research is needed on the topic.  Maybe someone could survey obese patients about how they perceived therapy in addition to surveying therapists.  I'm sure that would have interesting results.  From the answers to these questions will come changes in practice patterns and educational offerings. 

References
The Free Dictionary. (2009) Retrieved from http://medicaldictionary.thefreedictionary.com/morbid+obesity

Sack, S., Radler, D., Mairella, K., Touger-Decker, R,. Khan, H.  (2009)  Physical therapists' attitudes, knowledge and practice approaches regarding people who are obese. Physical Therapy, 89, 804-815.

That's the problem.  The Neuro docs want the patients mobilized every day even if it is only ROM exercises.  Because of caseload demands and staffing patients who only perform bedside exercises usually aren't seen daily.  Those that receive PROM are seen even less.   No one in the Rehab department has a problem with this.  Bedside exercise, especially PROM isn't a skilled service.  A tech or nursing assistant can be trained to do them.  Exercise only becomes skilled when additional skills such as facilitation or motor learning training is performed.  Moving a body part passively through its ROM doesn't require skill, just a little training and education.

The doctors have a valid point.  Their patients should be moved around daily and out of bed if at all possible.  The problem is who should be doing it.  As a PT, I am expected to provide skilled services.  If I perform an evaluation on a patient who isn't responsive, I may still do PROM exercises.   I usually do this as part of my ROM and strength assessments since I'm moving the limbs anyway.  I'm also assessing how the patient tolerates the movement and looking for pain responses and changes in arousal.  Those actions make that a skilled treatment.  If I come back the next day and the next and perform PROM I haven't really performed a skilled service unless there is a status change.  If I return once or twice weekly, I can include an assessment as part of my exercises which is skilled.  If the patient is waking up or cleared for out of bed I can change the POC.

Performing PROM one to three times weekly is generally accepted as adequate.  An argument can be made that the rules are a little different in a hospital, particularly an ICU.  That could be true sometimes.  But, if we as therapists, say PROM is an unskilled service in one circumstance, it should be in all circumstances.   We need to be consistent.  The exception might be a new stroke patient the therapist wants to follow a few days to monitor arousal.  PROM would be appropriate for that period of time. 

There is another part to this conflict.  If PT doesn't do the PROM, who does?  The obvious answer is nursing, or more specifically, the nursing assistants.  Bath time is an excellent time to move someone around.  So is turning for repositioning.  Nursing, however, doesn't feel that way.  I've yet to meet one nurse or nursing assistant who had the first idea about PROM.  To them it is a huge mystery.  It becomes the same argument as whose responsibility it is to get patients out of bed.  Just like the out-of-bed tug of war, if PT doesn't do it, it doesn't get done. 

The result is our conflict with the Neuro docs.  If PT doesn't do the PROM, it won't be done.  It isn't feasible for a limited staff of therapists to perform PROM on 20+ patients on a daily basis.  They barely make it through their caseloads when they divide the PROM treatments up throughout the week.  It's not realistic to expect administration to create a position just to perform PROM on ICU patients.  Nursing isn't about to add something else to their to-do lists.  The conflict will go on. 

Somehow this week during all the normal chaos of life I managed a major accomplishment.  I completed and mailed my registration to sit for the GCS exam next year.  I'm very proud of myself.  Completing the application isn't very difficulty.  Making the commitment to study and prepare for the test is.  The application is only the first part of the process.  Once it is processed I will receive information on the test itself and scheduling a time at the computer center where I will take it.  It still isn't real to me.  I won't finish school until early January so I want to take the exam in March.  Maybe when it gets closer I'll feel more anxious.

I was telling a non-PT friend of mine about the exam.  Her first question was how much more money would I be making?  The second was would it get me a better job?   My friend works in the world of computers.  Where she works each certification is worth additional salary.  Promotions are based partially on specific skills and certifications.  In her world having a geriatric specialist certification and a DPT would be worth a promotion and salary increase.  Saying she was flabbergasted when I told neither my pay nor position would change with the credentials would be an understatement.  She didn't understand why I would go to the expense and effort to get those if it wouldn't help me professionally.

I welcomed my friend to the world of PT.  In my world knowing more, having advanced skills or credentials or advanced education doesn't translate into more money.  Unless the advanced education is managerial it usually doesn't translate into a promotion.   It does earn the respect of your peers.  Sometimes it earns the respect of physicians.   But making more money isn't likely to happen.   

It isn't the profession of PT.  The push toward a doctoring profession with equal standing to medical doctors is proof of that.  So is the drive toward direct access.  The difficulty lies with the healthcare industry.   In the eyes of those who control the money there is no added value to having a DPT instead of a PT.  With the possible exception of some specialty OP clinics having a specialty certification doesn't make you more desirable to an employer.   The same applies to experience.  At least in Houston employers would rather hire a new grad than an experienced therapist because the new grad makes less money.    That doesn't mean the department doesn't want the experienced, specialized therapist.  It means the facility won't hire that person.

And that's not going to change anytime soon.   I don't know of one facility in Houston that will pay licensure.  The company I work for will pay it as well as provide some continuing education money.  The catch is a lower salary.  PTs and PTAs need licenses to practice.  If a facility isn't willing to pay for that, it isn't likely to pay higher salaries for certifications and the like.  As far as management is concerned a PT is a PT.  That PT completes X amount of treatments each day and costs Y amount of dollars.  Meanwhile the facility gets paid Z amount of dollars.  Since you can't change the amount of work a PT can do and you can't change the amount of reimbursement you obviously pay as little as possible to make a profit.  Nowhere in that equation are the variables of skill (diagnostic, technical or specialization), knowledge or the ability to accept more responsibility as well as pt. care.   I guess those things don't have a dollar value.

I didn't really have a good answer for my friend.  Because I want to or I felt I needed to sounded lame.   My next goal is to sit for the NCS in a few years. I know my treatments and POCs will be improved with advanced knowledge.  I know my patients will benefit.  I might be able to teach some of my co-workers a few things.  Beyond that I don't have an answer equal to I will make more money.  Eventually the APTA will have to address this.  A significant amount of time and money goes into sitting for those exams.   Passing one of them would create a sense of satisfaction and affirmation of knowledge.    It would be nice if the recognition was shared by other healthcare disciplines.  Sure I would like to make more money but it isn't necessary.  I would be happy if my GCS or NCS was valued by the healthcare community as within the PT community.

Now I'm not going to compare the care my horse received to that received in a hospital.  Nor am I implying my horse is equal to a person.  Additionally, veterinary medicine is provided in a different circumstance.  There are few third-party payers.  In my case, I had to provide a credit card number up front.  Vets are under less stress and with lighter caseloads than the average attending MD.  Unless the animal is at a teaching institution, there is no pressure to try new things.

That doesn't mean there aren't similarities between pet owners and family members. We're both worried about our loved ones.  Families are thrown into the confusing world of medicine.  I have a good grasp of medical principles, but no idea how those translate into values for horses.  HRs, temperatures, lab values and the like are completely different.   I had an advantage over the average family member.  I knew why the vet was running his tests and what he was looking for. That didn't make waiting for the results or handling bad results any easier. 

The father of one of the therapists I work with is in the hospital.  Every day after work she goes to see him and feeds him soup. Otherwise her father doesn't eat enough.  Every night after work I went to the vet and fed my horse hay or grass.  For four days, the only time he ate was when I came and fed him hay.  I had to stand next to him and hold the hay in my hand by his nose to get him to eat it.  Just as my co-worker talks about seeing how much weight her father has lost, I could see my horse getting thinner.  And neither she nor I could do anything else about it.

I spent several days waiting for my daily phone call update from the vet.  My patients are lucky. Their physicians round each day at specific times.  Family can be present at those times and ask questions, view films or simply talk to the docs.  While I often saw the vet after work, I didn't always get to talk to him.  I did have one advantage.  My vet was willing to spend as long as necessary to talk to me.  Most attendings are very busy. They spend very little actual time with patients.  Most rely on residents to convey information and answer questions. 

The worst part of this has been feeling helpless.  I imagine families feel the same way.  I wanted to do something.  I would have done anything asked of me to help my horse.  I know families feel the same.  Just like I couldn't make my horse drink water, they can't make their loved one get out of bed.  Nor, can they do the exercises for him or walk for her.  I spent a lot of time just petting his head and picking shavings out of his mane.   I've seen countless family members holding hands, brushing hair, applying lip gloss and the like.   Now I understand why.  I had to do something.  Even though it was meaningless I felt like I was doing something at the time.  My horse has yet to care whether he has bedding in his mane.  Removing it made me feel better. 

I didn't realize how lost I would feel until I found myself with a critically ill horse.  For two weeks my life stopped.  I don't know how I kept up with school.  An entire week is a blur to me.  I'm pretty sure many family members feel the same way and for a much longer time.  I can't describe the feeling of a weight being lifted from me when the vet said Phoenix was not only going to get better but could return to being a show horse.   From the very beginning I realized I just wanted him to get better and didn't care if he ever set hoof in another show ring.  I wanted him to come home to his barn and be my horse.  I think those same feelings are why families take home patients who require intensive care.  They just want their loved one with them at home.  As a PT I still don't see the logic in that.  As Phoenix's owner I understand the feeling. 

I hope having this experience will help me empathize more with my patients and families.   I have a better understanding of the grieving process including coming to the realization that this might be the end of the road.  I was lucky.  Not all of my patients/families have the same luck.  Many won't be the same ever again.  Many, especially the older ones, will be making life altering medications as a result of the hospital admission.  I now realize there is a process you go through as you make those realizations and decisions.  It can't be hurried.  No one can do it for you.  I just hope I don't have to experience this again for a very long time.

I work in one of the larger hospitals in Houston.  It is also one of the two trauma centers and has its own Life Flight fleet of helicopters.  As a result, a large percentage of patients are non-resource.   Many of them find their way to rehab because it's cheaper for the hospital to lose the cost of the extra week of hospitalization and send them home than it is to pay for additional care at other levels.  Since these patients are non-resource, when discharge rolls around they are reluctant to spend whatever funds they have toward DME and other equipment.  That's where the problem arises.  In therapy, we get them to the highest functional level we can.  Many times that level requires DME such as walkers, w/cs and tub benches.   Every day in therapy these patients use various DME.  Then when discharge rolls around they seem surprised that "we" expect them to go out and buy the equipment.

In the last month I've had three patients who needed DME to DC home tell me the hospital needed to purchase the equipment.  As far as I know none of their families made any attempt to locate any equipment.  This puts the department in a bind because we can't discharge someone without a safe discharge plan. The lack of needed DME falls under unsafe plan.  Yet, rehab doesn't have funds available to purchase these things.  Nor do we have resources we can go to for such funds.  The best we can do is charitable donations and those are limited to first come, first serve.  Nonetheless, some patients feel it is our responsibility to provide equipment.

Sometimes our patients don't want what we have to offer.  A few months ago I had a young man who needed a bariatric w/c and BSC.  We were actually able to locate these for him but he refused them.  He said they were uncomfortable.  Last week I discharged a man with a donated w/c.  He was angry because he wasn't given a WBQC as well.   We'd been using the gait for therapy but he hadn't progressed enough to be safe without at home.  He wanted a cane because he'd used one with me.    Another patient needed a w/c so he took one of ours. He told his nurse he was going downstairs to smoke and never came back.  Another patient who had some funds waited until the day of discharge to have his family purchase a w/c for him.  He told us he thought the hospital would eventually get him one if he was ready to leave and didn't have one.

I understand patients have financial hardship.  Nowadays everyone is having trouble getting by.  That doesn't mean it is the responsibility of the hospital to provide equipment free of charge to every patient who discharges from the unit.  It's our responsibility to make the patient functional and safe.  It's also our responsibility to teach the family and family how to use the appropriate equipment.  We provide instruction on measuring for correct fit.  We demonstrate how to safely secure things.  At some point the individual patient must take over responsibility for his or her care.

Tomorrow I am discharging a patient home with his wife.  He had just enough funding to obtain a rental w/c but nothing else.  He is angry that he will have to use a bedpan at home because he uses a BSC at the hospital.  He is angry that he will have to take bed baths.  He uses a tub bench during therapy.  He refuses to admit his home is too small to accommodate those items.  Instead he has spent the last few days taking it out on everyone else and refusing to participate with therapy.  No one has been able to get through to him that all he is doing is hurting himself.  Yes, he has a brain injury.  He also has the ability to decide whether or not to participate.  I feel sorry for his wife who had diligently come to family training and done everything in her power to make things work at home.

Maybe I expect too much.  I try to put myself in the patient's place.  I have trouble with that because I see things from the perspective of a therapist and of someone who wouldn't quit.  I just don't understand why some patients do that.  Correct that, I understand why patients might prefer not to spend the money on the equipment.  I also understand that patients might not see the value of the equipment or even might think it won't be needed at home.  What I don't understand is why they seem to think it is the responsibility of the hospital to provide it.

There are two courses coming up in Houston and I would like to go both.  Both are one day offerings that fit my budget.  I'd really like to go.  Both sound like they would be beneficial.  One concerns radiology, something I became interested in after my class.  The other covers motor control theory, something helpful for treating neuro patients.  The problem is I'm not sure I'll get my money's worth.

CEUs were introduced as a way for therapists to keep current on skill and knowledge.  Currently 30 states have a mandatory amount of hours required for license renewal. Some of those states (I couldn't find the exact number) use a peer review process for approval.  Texas is one of those.  The idea behind peer review is that someone familiar with the topic will be a better judge of the quality of the course.  There are three problems with this system.  First, there are no objective quality control standards for any courses.  Second, there are no requirements that courses be updated on a regular basis. Third, peer review only works if adequate materials are submitted for the review.

The APTA has published standards for CEU offerings. They cover things such as: the instructor must be knowledgeable about the topic; the instructor must include evidence-based practice; there must be specific written learning outcomes; the course must be designed in response to an identified need; there must be a written record of who attends, and so forth.  None of the 11 standards really describes any quality control.  Taken at the bare minimum someone could go out and research something in which they have no experience, develop a course based on the research and then offer it as a CEU opportunity. 

Since I've been a therapist a number of years, I've noticed that many courses have been around a long time.  I took one recently on neuroanatomy that probably hadn't updated since the speaker developed it.  The handout was crowded and difficult to follow.  She had a lot of knowledge but I doubt anyone got much out of the course because of the poor presentation.  While all courses seem to have handouts, not all of the handouts are adequate.  I've spent so much time trying to write down what wasn't included that I missed things that were probably important.  Yes, I got my CEUs, but I didn't get my money's worth in information.

Another problem with courses is that awarding of the CEUs is based on attendance, not knowledge.  One of the APTA standards is that each course must have a way of evaluating a participant's learning.  I know people who wait until the last minute to take courses.  They take whatever is available and pay little or no attention to what is being taught.  I have a PTA friend who a few years ago waited until the night before he was due.  He bought a bunch of online courses and finished them in a marathon sitting.  He learned absolutely nothing but did have enough CEUs to renew his license.  What part of that improves skills or increases knowledge?

I'm a volunteer peer reviewer for Texas.  As a result, I see bits and pieces of what is submitted.  Texas has a form it requires each sponsor to fill out.  Some sponsors do a good job and include all pertinent information. Others, and these seem to be courses from one facility or a small setting, do the bare minimum.  I've seen several that were at least 10 pages long.  Nine of those pages were resumes of the presenter(s).  One actually described the course.  The only sort of review included is one of the course itself.  Okay, it's helpful to get feedback if I'm the course sponsor.  But what does location and room comfort really have to do with what I may have learned?  We've all filled these out.  The questions are pretty much standardized. 

Obviously the system needs an overhaul.  The idea is good. The implementation is a little lacking.  The end result is a potential participant debating whether the course is worth the time and money because there is inadequate information upon which to make the decision.  Nobody has money to waste.  No matter how much I enjoy courses, I want to actually learn something from going.  With the economy today I have to be picky.  Later this year the TPTA is sponsoring a CI certification course in Austin.  Austin is about 2 and half hours away.  If I go, I would have to drive up the night before and drive home afterwards.  The whole thing isn't that expensive, but now it's a question of which courses I would rather attend.  At least in that instance I know the quality of the course in advance.

There are several solutions.  Implementing them would slow down the CEU approval process and probably drive up the costs.  I would like to see courses reviewed every 3-5 years.  The renewal date would then be included on any literature advertising the course.  In peer review states the sponsors/presenters should submit a copy of the handout as well as required forms.  I can tell a lot more from a handout than a form.  The APTA needs to redefine or develop more specific criteria for courses.  Finally, and I know this is unpopular, each course needs a brief pre/post test. The instructors would be held accountable for the results.  If the courses are poor, the course doesn't get renewed.  Yeah, there are ways around that, but it's a start.

I think PTs always try to think of the best interests of their patients.  I would never deliberately recommend SNF over rehab if I thought the patient would benefit from rehab.  If the patient can't tolerate three hours of therapy daily, he is wasting both his insurance and precious recovery time.   He won't get any benefit from therapy if he is too tired to participate.  The same applies to my man with the quad cane.  He is able to walk with total assist of me to advance the leg and help him balance.  It would require extensive training to teach a family member to do that. Even then safety might still be an issue. The question became which is better: keeping him from walking or preventing a serious fall?

I divide my time between an acute stroke unit and inpatient rehab.  On the stroke unit I assess patients and make discharge recommendations such as SNF, rehab, home with home health or no needs.  The stroke physician, who is a neurologist, has the final say on disposition but usually listens to me.  The reason for that is simple.  A neurologist knows neurology while a PT knows recovery potential and realistic goals. On the rehab unit the PTs help decide if someone goes home as planned or requires placement.   Sometimes that means being the bad guy.  I'd rather be the bad guy with good intentions than recommending rehab for everyone just to keep the unit full.

No one becomes a PT in order to prevent patients from improving.  We become PTs to help people get better.  In the process many decisions are made.  All are made with the best intentions.  Sometimes I'm wrong.  Sometimes a patient does much better than I expected.  I like being wrong like that.  Sometimes a patient doesn't do as well as I hoped.  I was wrong because I wanted the patient to do well.  Anyone PT will agree patients are unpredictable.  No matter how hard we try the end result depends upon the patient.

It wasn't until I started working on the stroke unit that I realized how much responsibility I have for my patients.  The unit is small with high turnover.  Nonetheless, I think of every patient on that unit as being on my caseload and thus my responsibility.  Whenever I'm in doubt or unsure I make it a point to see the patient the next day to reassess my original impression.  I don't want to make a mistake about someone else's future. Life is much simpler on rehab.  Not only are the OTs and STs involved in the decisions, but we see the patients for more than one or two visits.  We have a lot more information to work with when discharge planning rounds come around. 

If I ever stop and really think about what I do each day I'm not sure I would be able to be as effective.  I try to be as objective as possible.  I base my decisions on my experience, knowledge and what I reasonably believe is possible.  I have to remind myself that I'm only involved in one part of the patient's recovery and my job is to make decisions to facilitate that.  I've never ask any of my co-workers how they interpret discharge planning.  I'm sure many would say it is another part of what we do.  As professionals it is our responsibility to make the decisions in the best interest of the patient.   I agree.  Sometimes, though, those decisions make me feel like the bad guy.

Once an individual survives into midlife it is likely that person will reach his or her life expectancy because most of the things that shorten life occur in the earlier years.  The problems we face as therapists with the geriatric population generally aren't related to age so much as the co-morbidities that accompany the aging process.  These can include problems arising from diabetes, HTN, debilitating arthritic pain, CVAs and vascular issues to name a few.  Patients don't come to therapy because they are old.  They come to therapy because a co-morbidity has impaired their functional status. 

The text pointed out that as therapists our role is to help delay the onset of the co-morbidities.  That would allow the elderly to have the same life expectancy but spend less of it in a state of debility.  This assumes that eventually everyone will fall victim to some sort of illness or disease process resulting in some state of dependence and/or a lesser quality of life.  It assumes that as therapists we can somehow cause our patients to make the necessary lifestyle changes to enable that to happen.  It also assumes everyone has the same potential to prolong morbidity free aging. 

I have a problem with all of that.  No one, PT or otherwise, can make another person make the healthy lifestyle changes necessary for that to happen.  Even then there is no guarantee something unforeseen such as cancer or a major trauma won't still occur.  There is no strong evidence out there that specifically links any of the preventive strategies discussed in text with actually preventing morbidities.  The best the book could do was anecdotal evidence. Granted an individual who has out of control DM or HTN is a stroke waiting to happen.  That doesn't mean I can do anything definitive about it. 

Many of my stroke patients have numerous other medical problems.  These people already have the co-morbidities the text is talking about preventing.  By the time I'm working with them it's a little late for prevention.  I think that's generally true everywhere.  The people with healthy lifestyles probably aren't going to need therapy for awhile.  It's the ones with the co-morbidities that need us the most. 

Therapy is about helping people overcome impairments no matter what age group they fall into.  If by helping someone recover from a stroke I'm delaying a morbidity, great.  The geriatric population is unique.  Aging changes how the body responds to the challenges it is exposed to.   Preventing debility and morbity is a wonderful goal, but it isn't the only focus of therapy.  When an elderly patient comes to me for therapy my job is to provide that therapy taking into consideration the circumstances arising from the aging process.    Some people are going to age better than others.  Those differences are what impacts therapy.  Certainly I can encourage lifestyle changes but I can't make them happen.

As I progress through this course, I hope to learn how aging affects the body and how those affects alter therapy.  My caseload will include both "healthy" and "unhealthy" geriatric patients.  I'm sure there will be more of the latter than the former.  Those are the ones I want to know more about.  This week's reading made me look at how I think about the aging process.  Since I'm nearing 50 this is becoming more important to me.  So, yes, I want to know about remaining healthy as I age.  I also want to know how to better treat those who've aged in poorer health.

One could argue that ethics are universal and based on common sense. Everyone should have an idea of what is ethical and what isn't.   Physical Therapists learn what is ethical during their training. They are taught to behave ethically. The same argument can be made for the Code of Conduct. PTs are taught that in school.  They know they must abide by it. The APTA also has a section describing professional behavior. It is based on the Codes of Ethics and Conduct. Until recently, when I researched it for class, I didn't know it existed.  I'm probably not the only one.

I accept the argument that PTs learn ethical behavior. I also accept that they learn how to conduct themselves for the most part. Obviously no one will harm a patient. When providing treatment a PT decides on the best available treatment.  Things start getting a little fuzzy when we get to appropriate charging, altruism and social issues.  In Texas we charge in 15 minute units based on the 8 minute rule.  Anything treatment greater than 8 minutes is counted as an additional unit.  I'm sure that gets fudged occasionally.  I'm also sure there are those who consistently round their units up to look more productive.  I worked with an OT who did. She would indicate she did 40+ units in an 8 hours day.  That's just not possible.

Altruism refers to putting the pt. first.  I can't count the number of PTs who put themselves first.  They schedule times based on their convenience not the pt's.  They do the same thing with everyone no matter what.  I worked with a PT who was salaried.  He never worked a full 8 hour day in the year I worked with him.  He arrived late.  Usually left early and always managed to get a full hour for lunch.  He never offered to help anyone.  He never took a patient that wasn't on "his floor".  He considered himself a good, patient oriented therapist.  He's not alone.  Granted things aren't black and white, but the majority of the time should fall in favor of the patient.

What I find sad is that the very therapists I'm describing wouldn't see the problem if they read those documents.  It wouldn't strike them that their behavior is unprofessional to say the least.  They're worse than those who refuse to accept evidence based practice.  At least those therapists are trying to do the best for the patient.   I admit I make mistakes sometimes.  Everyone does. The difference is I don't make those mistakes intentionally and always try to correct them in the future.

Professional behavior is becoming more and more important.  PTs want to be taken seriously.   Vision 2020 states the DPT is equivalent to an MD, DVT, etc.  The APTA has run into a lot of trouble trying to get that point across.  One reason is the lack of professional behavior by some therapists.  I work with many residents.  I see what gets beaten into their heads.  They are taught professional behavior and responsibility from the beginning.  Until PTs consistently demonstrate the same level of professionalism the DPT won't be taken as seriously.  There's a big difference between developing a friendly relationship with a patient and being unprofessional.  A therapist who is only concerned with how many units she can generate in one day isn't acting in a professional manner. Neither is a therapist who skips a beneficial treatment because he would actually have to put his hands on a patient. 

 We all know these people. Nothing will change until they realize their behaviors are unacceptable. I consider everyone I work with to be professional. If I saw something I didn't like they would list to my concern and possibly correct the behavior.  Someone who doesn't care will not listen to my opinion much less change a behavior. Since we can't change them we have to change the environment by modeling what is acceptable and what isn't. That might make a difference. It might not. What it will do is demonstrate professionalism on a larger scale so that others will take us seriously.

All three documents I mentioned can be found at http://www.apta.org/.  Go to the main page and type the document title in the search box.

In other words, we have a discharge nightmare. The only blood relative lives out of state and refuses to get involved.  She doesn't want to argue with her mother. It's obvious placement will be required. It's also obvious the patient will not agree to it.  What's less obvious, but just as important is the patient isn't capable of making that decision. Therein lies the problem.  The patient is able to make basic decisions about day-to-day matters. She can decide on her menu and what to wear. She is able to dial the phone. What she can't do is make a decision about discharge plans and no one has been able to definitely state why.

I did some research into the subject. According to several sources, the patient must be able to understand and describe her condition. She must be able to verbalize and clearly explain each option including the pros and cons of each.  Finally she must be able to verbalize a plan that accommodates her present needs and safety concerns. The only plan this patient will verbalize is going home as soon as possible. She won't entertain any other idea or suggestion. Since there are no other relatives, the facility is going to have to request guardianship be awarded to an independent third party. In the meantime, the patient will stay in the facility and receive therapy. Her participation is intermittent at best. Continued therapy may not increase her functional status enough to eliminate the problem.

The situation got me wondering how many other patients are in the same situation, but it isn't so obvious? The elderly can present challenging discharge circumstances. Patients with cognitive problems learn to mask them early on. I wonder how many have talked themselves out of the hospital and into a bad home situation. I wonder how many have convinced family that no assistance is needed when it really is. Many of those patients probably end up back in the hospital in worse shape than they were previously. 

I checked with some of my OT friends. They tell me there really isn't a cognitive test they do that would identify something like this. Even the MMSE is ineffective for this. I'm not sure what can be done because patients have the right to make their own health care decisions. I don't think anyone really wants to put someone in a facility unless absolutely necessary. I talk about discharge arrangements with my patients. I guess I'll now be thoroughly documenting those conversations. At least now I know what to ask and what responses to look for. 

That stopped me cold.  I have always believed that once the consent to treatment form is signed the patient has consented to be cared for.  The patient must be asked if therapy is desired because it can be refused.  I never even thought about in relation to every single treatment I provide.  If I want to do something new or a little different, I will explain it and make sure the patient is comfortable with what I want to do.  Sometimes a patient will only agree to walk in the room or doesn't want therapy at a specific time.  To me, those are examples of patient autonomy. 

Informed consent arose from unethical use of human subjects in medical experiments.  Over time it evolved into patient rights. Obtaining permission for each intervention makes sense when talking about invasive or risky procedures.  It doesn't make sense when talking about ROM exercises.  If I had stopped to think about it, I would have thought overall permission for therapy would be granted at the time of the evaluation when the POC was discussed.  I describe what I plan to do but not specifically how.  That's practically impossible with PT.  Patient status changes from day to day.  What was appropriate one day might not be the next.  As long as my patient progresses, I'm going to process therapy.  I can't predict exactly how that will occur.

I looked into it a little further.  There is still debate about what is considered informed consent.  For awhile the accepted standard was what another physician would reasonably say.  That doesn't really work because few people outside the medical field have that level of understanding of medical terminology.  Now the focus is on explaining in terms the patient can understand.  That's better, but it doesn't take into account who is doing the actual explaining.  A physician or experienced therapist who has done the intervention many times will present the information differently than an inexperienced new graduate or resident.  If the new graduate can't answer all the questions, is it still informed consent? 

This is even more significant in a place such as Houston where a large number of the population has a language barrier.  Frequently non-English speaking patients will agree rather than ask questions if they don't understand.  A good example is explaining weight bearing status to a non-English speaker who may be hard of hearing or slightly confused.  I've had Spanish-only patients get up and move around when they were in severe pain because they didn't know they had a choice.  I usually find out after I ask a Spanish-speaking therapist to find out if the patient is OK because the patient looks uncomfortable.  If I have to get specific consent to each treatment and there isn't a translator available that patient probably won't receive therapy.  It wouldn't be ethical. 

This is a huge gray area that I hadn't previous considered.  According to the APTA Code of Ethics and Standards of Care, our current practice is adequate.  Both of those documents bind the PT to do what is best for the patient while considering the patient's individual needs and desires.  That's good.  It will probably remain adequate since few people outside the therapy field are even aware of the differences in what we do.  There is also minimal risk to therapy and the evidence is still out in many cases on what is the best treatment. It would be a different story if the choice was between something very effective but a high fall risk and something less effective with no fall risk.

The things I read were published within the last few years.  The topic appears to be relatively new to discussion.  It may take on more significance as we move to direct access and Vision 2020.  Autonomous practice will require more disclosure and more specific consent.  Therapists in private practice will need to have some kind of consent to treat form to cover them legally.  This might not be anything right now but I don't think it will go away.

Heavier patients, on the other hand, are a problem. The more a patient weighs, the harder it is to mobilize that patient.  The truly obese ones require bariatric equipment to safely mobilize. That equipment isn't always available. My hospital rents the equipment when it's needed. It can be as many as two days before it arrives.   When patients are immobile any extra weigh usually becomes dead weight. Dragging the extra weight during transfers increases the risk of skin damage. A small skin tear can easily lead to a decubitis if the patient isn't able to shift weight.

Heavy patients require extra man power which is always at a premium. Treatments must be scheduled when assist is available. Missed treatment time is difficult to make up.  The risk of care giver injury is also increased.  Mechanical devices can significantly decrease the risk but don't eliminate it.  The unit I work on doesn't have such a device because the goal is for the patient to move himself. A max assist X 2 transfer is an injury waiting to happen if the patient slips or loses his balance. Getting hurt is something I worry about more and more. I'm getting old and probably weaker. It's not as easy as it was to move those bigger patients around.  I'm very careful but I can't keep from thinking what if.  Where is the line between patient benefit and therapist safety?

These aren't easy patients to work with.  Gone are the days when a medically complex patient was a 90 pound little old lady.  It's been awhile since I've seen one of those.  This is a trend that needs to be monitored. More acute patients don't automatically translate into more staff. More staff might be required but won't be available because of cost cutting measures. I've worked in units where nursing wouldn't get anyone up so it fell to therapy.  The evidence suggests early mobilization and OOB is related to better outcomes and shorted lengths of stay. The evidence doesn't indicate who should be responsible for doing it.

If this trend continues the future isn't pretty. There is a finite amount of work you can get from any one group of people. It doesn't matter how much work is assigned.  One therapist can only do so much. If every patient requires two people to mobilize that therapist will be doing more bed level treatments and getting fewer people up. If the patient has a trach the problems multiply. PTs are capable of treating these patients no matter what situation.    The limiting factor isn't knowledge or skill. If these are the patients of the future I hope the present day planners are looking ahead.

I knew there would be a problem almost immediately. She tried to rearrange her schedule with an abundance of orthopedic patients. It wasn't that she wanted to change the patients. It was that she came in after many of us had already started our day. Making changes would have been difficult for us. She was scheduled to fill in one day. When you fill in, you take what you're assigned. Later she tried to help me transfer a patient. He was a larger man with a dense hemiplegia. I'd been working with him for a few days and had a transfer technique that worked. As soon as she came into the room she wanted to do everything differently. I don't mind someone making suggestions. I do mind someone coming in and telling me how things should be done without asking me why I was doing them differently.

By lunch I'd decided to stay out of her way. She obviously had her own way of doing things that worked for her. She'd made it clear earlier she wasn't going to change. Then she brought up evidence-based practice. She was tired of hearing about it. She missed the days when you could do whatever you wanted. She didn't think she should have to do anything different. She'd been doing the same things for years and had good results. I can't even describe all the things that went through my head.

This woman is an example of one of the challenges facing PT as it moves toward 2020. She is stuck in the "old way" and is refusing to move forward. The DPT can be debated on end. Having treatment interventions supported by research makes sense. Medicine has been using evidence for years. Having evidence to support what we do is a necessary part of practice. With evidence we can defend interventions to third party payers, to other health care professionals and support our requests that patients receive continued therapy or defend why someone is ready for discharge.

After listening to her I realized how difficult it's going to be to move our profession forward. She couldn't even tell me what she meant when she said evidence. I can't imagine her doing a literature source for answers. In her world she has no reason to do things different. She believes her treatments have been successful. She is one person. Now multiply that by the number of PTs and PTAs out there who feel the same way. All the education in the world won't do a thing if those therapists don't buy into the vision of what we want to be. I'm beginning to think that Vision 2020 is going to be Vision 2030 because the only way those individuals will change is when they retire.

As I said, her presence was a learning experience for me. I saw firsthand what we're facing if we want direct access, autonomy and the like.  Now I have a better understanding of how someone on the other side of the issue sees things. I also understand why someone might think Vision 2020 isn't that important. Whenever she's back I'm going to talk to her. I won't try to change her mind. Instead I'll try to explain my thoughts and hope for understanding.

It turns out the chairperson of the committee that would hear the bill and recommend it for debate is a physician. The person behind her is also a physician. So far they have been turning a deaf ear to the problem. It's no better in the senate where the committee chairperson is married to a physician. That sounds a lot like conflict of interest to me but apparently it isn't. Neither chairperson has done anything with the bills. It isn't expected either will even make it to the floor for debate. There has been some debate. A compromise was offered. I will paraphrase what it said. They will allow PTs to treat patients without referral who they've seen in the last 2 years from the same physician for the same diagnosis provided the physician is notified the patient is seeking treatment. I don't see much compromise in that.

One reason this is happening is because there hasn't been much support forthcoming from the rest of us. The representatives and senators aren't getting tons of emails and faxes in support of the change. Every week some therapists travel to Austin (the state capitol) but have yet to see anyone plead our case. Now I'm asking myself if physical therapists, as a profession, really want to have direct access. It doesn't seem to be getting grass root support. There are some very dedicated people working on this but it will take more than that. But no one else seems to be making the effort. Why is that happening? As a rule, PTs aren't passive people. We're all busy, but sending emails don't take that long, especially if you already have the addresses. Maybe we, as a whole, just don't care.

I did a mini poll today at work. None of the PTs I spoke with had a clear idea of what direct access means. Everyone said practice without referral but no one could really describe what that means.  Some told me it only applies to those practicing in OP settings. That's true to a point. If you read Vision 2020, it sounds like they want direct access in all settings, hospitals, SNFs and OP clinics. I also discovered no one had thought about how patients would know what PTs do and when it's appropriate to seek our treatment. Accomplishing that will require a nationwide push of education and probably several years of effort.

I'm think there are two issues for this. On one hand, those that want direct access are willing to sit back and let someone else do the work. Simply saying I want direct access isn't enough. We can't sit back and let someone else get this done. It's going to take a group effort. The second issue is lack of understanding of what direct access is. I think these are the "old school" therapists who don't see the need to change a system that is working. On one hand, these PTs might agree direct access is a good thing but they haven't bought into the need to have it and probably never will. I know PTs that fall into this category. They're good therapists. They've kept up their skills. They just don't see the need to do anything differently. There is a subset of both of these groups composed of those who oppose the DPT.  To them you only need a DPT if you're going to have direct access. So if there isn't direct access, why have a DPT? I'm going to skip that can of worms this time.

If we want direct access now is the time to jump in with support. If you want it, send an email. Explain to others what direct access means and why it's important. Vision 2020 may be too optimistic but we have to start somewhere. This isn't going to happen quickly. Based on what I've heard when working in different locations, I think the APTA might be better off focusing on educating practicing therapists about what direct access means to them and eliciting their support. Then we should put the push on congress. I've come to this realization slowly. Now that I have, I will be sending emails when requested. I'll support the effort as much as I can. It isn't much, but it's a start.