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Toni Talks about PT Today

Request for Submissions
by Toni Patt

It's that time of year again. The company that I teach for is requesting submissions for an education summit next year. I'm supposed to select a topic, describe what it is and why I think people would be interested. Then I submit that and five references no more than a year or two old. They try to present newer information.

The problem is I can't think of topics. Each presentation is two hours. I teach a six-hour class. Two hours is nothing. I've already been told pretty much anything I submit will be accepted because I'm the neuro person. With one exception, everyone else who teaches is either an orthopedic person or pediatric person.

Naturally I want to fall back on stroke-related topics. All the newer stuff in stroke research is medical in nature, not related to physical therapy. That won't work. It's time to broaden my horizons. I'm an NCS. I should have a good grasp of neurological therapy in general. But it has to be interesting to me. So far I haven't thought of much.

There's another problem. I like acute and subacute stuff. Most of the research is done with chronic patients, particularly with stroke. So there isn't much research to support anything. There has been work with acute brain injuries but I'm not sure if I can make that interesting for two hours. That would entail breaking down what the lines and wires are for, which I think is common knowledge.

A lot of what I do is based on anecdotal work I've done. I try things and see what happens. I know it works. I have research that supports the theory I started from. I've considered submitting two case studies that support things I do, which would then be literature. That's difficult because few publications will publish case studies.

I have a week to figure this out, pull articles and write descriptions. That would be challenging if I knew which topics to research. This is going to be an interesting week.

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My Worlds are Colliding
by Toni Patt

Anyone who knows me is aware that I have two lives. One is my professional life. The other is my horses. Thanks to planning and a little luck, I've always been able to avoid scheduling conflicts. Sure there's been the occasional afternoon scramble to leave work in time to make a lesson. And obviously one of the reasons I work as much as I do is to support my hobby.

Next month will be the first time there's a conflict with an either/or choice. The last Saturday of the month I need to be in two places at the same time. Both are supposed to be optional.

The first option is to travel to Austin, Texas, for a legislative activity with my leadership training group. I'm a member of a leadership development program to prepare individuals to assume larger roles in the Texas Physical Therapy Association and, if desired, on the national level. I believe we're attending that session in support of some legislation that is pro-physical therapy. I would leave Friday after work and return Saturday after the session ends. Austin is a 2- to 3-hour drive from Houston, which is doable.

The other option is a horse show. Only one of my horses, the younger one, would attend. It's being held in a facility just outside of Houston and is a practice show. The purpose is to give my horse more experience in the show ring at a lower cost. It's scheduled for the same Saturday and because it's local, I would drive there, ride, and come home.

The cost for both is about the same. I had already made arrangements to be off from my weekend job. One has a greater time commitment than the other. One will probably be more fun. Only some of us in the leadership program are attending. The show will be small and doesn't count for anything. I truly don't know what to do.

What do you think? I don't have to commit to either one until mid-April. Should I develop my leadership skills or my horse?

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‘We're All Gonna Need Physical Therapy Soon'
by Toni Patt

I spent last weekend at a horse show in San Antonio. Even though I had both show horses with me, there was still a lot of down time. Since everything is close quarters it's easy to overhear conversations. While I was waiting I was surprised to hear someone in the barn next to us say, "We're all gonna need physical therapy soon."

I wasn't surprised to hear he was sore. I was surprised to hear he knew what physical therapy was. My first thought was the efforts of the APTA must be paying off. People are starting to know what physical therapy is and what we do. I took this as a good sign since a horse show is a good sample of the general population. We have everything from engineers to teachers to truckers in our midst.

My bubble was quickly burst. His very next words were, "I need a good massage." The message hasn't gotten out as clearly as we'd like. I guess this is progress of a sort. He knew that physical therapy existed and treated muscle problems. He just has no clue as to what we can do. I bet this is someone who goes to the chiropractor for a backache.

No, I didn't correct him. It was neither the time nor the place for a teachable moment. I felt the same way at the time anyway, only I was thinking hot shower.

Besides, I have a bigger problem in my barn. One of the show mothers is also a PT. She treats menstrual cramps and stomach aches with who knows what. I'd be thrilled if she would limit herself to massages and muscle spasms.

Guess we have a little more work to do on brand identification.

In case anyone is curious, Flame aced his sport horse classes and Allie managed to beat seasoned horses at only her second show.

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You Can't Discharge Her, the Family Will Complain
by Toni Patt

We've all had patients we've kept on caseload longer than necessary. Sometimes it's just one more day until discharge. I've occasionally kept patients on caseload because they wouldn't get out of bed unless I did it. When I worked in the ICU, I'd keep patients because I thought they were waking up.

I can't say I've ever kept someone on caseload because the family demanded it. I have of one those right now. The patient and her husband have learned the louder they complain, the more a facility will acquiesce to their demands. At least it's understandable when a family wants to continue therapy because they're convinced the loved one will get better. This couple simply likes being in control.

Yes, getting out of bed is therapeutic. She gets up twice daily with a sling lift, which nursing can do without us and therefore is not a skilled service. She refuses to exercise and will never ambulate due to orthopedic problems. A slide board is out of the question due to sacral wounds. She's been doing this more than two weeks so orthostasis isn't a problem. Yet she's still on caseload and we are still charging for the service.

I brought this up with the other therapists. They have no problem with keeping her on caseload because the couple is difficult to deal with. Difficult to deal with or not, by keeping her on caseload we're charging for a skilled service that isn't skilled. And that's the problem. I don't care about getting her out of bed. I care that we're calling it a skilled service when it isn't.

One of the biggest complaints PTs have is being referred to as a lifting service. Nursing calls therapy to get up anyone who's somewhat difficult or overweight. The only skill required is body mechanics to prevent ourselves from getting injured in the process. We might complain but still get the patients up, thus becoming a lifting service.

Thus we come full circle. We're not providing a skilled service. She should not be on caseload. This doesn't mean therapy won't help with getting her up if needed. That both the patient and her husband complain loudly shouldn't enter into the equation.

I don't care if we've been doing it this long so what will a few more days matter. In theory we're providing skilled services, not simply lifting patients. In reality she'll remain on caseload because I need to pick my battles and won't win this one. What's disappointing is that my coworkers don't see anything wrong with the situation.

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Are Groups the Answer?
by Toni Patt

One of the take-home messages from the APTA Combined Sections Meeting last month was that more therapy is better. I think everyone agrees with that. What we can't agree on, or even figure out for that matter, is how to squeeze more therapy into an already overcrowded day. One suggestion was to utilize group therapy in addition to what we're already doing.

On the surface that sounds like a great idea. You can work with more patients with less staff. Group is even billable, although not for very much. When performed in addition to regular therapy, there would be a net increase in revenue. At least that's how it sounds. If a couple of groups were incorporated into the weekly schedule, we'd have more therapy.

I see two problems with the idea. First, who is going to staff the group? Generally everyone will have a full caseload. I don't know of one facility that allows overtime. Nobody has time in their schedule for extra therapy. Bringing in an extra person probably isn't feasible. Even with some revenue generated, the influx will not cover the salary of the staff needed to have the group.

The second problem is reimbursement, as in who will pay for it? Even if you somehow find the time and the staff, someone still has to pay for it. One suggestion was to have patients private pay for the group when provided on an outpatient basis. I don't know about everyone else, but at any given time at least one-third of my patients are non-funded. Many others are on a fixed income. Even if they want the therapy, they can't afford it.

You would need to have the group meet at least three times a week for it to have any meaningful impact. Multiply that by a few weeks and the cost rises quickly. If the cost is kept low, larger groups will be needed to offset expenses. Larger groups mean more staff. If you limit the number in the group, the cost will need to be higher. Many patients grumble about outpatient therapy copays. I can't see this going over any better on a large scale.

So we have a reasonable suggestion but no feasible way to implement it at this time. Obviously increasing the amount of reimbursement for our services would be a big help, but that isn't going to happen.

Until someone on the payer side realizes all the benefits of therapy on keeping costs down and decreasing length of stay, nothing will change. The same studies that say more is better also show how increasing the therapy actually decreases the bill and length of stay. Maybe they don't want to see it. Maybe they don't believe it. One reason our system is dysfunctional is because of the numerous groups and entities invested in keeping it the way it is.

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Customer Service
by Toni Patt

I don't think you can work in healthcare for any length of time without attending the mandatory customer service inservice. It usually includes a segment on making upset customers happy. In our case, that would be patients and families. One strategy is to listen, verbalize back and then address each complaint.

I'm skeptical when I hear that. It might prevent that customer from having a bad experience, but what about the ones waiting in line while the service is being provided? When I was in South Dakota waiting to check in, a man was complaining loudly. The registration person spent 5 minutes resolving the issues. I know this because I, and eventually four others, stood in line that long. That man was happy but five other people had a bad experience.

Last weekend I had to go in on a Saturday to do an evaluation. I was told there were a lot of problems when the patient was admitted, so everyone was trying to make the family happy. Normally the facility doesn't staff for rehab on the weekend but because the family wanted therapy to start immediately and the physician ordered it, someone had to provide the service. I work in an LTAC. Evaluating the man on Saturday instead of Monday wasn't going to make any difference in the outcome.

Everywhere I've worked, facilities have practically bent over backward to make a complaint go away. They'll do anything to prevent a bad experience. Those same facilities never think about the patients who aren't being cared for, call bells that aren't being answered and therapy not provided because everyone is trying to make one person happy.

After I return from teaching, I complete an evaluation of each facility. The one in South Dakota got a bad one because of my experience. Because I worked on a Saturday for something ridiculous, I'm much less likely to do it again. It accomplished nothing. The family was just as unhappy when I left as when I arrived. The ordering physician probably forgot about it as soon as he wrote the order, so isn't any happier either.

Maybe we need to change how we think of customer service. Facilities create much more ill will when they inconvenience one person to make another happy. The inconvenienced one might not complain but won't return either.

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Bariatric Patients are Nationwide
by Toni Patt

One of the benefits I get from traveling is talking to therapists in different parts of the country. Things are not the same all over the country but there are a few recurring themes. We all agree that our patients are getting bigger. I started including trunk exercises for the obese patient because I was asked that question in every seminar.

Whenever the topic of large patients comes up, it's always followed by the words "and we aren't equipped to treat them." Sometimes the problem is inadequate staffing. It takes more people to mobilize an obese patient. This is a problem when staffing is cut to the bare minimum. An even bigger problem is lack of adequate equipment. Bariatric wheelchairs, beds and walkers are a must for this population.

This morning, I had an order to find a wheelchair large enough to fit a patient so she could get out of bed for 30 minutes. She wasn't comfortable in our 30-inch chair. Plus we don't have elevating leg rests for that chair. Nor do we have a large enough cushion to accommodate her and her wound.

Equipment is another area feeling the brunt of cost-cutting. Anything bariatric is almost twice as expensive as its normal-sized counterpart. Facilities might buy some bariatric equipment. Problems develop when there are more plus-size patients than plus-size equipment. I have four decent cushions. To accommodate my large lady, I will need to take some away from other patients.

Meanwhile both the patient and her doctor will be complaining. The doctor will write orders for a bariatric cushion, wheelchair etc. Despite the obvious need, the facility will not allow me to purchase anything. Rather than spending some money to solve the problem, we'll be told to make do. We might save a little money but the stress will escalate.

I've heard similar stories many times. The research is showing early mobilization of stroke patients improves outcomes. Facilities say they want good outcomes but stop short of spending the money. I don't have any answers. There is no substitute for getting someone out of bed.

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Agitation or Aggression?
by Toni Patt

Recently we had an elderly man on caseload with a diagnosis of advanced dementia. It was obvious he was in the later stages of the process. He couldn't follow commands. His swallow was diminished. He was disoriented times three and demonstrated poor motor planning with any voluntary movement. However, he could still move and verbalize spontaneously.

Unless disturbed, he laid quietly in bed. The problem arose when we tried to get him out of bed. He didn't want to be disturbed. As soon as we started to move him, he told us no and began cursing. This was followed by swinging.

Anyone who works with the elderly knows there are two kinds of swings. Some are ineffectual. These may be taps. There may be a little force. Patients with brain injury frequently flail in bed during the restless state. The intent isn't to strike someone so much as to move. These people might be described as agitated. Restlessness while in bed is certainly agitated.

Then there is the man I described above. He wasn't agitated. He was aiming for us. He didn't want to be moved and was resisting it. On a few occasions, his wife was present when we attempted to get him out of bed. She told us to ignore him. He didn't mean it. Mean it or not, he was trying very hard to hit someone.

Patients have the right to refuse therapy. That statement is made with the assumption the patient understands what he is refusing. In cases of dementia and confusion, we often have to rely on family members to give consent for treatment. This man was clearly refusing despite his wife's statement to the contrary. He knew he didn't want to get out of bed.

After a couple of days of struggling, I discharged him from therapy. Someone was going to get injured if things continued. One of our PRN PTAs knew him from previous interactions. She said this was normal behavior for him and they got him up anyway. He was just agitated. Obviously I don't agree with that. Despite the benefits of being out of bed, there is the real risk of injury to either himself or a caregiver. This went beyond any level of agitation. He was aggressively trying to strike someone.

He has since discharged to a SNF. I don't know if it's the one he came from or a different one. For his sake, I hope a different one that recognizes the difference between agitation and aggression.

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Dosage Matters
by Toni Patt

There were two common themes at CSM this year: dosage and intensity. Every clinical presentation I attended mentioned one or the other. Intensity was defined as how hard the patient is working. Dosage referred to the number or reps or duration in the case of a static activity. In both cases, more is considered better.

Last weekend I worked at a SNF. One of my patient's treatment notes indicated he was doing 100 reps of his exercises. Given the concept that more is better in a population that often needs encouragement to do anything, this sounds wonderful. The problem is the patient was doing 100 reps of the wrong exercises.

Yes, his legs were getting stronger but weakness wasn't the problem. It's a motor recruitment issue with compensatory movements. Unless someone corrects his gait pattern, he isn't going to improve. He doesn't need strengthening. He needs motor training. I didn't know whether to laugh or cry. More of the wrong thing isn't better. It might even be worse.

The reason the therapist was doing the wrong thing is the topic of another blog. Suffice to say that unless it's more of the correct activity, nothing will be accomplished. Obviously the treating therapist was listening to the message. He just didn't hear all of it.

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An Attendee's Perspective
by Toni Patt

LAS VEGAS -- The 2014 Combined Sections Meeting is getting started. I've been in Las Vegas since Saturday evening for my preconference course. It was two days of sitting for eight hours listening to people read information off slides. The next three days will be three presentations of two hours each spread over the course of the day. In between, the expo center will be open.

I have to say I was disappointed with the preconference course. The information was good but very basic. They stressed evidence but very little was practical application. There were several presenters. I don't think they were accustomed to presenting to groups. Reading the lecture directly off the slides is boring and invites loss of attention.

I've already changed my mind several times about which courses I'll be attending. That happened to me at other CSMs so I was prepared. I printed the handouts for every presentation I thought I would want to attend. I have them all in a binder in sequential order, divided by days. Plus I carry a pad of paper for notes. I'm prepared. Once the expo hall opens, I'll also have plenty of pens, post-it notes and notepads.

People have been arriving throughout the day. The line for registration started before 8:00 this morning and was still there when I left my class this afternoon. I'm seeing more and more people carrying the CSM program as I walk through the hospital. This year they gave us a small tote bag when we registered. It will come in handy. I brought one from home (that one of my horses won) so now I have one for my program and binder and one for the expo center.

I'm staying in the Venetian. Vegas is a completely different world compared to everywhere else. The hotel is easily the size of a city block. During breaks we joked about getting lost walking from the hotel room to the convention center. This morning it took me almost 20 minutes to complete the walk without getting lost. You have to walk through the casino to get anywhere. People really are in the casinos at all hours.

There's a shopping mall built into the hotel. I've gotten lost every time I've tried to walk through it. The shops are mostly upper-end merchandise. I did find a few bargains though. During lunch today we decided the casino, while seemingly endless, is a good marker. If you can make it to the casino, you can find your way out.

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It's Time for CSM
by Toni Patt

It's almost that time of year again when thousands of us gather for the APTA Combined Sections Meeting. This year we're in Las Vegas. According to what I've read, they're expecting more than 10,000 PTs and PTAs to attend. I'm going. To use a Texas-like phrase, this isn't my first rodeo.

This will be my third CSM, so I know what to expect. The exhibit hall will be the size of a football field and filled with gadgets, technology, DME, facilities looking for staff, tDPT programs looking for students, publishers and the APTA. It will take me all of two days' worth of breaks to see the entire hall.

This year I'm attending a preconference course on, of course, stroke. I've already printed the handouts. I'm familiar with everything I saw. I'm already teaching about a third of it. I know I will learn something. But this is a two-day course sponsored by the Neurology Section. I'm expecting to learn more than a few things. I hope to expand my knowledge of the things I'm already familiar with.

I pre-selected my courses when I registered. Once again, I'm pretty much sticking in the neuro section. A couple of the courses are co-sponsored by the Geriatrics Section. I naturally gravitate toward stroke and brain injury. My goal is to attend either a degenerative diseases or vestibular lecture to increase my overall knowledge.

Most of lectures I've attended have been worthwhile. But I've learned you have to read between the lines of the descriptions. Pre-reading the handouts helps with figuring out what the true topics will be. Last year one of the most interesting lectures I attended concerned gene mapping. They didn't cover anything clinical but it was fascinating. Sometimes fascinating is better. I try to pick things that I have an interest in or relate to what I'm teaching. Naturally most of the ones I want to attend are offered at the same times. Decisions, decisions, decisions.

I'm staying at the Venetian, which is the main hotel. I've checked the website. It's huge. I won't have to leave the building for anything: food, shopping, entertainment, spa services and of course casinos. There is actually a mall on site. In fact, the only time I'll go outside is to make a quick trip to the "Pawn Stars" pawn shop. It's a 10-minute taxi ride away. The last time I was in Vegas, I played the slots. I lost two dollars. Been there, done that. Now I'm going to the pawn store for entertainment.

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Merit Raise
by Toni Patt

This week I received confirmation that I would be getting a merit pay raise. It was explained to me that merit raises are based on years of employment and not linked to job performance. Thus everyone who's been there one year gets the same percentage increase. The raise went into effect as of January 1.

Imagine my surprise when I opened the letter telling me how much the raise was and learned I will get a $0.23/hour raise. That isn't even a 1% increase. My insurance premium increase alone is 3% of my salary. That's less than $10/week before taxes. I appreciate the thought.

Am I supposed to be excited about this? Yes, I'm happy I have a job. Yes, I'm happy I got a raise. There are many out there who can't say the same thing. At the same time, I'm insulted. I'll miss the 3% decrease for insurance more than I'll ever notice the increase. If you're going to give someone a raise, give them a raise.

I'm guessing the motivation is to encourage longer-term employment, as in stay with us and you'll eventually get more money. This raise isn't going to affect my employment one way or another. It makes me wonder if this is another trend to cut costs in healthcare. These raises were across the board to all disciplines.

I have friends who get significantly greater increases based on job performance, competency and experience. Healthcare is the only field where those things are a detriment rather than a plus. I can't decide if this is sad or funny.

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Working While Sick
by Toni Patt

Deciding whether or not to call in sick to work is one of those decisions everyone dreads. Some don't want to let their coworkers down. Others don't want to waste the PTO. I've never heard a universal guideline published. Although the unspoken one seems to be don't come in if you're contagious.

I've been facing that dilemma the past few days. I have whatever is making the rounds. I think I'm the third in the department to fall victim. It's very insidious. You don't feel bad in the morning but come noon and it's another story. I generally decide about work based on how I feel in the morning, not how I think I might feel, so it's hard to know.

I worked three days progressively feeling worse. I didn't have a fever, wasn't sneezing and although I was coughing, I wore a mask. When I caught myself wrapping up in an extra patient blanket right before lunch, I decided it was time to leave. I went right to one of those stop-in clinics that can be found next to almost any pharmacy.

I was in luck. I had a sore throat and therefore was given antibiotics and prescription cough medicine. Maybe lucky isn't the right word. That was a Friday. I slept two days and went back on Monday. Yes, I felt better. No, I wasn't contagious. I probably should have stayed home anyway. Before the end of the day, everyone in the department asked me why I hadn't gone to the doctor yet. I'm guessing I didn't look so good.

Or, rather, I didn't sound good. Even though the disease process itself was relaxing its grip, the cough was much worse. I was coughing so hard I had to sit when I coughed to keep my back from hurting. One of the physicians seated a few feet away glared at me so hard I thought I was about to get another prescription gratis.

Thus sickness is more the appearance of being sick, rather than actual illness. No one tried to send me home when I really was sick. As soon as I started coughing, everyone thought I should leave. It would have been smoother if I could have taken the cough medicine, but it contains something I wouldn't want to pop up on a drug screen so it's reserved for home use. I might have to risk it tomorrow.

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Is Diathermy a Skilled Therapy?
by Toni Patt

One of my OT coworkers and I have fallen into bicker back and forth in fun. We have an unspoken agreement to agree to disagree. Usually we find some middle ground until the topic of diathermy came up. We disagree about whether this is a skilled therapy or not.

I say it's not. To me this is like a neuro chair transfer. Just about anyone could perform one. The skill isn't in performing the transfer, it's in the clinical judgment as to appropriateness and patient tolerance. Nor is the transfer therapeutic. That comes from being out of bed. Except for the first treatment, I don't believe diathermy is skilled. I can easily train someone to use the machine. Some of the newer ones even come with recommended settings printed on them.

The OT says skilled. He holds that it requires skill before and after each treatment to determine whether the treatment is needed. Further skill is needed to choose the appropriate settings and position the head. He agrees I could train someone to set it up but only a therapist can make those decisions. Hot packs are not a skilled service but diathermy is.

The discussion is further complicated because diathermy is a skilled charge. I maintain being able to charge for it doesn't make it skilled. That just means someone successfully lobbied for it to be possible. My OT counterpart maintains that because it can be charged, it is skilled.

We're not debating whether diathermy is an effective treatment modality. Research exists that supports both positions. From what I can tell it works for some, not for others. I'm told that is due to user, I mean therapist, error. Set up properly with the correct settings, diathermy is an effective treatment.

We aren't going to find common ground on this one.

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How Not to Prioritize
by Toni Patt

Over the past weeks, I've been blogging my concerns about staffing levels and quality of care. More and more it looks like staffing will continue to be diminished in cost-cutting efforts. In one blog, I posed the question of how to prioritize patients when caseload isn't manageable with the goal of seeing as many patients as possible and still providing adequate therapy.

Last week I got my answer. On Monday we were short-staffed, with each of us having 17 patients on caseload including evaluations. I decided to limit therapy to the most important thing for each patient. Therapy sessions would be shortened but something could still be accomplished. In some cases, that meant getting out of bed without performing bed exercises. I saw all but two people on my list and thought I had done pretty well considering.

Thus we come to my patient in the ICU. My plan was to sit him edge of bed for balance, then attempt a functional transfer to a high-back wheelchair. Initially he refused to allow me to transfer him. He made no effort to balance when edge of bed. Once he was in the chair he requested the tech lift him back to bed.

On Tuesday the lead therapist, an ST, summoned me to his room because he had a complaint about his therapy. He complained that he hadn't done anything but get out of bed, via the tech, leaving out that he refused to allow me to do it. I suspect there was more to it but he toned it down when she pulled me into the room. I tried to explain to him that instead of exercises I attempted to do something more functional. That the lead therapist wasn't backing me up didn't help.

In fact, after the conversation she commented she was tired of having her behind used as a chew toy. Yes, pulling me in was politically savvy but it didn't help. I went from being proud of myself for thinking I had accomplished something to having handled the situation completely wrong. No one wants to hear the therapist is too busy, but the man was offered an opportunity for more and he declined. I wasn't going back.

I'm not sure what else I could have done. I could have spent more time with him and skipped several other patients. I've since learned his normal therapist skimps on patients who don't do much. She believes this gentleman benefits more from her time so she does little with them and spends extra time with him. Had it been her with 17 on caseload, I suspect she would have skipped the lower-level people and given him his full treatment. That doesn't work for me.

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