Toni Talks about PT Today : Ethics & Legal Issues

Quit Complaining

Toni Patt — Wed, 25 Nov 2009 13:44:00 GMT

Over the last few weeks my department has been undergoing some changes. After reviewing our numbers over the last few months, our manager realized we haven't been complaint with the three-hour rule. For those who don't work in a rehab setting, the three-hour...(read more)

The Pretty, Young Therapist

Toni Patt — Thu, 12 Nov 2009 13:10:00 GMT

Last week something was said during rounds that I'm still angry about. We were discussing a new admission. Since my case load was low, I asked if I needed to see the patient. In response, I was told the patient had been given to the young, pretty therapist...(read more)

My Patient Doesn’t Want to Work With Me

Toni Patt — Thu, 15 Oct 2009 14:32:00 GMT

Last week I inherited an interesting patient from a therapist who went on vacation. The patient is an 87-year-old Chinese female admitted with a diagnosis of right MCA infarct. She has a history of undiagnosed dementia. She lives with her husband and...(read more)

Informed Consent

Toni Patt — Wed, 27 May 2009 13:12:00 GMT

While I was researching an assignment for my latest class, I ran across an article about informed consent and physical therapy. The article stated that in a patient centered environment, consent must be granted for any procedure or activity that is outside...(read more)

We Should Always Be Professional

Toni Patt — Mon, 23 Feb 2009 16:42:00 GMT

This week my assignment is a smaller hospital in the suburbs of Houston. I've been there before on weekends and some holidays. I was looking forward to being there. Now I'm looking forward to leaving. The lack of professionalism I've experienced there has shocked me. I've heard some things that I never expected to hear from a PT or PTA especially to and in front of patients. In their defense, nothing I heard was meant in a negative or derogatory manner. It's possible no one realized how what was said actually sounded to someone else. Still, we're professionals. We should act professional.

The thing that surprised me the most was the manner in which one of the PTAs interacted with her patients. Now I realize in smaller departments the staff is going to be more familiar with the patients. However, it's never appropriate to discuss patients by name in front of patients. Several times I heard her talking to a PT about patients by name while treating someone else. That is a HIPPA violation. Worse, the other PT, who is the inpatient supervisor, responded in the same manner. These conversations happened several times and in a busy treatment area. I got the feeling it was standard practice.

I overheard the same PTA talking baby talk to her patients. I hate that in any circumstance. These were outpatients who could easily understand adult conversations. The worst I heard was her reference to slough as "loosey goosey" that needed to be cut off. I never heard her explain what she meant to that patient. This patient was a chronic wound patient. He would have understood removing dead tissue. There is no excuse for talking down to someone. I was offended for the patient.

The manager might want to review her HIPPA rules. The schedule board is in a cabinet behind hinged doors because it is in a high traffic area. More often than not at least one of the doors is open. Anyone walking by could easily see patient names. Yes, the printing was small and difficult to read unless up close. That doesn't mean the doors should be left open. While she's at it, she should review sterile technique. I'm not sure why they insist on sterile technique for every wound procedure. Research has shown clean technique to be as effective. However, if one is wearing personal protective equipment, it should be removed when walking away from one patient to cross the room to give an opinion about a different wound. There are curtains which indicate room "walls." Passing through the curtain is the same as leaving the room. The protective equipment should have been removed and freshly donned upon re-entering the "room."

I was assigned to do wound care on inpatients. Because that can be challenging, I was assigned a tech to assist me. As I was reviewing the list with the tech, she informed me she couldn't help with one of the patients because he was too big for her. She later refused to help me reposition a patient after treatment because he was dead weight and hard to move. Even after I explained that I didn't want to leave him in a bad position she refused, telling me the nurses would eventually do it. Since I couldn't find the nurse, I did the best I could and used pillows to prop up the involved foot to prevent additional pressure. I have never had a tech refuse to help me reposition someone before. To make matters worse, the tech is trying to get into PT school. I found out later she wants to work in fitness and not with sick people. I think she might want to rethink her chosen profession.

I don't expect this sort of behavior in hospitals. Anyone who works in a hospital has HIPPA drummed into their head. I'm not saying referring to patients by diagnosis or body part is much better. However, at least no one else knows who I am talking about. My preference for HIPPA compliance is to use room numbers. I don't think it's the facility. I've worked with the OP side of the department and never heard anything amiss. At one time those therapists knew better. That's no excuse for acting unprofessionally. PTs are professionals. We must remember to always behave that way.

Don’t Tell Me to Ignore the Practice Act

Toni Patt — Thu, 22 Jan 2009 13:29:00 GMT

I heard something today I just couldn't believe. I was talking to the department manager about who is responsible for putting patients back to bed. My point was in order for physical therapy to be physical therapy, a skilled intervention must be involved. The intervention must be goal driven toward a functional outcome. I've said this before. What took my breath away was his response. I was told he didn't care about the practice act or what is functional. Nursing is short staffed. If nursing asks me to put a patient back to bed I am to do it and do it with a smile on my face. He went on to acknowledge that was a job duty of a CNA. He told me charges don't matter because our reimbursement is DRG driven. He only cares that the patient be happy and willing to return to the facility. If good patient care means I put the patient back to bed, I should put the patient back to bed.

I have no problem with providing good patient care. I go out of my way to take care of my patients. My problem is being told I should disregard the document which governs how I practice. My problem is being told to perform non-skilled interventions because nursing is telling me to do so. I have a problem when the department carries patients on caseload for the sole purpose of lifting them out of bed and charging that as a skilled service. That is called fraud. Not only does Medicare frown on that, it is illegal.

I don't know what to think. Physical therapy has spent years educating other health care professionals on what we do. PTs are recognized for their skills in treating neuromuscular disorders. That is one of the principles behind the push for the DPT. For a fellow PT to tell me to ignore the practice act is beyond me. If I practice outside the practice act, I lose my license. If I provide unskilled services and charged them as skilled services, I am committing fraud and can not only lose my license, but go to jail.

It would be one thing if he told me to suck it up because that is department policy. I wouldn't be happy, but it wouldn't be heresy. This man has gone so far to the dark side even he makes Darth Vader seem good. At least Darth had principles. It doesn't matter to me that this situation isn't a frequent occurrence. It's going to happen. When it does, I deal with it. What matters is that this manager equated what I do with what a CNA does. Instead of defining our profession, he let us down.

I don't know what to do. Up until today, I enjoyed working at that facility. I'm not fond of the man, but respected his position. Now I'm not sure he deserves his position. I can report him to the Texas board, but I don't think anything will result. Since no one else heard him, it's my word against his and I doubt they'll act on that. I can ask to be transferred, which gets me away from the problem. I can go to his superior, but I suspect an administrator would be more concerned about the patient coming back then this. No matter what, I'm not going to do what he said. I can only be responsible for myself. When I find myself in this situation, I'll find an acceptable way to deal with it that makes the patient happy and is within the practice act.

Patient Abandonment

Toni Patt — Wed, 31 Dec 2008 13:15:00 GMT

The hot topic at lunch this week was the definition of patient abandonment. We all agreed that it involved leaving a patient who needs therapy without it. What we can't agree on is at what point does the abandonment occur?

Taken to an extreme it could mean someone who doesn't see all the patients on caseload and makes no arrangements for someone else to do so had committed abandonment. It could also refer to a therapist leaving a facility without another therapist available to assume the caseload. I think this is the definition that most frequently comes to mind.

Our scale is much smaller. Our question is if someone misses work without calling in and no additional coverage is available... is that abandonment? That happened last weekend. A PT who was on the schedule didn't come in and couldn't be reached by phone. He had a caseload assigned to him. When we realized he wasn't coming the caseload was divided among everyone else. As a result not everyone on caseload received therapy that day. If the PT had come to work it could reasonably be assumed all the patients would have been seen.

One side of the debate says yes, that was abandonment. He left those patients without making arrangement for them to receive therapy. Because he didn't come to work some of those patients weren't seen. The opposite side says no, it was poor judgment and not responsible behavior. It wasn't abandonment. The PT knew there would be others present to treat those patients. One individual thinks we should contact our state board and report him so that disciplinary action can be taken.

What that PT did was definitely wrong. There is no excuse for him to just not show up for work. Disciplinary action of some kind is appropriate. In this case, I think the facility is more likely than the PT Board to take action. The question still remains. Is what he did considered patient abandonment? If it isn't, what is considered abandonment? I'm on the side of very wrong but not abandonment. To me abandonment implies something more permanent like the example of leaving before a replacement is hired. This isn't the first time patients have been missed because of staffing issues and won't be the last. The discipline should be for the no call, no show and not abandonment.

This has made me start thinking about what would be considered abandonment. Several years ago I worked for a large hospital. They were notorious for lacking adequate weekend staffing. Some patients weren't seen again until Monday because there weren't enough people. Some of my co-workers felt that was abandonment. The staffing level was a decision on the part of manager who knew patients were being missed. Is that abandonment? What about a facility that suddenly loses a PT?. The remaining PTs would be expected to pick up the slack. In that situation it's reasonable to assume some patients would be missed.

Maybe the question isn't what constitutes abandonment. Maybe the question is at what point is a disciplinary action necessary and at whom? Is it the therapist who left? The remaining ones trying to take up the slack? Or the facility for allowing it to happen? It isn't fair to discipline the therapists with expanded caseloads. They are trying to see everyone. Is it fair to discipline someone who gives adequate notice before resigning? Should the facility be punished because it can't find a replacement? If these are the standards a lot of PTs and facilities are in trouble.

Prior to writing this I checked the Texas PT Board Rules. I couldn't find anything that specifically addressed the issue of patient abandonment. I couldn't even find a definition of what is considered abandonment. I checked the APTA website with the same result. I found statements addressing ethical treatment. I found statements concerning how a therapist goes about providing care. I found statements forbidding patient endangerment. If current healthcare trends continue this problem isn't going to go away. If anything, as staffs are cut to save money the problem with exacerbate. What is a debate now could become a reality in the future.

We Need to Limit Our Use of Modalities

Toni Patt — Tue, 02 Sep 2008 16:53:00 GMT

In the most recent print issue of Advance for Physical Therapists and PT Assistants (vol 19, # 18, p. 138) the Rehab Roundtable section poses an interesting question. Should physical modalities be removed from physical therapy practice? This is a legitimate question. Modalities, particularly ultrasound, are overused. The question was put out to a panel of four. They were unanimous in their answer of no. They were also unanimous in stating that modalities are useful when used properly, but this is often not the case. They also agreed more research is needed because the current evidence is ambiguous.

This got me thinking. My answer to the question is a definite maybe. It depends upon who is using the modality and why it is being used. In a perfect world there wouldn't be an uncertainty about the use of modalities. But our world is not perfect and modalities are misused. The issue questions our clinical judgment. Taking modalities from our treatment arsenal would be seen as an insult to our skills and reasoning. How can something be a skilled service when it is used for just about anything and performed by a technician? Under those circumstances I can see why the question would be raised.

Why are modalities used so much? There is the obvious reason why they are very effective when used correctly. I thought of some additional reasons that don't reflect well on those guilty of overuse. Using modalities makes the patient feel like something has been done. Modalities are a billable unit. There is lack of knowledge of more appropriate alternatives. A tech can perform the treatment so the therapist is freed up to do something else. And, of course, because that's what the doctor ordered. The last one is of a different nature and results from lack of knowledge on the part of the MD not the therapist.

Look at the remaining reasons. Doing something solely because it is billable raises an ethical question I'd just as soon avoid. The rest are easily rebukes. There are other ways to make a patient feel something has been done. Some continuing education on the subject can correct a knowledge deficit. If a treatment is done only because a non-licensed tech can perform it indicates to me little thought went into the POC. That's similar to everyone with this diagnosis gets the treatment, so this patient should too. None of these are valid reasons for using a modality.

I don't know one therapist who would answer yes to the question. My gut reaction is no. My thought out reaction is no, but we need to be more responsible in how modalities are used. Use of modalities should be individualized and based on diagnosis and expected outcome and not a generalized treatment. If therapists as a whole rein in overuse of modalities the question becomes moot. It will no longer be a problem.

The Right to Decide

Toni Patt — Tue, 17 Jun 2008 11:52:00 GMT

In the May 2008 issue of GeriNotes, William H. Staples PT, DPT, GCS tackles the topic of informed consent and cognitively impaired individuals. Mr. Staples talks about the importance of determining if a patient is capable of giving informed consent. He approaches his topic from the ethics of asking someone-who doesn't have the ability to make decisions-to consent to something. Included in the article is a list of tools that can be used to determine decision making capability.

This made me stop and think. If I were to follow Mr. Staples' recommendations I would first need to determine the patient's ability to give informed consent. If that isn't possible, I would then need to contact the individual with medical decision making power to obtain consent. Mr. Staples makes a good point but doesn't address what therapists face in the real world.

I currently am working at an acute care hospital. The majority of my patients are elderly so I expect some of them to have dementia. As in all facilities there is pressure for PTs to see patients ASAP and continue to follow them. Physicians, a group not known for being patient, want their patients seen now and aren't happy about delays. Mobilization gets patients better faster as well as helps to prevent unnecessary complications. If I take a day or two to obtain consent, I'm going to have some angry physicians to answer to.

I'm not saying we should force a patient to participate against his will. If someone is agreeable to therapy I don't see a problem with taking that as consent. All the facilities I'm familiar with have patients or a representative sign a "consent to treat" form. That covers all treatments ordered by a physician. I can't imagine any therapist forcing someone to do therapy that doesn't want to do so.

Admission to a hospital or nursing facility comes with an unspoken acknowledgement that treatment is needed and puts the reasonability to provide the treatment on the facility. Informed consent becomes more meaningful when considering outpatient and home health settings where the tacit acknowledgement for care that comes with admission doesn't exist. These are patients that require an explanation of what is planned. The assumption that care needs to be provided isn't there. Nor, are the diagnostics as clear.

I'm a therapist. When I work with patients I explain what I am and why am I there. For the most part patients agree to participate with therapy. For those who are unable to indicate a decision, I have a consent to treat form giving me permission. If someone says no, I move on. This is going to grow in significance as the role of the PT changes. Therapists are going to find themselves facing issues they previously never considered. Therapists are also going to have to find the answers.

My Cat Died

Toni Patt — Tue, 15 Apr 2008 17:59:00 GMT

My cat died last night. He was old. He lived a full kitty life. He died last night in my lap and I gently petted him. I could have taken him to the vet but all that would have happened is he would have been put to sleep. I couldn't do that to him. He died at home in familiar surroundings, not in a cold, unfamiliar vet clinic. As soon as I picked him up I felt him curl up and relax. It probably took less than 15 minutes.

That is how my cat died: at home and in peace. It's sad that we don't give our elders the same consideration. Many will die in the hospital either alone or with strangers. It won't always be peaceful. It probably isn't how the person wanted it to happen. Once an elderly person enters the medical system our society doesn't allow for much choice in how one dies. As soon as someone is admitted to the hospital, the focus is on keeping him alive at all costs. Many years ago my grandmother died in a hospital. She had a massive stroke. She went to the hospital. They didn't hook her up to anything. Instead she passed quietly in her bed. That could never happen today.

Living wills aren't a guarantee. If a family member says so, health professionals will ignore it. I've seen this happen several times. Family members have told me their parent didn't want to be kept alive but they can't let go. Even if a patient can voice an opinion on how things should proceed it will be ignored. I can't count the number of times I've gone to see a patient only to be told to go away. These patients have made a decision about their care. They don't want any. They want to be left in peace. I'm not advocating letting people just lay in bed. I am saying that some of those patients have made decisions about how they want things to end.

Being a PT in a SNF is a challenge. The mechanism by which a SNF makes money is based on the amount of care a patient receives. The more care provided to the patient, the greater the amount of money received. Amount of care is measured by the total number of minutes the patient receives care. So a SNF wants everyone to receive as much care as possible.

This weekend I worked in a SNF. I had a patient refuse. I was supposed to see him for 35 minutes. He told me he didn't want to do therapy. He knew he was dying and just wanted to be left alone in bed. I was caught in the middle. On one hand I'm supposed to provide 35 minutes of care but doing so meant encouraging him to do something he didn't want to do. ICUs are another place where this happens. Doctors want their patient s up no matter what. Sometimes it seems the therapy is worse than the disease.

I don't have an answer for this. Sooner or later we will all meet a patient like that gentleman. I have two ICU patients right now that fit that bill. One is a 77 year old new quad from an MVA. Assuming she survives what kind of life will she have? She is A and O X 3. I wonder if anyone has asked her what she would like to have done.

The other one is a 15 year old with severe anoxic brain injury. The chart said he was without oxygen at least 10 minutes. I can work with him. Maybe I can make him a little better. Better is a relative term. Better than what? He is high risk for just about every complication a patient can develop. I'm not sure how much help I'm really providing.

Ultimately these decisions fall to the physicians. When my time comes I want to go quietly surrounded by things I care about. I hope there is someone around to watch over me, like I did for my cat, to make sure it can happen.

Who is Responsible?

Toni Patt — Wed, 26 Mar 2008 18:55:00 GMT

Like most therapists, I'm a veteran of interdisciplinary turf battles. Usually the problem is PT and nursing going around over getting a patient out of bed. Sometimes it's about whether out of bed to chair is a PT or a nursing order. This time was a little different. The conflict arose over a VAC. I'm starting to really dislike those things. Night shift had taken the VAC off over night because it wasn't working. I was leery to put it back on because the location made getting a good seal difficult. The patient's nurse was angry at me. She told me she wasn't going to be responsible for the VAC not being on the patient.

I still don't understand why she was upset. At that facility, PT is responsible for all wound care including VACs. If I didn't put the VAC back on, I would write a note and document what I did and why I did it. At the same time, I would have applied an appropriate dressing to promote wound healing. Other than letting me know the VAC was off, nursing had nothing to do with this. The issue here wasn't the VAC. It was the nurse not wanting to be blamed for something that didn't happen. She wasn't concerned that the patient might not have received wound care. She was concerned that she would be blamed. I'm not a nurse, but I don't think that's the best philosophy for patient care.

Responsibility or as in this case, blame avoidance, is an ongoing point of contention. Disciplines are concerned only with their specific area of care. Frequently, the issue isn't that something was or wasn't done. Instead, the issue is who is to blame.

Tunnel vision isn't limited to departments. We do this within the rehab arena. I wonder how many PTs fully assess the arms of a patient who receives both PT and OT because OT "does the arms." I've been guilty at times. One problem with this is using the arms to help with gait and mobility. How can I assess accurate goals if I don't know how much the patient can use his arms? You can't walk on a walker if you can't support yourself with your arms. It's a minor example, because most PTs will figure this out very quickly. On a much larger scale, such as when rehab and nursing are butting heads, the problem is much more significant.

A friend of mine is working on her PhD in nursing. Her area of concentration is process improvement through improved team work. She puts nursing and medical students together and simulates a patient care situation, then observes the results. So far her research has shown better outcomes result when everyone works together. That shouldn't be a surprise. What is less obvious is that individuals are reluctant to accept responsibility for making a mistake. She has had to show the video tapes to individuals to prove her observation. That is a little frightening.

Everyone gets sucked into the blame game. Rehab and nursing will forever argue over whose responsibility it is to get patients out of bed. No one will ever agree on who should be responsible for cleaning a dirty patient. But we must remember the big picture which is taking care of the patient. My VAC patient received appropriate treatment. PT and OT work together to mobilize patients regardless of what body parts are involved. As long as we keep that in mind, we won't sink to the level of these two doctors: Neither one wanted to be the one to pronounce a patient. While the they argued, the expired patient was lying in a room waiting for someone to take responsibility so he could officially be pronounced dead and taken to the morgue.

Vision 2020

Toni Patt — Mon, 26 Nov 2007 14:29:00 GMT

In his 11/07/07 blog Brian Ferrie discusses Preview 2020. Preview 2020 is a statement of where the profession is expected to be in 2020. In his blog, Brian asked for opinions about the vision. I have an opinion. It may not be popular. I think someone needs a reality check. I like the idea. I can't buy into it. Nor do I understand what information was used to develop this vision. I would like to have some other issues addressed.

First, I would like to know who was questioned to reach this conclusion. I don't think it was many of us in the trenches providing therapy. My day is a struggle to provide the best care possible, meet insurance requirements while completing my documentation all without running into overtime. I, like most therapists, don't have time for anything else. One problem I see is the amount of education that will be required. The DPT has increased the amount of education to become a therapist. As costs continue to increase, the price becomes prohibitive. Current therapists may feel pressured to pursue the advanced degree. Yes, there are many online programs but at a cost of upwards of $30,000. That's a lot of money if you're barely making ends meet.

Second, our health care system needs a major overhaul. Social Security may not exist by the time I reach retirement age. Baby boomers are beginning to reach retirement age. We haven't begun to feel the effect of that many people entering the health care system creating a need that didn't exist previously. I would rather have emphasis placed on solving this problem. Meanwhile commercial insurances cut reimbursements and limit what they will cover. While practice without referral exists, most insurance companies still want a doctor's prescription before they will pay. That has to be resolved for Vision 2020 to happen. Medicare has recently said it will no longer pay for nosocomial wounds. That means everyone else will as co-payments and deductibles rise further.

Third, I want to know where we're going to get the therapists to treat all the people who will be needing services. Increasing the required schooling may cause individuals to become PTAs or look at other occupations in the therapy world. At the same time, experienced therapists, such as myself, are beginning to reach a glass ceiling. Job descriptions are starting to list a master's degree as a requirement. Some of these therapists are going to leave the work force. Some of us are going to try to stick it out. Eventually it won't be an issue as we'll all have retired. That won't happen in 13 years though.

Finally, I want to know who decided this was in the best interest of physical therapy. I want to know who sat down and said Vision 2020 is better. How was that judgment made? What criteria were used? In Vision 2020 we're moving toward a different model of providing health care. To me it resembles how physicians practice medicine now. Those same physicians are moving away from that model either by limiting the hospitals they admit to or relying on hospitalists to care for their patients. So I'm asking, how is this better? How is a patient going to receive BID treatment if the therapist isn't based at the hospital? How is someone in ICU going to receive treatment if the therapist is only available once a day but that's when something else is going on? I don't see how this is better patient care.

I think therapy will change. It will probably move in this direction. Reaching our Vision will depend on many other things happening first. Change doesn't happen quickly. Vision 2020 may be too optimistic. There will need to be payer sources and enough therapists. True practice without referral will need to exist. The education questions must be answered. Right now I think we need to focus on immediate challenges and move ahead when we're prepared.

The Memo

Toni Patt — Mon, 12 Nov 2007 18:57:00 GMT

I received a memo recently that reviewed guidelines for documentation on Medicare patients. It told us what to write to prevent denials. Anyone who has ever treated a Medicare patient is familiar with the word games we play with documentation. Medicare has its own language. Therapists have to learn the language and then learn how to use it. One wrong word or phrase and everything will be denied. All therapists were instructed to immediately alter how we document to fit the guidelines.

That part didn't bother me. It's what came next. We were also instructed to continue seeing only those chronic patients with a clear status change. That sounds like we're supposed to discharge the other Medicare patients as soon as possible. Many patients on Medicare are referred for therapy due to deterioration in functional status which usually develops over time from inactivity and worsening medical conditions. Unless they fall or require a hospitalization there isn't a clear cut onset date or event. These are the patients who are to be discharged.

Ranting against Medicare won't change anything. The APTA is fighting the reimbursement battle with them. Ranting against the facility won't help, either. Administration won't listen. Medicare didn't tell us to discharge these patients. Our administration made that decision. They looked at the bottom line and saw revenue loss from denied payments. They decided to do something about it. This is an extreme knee jerk response. Patients are costing them money so they must be discharged. While this may be good business sense, it isn't good for the patients.

This is scary. Patients are being denied care based on the assumption of non-payment. Taken to the extreme it could lead to no one accepting Medicare patients because they are afraid of not being paid or not paid enough. This has been happening with physicians for years. Therapists have been playing word games with Medicare for years to get payment for these patients. Medicare didn't change anything. My facility decided it was losing too much money and investigated. The memo is the result.

There are other options. Referral sources can be educated about correct language when making a referral. Therapists can be trained in Medicare documentation. A system can be put in place to monitor these patients and keep their treatment duration as short as possible. The problem is these solutions will take time to make an effect.

Now Hear This

Toni Patt — Fri, 02 Nov 2007 12:55:00 GMT

I've been a therapist for many years having graduated in the 1980s. I've seen things change. Trends have come and gone. In many cases what we do now didn't exist then. I've seen my profession grow to a major component in modern health care. I've seen good therapists, bad therapists and a few I'd call exceptional. But only recently have I seen this. Therapists who've stopped caring about what they do.

What has happened? When did we place money over providing care? When did we start choosing continuing educations courses because they were cheap and easy rather than to learn something? Why is it acceptable to pass off challenging, time consuming patients for the quick and easy ones? ( I'll have more to say on this one later.) When did hot pack, ultrasound and massage take the place of good old hands on? Certainly some blame lies squarely at the feet of the payment sources. More blame lies on health care facilities who value numbers over quality. Ultimately it is the individual therapist who makes these decisions not Medicare, administration or any other outside force.

This isn't everyone. There are so many good people out there who would do anything for a patient. But there are those who don't care. Or, maybe they just don't know any better. Ignorance is not an excuse. The ones who suffer are the same ones who depend upon us the most, our patients. If we're not going to help them, who will? Everyone takes the occasional cheap course or cuts a few corners. One of the buzz words for this phenomenon is disengagement. I have a few different ones: burned out, exhausted, fed up and indifferent. For those of you falling into option number four, I have a message. Get it together or get out. And please, take those therapists who only know one way of doing things and don't want to know another with you.