Now for the difficult part.  I work with a PT who is constantly behind on paperwork.  That is not unusual; we all get behind at times and then we catch up eventually. Well, this PT has not caught up for a long time and it affects patient care. 

For example, a patient has met their goals and I communicate to the PT that the patient needs a reassessment and an update on the goals if they are to continue.  The PT does the reassessment but does not update any goals.  There is no verbal feedback as to what we are going to continue with the next day when the patient is on my list.  So I ask. 

I was met with confusion on the PT's part.  It was as if I asked her in a foreign language.  I simply want to know which direction she would like the patient to go in.  I honestly think she didn't have a clue as to what to do.  So she said she would take the patient.

Two weeks go by and goals are finally written after she had a discussion with our district manager.  If she would ask me I could have suggested several goals that the patient needs to work on.  But then again should I have to tell a PT with 20 plus years experience what to do?       

I think there is a problem.  The PT may not see it as one but if there is failure to communicate and a patient is on my list I would like to know what the intentions of the PT are before I proceed with therapy.  If I continue to get the nonverbal confused look feedback I have been getting it might be time for one of us to leave. 

Then Father's Day comes and my wife reminds me I have been a father for 14 years.  It became a time for reflection as I expressed my joy at the handmade cards that the three of them made for me.  And then I drift again, has it really been 14 years? Wow!

So once again I sit here and think, I should make an appointment?  But the more I think of it, I haven't made an appointment in years.  My wife makes all the appointments for us and keeps track of them on a calendar.  I don't even know the number to the clinic, let alone find it by myself (my wife usually comes to the appointments with me).

So, even though I express the need for men to be men, we couldn't do it without our other half to help us along the way. 

I hope all the Father's had a great time; I personally relaxed on the couch and watched T.V. all day.  I guess that's not the best way to end Men's Health Month.

I recently read Gloria Allred's book "Fight Back and Win."  I think if she took on the health care industry there would be a lot of people sweating under her scrutiny. 

I bring this up because the definition of "skilled" therapy seems skewed at times.  I have seen questionable services provided by therapists that could be given to the restorative nurses or the therapy aide. I guess it depends on the therapist and what is being provided. 

I refused to see a patient because I didn't think the service was skilled enough and there were other patients who required my time and would benefit more from the services I am able to provide. Was this the right thing to do?

Should I be the one deciding who gets seen and who doesn't? Maybe I should report the questionable services to the fraud department and let them sort it out. But we should all know when a patient has reached their max potential in the environment they are in. If we don't then we should ask another person and get feedback on whether what we are providing is skilled and can only be provided by a PT or PTA. 

Sometimes I wish lawyers would haul us into court and review our notes more often.  Insurance companies should question every bill they receive from us and ask for more supportive documents, if needed, that justify our services. I realize they already review cases and justification letters are written if requested. 

I certainly question every bill I receive from hospitals and clinics I go to. They may make an error (intentional or not).  I request all medical notes as well to ensure proper follow up is done and if it is not I ask why.  If I pay for a service I want to ensure I get my money's worth.      

If I do get hauled into court I am hiring Gerry Spence. I could sit back and relax a bit since he has never lost a jury trial since 1969.  (I have read most of his books as well.)

So what do I do?  I pivot the patient using techniques that I learned from the years I have been doing this.  Is it safe? Always.  I would never intentionally jeopardize a patients safety.

If I can do it using transfer techniques that will get a patient up and moving faster then I would expect the same from others that see the patient for therapy.  This is the problem.  Not everyone can do a pivot transfer safely. 

Am I given these patients to see because I am able to effectively get them up and moving and I don't need a nurse to assist me or devices to get a patient up?  Are my techniques better than the PT's with transfers, or is it that I am stronger?

I recognize that some therapists and assistants are lazy and do not want to put in the full effort to get people up and moving.  They would rather see a patient in bed for supine leg exercises or after nursing has transferred them (via Hoyer lift) they will have a patient do sitting LE exercises. 

It is easier for me to take on those patients because I know they will get transferred to and from a plinth and if all goes well they will stand using a FWW within a week.  I would hope most PT's and PTA's would not "cheat" a patient out of therapy by doing simple treatments an aide can do.  I figure if I can transfer a 300+ pound person from supine to sit at the edge of bed and then pivot that person into a wheelchair every other therapist should be able to do that as well. 

Is this a superhero complex? No I just want the patient to succeed and if one person is not capable of doing it then step aside and let another take the place.

I've had men weep in front of me while talking about World War II.  These were men who trudged up hill while bullets kicked up dirt all around them.  These are true heroes who have the scars of battle which I will know nothing of, although I try.

I listen to their history of pulling comrades to safety, patching up wounds in the midst of battle, and freezing in foxholes in Bastogne.  These are warriors in the truest sense. 

Because some have wept in front of me are they less of a man?  No, they have shown me true emotions of a human, yet they emerged as something greater than I will ever know.

I listen close when they have spoken about their triumphs and their failures about being a guy.  I listen closer as they express fear of death and fears of the unknown in their current situation while in the therapy gym.  But haven't they faced that before running uphill towards gun fire?

The men I see for therapy are fun to be around, and with the right combination of guys in the room it is riotous.  Men who were quiet a week before will suddenly surprise me with a wisecrack that will have the room rolling.  I try to get the men engaged in their therapy as soon as I see them and will try to connect in some way with them.

Since my father was in the military, we had an opportunity to travel around the United States and to many countries in Europe.  And with my own travels I have many stories that I can relate with them. Sometimes this is not enough and I will have to sit down at their bedside and shoot the breeze for a while about Mustangs (my brother had a '66 we use to fix up), children, wives, and why the medical establishment is the way it is.

This helps them and it helps me to get to know the men who have helped shape this great country of ours.         

There was one gentleman who was initially hesitant to speak but once he began to talk he dominated the conversation, only allowing interruptions to clarify a point.  After lunch, myself and some of the other guys smoked cigars. 

My son and I went in search of one gentleman who sometimes will speak openly about his war experiences in the South Pacific.  He told several stories about his unit and after describing a battle he stated, "I lost my best friend that day."  He paused for a long time and added, "I don't want to talk about that anymore."   He was teary-eyed throughout most of our private talk together and within minutes he was describing his hat that he paid so little for but kept his head warm all year round.  It was a great distracter.

Unfortunately, many of these private stories are being lost or not told to others. That man was part of history that people tend to forget. Does it mean as much to him who has experienced it as it does to those who collect it?

OK, I can hear it now: I am a health provider and how dare I smoke a cigar with my son present. What message am I sending everyone?

I have eaten vegetables, meat, potato chips, drank soda and water in front of my son and hardly anyone will bat an eye, yet if I sit around a table with the guys and smoke a cigar some will question why I would do that. 

I do it because I am a man and that is exactly what I want my son to become.

Are they surprised that a father is taking an active role in their child's health and asking pertinent questions that relate to medication changes and is able to "talk the talk" when it comes to health related issues.

How many times have I done this when discussing a child's progress or an adult patient's mobility?  I try not to.  I will try to engage dad into a conversation when discussing the child and I certainly want to include the male patient into the conversation when talking to his wife. 

Maybe it has to do with the way information is processed by dads.  When I first found out about our daughters epilepsy I was standing outside of the Spa Casino in Palm Springs.  I just finished lunch with co-workers and called my wife.   My wife was emotional at the news and it took some coaxing to get all the information out of her.  I felt numb and was quiet for the rest of the day until I could research it and digest it all and what it would mean for the family as a whole.  

I didn't unload any of what I felt to those I worked with or those I knew.  I kept it inside and read a lot about the diagnosis.  I was organizing the information into how it can fit into my already hectic life and tried a way, any way, that I could change it or fix it to make it better for all of us.

Years go by and reality is what it is, I can't change it. 

My dad was the go to guy when a big project needed fixing like a bike or a car.  Mom handled all of the other stuff.  The boo boos, the holding and hugging requirements that are needed when growing up.

I want to change that.  I want to handle the big stuff like my dad did and the other stuff too.  I don't want my children to only go to mom when they skin their knee.  I enjoy being the one they ask for first.  I am taking an active role in their health care but some providers make this difficult when they address all their comments to mom. 

Imagine if you never had a thorn in your side asking questions trying to absorb and understand where you (the PTs) are coming from.  Some of you could. 

I am trying to be a better therapist and with that comes questions; lots of them.  If I question a therapist about progressing a patient, am I criticizing them or just being curious?  People have told me to keep communication open between the PTs and the PTAs and it is difficult if I get shut out and shot down with my questions and concerns about the patients. 

Years ago I felt burnt out, frustrated and my work performance significantly decreased.  Then I met someone who asked me simple enough questions that allowed me to explore and change the way I thought about my career.

1) Are you happy where you are now?

This is straight forward and it is not about the people I work with nor about the job itself.  It encompasses everything about your life: marriage, children, commuting to work, everything.  I answered "No" and took a three-month vacation with my wife and children.  When I returned I was rejuvenated and excited about my job again.

2) Why are you still doing this?

Great question.  Is it about money, fame, the older ladies I meet? No, none of that.  I want to help other people. 

3) What can I do to help?

This was probably the best question that was asked of me.  I couldn't answer it immediately.

So how did I translate that into performing better and trying to get others to perform at that same level?

I answered question number three.

Over the years I have learned simple techniques that drastically improve patient care and have tried to pass that knowledge on to others who will listen and actively watch. Some PTs and PTAs do not want to be "taught" anything by me and that is fine, but it seems a disservice to the patient.

What I usually observe is that the therapist will try to copy techniques and treatments rather than ask me why I chose that particular one for a patient.  As with anyone who works, I find new ways to perform an activity to increase the challenge to my patients.   

One PT continued to have a patient perform seated LE exercises after a TKA (no weight bearing restrictions with this patient) and limited stretching until I came on the scene. This was about three weeks post op.

Not that I am the most knowledgeable with TKAs, but I realize how valuable increased mobility is with some patients.  So she was given HEPs and began standing LE exercises with a progressive stretching program.  A week later, cadence improved as did her perception of therapy.  She had never been challenged until I asked her to perform.

My first question is why was the patient still doing seated LE exercises with a PT when they should know increased mobility will increase the patients function?  Should I ask the PT why they didn't progress and challenge the patient when she was capable of it?

When a PTA is progressing patients and getting positive results how do you think the PT feels?  Or should it really matter because the bottom line is that the patient is getting better?  Do you think some PTs get jealous if the PTA is better at a skill set than them?

Let me know what you have observed.

But what about PD and dementia-related diseases that are slowly progressive in attacking the brain?  If insurance companies hesitate to approve physical therapy in hospice care, how do they justify approving care with other diseases that are just as debilitating in nature?

In six months, a person with dementia can go from stand by assist to max assist and insurance companies will continue to approve therapy car. Yet someone with metastatic bone cancer has a potential to go from moderate assist to CGA in less than six months, but insurance may not approve treatment. Why?

In acute care, therapy is provided but it is limited until the next level of care for that patient. In order for a patient to continue to progress, they will need therapy but hospice and insurance companies often have their own agenda for what the patient will need.  It seems once a patient is on hospice they are forgotten and are expected to die, yet I have seen patients go on and off hospice for a year or more and PT will pick them up every time they are off hospice.  It would seem easier to keep the patient on hospice and still provide therapy services as needed for transfers, stretching, and patient and caregiver education. 

It surprises me that insurance companies will pay for pediatric care for some of the patients that are too slow to progress over a school year and there are pediatric brain impairments that are progressive in nature, yet they continue to receive treatment from therapy until the child is 21.

Why do we continue to allow insurance companies to dictate who we see and why?  If a therapist sees a need to intervene and can justify services, shouldn't that be enough for an insurance company? Or are we puppets in an insurance company's play? How long will we continue to dance?

Since we, as PTAs, want our voices heard by any developing (internet) bridge programs and the APTA we should do something about it. 

My proposal is to have a day at work without a PTA.  Imagine the collective voice (kind of like the Borg on Star Trek) and the impact on care provided to clinics and hospitals everywhere.  There are those who don't respect what we do so let's show them that they need us to provide services that the PTs can't because there aren't enough of them. 

Do you think we really have such a large number of PTAs that are dissatisfied with the lack of bridge programs and are not happy with the APTA?

If I hear from enough of you PTAs let's do it.  And if only a handful respond, please, no more complaining.

I was initially told this was covered by my CEU money, and later told it was not.

Then I thought, why wouldn't it be? It could turn into a great marketing tool for the company and the facility by advertising that we can instruct family and private providers with first aid and CPR for free if they want it. Is that kind of marketing too innovative? 

I guess nobody wanted to foot the bill for that one. But they will pay for yet another balance and the elderly class. If I wanted to take that, I would have picked it.

I told them since no one wants to cover the cost of the course, not to advertise that we have staff who can provide BLS instruction. Maybe that's a bit harsh, but I can advertise on my own. (I could probably find another therapy company that would pay for the course too.)

The administrator may come to the rescue and provide the financial backing for the instructor course. We'll see; I will keep you updated.

I still need to buy the equipment, which is not a big deal since I will be instructing people how to save someone's life. I even interviewed my wife to become my secretary in case I get busy doing the CPR classes.  I told her to give me a call back in two weeks and I would let her know if she was hired!

After close to 20 years, May retired from the field. "It felt right," he says. He has written extensively about fathers with children who have special needs and received the Duncan Award last year for his dedication to children who have disabilities.

Greg Schell, director of the Washington State Fathers Network and co-founder of The Fathers Network, reports "We have an ongoing newsletter, a new 13-minute video for Spanish-speaking fathers whose children have a disability and continue to search for funding through state, federal and private donations," when asked what was new.     

Schell spent 15 years as an elementary school principal and noted that fathers and families need information that is relevant and timely. "One place we direct people to is www.wrightslaw.com, which provides families with a manual when dealing with IEPs and a difficult school district."

"We have a public health nursing network which helps identify those who are in need of services, and church groups can also help identify families who need assistance. What happens is that some fathers will hand off the childhood duties to their wife, but once they realize there are other fathers who are involved in the care of their children they are relieved and the overwhelming feelings can be dealt with through individual counseling.  We want to address the issues but not go too fast or too slow with them."

Visit www.fathersnetwork.org for more information.

If a patient needs an assessment on blood pressure, oxygen saturation, pulse rate, respirations, etc., therapists often divert to nurses.  WHY?

The therapy community is trying hard for direct access, yet will consult a nurse if a patient needs their blood pressure taken.  I say do the assessment yourself and continue to show what our profession is made of. 

Tasks such as changing an oxygen tank take less than one minute, yet I have seen PTs and PTAs ask nursing assistants to get a new tank.  The nursing staff is just as busy as us and if we are constantly relying on them so we can continue our duties of care, we are doing the patients and our profession a disservice.

In our continuum of care, the patient comes first.  If this is true, we should strive to learn a new skill and revive old ones that directly impact a patient.  Everyone in health care should know how to take vital signs and ask about pain.  Taking a patient to the bathroom is a concern for a lot of therapists, yet is it unreasonable to ask a patient to walk 10 feet and sit down?  A pull of the call light will direct nursing staff in the right direction and then walk the patient back to their chair for 10 feet and sit down again.  Co-treating with the OT staff may make this easier in that it becomes a more functional activity for the patient.

And remember, everyone within ear shot will know you are not a nurse and I am sure everyone will realize you are a therapist when you don't know how to take vital signs and change an oxygen tank.   

Schell is the director of the Washington State Fathers Network and co-founder of The Fathers Network. He provides a starting point for fathers who need direction about their child's needs. 

"There are many concerns that the fathers have, but one of the biggest is whether they are able to address the issues that will arise when dealing with a child with special needs," Schell said.   

He went on to say, "Some dads get overwhelmed and we work on the health of the family. We have programs that incorporate siblings, grandparents, and an 8-week course called ‘Unexpected Journey' for couples to attend."

May spent 18 years with fathers whose children have special needs. The focus was a men's group to help fathers cope and understand their own complications when dealing with a child who has special needs. 

"Humor is part of the process," May said, "It can take the pressure off and most guys can relate to some of the situations about a child that is funny."

When asked about a shift in the expectations the fathers have of their child, May said, "Hopes and dreams are built off of expectations. Most men feel crushed for a while as the future they planned for their child seems dashed. Working with other men helps men redefine their values and plans for their children. They also learn to become a different man, husband and father-probably more likable than the one that existed before. This is extremely exciting to see. It takes time and insight."

I will continue with their journey in the coming weeks.

Greg Schell and James May can be reached by calling 425-653-4286 or visiting http://www.fathersnetwork.org/