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PTA Blog Talk

Missed Patient Visits
by Jason Marketti

Typically patients are scheduled for 6-7 days a week for therapy based on the need of the patient. If a caseload increases, there are only so many hours in a day (although we have until midnight to get the minutes) and patients are only willing to work up to a certain time in the evening. A therapist could easily work 10 hours a day and still not accomplish everything he wanted.

At some point, patients will not be seen for their therapy. Doctor appointments, family visits outside of the facility or sudden medical problems can cause patients to miss therapy. Who is responsible to ensure the patients get the prescribed treatment when they are gone for 6-8 hours of the day? Is there a designated person who stays late to make sure those patients are seen, or are they written off as a missed visit?

Essentially it is the PT's responsibility to ensure that patients receive their therapy. Some may argue that it's a shared responsibility, but it isn't. I have no patients I'm responsible for under my license. I practice under the PT's license and the PTs alone are responsible for every treatment.

When patients are sent to the hospital in the early morning for further testing to rule out a more serious problem and return to the facility at 9 p.m., who should see the patient? If the patient is in the facility for rehabilitation 7 days a week, why wouldn't he be seen when he returns late in the evening? Is it because it's an inconvenience to stay late to provide services to patients? Perhaps we're in the wrong business if we cannot accommodate patients.

Patients who leave for several hours are often fatigued upon return, but they are in the facility for therapy and we should be providing that service. If we're unable to provide therapy to patients, then why are they on the caseload? It's not the patient's fault he was sent to the hospital or the caseload is too high and there are very few therapists able to provide services. And this falls to the PT, who is ultimately responsible for all therapy treatments that are and are not provided.

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Adapting and Accepting
by Jason Marketti

Patients and family are often looking for a cure and return back to how they were before serious illness caused them to come to rehab. Some are resistant to using adaptive equipment or learning to self-propel a wheelchair because they don't want to adapt to a new lifestyle. Few of us do.

Some know I have children with disabilities. I know there are certain milestones they will never reach and experiences they will never have. Their lives are managed through medication; there is no cure for what they have. That is part of acceptance and the sooner families recognize their loved one will never be the same, the easier it is to move on and figure out what to do next.

Being in the medical field and having access to materials that others don't made acceptance easier for me. With the availability of computers, there's no reason families shouldn't be able to look up diagnosis and treatment outcomes and figure out a plan. When families and patients understand that life can be managed and not cured, the focus can be more therapy-driven. When I see those types of patients, I know they have done their research and are willing to try everything available to attain the highest level of function and mobility.

A 90-year-old patient will not be the same after a CVA. Families have difficulty understanding this and some will get upset at the therapy department for not curing their loved one. We assist with mobility to get people back to their highest level of function, we instruct patients in adaptation techniques, and facilitate how to sequence for easier movements. We show them how to manage their lives after an event. If we were able to cure people, we would be working for someone else.

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New Therapy Treatments
by Jason Marketti

Working with patients to achieve goals for increased independence and a way to get back home is what I do. When patients want to deviate from their goals, I don't mind but often have to redirect their efforts so the short-term goals can be met. I will discuss a patient's progress weekly (or more frequently, depending on the patient and diagnosis) with the PT to ensure the patient is on track to what the expectations are.

When another PT comes in and changes a program or begins a modality that wasn't part of the initial evaluation or goals, I end up with a little dilemma. Do I follow the PT who was there for a day who decided to change a program or do I track down the evaluating PT for advice? Most of the time I'll find any PT available and ask what he would like done for the patient.

This isn't always fair to that PT because he may not know the patient or what warranted a change in the program. And not every PT will explain why he decided to expand or delete a particular aspect of treatment for a patient. Reading through the notes helps and I can often deduce why things were changed, but if the documentation isn't updated to explain why ultrasound was suddenly used, I have nothing to justify my use of it.

Perhaps the PT had an epiphany that ultrasound would reduce pain and free up a joint from adhesions, but without a clear CPT code to document the treatment and without a clear indication the treatment should continue, I have a hard time following what someone else did. Most of the PTs and PTAs who come through a facility will do a "copycat treatment" from what was done before. It is the safer way and causes fewer problems and confusion, but it may not be the best treatment for the patient.

My suggestion is if a therapist comes to a facility and assesses a need for a new program or to trial a modality, it should be very clear in the notes as to the duration of the trial and a justification for its use. Placing a goal to adapt the new program is icing on the cake but may not be necessary for every patient. Talking directly to me also helps because then I have a professional responsibility to ensure the patient will receive the treatment desired by the PT.

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Treatments I Won't Perform
by Jason Marketti

A PT can come to the facility and decide not to follow any of the previous treatments or goals, and may decide to change many aspects of the treatment program. This isn't inherently wrong since the PT is responsible for the patients, but if the treatments include Kegel exercises where the expectation is for me to palpate regions I normally don't on patients, I won't do it.

For any modality or treatment that is used near the perineum, I will not only voice my objection to but refuse to perform. This is really no different than asking me to do some Tai Chi with a patient. I do not feel comfortable performing a treatment unless I have some formal professional training including CEUs. And there are some CEUs I simply don't intend to look for. I can also refer patients, families and other therapy staff to more qualified individuals who can perform tasks I'm not qualified to do or don't feel comfortable performing.

Some may say it is unprofessional to deny doing a treatment simply because I don't feel comfortable performing it. My statement to that is: I haven't been formally trained to perform that particular task or treatment and I feel I would not do an adequate job to justify its use. I could then quote some state regulations regarding a PTA's competence in relation to performing therapy treatments.

I've discussed sex with a patient and that person's partner after a surgery because the questions were appropriate and related to following hip precautions, but I certainly didn't follow up with any specifics. It isn't something I feel comfortable doing. I've performed wound care to the gluteus region on a patient and that was done with a family member in the room and a PT aide who assisted me. Plus, I was very interested in wound care and would have done it anywhere on a person's body to get the experience.

Today, trying to find an aide to assist me with any treatment is impossible; there are none. A CNA or other nursing personnel also aren't available to stand around while I perform any task with a patient. It would be good if I could convince another therapist to stand around while I perform a task, but a decrease in that therapist's productivity would result and companies don't like that. So, a polite refusal to comply with a treatment technique I'm not qualified to perform is the best I can do.

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Believe the Premise
by Jason Marketti

If someone told us in 1769 there would be horseless carriages (automobiles), we may have laughed and dismissed that person as a lunatic. Would you have believed someone if he told you back in 1969 that linking four universities would eventually lead to the Internet? What about if a Star Trek fan told you 20 years ago that the use of replicators was real and long lists of reports could be put on a handheld device for easy reading?

If I told you I could heal someone with the power of Chi, would you believe me? Some claim there is no scientific or clinical evidence for alternative healing, and insurance companies call it experimental just like people did with automobiles, computers and the Internet. I'm sure there were some skeptics years ago about the use of physical therapy to heal patients. If I showed you evidence regarding the ability to use energy to move things, could you believe the premise that it is possible to store up unseen energy and use it?

If you cannot believe it's possible, then why do some people spontaneously heal from devastating injuries or fully regain use of limbs after a severe CVA? Is it because the therapy was so great, the person was healed by some ROM and functional hand-over-hand tasks? Or did some young hotshot doctor give the right medication at the right time? Maybe someone laid hands on that person and prayed over him when the therapy department wasn't looking.

Some will denounce the power of prayer and its effectiveness, but because you do not believe, doesn't mean it won't work. Perhaps a Reiki master was called in one night and provided care that PT services weren't able to provide, or a massage therapist was asked to provide care and it was enough to cause healing that's unexplainable.

Some things are not easy to understand and even if they were, there would be professionals in our field of practice that would refuse to believe.

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My New Job
by Jason Marketti

I recently changed from one employer to the next. I still work at the same facility but rather than working for a contract company, I work as an "in-house" therapist. There was no real change in the caseload or patients I see, so the transition was relatively flawless in that regard. The other big advantage I wish other employers would do as well is that I didn't have a waiting period for medical, dental or vision.

One company I interviewed with required a 90-day waiting period for any benefits to begin. With my children's medical history I was hesitant to accept the position. As I thought more about health benefits, I wondered why I would have had to wait 90 days before I could use any of them. There was no valid reasoning behind this since I had insurance for about 4 years with my old company. Although that was ultimately not the deciding factor for me to work with them, it did play a part in the decision-making process.

Maybe other employers will take note and waive any waiting period for benefits to begin. A lot can happen in 90 days and it would be better for employers to take care of their therapists immediately rather than have them take time off work due to illness or other medically related issues. And taking care of therapists should include family members, if they're looking for any long-term commitment for us to stay at one place.

As I get older, I look more at benefits and other related perks than salary. Yes, I need to pay for food and housing, but it isn't a large factor when deciding on a change in jobs. I would rather have time off when I need it more than anything else. My household expenses are fairly low but this of course is offset by the high medical and health-related costs of having children with any disability.

The key factor is having healthcare immediately upon hire. This should be a given since we're in a health-related occupation and should be taking care of ourselves and immediate family members without concern, so we can concentrate on getting our patients better.

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Patients Who Give Up
by Jason Marketti

At what point do patients give up doing things for themselves? I've seen patients sit still while their spouse dresses them and combs their hair. One even admitted she brushes the other's teeth for him. I completely understand if the other person was incapable of assisting or was incapacitated in some way, but these are grown adults with functional limbs and they're aware enough to allow this to go on.

Some assistance is expected because the spouse wants to help, but certain activity is beyond normal assistance. I've assisted patients with buttons because of dexterity issues and tied my fair share of shoes because of ROM and pain issues. I also educate patients on the benefits of other clothes for ease of donning and doffing and mobility. Some follow through, others consistently wear the hardest clothes to button and most difficult shoes to put on and walk in.

At some point between illness and recovery, some patients will stop doing normal everyday activity because they know it will be done for them. If there's an appointment, the CNAs will bathe, shave and dress them, their spouse will finalize combing of the hair on the way into the MD's office and the patients won't have to say a word because it's often the spouse who will speak up and answer questions.

I've educated patients who have come in for pneumonia regarding the risks of staying in bed versus getting up and moving. Inevitably the patients will end up in bed more hours than out. When I see them eating in bed, I give them my speech about what they would do at home and whether they would eat in bed. When spouses speak up and say they would serve the patients breakfast, lunch and dinner in bed, I know I should keep walking down the hall to the next room.

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How Much Do I Make?
by Jason Marketti

Pay scales are all over the chart in the therapy profession, yet reimbursements in most states are the same whether a PT or PTA (and sometimes an aide) treats the patient. So, should the PT still make more than the PTA?

The argument over the higher education does not seem significant when there are PTAs with master's degrees working under a BSPT, as I have done in the past. And if education is the reason to get paid more, the DPTs should make significantly more than a BSPT. Years of experience may have some sway, but just because somebody has been in the therapy profession for 20-plus years doesn't make that person an expert or good at what he does.

What about certificates and CEUs? These are essentially worthless because they don't increase our reimbursement rates. Even nationally recognized specialization will not increase what the insurance company reimburses for a therapist's expertise and years of training. As a personal goal, they are fine. But speaking strictly business, a PT with the certification will not be reimbursed any more than a new grad PTA. You do the math on this one for companies to stay afloat.

Of course someone will make the argument that a PTA won't know what to do with a complex patient. And a new grad DPT will? There's no guarantee a PT will be better off treating than a PTA. I've known PTs who have injured more patients than me. Are they more incompetent than I am? Where was the extensive training they went through while their patient face-planted into the linoleum floor? Was the PT trained to keep a heat pack on the patient too long and cause a burn as well as forget patients in treatment rooms for over an hour? There is incompetence across the board with PTs and PTAs, let's leave it at that.

The discussion here is about pay scales and whether a PTA should make the same or even more than a PT. My question is why couldn't a PTA make more money than a PT? Perhaps the assistant saw more patients and brought in more money than the PT. Just because someone has different initials behind a name doesn't entitle that person to a higher pay scale when reimbursements are essentially equal.

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Future of Therapy
by Jason Marketti

With today's technology, there's no reason for therapists to sit and wait for equipment to be delivered through a third party. When every therapy department has a 3-D printer, we can receive a 3-D fax that will print up the equipment we ordered. Knee braces, walkers, extra parts for broken equipment, you name it and we'll have it.

X-rays will no longer have to be a specialty for someone to come into the facility. Scanners will provide an instant image and be sent to an MD for reading, which can immediately be sent to the primary PT's mobile device. The patient will not have to wait for the next appointment to see an MD or be rushed to the ER for them to tell us what we already suspect, a fractured radius from a fall. The patient can be wheeled right into an ortho clinic and have a cast or splint put on. Or, with further training perhaps PTs will be able to perform this complex procedure.

Since we're involved in wound care, how much more education or training would it take to do minor stitching on open wounds? Some paramedics are already doing it and prescribing medication through the new EMT-Rx program. Why aren't PTs? Surely a devout PT student should be able to comprehend what an EMT/paramedic can learn. Allowing therapy to involve themselves in this would reduce healthcare costs overall and ease the burden on the ER system.

The mobile devices used today in any setting are a potential stepping stone to where therapy should be. Patient diagnoses, goals, past notes, treatment suggestions, and even potential outcomes should be available on mobile devices used in a clinic. Interactions with medication should also be included for a thorough patient assessment. Perhaps Google Glasses will be required for us to enhance our patient interaction and understanding of complex medical issues related to patient care. Imagine if those glasses would allow us to "see" into patients to better understand their pain or illness.

A blending of a PA-C program and a DPT program should also be in the works to enhance the competitive edge and delivery of patient care in a progressive manner. Physician assistant programs can run another 2 years and when a student invests 6-8 years in the health profession already, another 2 years goes by quick. The PTA should also have the option, before graduating, to earn a nursing or other health-related degree.

No longer should patients have to see several providers to accomplish their health goal. It's a waste of resources for patients to travel to different clinics across town when they could come to one place to receive a physical assessment and medical treatment without seeking MD approval. If a chiropractor can take X-rays and perform PT-like treatment, why couldn't a PT clinic offer X-rays and limited prescription medication? We learn about drug interaction in school and there are courses we can take to enhance our knowledge about it now.

But maybe I'm looking too far ahead because this will all end up being road-blocked by administrative red tape. But one can imagine what therapy could be if left to design a program with the patients in mind.

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The Health Fringe
by Jason Marketti

Stay active, eat healthy, get plenty of sunshine and take colloidal silver. Okay, so don't take the silver, take something else, like, bitter cola. I think I could produce enough clinical evidence to promote either one though and patients would probably listen to me like I'm an authority on healthy living.

Isn't that part of what we do -- instruct patients on better lifestyle choices? And if I happen to have a fringe mentality on what exactly constitutes lifestyle choices, no one should judge me or my ideas. Would you tell a patient not to use a neti pot even though he has done so culturally for years? Would you have told George Burns not to smoke and drink? Think about it, he lived to be 100 years old.

When treating patients, we don't treat only the part that hurts, because of the interconnectivity of the body. If a patient has a TKA, I won't focus only on her knee but also gait cycle and sequencing, as well as hip strengthening, balance activity and safety with all aspects of transitional mobility. And in some instances, diet, nutrition and fluid intake, which is just as important as exercising and resting.

Healthy lifestyle choices vary in patient populations and we have to respect what some people consider healthy eating habits. Obviously we know potato chips and soda don't make a good breakfast, but cereals can often have high sugar content and some people don't like the consistency of oatmeal or their diet precludes its intake. Grainy bread is good but tell that to your patient who has dentures and the seeds get stuck between his gums and dental work.

For years I was told ice cream is a dessert, however, the high protein and calories can encourage weight gain in some residents. When mixing ice cream and a nutritional shake that tastes like chalk, it's a full meal and kind of good for someone who won't eat meat at meal time because it's hard to chew.

Being realistic with patients, whether it involves using an assistive device and exercises or offering commentary on healthy living, can go a long way. I've heard therapists berate patients when they consume a candy bar, but the therapists forget there are calories in that candy that the patients will need during their exhaustive 75-minute workout.

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Strictly Science-Based
by Jason Marketti
Stem cell research is not a new topic but can be controversial for some. Often it is the embryonic stem cells that get people upset, but there are other stem cells out there that research and biotech companies are looking into for healing and helping people recover from devastating illnesses.

As a purely scientific reading, stem cells are fascinating. You often have to put aside your personal and/or religious beliefs and read the information as if you are researching a topic from school. That, for some, is the hard part. For those who have difficulty with this, remember there were ecclesiastical authorities in the past who made decrees to ban surgery, a practice that's now routine and we actually know enough about to educate patients on. 

Total-joint replacements of hips and knees, titanium cages around the spine that allow people to get up and walk again with less pain and more mobility, it's like an Isaac Asimov sci-fi story. But it's real life and we treat those patients routinely so they can heal and recover from their surgery. Few people make a big deal about putting metal into a human body or electrodes when using a spinal cord stimulator and pacemaker, but mentioning the use of cells that can reproduce into other cells and, well, it becomes a political, moral and religious issue for some.    

Would it be any different if the patients you were treating received stem cells and could now walk or move easier or feel less pain because of the medical treatment? Could you be happy for them and cheer them on with their recovery? Would you still treat the patients even though they received medical treatment you personally or religiously cannot fathom? Remember, you have thoroughly studied the human body inside and out, some have touched a cadaver, and you know the regions of the brain and what part controls where. Wasn't this type of study considered barbaric at one time?

When doing research for any medical advances, we have to look at the information from a different point of view. A clinical mindset and an understanding of scientific data will help. Similarly, when treating patients who have different ideas from our own, we have to put aside those differences and work toward a common goal, to heal people and get them well. 

Some additional reading on human-induced pluripotent stem cells, bone marrow stem cells, and human spinal cord stem cells among others may help you understand what stems cells can do for patients and us, as clinicians, treating them.

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Assessing Physicals
by Jason Marketti

One clinic I worked for provided drug screening and physicals for various employers. I was tasked with a checklist and some basic lifting scenarios to put potential employees through. At the time, the construction business was in full swing so there were a lot of people coming through who wanted employment.

When an older gentleman came through and passed the drug screen, the owner of the clinic (who was also the supervising PT) pulled me aside and told me to make him go through extra scenarios. Who am I but a pawn in the great city of Theratropolis? So my supervising PT gave me instructions on what to do during a screen and asked me to do a little more to ensure the gentleman was capable of performing all the skills necessary in order to gain employment.

I don't know if race had much to do with it at the time; however, the older man spoke very little English and performed well enough on the basic tests of lifting, squatting and moving about. Now I had to test him further than I would test someone else because of his... age? Race? I wasn't really sure why I was providing further testing for a man who passed all the basic skills necessary to do a job. I was never asked to do any other type of testing on anyone else, so why him?

Being a simple-minded PTA, I could have complied, put the man through some extra tasks and been done with it. Instead I talked with him about his family and what type of work he was going to do. It turned out he was trying to make some extra money to put a granddaughter through school. The position he was applying for had nothing to do with lifting or squatting skills. I discussed and reviewed body mechanics with him, signed off on the paperwork and wished him well with the job.

Being able to make a determination on whether to provide services and activity to someone who needs it was part of my position. I assessed the situation, then made a decision based on my questions to the patient as well as the results of the standard lifting and moving tests we provided. The man gained employment, paid taxes, and helped his granddaughter achieve her educational goal without wasting his time performing extra testing.

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Making a Mess
by Jason Marketti

As I opened the gym door early one morning, I was stunned by what I saw. A large polyurethane mug with those beautiful white rings left from the wet bottom of the cup practically glowing on one edge of the mat table. Someone brought their drink into the gym, was treating patients, and left the cup and mess for someone to clean up. Outstanding.

Now it could have been a patient who left the cup, but I know better. I know who it was because this person always brings a drink and proceeds to slurp from it in front of the patients. I once met a psychologist who did the same thing while conducting interviews with new patients. When asked about it, she said she gets thirsty when talking with the patients and didn't see anything wrong with taking a few sips while doing interviews.

Perhaps if I brought in a 72-ounce jug and glugged from it, made that "aaahh" sound while smacking my lips, then maybe people would understand how unprofessional it appears to drink in front of the patients. I wonder if anyone would see anything wrong if I ate several slices of pizza in front of the patients and then left the department looking like a Katy Perry Friday night party. Some therapists probably wouldn't notice a difference.

There's nothing wrong with having water, soda or coffee at work. But why drink in front of the patients? Put the cup in the office and excuse yourself for a moment to take a drink while the patient is resting. Imagine if your surgeon came into the hospital room with a bag of corn chips and a Dr. Pepper, crunching and slurping away while trying to sound professional talking about what type of surgery you are going to have in a few hours.

Or how about a therapist spitting sunflower seeds into a cup while treating patients? Is that any more professional than having a six-pack of soda on ice next to the recumbent stepping machine in case you get thirsty? I would normally say use good judgment when conducting patient care; however, there are some brilliant therapists who refuse to do it.

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Healthcare Economics 101
by Jason Marketti

Would you invest in the company you work for? How about an "Improshare" where the savings between hours worked and production are shared between the company and the worker? Can you "feel" the viability of your company and are they open enough to allow workers to see their bottom line?

It can be difficult when you read that a company you work for has committed fraud, abuse, or is under investigation by the state or federal government. Circumstances like this can put a negative vibe in a working environment. However, just because there's an investigation doesn't mean the company you work for has committed any offense.

There are companies that promote openness and foster a better working relationship between management and therapists. Companies that promote professional development and encourage integrity without risk of punishment are the places to seek out and work for. And if these companies allow you to invest with them, do it, because they will be here for a long time. They understand therapists are vital to their industry and will support decisions made provided they conform to their list of standards to promote individuality.

Investments made early in a career with one company can come to a halt when the company is sold or dissolved. You have to start over and this can be frustrating in the extreme. Mutual fund investments made through an employer are worth it, especially if they match 3-5% of your investment. Start early in your career though, so if you have to take a loss like I did in 2007-2008 you still have something to show for it.

Business and financial courses are often underrated for those in the healthcare field and I don't understand why. Perhaps therapy schools should encourage several courses in the business revenue department or some financial awareness courses for those entering their programs. An understanding of labor, production, and revenue generation allows us to make better decisions about our day professionally as well as personal finance decisions.

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Physical Therapy Prime Requisite
by Jason Marketti

Name: Theraman Walkis

Race: Human

Alignment: Lawful Neutral

Class: Therapist Assistant

HP: 96

Level: 18

Strength: 15

Intelligence: 14

Wisdom: 13

Dexterity: 16

Constitution: 13

Charisma: 17

 

Magic Items

Mordenkainen's Gait Belt of Walking, +2 Fall Prevention

Bigby's Gloves Against Communicable Disease

 

Money/Jewelry

2 Copper Pieces

 

Equipment

Standard Clothing of the Flanaess

 

For those of you who are familiar with the Dungeons & Dragons gaming systems, I most enjoyed the original basic red box set as well as the first edition of the AD&D system. I always tried to increase my prime requisite, that is, the main attribute for the character played. As PTs and PTAs, what do we consider a main attribute for our profession? Is it intelligence, manual dexterity, a therapist's charisma when speaking with family members? Perhaps strength is what we want if a patient were to lose his balance and for all those max assist transfers we do.

For us in therapy, our prime attributes allow us to complete tasks and they may change throughout the day. In the morning, we may need the strength to get patients up and going. In the afternoon, we may have to dig deep into our memory for the intelligence and wisdom of years in the field to answer a patient or family member's question. By the afternoon, maybe it's our charisma that gets people up and motivated to come into the therapy gym. Our dexterity allows us to palpate those bony prominences and our constitution keeps us above the 85% productivity range every day.

To improve one of these requisites takes practice and devotion to the art of therapy, as well as an understanding of patient dynamics and abilities. Sure you can be intelligent, but do you have the charisma to talk to the patients and get them to the gym? Or how about if you have the dexterity to feel the psoas musculature but not the strength to assist a patient from supine to sit? The skills we have must come together and allow us to develop our whole character, not just one area of it. We also have to know when to ask for help if a patient becomes too difficult or we become stagnant in our treatment approaches.

I will always be a happy adventurer in the field of therapy as long as I don't have to go into fellow ADVANCE blogger Toni's Temple of Elemental Evil. And a special thanks to E. Gary Gygax (1938-2008), the original Dungeon Master, for those wonderful and frustrating adventures in Greyhawk.

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About this Blog


    Jason J. Marketti
    Occupation: Physical Therapist Assistant
    Setting: San Jacinto, CA
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