I get frustrated when I give a patient HEPs and theraband with detailed instructions on its use only to be told they did not do them the whole weekend and stayed in bed to "rest." 

Then the next week the patients will say they want to leave and wonder what I am not doing for them so they can achieve this goal. I turn this around and ask the patients what they have been doing to ensure they will go home.  I will sometimes assist them in breaking down their day by the hour and figure out times they can do independent exercises.  This is usually frustrating on their part because it brings to light what they could have done but choose not to. 

I generally drop it there and encourage them to increase their participation with activity to their tolerance and get out of bed every day and wheel themselves down the hall independently. 

I remember reading in ADVANCE one time about a PT who took another perspective on this. She wrote that every time she instructs someone in exercises she reminds herself that it is probably the patients first time learning how to do them.  I must remind myself this and not get frustrated about it. 

I will try to be a good coach and a better therapist. 

I am not saying this because he e-mailed me back and gave me a great website to browse nor would I say this only because he is a PTA who does research about stroke rehab. I am saying he wrote a book families and clinicians can read and understand easily and I appreciate that. 

He did not advance me a copy with a fat check to endorse him either (although I am open to this). It took me about a week to read through the material and I thought "Wow." He is empowering families and survivors of strokes to ask pertinent questions about rehabilitation to their MDs and PTs. 

He is directing and encouraging survivors to take charge of their lives and act on what the therapists and MDs have directed.

Since reading his book, I have changed the focus of how I interact with stroke patients.  I use the term "you" more than "we" and I try to be up front with the families and the patients themselves to encourage them to take charge more. 

The book also mentions the insurance factor, which I have rarely seen written so clearly.  Basically it tells the patient their insurance will stop paying for rehabilitation if they do not progress and it encourages the patients to do as much rehabilitation as possible so they can progress. 

The book is encouraging to patients and it allows the care to be focused on what they can achieve rather than what they are not able to do. My copy went to work with me and I encouraged others to read through it.

I need someone that can understand my point of view but allows me the insight into another perspective.  I would like someone who can talk about Legos, Graeme Obree, Hannah Montana, 101^st Airborne, Spongebob, Sci-fi, children, psychiatric disorders, and the UFC. 

I also need them to assist me on focusing and honing in on my strengths to assist me in becoming better in all facets of my disorganized and dysfunctional life. 

My quest has yet to reveal someone I can trust in not judging me or my rash decisions and situations I help create. 

Perhaps I am reaching far too much. 

Maybe I am not looking hard enough.  I have met several potential people that I could have asked, but the more time I spent with them the more I realized they were not a good candidate for me. 

In the meantime I will continue to look and if there are any takers on becoming my mentor we can talk about it, just leave your e-mail address in the comment section.   

"You do not need to address each goal in your daily note.  Focus on what you did that was skilled."

This is a direct quote from our DOR to me.  I really like our DOR, she is fair, concise, and a great clinician but I didn't get what this meant. 

So I asked, "How can we document progress and attainment of goals if we don't address them?"

After several more short conversations throughout the day and confusion about a progress note that was due it was decided (I assume) that I should address goals in the daily notes. 

The confusion about the progress note was a goal was not addressed in the daily notes so what should be written?  Should we write "not assessed", ignore it or make it up?  My contention is that if it was not documented in the daily notes for the last two weeks it was not addressed by anyone and I would have written that is was not assessed.  This did not sit well with the department and the PT decided to write the progress note.  I hope she didn't make it up. 

Help me out here.  Do we address goals in the daily notes or have I been doing this wrong for the last 14 years? 

They are.  My wife and I have visited several Nordstrom stores and everyone we met was genuine in nature.  I am sure it was partly due to the commission they receive from selling, but my wife and I are not big spenders yet the salespeople treated us like royalty when we were there. 

How can we in therapy deliver that type of customer service?  Perhaps more one-on-one time with the patients. Perhaps more patient education during the delivery of services.  Or is the culture we have developed to see as many patients as possible during our 8-hour day to maximize our reimbursements and have the aides do half the treatments?

Imagine going to purchase a pair of shoes.  In most places you don't have to find a clerk to assist you, but if your size is not there you end up spending your time looking for a clerk who may not want to go to the store room to check if there are any more shoes available in your size. At Nordstrom's, a clerk will kneel in front of you and personally assist you in your shopping experience. They will offer to look for a size that will accommodate you. They will even assist in finding a shirt, tie, pants, dress, etc that will complement one another to make you a better person when you leave. You become a customer of theirs for life most of the time. 

That's what we should develop, customers for life. Being able to know a patient's wants and deliver them so they will walk away a better person is what I would like to strive for. This is what we should all strive for. But how can we do this with the current system?

Jerry Maguire spoke of decreasing case loads to give more personal attention to clients. Can that work for our profession too?

The downfall is that some of the patients are not able to hear the radio when it is turned down so low.  The benefit is that some of the younger patients will recognize the songs on the radio.  I know younger is relative in the SNF setting but we have some patients that are around my age and I am almost sure they do not want to listen to swing and show tunes every time they see us in the gym.

At one place I worked we switched stations daily to keep us all well versed in music tastes.  One day it would be country the next day rock and roll and the patients did not seem to mind the changes.  It often stimulated conversations about who sang a particular song.

One patient allowed us to borrow a CD from her and we would sing along as "Rum and Coca Cola" played.  We had never heard the song before so it was nice to be introduced to a "new" type of music.

I am not sure how well some of the patients would enjoy Eminem's new CD though, I may keep that exclusive for my ipod.

And Office Space is one of my favorite movies to watch when I get frustrated at work. 

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.