As I've written before, I enjoy reading books. Books allow me the opportunity to learn something new, and although they may not be directly related to physical therapy, almost always improve my professional practice. One of my favorite books, Blink by Malcolm Gladwell, for example, has no reference to physical therapy but helped me to understand good decision-making, which I saw improve in my clinical work. Now, while I enjoy the nuggets of information I learn during our department journal clubs, I wonder if there is an opportunity to expand the concept into a professional book club. Would other physical therapists be interested in reading books to stimulate ideas and conversation?
I haven't heard of any of my colleagues or professional acquaintances participating in anything like a book club. Even journal clubs are at times difficult to make time for, and sometimes the topic is too diagnosis-specific to be relevant to all physical therapists. Is there value in expanding the requirements of a journal club? Would others find a professional book club beneficial?
As I think about this idea, I'm certain it would be advantageous to make the group as well-rounded as possible -- to include other professionals outside of physical therapy. There have been many times when I've networked with nurses, IT, case managers and want to hear more about their perspective because it helps me understand the whole patient experience.
I know what you are thinking -- what books would be on my list? Well, I've recently come across a few books that I would love to read and discuss with other people. They include: The Oz Principle by Roger Connors, Tom Smith and Craig Hickman ("Getting Results Through Individual and Organizational Accountability"), Healthcare Kaizen by Mark Graban and Joseph E. Swartz ("Engaging Front-Line Staff in Sustainable Continuous Improvements"), and Sticking Points: How to Get 4 Generations Working Together in the 12 Places They Come Apart by Haydn Shaw. I think I could learn a lot from these authors and from a good discussion with others.
What do you think? Would you be interested in a professional book club?
(Editor's Note: Throughout the month of February, ADVANCE bloggers Lisa Mueller and Michael Kelley will post "Dueling Blogs," in which they argue opposing sides of the same issue. Topic #4 -- "What Is the Biggest Challenge to the PT Profession?")
When Michael and I discussed writing four weeks of "Dueling Blogs" in mid-January, we wanted the last blog debate to be an important one, and decided to contrast our opinions of the biggest challenge to physical therapy practice. We had no way of knowing then that the APTA was writing a similar story for the February issue of PT in Motion, with an article titled "Addressing the ‘Biggest Threat' to Physical Therapy."
Obviously, this is an important current issue in our profession. I couldn't agree more with the article's author, Eric Ries, who quoted a therapist saying, "The biggest threat to physical therapy, I really do think sometimes, is physical therapists."
We are by far the biggest obstacles to our own practice. I've had the privilege of meeting lots of therapists over the past few years through CE courses, APTA conferences and social media outlets like LinkedIn, and I'm always surprised by the low standards we accept.
Therapists who half-jokingly mention taking naps at work while volumes are low. Experienced therapists who honestly confess they don't understand the difference between timed and untimed codes. Therapists who believe ignorance is an acceptable excuse for billing and documentation errors. Therapists who work hard to give "unskilled" work to other professions, which directly reduces the scope of our work. If we don't take our profession seriously, no one else will.
So, how do we bridge the gap? How do we inspire all physical therapists to engage in their careers and be accountable to drive forward? I think this is where the APTA could flex some muscle (musculoskeletal pun intended). But, as I write this I'm wondering how I plan to be less of an obstacle to the future of physical therapy practice. What can I do? It isn't just the APTA that needs to step up -- I need to as well. I need to be more informed about the current events of my profession and help celebrate the small wins with my colleagues. I need to do a better job of educating my patients on the role of physical therapy.
What do you think? What is the biggest obstacle to physical therapy? Is it regulations? Third-party payers? Inadequate access to information? Employers? The APTA? I encourage you to get involved in the conversation by leaving comments below. It is only in truly understanding the problem that we'll be able to find a long-term solution to make the physical therapy profession even better.
(Editor's Note: Throughout the month of February, ADVANCE bloggers Lisa Mueller and Michael Kelley will post "Dueling Blogs," in which they argue opposing sides of the same issue. Topic #3 -- "Does the Inpatient or Outpatient Setting Allow Greater PT Practice?")
Since I graduated from physical therapy school almost five years ago, I've been lucky enough to have the opportunity to practice in both inpatient and outpatient settings. While they both provide unique advantages, I'm writing today to debate that the outpatient setting is better aligned with the fundamentals of physical therapy practice.
I remember making the transition from inpatient to outpatient practice and was stunned by the realization that patients of outpatient physical therapy seek out our services.
Patients drive to our building, sit and wait for us to work with them. This was the opposite of my experience with inpatient, where I frequently had to encourage my patients to participate in the most basic therapy sessions. It was such a compliment to know that my outpatient folks were going out of their way, making time in their day to see me. I know there are exceptions in every situation, but I think the outpatient setting highlights how well physical therapy services are understood, implemented and appreciated.
Inpatient facilities are commonly organized by pathologies -- hospitals will have a floor for patients with neurologic pathologies, a floor for patients with cardiac problems etc. For the sake of argument, I'm going to simplify that therapists follow those patterns and end up practicing basic physical therapy interventions (gait, balance) to very similar populations. There isn't a ton of diversity. Outpatient is quite the opposite. I can start my day with a cervical disc and end with prosthetic training. You have to be ready for anything that walks through the door.
Speaking of walking through the door, that's another advantage of outpatient practice -- fewer interruptions. While I appreciate the collaboration in an inpatient setting with other healthcare providers, physical therapy sessions were often put on pause for lab draws, X-rays, or visitors. These things are important, but I'm very happy in outpatient when the whole appointment time is spent on treatment, and not waiting patiently!
I think the biggest advantage outpatient physical therapy has over inpatient is the patient relationship. I enjoyed building relationships with patients in the inpatient setting, but generally the length of stay was very short. Outpatient is a little different in that regard; I typically see patients over several weeks. I feel like I get to know my patients better in the outpatient setting, and making those connections is the biggest reason I went into the PT profession.
What do you think? Is inpatient or outpatient a better location to practice physical therapy?
(Editor's Note: Throughout the month of February, ADVANCE bloggers Lisa Mueller and Michael Kelley will post "Dueling Blogs," in which they argue opposing sides of the same issue. Topic #2 -- "What Drives the PT Profession?")
There are many different components to a physical therapist's career: patient interaction, documentation, reimbursement and finances, research, and management to name a few. Each of these impacts the therapist and the profession in different ways.
When the physical therapy profession began, around the time of polio in the early 1900s, I would argue that patient interaction was the primary driver of the profession. There was a clear need for restoration of physical function, and working with patients directly catapulted the profession to become defined as a separate entity from other healthcare roles. In the past few decades, physical therapy (along with the rest of healthcare) has been influenced heavily by reimbursement and third-party payers. Today, the future of the PT profession will be driven by research and improved patient outcomes.
We are living in a very transparent, competitive time. Our society is in the best position it has ever been to compare costs of providers and satisfaction with care. So, how are we going to move forward? By proving our value through research. Evidence showing the effectiveness of intervention by a physical therapist compared to other treatment options will speak loudly. Knowledge is power, and educating our patients on the research supporting their plan of care will drive the PT profession forward.
Patient outcomes are the other important driver in our practice. Patients, payers, referring sources, and even our colleagues have seen the qualitative value of our work, but the quantitative data will be critical in the future of our profession. Being able to show a patient progressing from wheelchair mobility to walking around the block compared to a patient improving by 20 feet on a 6-minute walk test in just one number is important. Sure, both patients improved but one made much bigger strides than the other. We need to be able to show that. Connecting the outcomes to research will tell a complete story of the role of physical therapists, and only we can be those storytellers.
The big question is -- drive the PT profession to what? What's next for us? Direct access has been accomplished. The APTA's Vision 2020 to have all physical therapists obtain their doctorate degree is just seven years away. How will we measure the next physical therapy accomplishment?
What do you think? What is the biggest driver of the physical therapy profession?
(Editor's Note: Throughout the month of February, ADVANCE bloggers Lisa Mueller and Michael Kelley will post "Dueling Blogs," in which they argue opposing sides of the same issue. Topic #1 -- "Is APTA Membership Valuable?")
More than five years ago when I was a student of physical therapy at Marquette University, APTA membership was highly encouraged by my professors. At the time, I perceived the APTA as a requirement that was necessary for my schooling, but also felt like I was finally a professional when I received my membership information. I was part of something! Beyond feeling a sense of belonging, I believe the APTA is a valuable tool to the physical therapy profession and offers both members and non-members important benefits.
Moveforwardpt.com is a patient-facing portal that proves singlehandedly the impact of the APTA. This site houses a collection of symptoms/diagnoses and promotes in each example the ways physical therapy can play a role in recovery. Prospective patients can easily navigate through information on Medicare caps and locating a physical therapist, as well as read through the benefits physical therapy offers. If you look at other professional association websites (American Chiropractic Association, for example), you'll find gaps compared to the APTA's site. It's a wonderful resource to use with patients and a prime example of how the APTA adds value to the physical therapy profession.
Direct access, while not completely accepted by all physical therapists, would not have happened without the APTA's support and advocacy. The APTA's advocacy efforts at the national and state levels help the physical therapy profession stay on top of legislative issues, including Medicare standards. The APTA helps translate the changing requirements so physical therapists can focus on patient care while they do the "grunt work" in the background.
Finally, the APTA helps develop and communicate evidence for improved clinical decision-making and treatment. Membership to the APTA includes access to articles and abstracts, and monthly mailing of the PT Journal keeps therapists updated on new research. I probably wouldn't be as informed about evidence-based practice if it weren't for the APTA's efforts.
Continuous improvement is a part of every group -- colleagues, marriages, families, associations, and governments. The APTA has room for improvement like any of those and I'm confident they will be a strong factor in the advancement of the physical therapy profession in the years to come.
What do you think? Are the benefits of the APTA worth the membership? What would the APTA need to offer to gain your membership, if you aren't already?
Starting next week, fellow ADVANCE blogger Michael Kelley and I will be hosting a series of "Dueling Blogs" for the month of February. Each week we'll debate our perspectives on trending topics in physical therapy. We'd love to hear your perspective, too, so please read and join in the conversation.
In prep for those upcoming blogs, I thought I would take some time for myself this week and write about something completely unrelated to my career. I enjoyed a great dinner last night with a number of my friends -- colleagues and mentors -- and the idea of starting a book club came up. I'm currently in the middle of reading two books, The Oz Principle (Roger Connors, Tom Smith and Craig Hickman), which I was just starting when I borrowed a copy of Steve Jobs by Walker Isaacson.
I've been enjoying them both and have found more time to read than normal since the weather in Wisconsin hasn't been very conducive to much else! One of my friends suggested Sticking Points: How to Get 4 Generations Working Together in the 12 Places They Come Apart by author Haydn Shaw. I've never been part of a regular book club before, but this group of friends includes a wide variety of ages and experiences, so I think I could learn a lot by participating.
I finished a major project this winter that I've been working on for almost two years -- creating photo albums (online) of the past five years of pictures I've taken. When I used 35mm film, I had a good system of getting my negatives developed, prints made, writing details of the photo on the backside and creating photo albums. Since I transitioned to a digital camera, I've just dumped the photos on my computer and never really did much with them. The mess was making me anxious just contemplating the process. So, I slowly started organizing the photos and making an online album, which I finally finished. Now I just have to buy them!
I was very lucky the past few years to have great vacation opportunities come up -- Hawaii, California, Costa Rica -- just to name a few! This year, so far nothing planned. I'm looking into a long weekend in New York City and also debating a week up in northern Wisconsin in the fall. So far, I have five weddings this year to be part of, so those will be busy weekends alone! I should make a spreadsheet with some vacation options to compare prices, potential activities, and see where that leads me...
Here we are, well into 2014 and I plan to use this year to fully embrace technology professionally. Now, you may recall one of my New Year's resolutions was to keep my email updated. Our rehab department has embraced the use of video conferencing for staff meetings, which has helped us cut down on travel costs for those driving from other clinics. I recently finished (with the help of my talented colleagues) creating online computer-based training (CBT) for part of our software functionality and was so impressed by how easy it was to organize the material, as well as record the directions for anyone to watch the CBT on their own time. Wow!
The next piece for our department is to determine how was can use technology to better share research and treatment ideas. We now have a discussion board to post topics, attach articles and share comments. It's still in the early stages of development and I'm still learning to remember to interact on that kind of platform. The nice parts of the discussion board are that people can contribute to the topic on their own schedule, and some prefer communicating in writing to be better prepared to share their perspective.
One recurring thought I have on using technology in physical therapy is how to educate other therapists on things like palpation, hand placement, or end feel digitally. Photos included in research articles are fair, but what about videos? I've seen some research articles include links to videos and enjoyed seeing the treatment technique that way. Are videos of exercises, special tests and manual treatment techniques helpful? And if so, should the APTA be the business owner of that product?
How do you think physical therapists can best implement technology into practice? Tele-medicine? Tablets for use of improved digital documentation! Share your ideas below!
I still drive the first car I ever bought, a 2004 Honda CRV. Hard to believe it's nine years old already. I love my car. It's the perfect size for hauling stuff around and tall enough for me to see everything when I drive. Over the past few years, but especially in the last few months, my cute car has started to make more rattling noises. Turning either left or right will create a lovely chorus of sounds from the wheel bearings. I've grown used to these noises and assumed they were a natural part of adding miles to the car, or "normal."
My car mechanic thinks otherwise. The noises aren't normal and indicate areas of harm to the vehicle. He was surprised I drove the car as much as I do considering the new "symptoms." I just didn't know enough about cars to know the noises were a problem. You don't know what you don't know, right?
Over the past five years of patient care as a physical therapist, I'm surprised some of my patients have the same mentality about their bodies. They think new symptoms are "normal" and often ignore red flags for what may be more serious pathologies. I remember one patient with massive abdominal masses restricting lower-extremity lymphatic return and resulting in significant edema who thought, "This is just what happens when you get older."
The patient and family were shocked when they learned the mass was cancerous and felt terrible that they hadn't said something sooner, but just didn't know. This example is somewhat similar to patients who ignore small, acute symptoms until they develop into larger, chronic symptoms before receiving care. I've worked with many patients who introduce their background as "I think it started one or two years ago, but I just thought it would go away."
There are times when I've had to talk with my patients about their symptoms and refer them to a specialist. It can be hard to teach patients that what they are feeling isn't "normal" and they will need further medical attention. But, I think this is why I enjoy teaching so much -- I love seeing patients learn new information because I believe they're empowered by the knowledge about their bodies. I hope my message and their experience within a healthcare environment will help them continue to learn to better their quality of life, and the lives of their families.
What do you think? Have you ever been surprised by what a patient interprets as a "normal" symptom? Do many patients consider changes in their bodies to simply be part of the aging process?
A friend of mine asked me to meet for a cup of coffee while I was home for Christmas so she could show me some paperwork she received during her recent experience with physical therapy. I assumed she wanted to show me her home program and we could converse on my line of work compared to her experience. I was looking forward to seeing her and catching up after almost a year since our last visit.
After we talked about our holidays, husbands and jobs, my friend started to show me her home program and some simple sketches of her scapulothoracic joint (she had been going to physical therapy for shoulder pain), explaining her therapist's explanation of the serratus anterior muscle. She demonstrated a few of her exercises (as best she could in a public coffee house) and repeated phrases from her therapist such as "shoulder blade stabilization." I was impressed with how much information she retained and was able to repeat to me.
I asked my friend how much better she was feeling since going to physical therapy, and she responded with, "A little better." I repeated, "A little?" And she confirmed, "It's not much better than it was before." I asked what kind of treatments had been done and she described common physical therapy interventions, which got me thinking. Do our diagnosis and handmade home programs matter if our treatment isn't effective?
I remember as a student struggling with determining a physical therapy diagnosis. My professors and clinical instructors were helpful, but internally I would debate the difference between capsulitis and bursitis and find myself disappointed if my diagnosis was incorrect. Even recently, I've had discussions with physicians about patient symptoms and special testing in order to determine a correct diagnosis. When writing an assessment, my documentation focuses on "Signs and symptoms consistent with this diagnosis." Physical therapists, and medicine in general, seem to focus on the diagnosis for a patient.
If I try to imagine this from a patient's perspective, there may be some relief in a diagnosis or label for my impairments, but that relief is likely only temporary if improvements in my pain and function aren't made. I could tell my family and friends, "Yes, I have a problem with a nerve in my low back," but that statement doesn't help when I still struggle to get out of the car.
What do you think? Is an effective treatment more important than a diagnosis, or are both equally as important in the care of a patient in physical therapy?
It's hard to believe it's 2014 already. I officially graduated from physical therapy school five years ago! Wow. Seems like it was yesterday. It also seems like I'm talking like my mom or grandma when I use phrases like "seems like yesterday," but so be it. Now's the time each year when I review my resolutions from the previous year and set goals for the upcoming year, although I'm slightly hesitant this year because I know I didn't achieve the ones I set last year. Either way, let's review!
- Read one book per month -- partially completed. I read six books this year, which was an improvement from 2012 but not quite my goal. I'll take it, though. I did enjoy this resolution, talking with friends to pick out my next book and reading book reviews online. I hope to continue reading more in 2014 as well.
Regular participation in department journal club -- major fail. I believe I participated in four of the 11 journal clubs in 2013. I have excuses, such as traveling and other meetings scheduled during the journal club, but I could (and should) have made this a priority.
Take a CE course of the thoracic spine -- partially completed. I'm signed up for a thoracic outlet course in two weeks. I also took some other CE courses at the APTA conference in June.
Don't delete all my own stuff -- successful!
For 2014, I have the following resolutions to focus on:
- Spend one hour each week cleaning out my email. The number of messages in my email takes my focus away from other important tasks if I can't find what I need or fail to follow up on an item because the message got lost in the shuffle. In order for me to succeed professionally, I need to be able to make my email communication more efficient, which includes regular management of the volume of emails.
Exercise regularly, with a goal of twice per week. This sounds so incredibly cliché and hypocritical, coming from a physical therapist, but I need to be honest with myself (and my readers). Exercise should be my best habit and a top priority each week but it hasn't been this year. Traveling for work and taking on new responsibilities resulted in me focusing on other things, and I need to make exercise a regular part of 2014.
What about you? What are your goals for 2014? Share them below!
Several of my family members are in the process of transferring old photographs, 35mm slides and film negatives into digital format. A project I encouraged my mom to complete for many years was one of the best Christmas gifts I received this year, as I can now click through hundreds of my childhood photos on my computer. (You may recall a previous blog where I wrote about winning a photography contest. Photography is one of my favorite hobbies). Now, there is still nothing like the old photo albums they came from but it's nice to have the photographs organized and more easily shareable.
One of my relatives took in a stack of slides to be transferred to a CD and told the staff at the photo shop, quite frankly, "This is a test." The small stack of 30 slides was a sample of more than 4,000 slides, which could all be transferred to digital copies if the test run went well. The sales clerk wrote on the package, "Test for possible larger order." We were all excited to see how the slides would turn out in a digital version -- images we had only seen on a small slide viewer could now be seen on any computer!
Over Christmas we popped the disc into the computer and clicked through the images of our priceless memories. Some images were wonderful; just as crystal clear and colorful as we had remembered. But, some were not great. Some had dirt on the digital copy because the slide hadn't been cleaned completely. Some images were crooked because they hadn't been lined up straight prior to being scanned. We were all a little disappointed because we were so hopeful the "test run" would be flawless.
What would happen if a patient of physical therapy told his therapist, "This is a test?" How would it feel to be tested? What if a patient's experience and outcomes determined if he would return? This is probably a theme prevalent in the minds of private practice therapists since referrals and loyal patients help sustain their businesses, but for some therapists, the idea isn't as strong. Would you practice differently if you knew you were being tested? Should every patient be treated as a "test?" Should there be a difference between a "regular patient" and a "test run," or should we be practicing our best with every appointment, every time?
Well, it's officially the holiday season. I spent last weekend wrapping all of my presents (three total hours), adding ribbon with name tags (two additional hours) and applying stamps and stickers to some of the packages (one hour). This weekend I hope to bake a batch of cookies that would fit in well with the five inches of snow that fell last night (and would also help me avoid shoveling the driveway).
Because Christmas falls on a Wednesday this year, I was able to take most of the week off but only needed to use two vacation days since my clinic is closed Christmas Eve and Christmas Day. The same pattern applies to the following week with New Year's Eve and New Year's Day. As I've been scheduling my patients for their follow-up appointments, I realized that although the time off is nice, it's also difficult for patients to receive the therapy they need when the clinic is closed.
What happens to your clinic over the holidays? Are you able to take time off to spend with your family and friends, or are the needs of your patients the priority? Is there a way to compromise? I remember working on Christmas at the hospital in acute care and many patients and families were always surprised to see physical therapists working on the holiday. I can understand their perspective since many times physical therapy is not "critical" for acute-care patients. However, I'm always grateful when our services are needed and wouldn't want to lose an opportunity to educate patients on the benefits of physical therapy.
There are some times when I struggle taking time off from work because I don't want my patients to have a gap in their care, and other periods when I'm not as concerned because I need the break. It's important to take time for ourselves throughout the year.
Here's to wishing you and yours a safe, peaceful and blessed holiday season.
One of the reasons I like being a physical therapist is that I'm able to help others. I like teaching patients and families new things that will (hopefully) improve their quality of life. I enjoy helping patients reduce pain and seeing their faces light up when they're able to complete functional movements with ease. When I can't offer much help to my patients, I'm somewhat comforted with offering alternatives and coordinating care for my patient with other providers -- so I know they are least have options.
An acquaintance of mine was recently diagnosed with ALS and has lost a lot of function in the past three months. For the first time, I really don't know how to help. I haven't seen any imaging results to know the severity of the pathology, but I know enough about the disease and the change in my friend to know the impact ALS has had this far.
There have been times during treatments when one of my patients might become overwhelmed with his physical or mental disabilities, or the prognosis of his disease, and become quite emotional. Physical therapy can many times highlight a patient's deficits (in order to assist the patient in improving), although in some cases it is the therapist's duty to emphasize the progress, and rightfully so.
The situation is that, I've become accustomed to speaking with patients from the perspective of a physical therapist, but not very often as a familiar friend. I don't know what my role is or needs to be. Although I know my friend well, this new diagnosis brings unfamiliar friendship territory. I'm not sure if my friend needs me to be a physical therapist -- interpreting some medical advice, recalling past experiences and emphasizing that miracles do happen. Or perhaps my friend needs some empathy, someone to vent to about the frustrations of a new diagnosis. Maybe both.
In either case, this experience (so far) has made me grateful yet again for the knowledge I have about the nuances of the healthcare system and the blessing of good health.
Every year I look forward to this time of year the most, and this year is no different. I have a lot to be thankful for. Writing those things down and publishing them on my blog makes it so much more real. So, as my faithful readers are anxiously waiting for my annual thankful blog... wait no more! This year I'm thankful for:
1. My health! Working in a medical setting reminds me daily how lucky I am to not have any pain, injuries or disease.
2. Spending time with my family and friends -- I was able to go on two trips this year with my family and I appreciated the time to relax, unplug and make happy memories.
3. My career! I took on a new role this year as a supervisor and am glad to have the opportunity to grow my skills and learn more about the different roles in the physical therapy field.
4. Reliable transportation. My car is gaining miles every year, and I'm always thankful when it starts every morning so I don't have to finance a new vehicle or invest time in finding a new car.
5. Friendly people! I've traveled a lot this year and am so thankful for those who helped me during my adventures -- whether it was giving me directions, suggesting restaurants or teaching me about the culture of the area, thank you!
6. Time. I told my mom earlier this month that when I was in college, time seemed to drag by. Semesters seemed like years. Now it seems like I blink and months go by. I'm grateful for each day I have.
Here's to wishing you, your family and friends a wonderful Thanksgiving day. May the rest of 2013 be an enjoyable one!
I traveled for work a few weeks ago and stayed at a nice hotel for the week I was there. Anytime I stay at a hotel with a pool, I feel like I've won the jackpot. After a long day of work, I can come "home" to not only a clean room (thank you, cleaning crew for all that you do!), but I can also float in the pool and feel my stress levels diminish with my weightlessness.
This trip was a little unique in that I was put in a wheelchair-accessible room. I walked in and thought there had been a mistake with my reservation. The room was huge! The bed had a ton of space around it and the bathroom door was wider. I felt like a giant! I wasn't accustomed to such a large space when traveling. I usually struggle to find a spot for my suitcase and separate spots for my clean and dirty laundry.
As I spent the week there, I started to think from the perspective of a person in a wheelchair and reflected on education I provided my previous patients in regard to their mobility. I identified a few areas that could have been challenging for a patient. For one, there was no transfer bar next to the toilet. There was a transfer bar in the shower, but no shower bench/chair, just a larger shower stall (not a bathtub). The power switch on all the lamps was at the base with a push-pin-like size, which even I struggled with my thumb one morning to successfully operate.
While each patient's abilities are unique, I don't think a "typical" patient needing a wheelchair would have been able to utilize the lamps or toilet without some supervision or assist. Nor could he have reached items on the tall shelves in the closet (iron, or extra pillows).
I've been lucky enough to be involved with the construction of new clinics and I've always been impressed with the contractors' knowledge of American Disability Act (ADA) requirements for a facility. This traveling experience will certainly make me think even more from the perspective of the patient!