It's hard for me to believe it has been four years since I graduated PT school. I remember working as a student with physical therapists who had been practicing for four or five years and looking at them as a source of information and experience. Now that I'm on the other side of that spectrum, I still feel like I'm learning every day. As the hundreds of PT programs prepare for graduation, that's one of the main suggestions I'd have for new graduates -- just keep learning. Here's a list of some things I wish I had known, or someone had told me, when I graduated.

1. Keep learning. Getting through the board exam is a major milestone, but don't put your books away. Keep reviewing and adding to them. Keep investigating and researching all the things that contribute to your patients' cases. Find ways to learn new treatment styles or continue mastering your current techniques.

2. Don't work too late...

3. ...But also say "yes" to opportunities. Try to find a balance between working hard and also spending time away from work. Don't get to the point where so early in your career, you're already burning out. Take on opportunities as they come, but also take time for you. You deserve it.

4. Start contributing to your retirement plan on your first paycheck. If you put a part of your paycheck into a retirement plan right away, you won't realize that it's missing. And then you'll start growing a nice pile of money that you'll definitely need later. It's much harder to make the adjustment after a few paychecks. On a similar note, it's not a bad idea to sit down and determine a budget. Having to juggle student loan payments on top of regular living expenses may be a new experience for you and it's important to know that you're setting yourself up for financial success.

5. Be confident. There will probably be times when you question yourself. Is this the right diagnosis for my patient? Did I complete this mobilization technique correctly? Is this the right plan of care for my patients? How do I handle this difficult case? It's good to ask questions and have a mentor (or sponsor) to discuss your work with, but try not to let those questions interfere with your relationship with your patients. Sometimes trusting your gut will tell you everything you need to know (balanced, of course, with some evidence based-practice when you have time to research the material).

So, to all new graduates of physical therapy -- congratulations! You've accomplished a tremendous task. The real reward starts now -- you have an entire career filled with impacting the lives of patients, families, coworkers and future students. Welcome!

My newest thought project for this week is to better understand how physical therapist staffing is predicted for a new clinic. How does a new healthcare company or private practice facility estimate what kind of staffing it will need in a new location?

My general understanding of private practice is that due to limited funds, staffing will start whatever the owner can afford, not be based on the potential volume or demand for an area. If the owner can afford two therapists, he will start with two therapists and later reduce the staffing if the reimbursement or caseload doesn't support both positions.

Bigger healthcare companies may be a little different because they might have the money needed to invest up front. Although the economy is tight everywhere, bigger corporations may be able to build a rehab facility based on the projected volume over a period of time and not limit it strictly to what they can afford right now.

The company I work for grows every year. A new clinic is opened fairly regularly. Before we grow any more, I want to make sure the staffing for rehab is appropriate. But I'm not a statistics major. I don't know how population health statistics are calculated. I don't love math.

I found a few documents on the APTA website about supply and demand that have some nice charts. I think I understand the basic principles. Take the number of people in the United States (or a single state) and divide it by the number of available (and potentially the open) positions for both physical therapists and physical therapist assistants, and you will come up with a ratio. That ratio can then be applied to smaller populations when a new clinic is opened to determine the demand for physical therapists in a given area.

The concern I have with understaffing a clinic is that if the therapist can't keep up with the demand for care, those waiting for treatment will either go elsewhere for care or continue waiting, which may worsen an injury. As a patient continues to live with pain or an injury, he may be developing compensatory movement patterns or an acute injury may progress into subacute or even chronic, which could take longer to heal.

What do you think about the supply and demand of physical therapists? How do you calculate the demand for physical therapists? Can you help me figure out if the ratio I described above is correct?

Since I've spent a lot of time in the past 18 months making changes in my own career and developing the content of the training and orientation program for new employees at my clinic, the concept of mentors has always been on my mind. Even when I graduated PT school (which seems like an era ago), the common words of wisdom from my professors were, "Find a job that offers mentorship." Seemed to make sense. I don't know everything and I'd need to have a job where I could ask questions and learn from someone with more experience.

My mom sent me an article this morning from The New York Times with a catchy title, "Mentors are Good. Sponsors are Better." Ohhh, sponsorship! I had to read. It's only two pages long and the moral of the story is that mentorship simply isn't enough in the career development of women and minorities. The author, Sylvia Ann Hewlett, writes that to stop the cycle of white-male-dominated leadership, women need more than a mentor.

She continues that women who have sponsors -- or individuals invested in the growth of an employee, who are willing to give feedback, guidance and opportunities -- are more likely to ask for bigger opportunities. Mentors are more laid back. Mentors are "sounding boards or a shoulder to cry on... expect(ing) very little in return." I'm not going to open up the men-versus-women conversation quite yet, because I think the concept of sponsors versus mentors is enough to ponder for now.

This article rang true for me. When I think about the role of mentors in my career, they are usually resources or individuals who know where to find information or answers to questions I have. I ask my mentors a lot about treatment ideas or techniques to better differential-diagnose a patient. Sponsors are more deeply invested -- they risk their own reputation by connecting the individual with other leaders and providing assignments. A mentor is someone you'd ask, "How do I find the keys to get into the building?" Whereas a sponsor would answer the question, "What can I do to make myself a better professional?"

How can we as physical therapists develop more sponsorship relationships for the many young clinicians who need guidance for their careers to grow? What do you think a sponsor could do for your own career development? Have you ever experienced working with a mentor or a sponsor?

Over the weekend I was reading the article for our staff journal club this week, a recent research paper investigating the effects of thoracic thrust manipulation (with non-thrust cervical mobilization) for the treatment of neck pain. As you may recall, participating in our regular journal club was one of the professional goals I wrote about earlier this year and I've dedicated some of my weekend time to read over the article in preparation.

Most of the time I perform thoracic mobilization it is in prone -- I palpate the patient's transverse processes and utilize a cross-hand placement to perform either PA or rotational mobilizations, depending on my findings. I can't remember the last time I used, or practiced, a pistol-grip hand placement with the patient supine to perform a manipulation, but that's what the authors in this article used. I found my binder of notes from school and flipped right to the page for spinal mobilization (one of the many benefits of tabbing your notes with post-its), and vaguely recalled performing the technique in class, but can confidently say I haven't used it since.

So, I Googled the phrase "thoracic thrust manipulation" and was immediately brought to two YouTube videos, both less than two minutes in length, of physical therapists demonstrating the technique. How wonderful! I was able to watch them, rewind the video and watch again. What joy! I was proud of myself for using technology, and social media, to not only review treatment strategies for physical therapists but also familiarize myself with as much information as I could prior to our journal club. I felt completely prepared and was looking forward to learning from my colleagues.

I try to be fairly active within the social media aspect of physical therapy. I follow other PTs on Twitter and read the conversations regarding our profession. I stay active on LinkedIn for my professional development and networking, Facebook for my personal life and Instagram for fun. But I haven't really researched the depths of YouTube, and judging from my first experience using it for developing physical therapy skills, I'd imagine there is a lot of very helpful information there.

What do you think? Have you ever used YouTube to either learn, teach or share physical therapy skills with others?

Resource

Masaracchio, M et al. Short term combined effects of thoracic spine thrust manipulation and cervical spine non-thrust manipulation in individuals with mechanical neck pain: a randomized clinical trial. J Orthop Sports Phys Ther. 2013 Mar; 43(3):118-27.

This weekend I taught a continuing education course with three other therapists. It took well over a year for us to organize the content, create the handouts and visual displays and market the course to get as many participants as possible. It was a fun process to figure out the best way to engage the participants and relay the most important information without being overwhelming or too simple.

Our course was titled "Challenges to Early Mobility" and focused on barriers to activity and physical therapy in an intensive care unit. We covered equipment, common diagnoses, other professionals working in an ICU setting, lab values and hemodynamics, along with treatment strategies and goal-setting. It was a great morning filled with many good conversations centered on providing the best care possible.

My fellow ADVANCE blogger Toni recently wrote about how teaching is now a very real passion for her and I feel very similarly. I love teaching. I enjoy speaking in front of others and sharing ideas about physical therapy practice. I like taking what I know and what I've experienced and letting others learn from it. I like reading the research involved in a certain treatment strategy for physical therapy and finding new ideas to treat my patients better. I like conveying new information to physical therapists, knowing that a patient will ultimately receive better care as a result.

A few weeks ago, our group of presenting therapists received an email from a hospital in Indiana asking if we could expand our current four-hour continuing education material into a two-day course. We discussed it and politely declined -- simply due to the massive amount of work that would be needed. But now after teaching the course, I'm more motivated to continue with any teaching opportunities that arise, and maybe the Indiana suggestion isn't that bad after all...

The highlight of my experience teaching was having a physical therapist approach me at the end of the course to tell me that she reads my blog and was happy to see how my career has developed. There are times when it's difficult to find a topic to write about each week, or to accurately describe my opinion on a subject while maintaining some professionalism and healthy perspective. There are plenty of people in my family who don't read this blog (no hard feelings). So to hear from a reader was a wonderful, unexpected honor. Thanks for reading.

This week during the show "The Voice" on NBC, Aflac aired a 60-second commercial showing the Aflac duck working with a physical therapist to recover from some injuries. (The injuries were aired in earlier commercials). I think Aflac is marketing services their clients receive while off work due to injury, including money for bills and other needs.

I was floored when I saw the commercial. Unbelievable. First, the fact that the commercial was 60 seconds and not the typical 30 seconds is a substantial amount of time in advertising. Second, it was about physical therapy!!! I can't tell you how many articles I read about athletes and their injuries -- Tiger Woods with his knee, Payton Manning and his neck -- hundreds of athletes and most of those articles never even mention the words "physical therapy."

And here, an insurance company spends 60 whole seconds dedicated almost entirely to physical rehabilitation. Wow. Third, I love the duck. Watching the duck's little feathers stick out of the cable system handles and putting the duck in an aquatic treadmill system was funny. My husband and I live near a pond with tons of ducks and geese are always walking in our yard, so ducks have become a little close to my heart.

I worked in a physical therapy department a few years ago that was part of a bigger healthcare system and our team would occasionally ask the leadership team why physical therapy wasn't included in the marketing efforts of the business. We would see commercials for cardiac care, pregnancy and even stroke care with nothing about rehab (which is somewhat frustrating considering the role PTs have in cardiac and stroke recovery). We weren't really given a good answer, but it felt like the marketing team worked in its own little world and we were a separate entity.

This Aflac commercial is a great step forward for PTs -- it recognizes the value of our profession and skills without focusing on just one company or healthcare system. Props to the advertising and marketing team at Aflac for focusing and aligning its efforts with our profession. Physical therapists thank you!

What do you think? Did you see the commercial? Did you like it? Are you involved with marketing as part of your job responsibilities? How do you successfully market physical therapy?

A friend of mine works as a nurse in a hospice setting and she mentioned to me a few days ago that many of the patients she admits into their facility come with orders for physical therapy. I've seen articles and research about the effectiveness of physical therapy for patients in a hospice setting, but the idea that many of them have PT orders is something to discuss.

Nearly all of the patients admitted to hospice will expire within six months of admission. Some will improve and transfer out, but most will not. I don't remember exactly what the statistics were, but I vaguely remember President Obama mentioning that most healthcare expenses are compiled during the last year of a person's life. Where does physical therapy fit into that?

I haven't ever worked in a setting like hospice before, although the ICU setting probably has some similarities. When I worked with patients within the unit, my role was often second to life-saving measures; like when a patient's blood pressure needed to stabilize, or if his breathing pattern diminished and needed assistance. I would take a step back and wait until the patient was stable and able to participate. Do those same concepts apply to hospice? I'm not trying to imply that we shouldn't "waste" money on our patients in a hospice setting; I'm just trying to understand that setting and our role as physical therapists better.

Aside from hospice, there are plenty of times that a patient has been given orders for physical therapy that are clearly inappropriate, even dangerous in some situations. Patients who are total assist for bed mobility and transfers, non-ambulatory at baseline, and morbidly obese with orders to ambulate three times daily. Patients with orders for modalities who have clear contraindications against their use. Patients with lower endurance who fatigue in the first rehab session of the day but have orders for hours of rehab daily.

In most of these cases, I'd send a note back to the ordering provider explaining why the order was either inappropriate or not achievable, and I'd also include a short statement about the current plan of care. Most of the time the provider was in agreement with me. This kind of goes along with a piece my fellow ADVANCE blogger Toni wrote this week -- that time-based expectations for some patients for therapy participation are completely inappropriate.

What do you think? Have you ever worked in hospice? Is physical therapy a priority in that setting? I'd like to learn more about our profession in that role. Have you ever spoken with a patient or provider to discuss their orders and if they are appropriate for the patient?

I'm traveling for work this week, my second "business" trip as a physical therapist. My employer is opening a new clinic in northern Wisconsin that also has a rehab staff member onsite, so I'm here finalizing the set-up and training the new staff member.

I blogged last fall about my first experience traveling and I'm much more prepared for this trip than I was for my first! My hotel room this week has a kitchenette in my room, which is making the whole week better already. I'm able to cook for myself instead of relying on eating out every night. It's hard to believe how much of an impact that factor alone makes, but I really do feel groggier and more lethargic when I eat out for three meals a day compared to making my own meals.

I'm also much more prepared for the nights. My first time traveling I didn't really think about what I'd do when the workday was over, and since I was alone I ended up just working until I went to bed. By the end of the week I was completely burnt out, and who wouldn't be after working until almost 8 p.m. every night? This time I brought magazines, books and some exercise clothes to have something to do when I'm done working at the end of my day. That way I'm not working late every night. Those things along with my kitchen are making this a pretty good trip.

Last year, I read and blogged about a book called The Corporate Lattice by Cathy Benko and Molly Anderson. It's been some time since I read it but I still think about the common theme of the book -- that a variety of experiences across multiple areas builds a much more powerful knowledge base, and ultimately a stronger employee in the changing world of work. Thinking about that makes trips like this (to northern Wisconsin, during winter) a little more tolerable because I'm learning more about the business of physical therapy and building more relationships with people outside my regular clinic.

I'm challenging myself to think about problem-solving and organization outside of patient care, and in the context of setting up a new clinic space I force myself to think about the entire patient experience. If I was a patient, where would I want to sit in a treatment room? Where should the table be positioned for the greatest ease for both the patient and the clinician? I'm thinking about the parts of physical therapy I haven't really given much thought to in the past.

What about you? Have you been involved in opening a new clinic? If you are a private practice owner -- what was the most difficult part of establishing the physical properties of your clinic space?

I worked with a therapist last week (setting up a new clinic in northern Wisconsin) who has many years of experience in PT. It was interesting to work alongside him and see his approach to patients and the sometimes immediate results his patients had with his effective treatment style. We had some time to discuss and a few conversations about mechanical pain (within the joint) versus soft-tissue pain and the differences in treatment style based on the therapist's interpretation of the source of the pain.

We learned about different sources of pain in school but I didn't recognize my own bias toward soft tissue until I had this discussion this week. We started talking about a patient with plantar fasciitis and I ordered some sensory stretching cones made for stretching plantar fascia for our new clinic (I often use the cones to have my younger patients jump over objects too). When I treat plantar fasciitis I usually include ankle ROM exercises, dorsiflexion stretching, modalities (ultrasound and iontophoresis) and some soft-tissue release along the calcaneous and medial arch.

My new therapist explained to me his approach to correcting plantar fasciitis was to have the patient stretch into end-range plantar flexion, three sets of 10, comfortably. He said the most important components are stretching to end range and repetition. He told me that most patients can toe-walk comfortably but have pain with heel walking (and pain in the morning), so he has them try heel-walking after each round of end-range plantar flexion stretches and usually sees a fairly substantial improvement in symptoms.

Hearing this treatment approach was somewhat unique as I don't believe I've ever heard anything like it previously. The therapist explained some of his education under the McKenzie model of treatment and his experience seeing its effectiveness. I was introduced to the McKenzie treatment as it relates to back pain in school, but have not learned much about it since then, and know almost nothing about the approach as it relates to peripheral joint pain. What about you? Have you taken McKenzie courses or are you certified?

Stories like these make me appreciate the opportunities I have in my job to travel to new locations and work with a variety of therapists who all have skills or talents to learn from. I'm anxious to see what it is I'll be learning next!

I'm getting a little bit nervous. The course is four hours and focused on the practice of physical therapy in an intensive care setting, which I haven't practiced in for about six months. Since the time the class was set up and canceled, I transitioned to outpatient practice and my ICU skills have likely diminished in that time. As I look over my notes and the presentation for the course, I'm slowly remembering all the components and important factors to review. I'm getting excited as it gets closer and closer.

I love teaching. I love teaching my patients and find that to be one of the most rewarding parts of my profession. This opportunity to teach other clinicians is an extension of that passion. I was lucky enough to find three other talented therapists willing to teach this presentation with me, and together we've compiled all of our experiences and knowledge into this great course.

What about you? Have you ever taught a course before? What makes a clinician a good resource and teacher for continuing education coursework?

"Success is achieved by developing our strengths, not by eliminating our weaknesses." -- Marilyn vos Savant

I just finished my performance review for 2012 at work. It's actually an enjoyable experience for myself as I like reflecting on the previous year, looking forward to the potential of the upcoming year and receiving feedback to make myself better. During my first few years as a physical therapist, I absolutely dreaded hearing anything that could be perceived as criticism, but now I seek out those learning experiences.

The final part of my performance-review process includes writing goals. Now, earlier this year I wrote two blogs about my own professional goals (I called them resolutions) for 2013, but that was more of a generalized area I could improve on. So, I scanned over my performance review and targeted the two or three lowest points I could find and started thinking of ways I could improve. It was just instinctive -- the areas I scored lowest on clearly have the most potential for improvement, right? Eh, wrong.

As I was scanning over my goals, I remembered my business teacher and a few books I've read, including Now, Discover Your Strengths by Donald Clifton and Marcus Buckingham, which emphasize growing your strengths further instead of focusing on your areas of weakness. This makes sense to me, but I find it difficult to implement. It makes sense that instead of taking something below average, for example, and making it average, it's more beneficial to take something that's average or above average and make it even better. I'd rather have a few really strong areas than a lot of average areas.

The problem I run into is not knowing how to make my strengths stronger. I'm very organized. I have spreadsheets and folders for everything, highlighters galore. I'm very good at keeping track of things. But, how can I make that better? How can I take something that I'm already very good at and be even more skilled in that area? That's the part I haven't figured out yet. I think it's somewhat easier in terms of specialization.

Clinicians who are good at treating a certain diagnosis can take more courses and hopefully see more patients to become an expert specialized in that area of patient care. I think the part that I'm stuck on is those soft skills -- organization, patience, listening, leadership etc.

What do you think? How do you develop your strengths? Do you give any thoughts to your areas of "weakness" or is your professional focus only on your strengths?

There are a few different perspectives to consider when thinking about physical therapy data -- what would you want to know if you were a patient? What would you want to know if you were a business owner? And finally, what would you want to know as a therapist? I've thought about all the possible measurement tools over the past few weeks and have come up with this list:

1. Measure therapists on their efficiency, or the number of visits per evaluation for a patient to be discharged from care. This seems simple enough -- a skilled or talented therapist will be able to help patients in a shorter amount of time. This measurement doesn't account for the number of patients who self-discharge from care, or the number of patients who are seen for an evaluation only.

2. Measure how many patients reach their goals. Our primary role is to help our patients reach goals that they have deemed most important, but part of this measurement tool depends on writing appropriate and achievable goals.

3. Measure patient satisfaction. I've read a few articles on how higher patient satisfaction is linked to higher-quality care, as engaged patients are more likely to listen and participate in their care. (I wrote about this recently).

4. Measure improvements based on outcome measure surveys. As a therapist, I think this is where our profession is moving toward, but this is also the most difficult to capture. Clinics need to have the right software in order to track outcome measures.

5. Measure productivity. This is probably the most common measurement tool in the physical therapy world, partly because it's an easy calculation to determine. Like I've mentioned before, I think this is a little bit of a dangerous tool because therapists measured by productivity alone can be driven to improper billing in order to improve their productivity data.

6. Measure number of referrals received. This is an important piece of data for understanding which therapists drive volume and business through the clinic. The truth is that talented therapists with good outcomes will attract more business by word-of-mouth referrals, and that's something all business owners will want to measure.

As many of these measurements include (to some extent) the patients (their outcomes, their length of stay), it's important to remember aspects of each patient that may influence the measurements. For example, if a patient isn't motivated or especially participatory in his care, it may reflect poorly on the therapist even though it's a factor that can't be entirely controlled.

What do you think about this? What do you want to be measured on? If you were a patient, what measurements would you consider before choosing a physical therapist?

The clinic I work at is busy. Every available appointment is booked for the next week and a half. As patients call to schedule an evaluation and I realize the volume of patients that need to be seen for rehab, I start to wonder when the time is right to add more staffing. I found a few articles online discussing the business and staffing of PT clinics and many seem to have similar themes on making the decision to add another employee position.

1. The current staff must maintain a full caseload (40-50 visits per week) for approximately eight weeks.

2. The number of days a patient waits to be seen for an evaluation is greater than two to three days.

3. If possible to monitor, estimate how many patients that should be seen three times per week are actually being seen one or two times a week.

Each of those points makes sense to me. Patients who can't get in for an evaluation within a week will go somewhere else to receive their care. Compromising a patient's frequency for therapy will ultimately compromise his outcomes and results as well. I'm sure there are other indicators in addition to these three, but they seem to be the easiest to calculate and monitor.

The process of recruiting staff can take time. Posting a position, scanning over resumes, interviewing candidates, extending a job offer and waiting for the individual to start can take months. That's why it's so important to monitor your clinic's volume for any of the signs that staffing may be needed, because once you need another physical therapist to take on patients, you need that person now.

Are you responsible for monitoring volume and subsequent staffing needs at your clinic? What do you measure to support your decision to hire additional staff?

February is American Heart Month and as we see more red-dress pins and other symbols recognizing the impact of heart diseases, I thought this would be a good time to review the signs and symptoms of two major pathologies impacting our patients' health: Stroke (cerebral vascular accident) and heart attack (myocardial infarction).

Cerebral Vascular Accident

To screen for a stroke, think "FAST!"

F: Facial drooping. Ask your patient to smile and watch for facial symmetry.

A: Arm weakness. Ask your patient to lift her arms, including making a fist.

S: Slurred speech. Listen to your patient, and assess her ability to enunciate and find the right words.

T: Time. Note the time that you first noticed the signs and call 911 as soon as possible. The sooner the better, as many medications to aid in recovery are only effective within the first few hours after the original injury.

Myocardial Infarction

Signs and symptoms vary somewhat between women and men during a heart attack; however, there are basics to watch for, including:

● Chest tightness or discomfort.

● Shortness of breath.

● Pain or discomfort in the upper body, such as the shoulder, arm, jaw, back and neck.

● Changes in heart rate.

As physical therapists, we have the unique ability to screen for warning signs of heart disease during each of our interactions with patients. And, even greater, the information we share to empower our informed patients spreads to their families and friends. Take time this month to educate those around you about the signs of these two cardiac pathologies. Finding the warning signs early can make all the difference.

How often do you screen patients for pathologies such as these? Have you heard of any unique warning signs that don't fit the traditional descriptions?

I'm right in the middle of reading The Tipping Point by Malcolm Gladwell. It's a pretty interesting book about how very small changes can result in big outcomes. He writes about small changes impacting huge reductions in crime rates, fashion trends and even political race results. This is the second book I've read by Gladwell, and I enjoy his writing style and content tremendously.

The chapter I just finished addresses the concept of how our external environment, or context of a situation, influences our internal decision-making. The book is loaded with studies, experiments and other evidence supporting Gladwell's writing. For example, he writes about how a person is more likely to commit crimes in a subway car vandalized with graffiti than a clean subway car (based on crime studies in New York City in the 1990s). He also describes a study where children were more likely to cheat on homework and exams in some situations, but not all. The basic morale of the chapter is that the environment (vandalized subway car or homework setting) is more influential in our actions than our internal character (being a criminal or a cheater).

While I don't want to make this blog a psychological microanalysis, I do want to consider how this concept impacts our work environment. Our primary role as physical therapists is to promote healing and reduce pain. How does our environment facilitate that? Are you able to adjust the environment around you so your patient is comfortable?

Factors such as space design, paint color and even the space available within your treatment room are difficult to change. But what about music or the noise within the space? What do your patients hear while they're working with you? Do they hear bed alarms or a beeping IV? Do they hear other staff talking about their weekend plans? What is the temperature of your space? Too hot or too cold?

What do you think? Does the environment of a physical therapy facility play a role in our patients' recovery? What do you think is the best environment for rehabilitation?