I took three courses of philosophy during my undergraduate years and never really got into it. I'm not even completely sure I understood the phrase, "the end justifies the means," until I was a little older. Experiences added up and I learned how to focus on the end result to get through the process, and like an "aha" moment, I finally got it.
I'm in the age of family planning. It seems like every week another acquaintance is sending photos of baby bumps and due dates. I remember working with a patient right after graduation who told me, "Don't worry, there's still time for you," when she learned I didn't have kids, and that was five years ago! I had dinner with friends a few months ago who told me that after years of trying, they wouldn't be able to have kids. My friends had other options, such as adoption, but the bottom line was if she wanted to carry her own children, she would (at the direction of her OB) need to try IVF treatment. And there it was -- the ends justifying the means.
I've seen this happen in physical therapy practice occasionally. I educate my patients on their treatment options, collaborate on a plan of care ("the means") and establish together the goals ("the ends"). Some patients decide that the ends justify the means, and others don't. For example, a patient wanting to walk again may decide the hard work of pain with weight bearing, the challenge of balance training, and the difficulty in learning eccentric control is worth the end goal of ambulation. Another patient may see the same process and determine he cannot tolerate the means to achieve the end.
Our role as physical therapists is simple -- help support, educate and guide our patients during the healing process to get to the end. We have the education and experience to see our patients' goals before they're able to visualize their own success, and our jobs require us to remind, reinforce and facilitate our patients as they work through the difficult processes of changing the way their bodies function.
What do you think? Do you have patients who struggle through the process of change, only to be pleasantly surprised by the outcome? Do you have to educate your patients on why the ends justify the means?
One of my student clinical rotations was at a smaller physical therapy outpatient clinic with just three staff members who managed all aspects of the operations. They all worked seamlessly together and the patients had a lot of fun during their appointments, partially because their therapists were very knowledgeable about every aspect of the business. As I think about that facility now, I have even more respect for those therapists than I appreciated when I worked alongside them.
When I interact with patients, my brain is focused on every component of practicing physical therapy. I consider differential diagnosis, muscle fiber length-tension relationships, observing my patient's response to changes in position and palpation... all of the factors that go into successful treatment. It's not easy for me to switch from that kind of thinking, to say, billing cycles or scheduling equipment calibration. The group I worked with in school kept track of all the billing, scheduling, staffing, ordering of supplies, as well as paying the building rent, electrical bills and insurance coverage. This is what a lot of private practice physical therapists take on, and I am impressed.
Many times we are asked to wear additional hats at our jobs. There are other components of physical therapy practice that extend beyond patient care and need to be completed, whether the setting is private practice or a large organization. Each of these parts are equally important in setting the framework to provide excellent patient care. We aren't able to treat patients without a building to practice in, equipment to use, and systems to collect payments, for example. I imagine the variety of responsibilities may be overwhelming for some physical therapists and stimulating for others.
Are you asked to assist with maintaining the equipment in your facility? Do you participate in patient billing? Do you work closely with the landlord of your facility, or schedule fire marshal inspections when needed? How do you balance the multiple hats you wear? How do you multitask your multiple responsibilities?
When I was in my outpatient neuro clinical rotation I learned a lot from my instructor about PNF skills as well as standing, kneeling and seated balance training. It was a lot of hands-on work and we didn't use a lot of equipment other than parallel bars and balance pads, and a mat table. The clinic set-up was simple yet effective; patients had what they needed but not a lot of high-tech gadgets I've seen at other facilities.
After graduating from physical therapy school, I became very familiar with budgeting. Every dollar had a place. That same budgeting concept probably applies to every physical therapy clinic. How do owners, supervisors and physical therapists prioritize their equipment needs? My style of treatment and the equipment I need to practice effectively may be very different from my colleague who requests entirely different supplies for her patients. What is the best way to mediate those differences so all patients have what they need during a physical therapy appointment?
There may be ways to offset an immediate equipment need, but it's also difficult to substitute for some supplies when you don't have them. Parallel bars offer a lot of functionality that can't be easily mimicked if they are needed by a patient. The best example I have of needing equipment at the right time was when I assisted patients with gait training in an inpatient setting and my patient was ready to transition from a wheeled walker to a cane. Finding a cane was somewhat difficult because they always seemed to be propped in a corner of a patient room, so I often used my hand as assist although this wasn't the same as the patient handling a cane independently.
This topic of equipment also ties in with the "lean" concept I wrote about two weeks ago. How do we make sure our clinics aren't wasteful with equipment and supplies? How do we remove excess or unnecessary equipment from our clinics? And, how do physical therapists think when budgeting for equipment and supplies? Do we invest in what patients need, in what we can market, or in both?
Have you read ADVANCE blogger Allison's post this week about her first resignation from a physical therapy job? It sparked a lot of comments (mostly about the PTA role), but it also got me thinking about her comment on "greener pastures."
We all often consider the pros and cons of various employment opportunities, like any other profession outside of physical therapists. I remember two years ago thinking about my commute time, skills I would be able to practice, scheduled hours and my colleagues when I made the switch from inpatient to outpatient. Now as a rehab supervisor, I'm much more conscious of the rehab team's engagement, morale, and overall satisfaction with their jobs. Patients like to be cared for by therapists who like their jobs. We've all had experiences with an unhappy staff member in any setting and know our experience as a customer or patient was impacted.
My mom recently told me, "The grass is greener where you water it" -- a saying I'm sure she heard or read from someone else. Does this ring true to physical therapy jobs? Can physical therapists invest time and energy into making their own job a place they want to be?
When I first started working as a physical therapist, I was so motivated and felt such a surge of independence -- my years of education had finally culminated in an actual profession, including a job which gave me a paycheck! I was so excited to work, I didn't really stop. After about a year-and-a-half I was very burnt out. My energy was gone, I had a hard time concentrating and an even harder time connecting with my patients as I normally did. When it happened, I was surprised and felt badly because I knew my patients deserve better than that. It was a good learning lesson for me -- to recognize the signs of over-working so I could take a step back and pace myself.
What do you think? Are you a happy employee? What do you do each day or week to make sure you stay balanced? If you don't get what you want or need from your job, what steps do you take to get it?
When I worked at the hospital, there were times when I needed to grab linens for my patients during our physical therapy sessions. Gowns, towels and even bed sheets were frequently changed. The hospital floors each stored linens in a slightly different manner to fit the best workflow for their staff -- some linens were kept in cupboards outside each room, some in centrally located carts, and some in the patient's room. I remember a handful of times where I spent easily 5-10 minutes walking around the hospital floor, opening cabinets and peaking behind doors to find the linen storage, and to find linens that were stocked.
It wasn't until I started at my current facility that I learned about the concepts of "lean" and "continuous improvement." What is lean? Well, I'm not an expert, but my understanding is that lean assesses workflows to make them more efficient. One example I've been told is rearranging equipment (such as fax machines or copiers) to a location where it's more accessible. Instead of walking 9 seconds to the machine and 9 seconds back to your workstation, arranging desks and the machine so the average walking time is 4 seconds, gaining 5 seconds per fax transaction, that over time will become time to be spent with patients.
Looking back at my experience in the hospital, I recognize the linen storage wasn't the most resourceful. Why weren't cupboards labeled, or signage posted to find linens? Did other staff spend as much time as I did looking for supplies, and how much cumulative time was spent away from patient care in tracking down items? It would be interesting to see a "before" and "after" to demonstrate how changes to simple things such as adding a label to a cupboard equates to improved staff morale (having the tools to do your job, feeling empowered to find what you need) as well as increased patient time.
This makes me wonder if lean or continuous improvement processes will become common language in physical therapy. If you were to open a clinic today, would you consider the lean perspective in how you set up your practice? What has your experience been in continuous improvement?
I remember my neurology professor at physical therapy school would frequently joke that her friends didn't understand what type of work she did. She would say "physical therapist" and they would assume orthopedic injuries and ask for help with their necks, backs, and other musculoskeletal concerns. She would politely correct them and explain her focus on traumatic brain injuries, spinal cord injuries and strokes, and encourage them to find a physical therapist with the skills to help.
This happens to me occasionally, but not frequently, and I'm usually able to find a resource for my patients. For cases needing a women's health or significant hand rehab, I have community contacts for patients. Within my own department and network of colleagues, I know the experts on vestibular treatment or rib mobilizations I can connect with for refreshers when I'm a little rusty on my skills.
But, what happens when you have to say no? I recently had a friend from high school email me asking for advice for treatment for her child with ambulatory deficits due to a congenital disorder. She and her family live in a rural area in Alaska with no nearby options. I shared her story with some of my pediatric physical therapist friends, but we all agreed the case was too complicated to discuss remotely. We considered using FaceTime or Skype to provide some solution, but the child's needs required hands-on care.
I felt terrible. A big reason I chose to become a physical therapist was to help other people, and this felt like a major failure. It was hard to know the child needed help and I knew physical therapy could help, but couldn't provide any intervention. My friend responded with, "That's okay, I understand," but I still didn't have a good feeling about how the story ended. How do you handle cases like that? When you have to tell patients you cannot treat them, what alternatives to you provide? What's the best way to promote physical therapy when our specializations may leave us limited in scope.
Over the past few months, I've heard more and more about the patient-centered medical home (PCMH) model of healthcare. I typically think about healthcare models in the silos my physical therapy clinical rotations were centered on: inpatient, outpatient, or a skilled nursing facility. The idea of healthcare facilities as a "home" elicits a nostalgic and sympathetic response for me -- at last! Healthcare can be a collaborative home instead of an insurance-led, difficult-to-navigate entity.
So, what is a medical home? The idea started in the late 1960s by the American Academy of Pediatrics and has seen serious development in the past 10 years. A PCMH is a team-based delivery model led by an MD, PA or NP to provide comprehensive care to patients. The team facilitates continuity of care (majority of appointments are with the same provider/team), follow-up on referrals, full accessibility to care, and the use of evidence-based guidelines to improve quality of care.
As a physical therapist, I think this model sounds wonderful. Too often patients seem to get lost in the gaps of care and a home model may prevent those lapses. Being able to work with a patient and report my clinical findings right back to the patient's care team is how healthcare should be delivered. I think this works well in an inpatient setting already, but in outpatient there are physical and operational barriers to working as seamlessly together.
Several news outlets last week reported on recent study outcomes of the medical home model, with disappointing outcomes in reducing costs or improving quality. The studies compared 11 quality measures over three years and saw improvements in only one for the medical home models.
I'm interested to see how the medical home model evolves over the next few years. What do you think? Do you practice in a medical home? Do you see improvements in patient care compared to traditional models of healthcare practice?
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?