My friends and regular readers of this blog know that I rarely shy away from confrontation. If I see something that I believe is a problem, I point it out. When I was a rehab manager, I depended on my employees taking this approach with me as well. I had worked for a large company and it would have been impossible to see all the potential problems that could plague the department down the road. It also helped keep my own thought processes in check... as well as my ego. I think questioning things is healthy.
One of the reasons I'm no longer happy in the position I'm leaving behind is a culture that's the polar opposite. Questioning is frowned on and upper management seems to only want to hear support for their own agendas and opinions. It's ironic that they've just begun to implement a shared governance program. As I'm winding down here, I simply say "yes" with a smile. My investment is over and my potential to have a positive impact on anything is nil.
Why does upper management behave like the emperor with the new clothes? Are egos really so much more fragile at that level? Having someone who is unafraid to say, "Excuse me, but you're heading for the edge of a cliff!" would seem like an asset to me. Being a team player doesn't mean always saying "yes." It means working for the best outcomes for everyone, especially the patients.
I went off to that job interview in England last week. The employer was adamant that the date could not be changed and an internet interview was out of the question. I knew that they couldn't tell me my chances over the telephone, but I asked how many people had been short-listed. Only three people had made the cut. I had to make a decision on whether to spend a hefty sum for airfare and go to the interview or to sit it out. I went.
The interview process consisted of meeting with senior members of staff, along with the other candidates. That wasn't so bad, it gave a chance to sum up the competition. Later there was a tour of the facility where it was disclosed that not only would the post involve working in the Accident and Emergency department (as advertised) but also supervising the physios in 9 other wards, including ICU (not advertised). I haven't worked in an ICU in nearly twenty years! "How did I get shortlisted for this post," I wondered? Is this a job I would want at this point in my career, among managers who clearly had a difficult time being upfront?
Finally came the actual interview in front of a panel of four people. The questions were inane. Someone finally asked me how I felt about working in the unadvertised ICU. I admitted that my skills were probably not up to par in that area. There was much "tut-tutting" among the interviewers at this point. They thanked me for my honesty (I think we all know this means I didn't get the job).
I'm angry. My CV clearly states the time frames of where I worked in each position. It was clear from the start that I wouldn't have met their needs-if they had actually read my CV and had advertised the job accurately.
Back at our flat, my partner and I commiserated about the whole thing while cooking dinner together and sharing a bottle of wine. It was then that I realized I had made the right move coming back for the interview. The interview tanked, but it made me appreciate what was really important...coming home.
Things are winding down here in NYC for me. I've just returned from a holiday in Italy to celebrate my 4th wedding anniversary. I was looking forward to coasting along for the next month. Ah fate!
I landed late Wednesday night and awoke early Thursday morning, still on Rome time, to discover that in my inbox there was an offer to interview for a very promising position in the UK! One little problem, the interview is in five days! I really didn't plan on crossing the pond again that quickly (or with that expense!). I called and requested either a Skype interview or rescheduling. That was not an option. There is an interview panel of five people who are all available only on that day.
This is a post I would really like, team leader working in emergency medicine at a large acute-care hospital. Full of new and exciting challenges! I booked my flight and will return right after the interview. There's still work to get on with back here in the US after all!
There was another interesting part to the interview, an "In-tray" exercise. Have you ever heard of this? I hadn't so I went online and discovered it is a test of relatively real-world abilities to prioritize, delegate, manage and respond appropriately while ignoring irrelevant or extraneous information. Here is an excellent description.
So this weekend will be a few days of packing, practicing "In-tray" exercises, reading up on the specific hospital I'll be applying to, as well as the population in the area, and trying to not recover from jet lag so that I'll already be on UK time when I interview. I'll let you know how it goes.
I've talked a great deal about the myths and realities of working in a foreign country for the past four years in this blog. Many people have presented me with the argument, "If healthcare is so great in other countries, then why do so many foreigners come here for care?" Until now, I've only been able to provide anecdotal responses of my experiences working in New York City, which would be a likely spot for medical tourism. An article came out in this weekend's New York Times demonstrating that actually, the trend is exactly the opposite. US citizens are traveling abroad for their care.
This highlights what APTA President Paul Rockar Jr., PT, DPT, MS, voiced earlier, that we must demonstrate value in our services. If people can get equally good treatment in another country and pay significantly less, including the airfare, then why should they stay here? The article showcases an elective joint replacement where the patient stays in Brussels for an extra week for rehab. There is no mention of rehab upon return to the United States.
Knowing the business of healthcare, not just rehab, is imperative for survival in this rapidly changing environment. I'm encouraged by fellow ADVANCE blogger, Mike Kelley, committing to read the Affordable Care Act. To quote his previous blog, "Knowledge is power!" It is time we all become empowered or we might be watching our business take flight across the pond.
I resigned from my job today. I've decided to return to England and resume working there. It's a little unnerving to be of a certain age, unemployed, and with nothing waiting in the wings professionally. I've already started applying for positions in the NHS. I hope something will come through relatively quickly. Any professional post in the NHS requires a criminal background check, so even if offered a position, it will be at least a month before actually starting. I still believe I did the right thing.
My meeting with our new director today gave me the perfect opportunity to have a conversation about leaving at the end of August. It was no secret to most people that I was not fulfilled in my role and I was missing my spouse... a lot.
I mentioned in a previous post that I too felt the frustration of my experienced blogger colleagues. I'm at a point in my career where being confident that every day I will do something to better someone else's life or ease discomfort is most important to me. I'm also at the age where I watch family and colleagues try to navigate the mayhem that is Medicare and think, "That will be me before long!"
I've watched relatives with sufficient funds for excellent private care decline rapidly because of substandard treatment. Their savings exhausted in the process. I posted a few years back that nobody in Britain has ever lost their home due to unpaid medical bills. Frankly, after observing the quality of care received by family members here in the US, the NHS does it every bit as well, if not better in some cases. Single-payer universal coverage better fits my personal ethics.
I've decided to stop bashing my head against the wall here.
Many readers of my blog know that I spent a significant period of time working in the National Health Service (NHS) of England and returned to the US last September to work with a former employer. That required resuming a long-distance relationship with my spouse who is a university professor in England. It has been most unsatisfactory.
Which? Both. I haven't been able to realize my potential in my current role for a variety of reasons, most outside of my control and which I'm prevented from writing about in this blog. Maintaining a relationship across an ocean, although made doable with things like Skype and FaceTime, is ultimately not what I wanted when I got married.
Last week the NHS came out with a new publication, "The NHS belongs to the people." There was one sentence in it that really struck me: "we will not contemplate cutting or charging for core NHS services -- NHS England is governed by the NHS Constitution, which rightly protects the principles of a comprehensive service providing high-quality healthcare, free at the point of need for everyone."
This is my personal belief about health are. I do believe that it's a right, not a luxury. I want to work in that environment again. I'm discouraged about the future of healthcare here in the States and also about the health of the people of the US. I don't feel like I'm going to have an impact here.
It's time for me to return to my spouse, my life and my passion. I have a ticket home in early September.
Reassessment is something we do daily with our patients. Are we making progress toward our goals? Are our chosen techniques having the desired effects? Are we going to achieve the desired outcomes or do we need to change course? The same could be said for our careers.
Nearly a year ago, I returned to the States after obtaining a new degree with the hope that I could have a positive impact on the people in my state. I was hoping to meet new challenges and apply new skills. I have to say that I don't think I'm realizing my potential in this post. In any situation, one has to reflect on the role he had to wind up in the situation in which he finds himself.
In truth, there were some situations where I could have handled myself more diplomatically, but on the whole, it's the combination of unfortunate circumstances and corporate culture that has put the entire company in its current state. I'm not seeing a role here for myself anymore.
In the three years I worked in the National Health Service (NHS), I grew immensely. I didn't appreciate it at the time. I was too close to the situation. I found that I'm no longer in sync with the way healthcare is run here in the States. I find myself banging my head against an unyielding wall.
Now the question is, how much longer do I want to keep doing that?
I've seen some interesting responses to some of my fellow ADVANCE bloggers' posts as of late. I've seen people suggest that they look for other careers, they negatively impact the profession, and they should essentially stop expressing their dissatisfaction the way that they do. I wonder if the people sending those responses have really sat down and contemplated why some of the bloggers have expressed things the way they have; a root-cause analysis perhaps?
I must confess, I once responded very inappropriately to a fellow blogger and had to send a letter of apology to that person (which was deserved) so I'm no saint on this topic, but I hope to have learned from my mistakes. Also, I've been feeling more negative myself as of late.
After hearing the comments and vision of the current APTA leadership, I'm somewhat encouraged by the direction they want to take the profession. However, working in a corporate environment, I'm seeing the harsh reality of what it's like to try to think and work outside the box of short-term financial gains. I say my fellow bloggers have every right to be angry! I'm angry. I can recall a time when I had time to spend with my patients in rehab and home care. I can recall a time when I didn't have to defend the most basic of treatments over and over again to managed care companies staffed by bean counters. I can recall a time when experience and expertise led to promotion, not an inability to get a job.
I say it's our responsibility to speak out when we feel something is unjust or the profession isn't being upheld to the best standard. Only by being outspoken might change occur. So for my colleagues who have been "negative" as of late, I salute you and join you.
We are finally learning to embrace evidence-based practice (EBP) as a way of life in healthcare. Before we develop treatment plans, we ensure that there's robust support for the techniques we choose. That is fantastic, when there is sufficient evidence. What about when something hasn't been examined enough yet? Does that mean a treatment or a behavior shouldn't be utilized?
I'm currently looking at care management delivery. I've been able to find evidence that support care management is successful in improving health outcomes. There are also articles that support the need to develop indicators as to the behaviors and interventions that make a good case manager. I haven't found any that actually talk about specific indicators. It's a bit like two decades ago in physical therapy. We knew it worked, but not necessarily which interventions were the ones responsible for those successes. Some of those interventions have held up to scrutiny, others not so much.
The current state of care management is where physical therapy was back then. We know it works, and we have some ideas as to why, but there aren't validated indicators to support the actions care managers perform. For me, this is a good thing. I'm getting to do some exploratory work, interviewing, chart reviewing and some statistical analysis. I hoping my results will drive the education of care managers, including physical therapists, for the future. I'll let you know how it goes.
Last week, I watched the four-part video series on the ADVANCE website where Paul Rockar Jr., PT, DPT, MS, and current APTA president, talks about the challenges facing the profession. He is spot on, in my opinion, and a reasonable, rationale voice in terms of what is needed right now. I strongly encourage a listen if you haven't heard him in person. He voices repeatedly the need for the profession to prove the value of what we do. This need was verified this weekend.
I was visiting a relative in Florida and spent a morning in the community pool. As usual, the chatter among the attendees focused on healthcare. For a change, it was all about physical therapy. People were sharing their "nightmare" stories about PT. I was tempted to jump in right away, but then I thought I would shut up and listen.
"I was left alone on a table for half an hour. When someone finally came in and asked how I was doing, I said I was leaving. They said they were short-staffed."
"I had physical therapy for my ankle. They didn't do anything! They iced it, gave me a sheet of exercises and sent me home. I could've done that!"
"They put my hand in this warm sand thing. That was it. What was that for?"
"My wife hurt her back. The last place I'd ever take her is physical therapy!"
"They don't do anything, really."
"Useless, totally useless to go to PT."
This wasn't just one practice being discussed; it was the profession on the whole. Five people, each with a bad story about physical therapy. Granted, the pool chatter can be a game of who can outdo each other's story, but this wasn't who can top whom. This was unanimous.
I think we need to heed Mr. Rockar's advice.
I've written before about the trend in the UK towards triaging all and treating some patients with musculoskeletal complaints over the telephone. I've been very skeptical of this approach to the problem of access to PT services. By its very definition, we're removing the "physical" from physical therapy.
A new paper came out last week in Physiotherapy 99 (2013) 113-118. This paper talks about the randomized controlled trial (RCT) underway (ISRCTN55666618), which is sponsored by the Medical Research Council (MRC), one of the primary research and funding bodies in the UK. The RCT is still ongoing, but this paper focuses on how the physiotherapists were trained to participate in the RCT and some of the discoveries made during the process. No determinations have been made yet about clinical or cost-effectiveness.
As one would suspect, the physiotherapists involved required a greater level of experience and a significant amount of training in order to deliver the protocol prescribed. I must add that current practice is to place Band 5 (new graduates) in these roles.
Why should you care? The results of the RCT could seriously alter the way insurers will cover our services and the rates of reimbursement. We may not be able to see and touch our patients for our first evaluation, but rather be restricted to a telephonic assessment. It could also open up services for patients who have difficulty accessing care in rural or other environments.
Based on this, where do you stand on the idea? Are you ready to talk about it with the APTA? Insurers? State representatives? Maybe you should be.
A few months back I blogged about how Gretchen Reynolds, the New York Times fitness writer, was doing a job that might be better done by a physical therapist. I've been reading her column fairly regularly and the responses from other readers are often more enlightening than the original articles themselves.
One arose today that made me confident many outpatient practices will thrive based on the misinformation about our bodies that abounds out there. This time the question is about stretching.
I'm particularly curious about her statement that "joints stiffen again within an hour" after stretching. Really? The capsule reacts that quickly? Stretching affects the capsule, does it? I hoping that she is disrespecting the intelligence of her readership and "dumbing down" her writing and that she doesn't actually believe that stretching and joint mobilization are the same things. She quotes studies but doesn't reference them. This infuriates me. There's no way to assess the validity of anything she says, but lay people may follow her writings because she mentioned a "scientific" study.
The responses from her readers are encouraging, with many voicing doubts about her statements. But what about the many who read her and take the information at face value? What role do we, as a profession, have in addressing pop fitness gurus who have the potential to do great harm (or great good if they had some advisement from the likes of a physical therapist)?
If pediatrics are your specialty, fear not. The New York Times has an equally unsupported article on "Tummy Time" and the normal development of babies.
A report from the Commonwealth Fund was just highlighted in the press. It's a remarkable comparison of healthcare costs between developed nations. It shouldn't be surprising that the United States spent more on health care per capita than any other developed country.
Unfortunately all that spending is not resulting in superior quality of care. The author essentially claims it's the prices (not necessarily the costs) that are bankrupting our system of care. For instance, Lipitor costs $124 in the US but only $6 in New Zealand while a hip replacement is $40,000 in the US but only $7,700 in Spain. Why should you care?
There's a finite amount of resources to be used for healthcare. If someone is spending more for his prescriptions, that leaves him less for physical therapy. If an insurance company pays more for an operation, it has less to allocate to rehab. As a profession, the very people and services who we're supposed to cooperate with are also our competition.
It's important to know why our prices are so high. One of the areas examined is physician salaries. US doctors earn more than any other nation. They also have higher expenses. In the UK, medical training is highly subsidized, therefore doctors don't have crippling debt upon graduation (nor do the physiotherapists). Our doctors have to charge higher prices to pay loan and malpractice insurance. So if you're tempted to think that the cost of Lipitor doesn't affect you in any way, it's time to re-examine that attitude.
A very important ruling came out February in the Jimmo vs. Sebelius argument. It clarified that improvement of function is not a requirement for Medicare reimbursement. Rather it's the need for skilled services that determines whether a claim is reimbursable. If a skilled service is required to maintain function or prevent decline, then according to CMS it's reimbursable.
This is incredible news to those who struggle with chronic and/or progressive conditions! For those with MS, Parkinson's, ALS, and even COPD, they no longer have to suffer through a remission in order to receive services that may prevent, or slow, their deterioration. From a public health point of view, this is brilliant preventive action.
Unfortunately I've heard stories of clinics, skilled nursing facilities and home care agencies still discharging people because "they're not making progress." In some cases that may be legitimate, but I'm sure others include those who could still benefit from maintenance interventions. As professionals, we'll be charged with sorting out who needs skilled maintenance and who simply needs an aide to assist them with walking or doing a home program. Based on some of my ADVANCE colleague bloggers' tales of pressure to keep inappropriate people on caseload, I can see this becoming a bigger challenge now.
It's good to know that we're empowered to give the right care, to the right people and be confident of our ability to be paid for it.
A friend of mine posted on Facebook today, "I've maxed out my health insurance deductible, in-network bills are on them now." What an interesting state of affairs when we're tempted to congratulate someone for being unwell enough to warrant full payment for health care costs. My only fear is that we're in May. What if they hit their maximum annual benefit? What then?
Since I've been back from England, I've been nickel and dimed for co-payments and deductibles. I've submitted claims for reimbursement and waited, and waited, and waited for those checks. Even with "good" insurance, one still has to have a significant amount of cash on hand to receive healthcare in this country.
The sad thing is that this is a luxury problem. So many people have no insurance at all.
What if I didn't have that money up front? Would I put off seeking care for some things? Probably I would. What if I put seeking care off for so long that I wound up in an urgent or emergent medical situation? It would cost the insurance company a lot more in that instance. It would also cost me a lot more too!
These payment challenges are not foreign to those of us in private practice. We often have to devote significant time and resources to billing and collection. If we don't accept insurance, our pool of potential clients is perpetually shrinking as the economy continues on its jobless recovery. How many patients elect not to seek a physical therapist's help or rely on the trainer at the gym instead? How many people could we prevent from injuring themselves or hasten their recovery if they didn't have to weigh the value of our services against their other needs?
Are we being penny-wise and pound-foolish with our approach to financing healthcare? I believe we are.