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PT and the Greater Good

A Culture of 'Don't!'
by Dean Metz

I was doing some research on a particular activity this week... head rolls. Not the soft round things one puts under one's neck to maintain the curve while supine, but the act of rolling the head around as an exercise or activity. I did this because I read an article in the popular press that said, "even physiotherapists say you shouldn't do head rolls anymore. They're too dangerous!" I thought about it, and although I haven't prescribed this for someone in recent memory (or at all that I can think of), I wanted to see if there was evidence to support the statement.

In terms of hard evidence, I came up with nothing. I did come up with pages of discussion on the topic from the members' section of the Chartered Society of Physiotherapy (CSP) though. Comments ranged from "Under no circumstances should anyone, ever do this!" to "If the body wasn't meant to move that way, it probably wouldn't." Granted, I probably accelerated the OA in my own neck by way too many Friday nights in the East Village of New York in the 1980s dancing the pogo and whipping my head around. Ah youth! There were a few reasoned discussions about athletes, dancers, and even jet pilots who would need to perform this activity to be able to function. Still a few physios held onto the belief that if an activity has any risk, it should be discouraged.

Since when have we become the profession of "Don't"? Shouldn't we be the profession of "Do... but do it right!" Our job is not to wrap every patient in cotton wool and tell them to avoid injury by avoiding doing things. Personal trainers, fitness "experts" and yoga instructors are teaching people how to keep doing things. (Oh, I just started yoga two months ago. Apparently I'm flirting with certain death according to some of the physios). These professionals may or may not be giving good information, but they are reaching the people we are not. Remember my post about working proactively and toward prevention? One good example of how we're not embracing that mindset on the whole.

So lets embrace, "I can help you do that better and safer!" whether it be a break dancer in the Bronx or a pensioner who wants to go shopping in Brighton. We are the ones for the job.

Do take my advice on the pogo though... don't revive it, it really isn't good for one's neck.

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What Part Will You Play in the Future of PT?
by Dean Metz

If you've read my last blog, which ranged from Facebook to Adweek, you may wonder what all that had to do with PT? Reasonable question actually. Physical therapy has the potential to impact greatly on improved health outcomes for every country. On the whole, we tend to be a reactive profession. We treat people once something has already happened. If we know best how to help people recover (which I believe we do), then why shouldn't we be the best to prevent injury and complications from illness?

We've spent a lot of time and money working to be more efficient, to get people better quicker, and to hone our skills to achieve those ends. Why don't we do the same thing for prevention? My cynical self says it's because there's no money in it. I suspect many of us wouldn't know how to begin. Some very well-meaning person may start a social media campaign... and we may wind up with, "If it's physical, it must be therapy!" (I'm glad we haven't seen those bumper stickers in over a decade).

I read my ADVANCE colleagues' blogs, and the responses to them, about how people don't really know what we do, or think we're glorified massage therapists, or worse, think we're useless (see my old post "Useless, Totally Useless"). Maybe the first step is to successfully heighten awareness of the good we do. Gretchen Reynolds, a fitness expert, writes weekly columns for The New York Times, many of them about how to prevent injury. Do any of you out there know of a PT who writes a column for a mainstream publication? Is it any wonder the public gravitates toward personal trainers, chiropractors and other more visible professions?

We can't depend wholly on the APTA to do that job for us either. Like the CSP here in England, they spend a lot of time and energy ensuring we can get paid for the work we do. Branding the profession needs to happen on a grassroots level. Letting the public know about what we do will take more than an e-blast or two. What can you do?

If you do nothing, don't complain if that bumper sticker starts being seen again.

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Public Health Campaigns That Work
by Dean Metz

A few years back, I was reading Facebook posts like this by my female friends:

"I like it on the floor."

"I like it on the kitchen table."

"I like it on the sofa."

This was an idea to get people wondering what everyone was talking about as a way to build awareness for breast cancer. What the women were doing was answering the question of where they put their purse/handbag when they came home. Clever, but did it serve its purpose? It was amusing, it caught people's attention, but did it raise awareness of breast cancer? Maybe among women in on the joke, but it resulted in a simple, "Oh, that's nice," from most of the people I know. Ladies, help me out here.

Did any of you who participated also go to a website and learn more about screening, or the signs to look out for, or actually give money to a cancer research organization? I took a fair amount of flack because I told some women friends that I thought it was the worst public health campaign possible. Why? Because it got people to participate in a way that made no difference, except to make people feel like they did something. My fear is many people would then think, "I've already done something for breast cancer this year," when really all they did was update their status on social media. Burnout with no turnout.

Compare that to the recent trend in the UK of no-makeup selfies. It probably won't happen often that my blog links to an article from Adweek, but there's a first time for everything. The difference between this campaign and the annual Facebook campaign is that it raised more than £2 million ($3 million USD) for Cancer Research UK. People visited the website, even if they only did so to make their £3 donation. Money was raised, odds are good that people looked over at least one thing on the website, and the message got out there. To me, that's what a successful public health campaign looks like.

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Teething Pains
by Dean Metz

Our multidisciplinary falls clinic started a few weeks ago. There have been a few challenges. My partner, a nurse, and I have had a few "discussions" about note-writing. I go for brevity and directness using the SBAR method. She is more of the old-school, "If it isn't as long as a Victor Hugo novel then we must have forgotten something." She is a brilliant nurse and once we negotiate our priorities on some issues, I think we'll work well together. The facilities are spacious... very spacious, particularly when our EKG machine goes missing to another clinic or the examination bed is claimed by another consultant.

Many of our patients are given transportation into the clinic. That's a really good thing, until the transportation runs late and we get the 9:00, 10:00 and 11:00 appointments all at 10:15 and the driver says he has to leave by 11:20.

Monday was the first full day of seeing patients. Up to this point we had been doing half-days to get over our learning curve and get a sense for how theory would become reality. We did OK. I was running around like a headless chicken for parts of the day, but everyone got seen. The notes all got written and letters to the doctors, referrals to other clinicians, and the medical team consultations all got sorted out. We were exhausted by the end of it.

Our capacity level is increasing, our very own examination bed and EKG are on order, and management is attending to the transportation issues. My colleagues are slowly getting over the shock of my East Coast directness and push for efficiency. I'm trying to recognize that nobody likes change and that I'm an outsider tasked with bringing about very rapid change. That will not endear me to many. That's OK, so long as it benefits the patients in the end.

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Beyond Multidisciplinary
by Dean Metz

Most of us are well familiar with a multidisciplinary approach to meeting all of a patient's needs. Input from doctors, nursing, OT, PT, speech, and social work help us to provide better outcomes for patients. Notice the key word there... patients. What about people? Once a person becomes a patient, something has already gone wrong. This is where my public health work starts to kick in.

Today I presented at a meeting that connected older adults falling over with cold homes and excessive winter mortalities (EWM). There were three people representing the health services, but most of the other attendees were from the local council, housing department, welfare office, telecare (the UK version of personal emergency response systems), and even someone from British Gas. There are so many risk factors for falls, but one of them is living in a cold home. In healthcare we're used to being reactive, whereas public health is more about being proactive. How do we prevent the fall from happening in the first place?

In my presentation on the risks for falling, the financial impact of falling on this community today, and the projections for the next 20 years, I was able to get the interest of people who thought they had nothing to do with fall prevention. By investing in some preventative programs now, such as ensuring older people have warm homes in the winter, we can avoid the financial burdens later on, freeing up money for other needs.

As PTs we know well the end results of accidents. We often have to figure out what caused them and we can apply that knowledge to preventing further accidents for others. That's the kind of service and work I want to be doing at this point in my career.

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Staffing Levels an Easy Problem to Fix... Badly
by Dean Metz

I've written a lot about the Francis inquiry into the failings of the Mid-Staffordshire NHS Trust. One of the most troubling findings was that in order to save costs, management had cut staff, primarily nursing, to levels that could not assure patients of a safe experience in that hospital. There is much chatter about what is a safe nurse-to-patient ratio going on right now. Notice that it is "nurse" to patient, not clinician to patient.

What could this mean? Physios could be sacrificed to provide a quick and easy fix to the nurse-to-patient ratio without changing overall costs to the NHS. This is dangerous because it doesn't really take into account the full spectrum of patient need, experience and outcomes. The Chartered Society of Physiotherapy (CSP) has already mobilized to ensure this doesn't happen. They are preparing materials on how outcomes in different settings, services and teams are not dependent solely upon nursing. The emphasis will be on sustaining service quality, reflecting all staff roles, and potential risks to patients and safety.

What I really like about the CSP is how nimble they are. As the playing field changes, they respond immediately with proactive plans to address challenges as they arise. I always thought the NHS was a bureaucracy beyond compare, but it actually changes much quicker and more dramatically than CMS does back in the States. The CSP has to work at an equal if not quicker pace. For that I have no problem paying my annual dues.

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Finally Merging Physio and Public Health!
by Dean Metz

Next week I'm giving a presentation to the local authority and public health department on the problem of falling in older adults and what needs to be done about it. It's helpful that this is the same town I did my master's thesis on and that I'm starting up a falls service within.

What's really exciting is that nobody has the breadth of knowledge I do on this subject! I'll be giving the same presentation at the Northeast Regional Falls Group (a consortium of specialist doctors, nurses, physios, psychologists, and OTs from this region of the country) to demonstrate how the NHS (health services) and public health (prevention) can work together. The goal is not just how to deal with rehabilitating those who have fallen, but how to ensure fewer people fall over the next 20 years. During that time period, the population of older adults will grow by nearly 20% and the financial cost would be devastating.

I have prattled on about how physios (PTs) need to think beyond clinical degrees in order to effect change in the larger scope of things. An MPH, MBA, PhD, even MD will open doors not previously welcoming to PTs. It has taken me time, more than I expected, but I'm paving the way for younger PTs to assume leadership roles in the design, formation and implementation of healthcare. I think that degree might be paying off after all.

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What Do Scores Really Mean?
by Dean Metz

The National Health Service was in the news again this weekend, and not for good reasons.  The children's hospital in Bristol has a high mortality rate. The medical director of NHS England, Sir Bruce Keogh, has ordered an independent review of the matter, which is remarkable in that normally investigations have to go through numerous levels before getting his attention. The hospital's chief executive defended the "good clinical outcomes" of her Trust, pointing out "98 percent of its patients' parents said in a survey that they had received excellent, very good, or good care." Patient perceptions are "good clinical outcomes?" Really?

I've written before about the imbalance between qualitative and quantitative measures used here in the UK. Both are important and neither should stand alone. One of the most widely disputed targets here in England is the 4-hour maximum wait time in Accident and Emergency Departments. The mid-Staffordshire Trusts did very well on those quantitative measures, but people still wound up dying unnecessarily.

We seem to be forgetting why these measures are in place in the first place. We want to be able to determine if our services are actually doing what they're supposed to be doing; getting people well and treating them well. If all we're doing as leaders is trying to achieve a target, we will fail.

This is not a situation unique to the UK. One need only look at the Medicare website to compare hospitals, home care agencies, and now even physicians! In the past, I've used the tools available on this site to see the rankings of providers I knew. Some brilliant companies were ranked low while some dodgy ones were ranked highly. So what do we really learn from these scores and how does that help us shape the future of healthcare?

I'm reminded of the old saying, "The operation was a success. Too bad the patient died."

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Modern Travel Is Killing Us
by Dean Metz

I've just spent 10 hours on a plane. That is a long time and doesn't take into account the hour-long flight from Newcastle to Heathrow or the 3-hour layover in Heathrow. Of course I'm coming home to visit my mom, so it's worth it. However, I think we have the major airlines to thank for any future pain-relief work coming our way.

The equipment was an aging 747 which had been renovated a bit to seem newer. I always reserve an aisle seat so I can get up without disturbing anyone. There were two seats between me and the window. In those two seats was a lovely couple, very pleasant, not too chatty, and very obese.

She took up her own seat plus a quarter of his. He took up the remainder of his and part of mine -- even with the armrest down. He overflowed his seat and when we sat shoulder to shoulder, my trunk was laterally shifted to the left and my head hung in the aisle. I was afraid I would be decapitated every time the trolley went by! It was a completely full flight with not another seat on the plane (at least not in economy).

Don't even ask how mealtime went... Cirque de Soleil has nothing on the contortions we went through! Despite getting up frequently and spending a fair amount of time standing in the back near the restrooms, I was still pretty achy and uncomfortable by the time I got off that plane. To be fair, the gentleman (and he was indeed a gentleman) in the middle seat got the worst of it. Poor guy was wedged between the two armrests and could barely move for 10 hours.

Another flight I took over in September was even more cramped aboard a brand-new A380, the double-decker, where the seat was so narrow I couldn't sit on my own hands because there wasn't enough room. Now I'm no athlete but neither am I obese. That was also a tortuous flight.

As airlines try to squeeze more and more sellable space on their aircraft, people are getting more and more twisted at their expense. On a short flight, people can manage a slightly uncomfortable position for an hour or so if they're in reasonable health to begin with. A 10-hour flight? Nope, one needs PT after something like that.

I think we need PTs on the design teams at Boeing and Airbus! I think there needs to be some oversight as to what is permissible in aircraft design. I flew different carriers on both the trips I mentioned and both were equally painful. I can't afford to fly business class in those gorgeous individual pods that go nearly flat. Nope, I'm stuck with a narrow seat that's way too close to the one in front of me. When will the shrinkage stop? We are a captive audience that on occasion, just has to fly no matter how painful the price or the experience.

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Can We Afford the Gold Standard?
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When I was getting my public health degree, we took numerous modules on statistics and research methods. One of the things we were taught, which I already knew, was that randomized clinical trial (RCT) was the best way to clearly answer a research question. It is the "gold standard." The other things we learned about RCTs were that they are time-consuming, the most expensive form of research, and contain some very ethical issues about who does and doesn't receive treatment.

The CMS has created the Innovation Center, which is looking at different ways to pay for and provide healthcare. What they are doing is a fair number of demonstration projects. What that means is they fund a project, evaluate the results, and apply mathematical models to determine things like efficacy, sustainability, and savings potential. I worked in a program in New York that began that way in 1998 and went on to become the benchmark in care management for the frail elderly as recognized by the Commonwealth Fund. There was no control group, yet the results bore out to be very beneficial.

Today, Gina Kolata of The New York Times (no friend to physical therapists after her article, "Treat Me but No Tricks Please") just came out with an article denouncing the Innovation Center as wasting funds because they're not using RCTs for most of their studies.

The responses are as interesting as her article. She's an MIT researcher by profession, so hardly an unbiased voice when commenting on this topic. It could mean whether or not she gets studies funded and articles to publish in professional journals.

So my question is: In this day and age, with shrinking resources and increasing demand, can we afford for all of our health policies to be based upon RCTs or should we make use of demonstration projects to accomplish more with less time and expense?

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Shoestring Budget
by Dean Metz

I'm having a whale of a time in my new post! I'm bringing American efficiency to my role as a consultant; evaluating people who have fallen in care homes and recommending a corrective course of action. I started out with a list of nearly 80 names of people who had been waiting from 1 to 3 months for an assessment, to a list of six people referred in January. The care home managers are rather happy with my work.

Then there's the other part of my role, revamping a fall-prevention service based at a small local hospital. The hard-working physios who have soldiered on through tough times previously haven't exactly welcomed the new carpetbagger with open arms. After today's meeting with the staff, I feel like I've been the board in a dart match. With much cooing and active listening (they have valid points after all), we were able to move forward with positive attitudes.

Wait lists are a big taboo here in the NHS. Government regulators come down hard on NHS services that make people wait for service. Unfortunately, sometimes the only way to get the people with purse strings to notice that additional support (budget lines) are required is to allow the wait lists to grow. For instance, see the paragraph above and you'll understand why my post was approved. It will all come out right in the end; of this I'm sure. Until then, I'm planning for the service I need rather than the service I can afford.

On another note: I won! The Trust, which erroneously called me across the "Pond" for an interview in August, has reimbursed my travel expenses. Never back down from unfair management! Pursue what is right, but do it in their language and on their terms. It may take time and patience, but right wins out in the end.

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Equipment Blues
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When I worked in New York in home care, I would always revisit a patient for whom I had ordered any piece of equipment. I needed to ensure the right item had been delivered, was installed and/or adjusted correctly, and that the patient was using it correctly.

I would argue with many insurance care managers about these visits. They would argue that vendors were paid to perform these tasks. I wish I had a dime for every time I would find a raised toilet seat still in the box, a commode with unadjusted legs, or a tub rail hanging by a thread. Patients also came up with the most inventive ways of using equipment. My particular favorite was the woman who had a potted palm in her bedside commode.

Here in England, equipment is loaned free of charge from the local council and the patients return it when it's no longer needed. It is then refurbished, sanitized and put back into service. Things unfortunately don't run smoothly here either. Today I went to visit a client who resides in a care home; something similar to assisted living as there are no nurses on staff.

His walker was delivered along with a set of wheels. At first I thought it odd that the wheels were sitting on the resident's bureau and not on the walker. I then realized the frame had been refurbished and was an older model than the wheels, so they didn't match. After being on hold for a while, a nice person apologized and arranged matching wheels to be delivered in seven days. The resident is able to use the walker without wheels safely, but will appreciate how much energy he'll save once the wheels arrive and I revisit again.

On both sides of the "pond," so much waste could be eliminated if people just did what they said they were going to do!

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It's Going to Get Ugly
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I'm on the train to Edinburgh for a night "on the lash with the lads" (a pub crawl with some friends) and I pick up The Independent, whose headline is "Battle Begins for the Soul of the NHS." I figure this should be interesting. Essentially the article states something I blogged about years ago, not long after the Tory party came into power. They're starving the NHS so that it will fail and have to be privatized. Really, Independent, you're just figuring this out?

If you think the Affordable Care Act has generated hot debate, you should hear the debate on this topic! Mud is being slung by both, or should I say all three, parties. I mentioned the Francis Report in my last blog. The Tory party is using that against Labour while Labour blames the Tories for reports of disjointed services and risks to patient safety.

If the NHS has a bad reputation overseas, it's the fault of the political parties using it as a bludgeon. Each blames the other for whatever is wrong... not so different from the US. Speaking of the US, if the free trade act goes through with Britain, US health companies may be able to enter the market here in Britain. Soon we may have Humana in Hounslow or Aetna in Alnwick.

It will be fascinating to see how the next few months play out for the NHS here in England. It might impact how other countries develop their health services. It may even impact the company you work for right now.

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What's Your Tipping Point?
by Dean Metz

In the year I was back in the US, a very important paper came out here in the UK; the Francis Report, which details the failings of one institution in caring for its patients. This report is having ripple effects through the entire country in terms of lots of bureaucrats creating lots of forms and ticky-box exercises to ensure their Trust doesn't repeat the mistakes of the Mid-Staffordshire NHS Trust. This is frustrating because it means a lot more work.

Tonight I watched a documentary called "Unforgotten." It's about the patients of Willowbrook, the state school for the disabled on Staten Island that was exposed by Geraldo Rivera in the early 1970s. It was years after Robert F. Kennedy called it a "snake pit" that any staff member spoke up and helped bring to light the horrors that went on within its walls. One of the primary problems at Willowbrook was staffing cuts. By the end, the ratio was one staff member for 40 patients. Is that trend recurring now?

I've read my fellow ADVANCE bloggers' frustrations with insufficient weekend staffing, ridiculous productivity targets, and inappropriate orders for therapy. The responses to these blogs have been even more disheartening. In one case, Michael Kelley was told, "You're being compensated for it. If you don't like it, don't write an article... get a new job."

Other times I've read other professionals talk about how they would speak out if they weren't afraid of losing their job. This idea of toeing the line or suffering the consequences just doesn't sit right with me, it never has. I got into this profession to help people and I've done a fair amount of that in my two decades of being a PT. I'm not about to shut up if I see something unfair to patients. The end result of Willowbrook, the Mid-Staffordshire NHS Trust, and even two previous employers of mine was a shutdown of operations. I've seen companies come and go... but I'm still here.

I encourage my colleagues to speak out about poor working conditions and insufficient staffing. Don't succumb to the bullies or the fears. Why should a patient's therapy be less on a Saturday because there's fewer staff available? Management wants a seven-day service? Then staff appropriately for it! Management wants productivity targets? Then give the necessary tools and support to reach them! It's time for long-term thinking and planning, not short-term profits.

I think I shall be more patient with the bureaucrat tomorrow. She's just trying to keep Mid-Staffordshire from ever happening here.

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Safe Bet or Bad Practice?
by Dean Metz

Over the holidays, we were sitting and whinging (English for complaining) over drinks about the demise of clinical and critical thinking in practice. In both the US and the UK, algorithms have been employed to standardize care in an attempt to assure everyone gets the same quality of treatment. As a public health advocate, I almost always advocate for something that reduces variations in care. Why should a patient have better treatment from practitioner A than practitioner B? Algorithms are an essential component to telemedicine and tele-physio. NICE (National Institute of Clinical Excellence) in the UK and the Milliman guidelines in the US provide those frameworks we need to work within in order to get paid.

That would work perfectly if every person with back pain presented in the same way, or with chest pain, or a hip fracture. When did you last see two of any presentations that were identical? For an algorithm to capture every possible presentation, it would most likely be unmanageable and of little practical use. Many professions are now being trained according to an algorithmic approach. At my last post in the US, we actually taught new employees about critical thinking because it was a skill lacking in so many newly hired people. Are we dumbing down the health professions in an effort to standardize care?

When I took a practical exam in PT school, many years ago, there would be wildcards in the patient's presentations. Our skills of thinking on the spot were harshly tested. I'm grateful for that now that I'm older and minutely wiser. I wrote about taking an OSCE (Objective Structured Clinical Examination) here in the UK when I first arrived. There was no thinking involved, simply a checklist to run through in 7 minutes. It wasn't easy, but it didn't prepare me for a real situation.

Are we risking our patients and our careers by trying to stay safe?

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About this Blog

    Dean Metz
    Occupation: Staff Development Specialist
    Setting: New York, NY – Newcastle Upon Tyne, Great Britain
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