Category Archives: Clinical reflections

Sometimes the best teachers are where you least expect

I am clinical faculty for a local PT program for their ICE (Integrated Clinical Education).  During the a student evaluation last month, one of my students recommended that I involve the patient during my instruction and education to students as she felt the patient (who is to be the center of what we do) is left out on the periphery.  Wow.  Best feedback I’ve received thus far.  I came up with an idea how to implement it for next year.

I’m also a CI this summer with a 2:1 model for first-year students.  As I was asking a student what he observed about a patient transfer, explaining what I saw, and working on ideas of what we could do, the patient said “hey, I’m right here – talk to me!”  Ouch.  So now I’m prefacing my interactions with students to the patient saying I’ll be talking PT jargon to the students, but they will be explaining it back to you in non-technical terms.  In doing this a) we are involving the patient (and they know what is going on) and b) the students get to practice patient-friendly language (if you ever get stuck try the rubber ducky idea).

I love being a physio and a teacher, and also a student.  While I do miss academia, you can learn anywhere if you are open to it, and bettering yourself and others in the process.

 

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Telehealth, tech, and the older adult

64946580_88fb60c7f4_qI received a tweet this morning – “Telerehab+fall predict platform= Game changing. Effective?” (I tried to embed it but it wasn’t working).  The American Telemedicine Association is having their meeting in Minneapolis this week, and it will include telehealth platforms for seniors.  Two quick thoughts about the idea before I get ready for work (I’d love your comments and thoughts in the comments or on Twitter).

First, I agree with the author of the article that cost will be a huge issue.  Those on a fixed income are not going to have much wiggle room, and those who are poorer and rely on SS definitely will not.  This will be an increasing concern with the Baby Boomers given the data out there on their savings (or lack of) for retirement.

Second, will THEY want to wear it/ use it?  There is a great section of dialog in Jurassic Park where the grandfather is defending all he has done to the scientists, that he spared no expense, and Ian (Jeff Goldblum’s character) says something to the effect of your scientists were so busy asking if they could they didn’t ask if they should.  In the same vein, are we so busy asking if we can do all this great tech we aren’t asking whether they want it? Yes, there are those who love tech and will embrace the idea, but are those the ones that are having the falls, experiencing incontinence, not eating well, etc?  It reminds me of the Fitbit – those who use it are often the ones who are already fit.  Will they view it as an invasion of their privacy, of one extra step closer to an ALF or a nursing home, despite assurances that the tech is “to keep them as independent as possible for as long as possible”?

I think the technology has the potential to be effective, and to be a game changer for many.  But I think that for many others the financial cost and the resistance against the tech intrusion will require continued personal monitoring and involvement by family and the home health community.

 

Photo credit: “Old and New” by Sparky

How Can You Improve Patient Interactions?

153570089_bb99d7108c_mHave you ever been a patient (for any provider, not just PT) and had a really great or a really bad experience?  What was the key to that experience for you?  For me, it was the interaction with the provider.  I’ve contemplated switching providers because of an interaction where I felt like a number, that my concerns were minimized and derided, and that his time was much more valuable than mine.

I received the most recent PTJ yesterday.  A few articles grabbed my attention, including “What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis” (O’Keeffee M, Cullinane P, Hurley J, et al; Phys Ther 2016; 96: 609-622).  It reminds me a lot of the PTJ article by Hush and colleagues from 2011 entitled “Patient Satisfaction with Musculoskeletal Physical Therapy Care: a Systematic Review” which is one I have my students read.

The authors identified four themes in their review: PT interpersonal and communication skills (active listening, empathy, friendliness, encouragement, confidence but not overconfidence, and non-verbal communication), PT practice skills (patient education – a big one for patients, and PT expertise and training), individualized patient centered care (individualized, and taking patient opinion and preference into consideration) and organization and environmental factors (time, flexibility).

The results aren’t all that surprising, but they bear repeating to ourselves as providers; I would argue while both articles examine this in light of musculoskeletal PT, it very likely applies across all specialties and settings. Do positive interactions enhance adherence and give better outcomes?  No evidence on this yet, but it would make sense especially for self-efficacy. I think I do pretty well in my interactions, but I think I’ll focus on my listening and patient education.  What can you work on to improve patient satisfaction and possibly their adherence and outcomes?

Photo credit: X-Factor by Pierre Metivier.

Research on Attire for Physical Therapists

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I’ve seen some recent discussion on Twitter about attire for PT’s (including #NoPolo before and after CSM), and my employer is facing a possible change in requirements (we are allowed to be business casual or scrubs, with jeans on Fridays, but are now opening up a TCU within a hospital where the staff will be required to wear black scrubs).  I thought I would pull up whatever research is out there for attire for physical therapists and briefly summarize each (there isn’t much!).

  • 1999 masters thesis by Angell, Glaspie, and Winters – Physical Therapist Characteristics and Practices That Affect Patient Willingness to Comply With Home Exercise Programs.  “The results of this study demonstrate physical therapist personality traits and clinical practices were perceived by patients to be more influential than appearance and role modeling behaviors.”  Interesting conclusion and I would agree that it is more influential. Appearance, specifically professional dress and casual attire, did not reach a level of significance (the majority of respondents said it made no difference), but that is not to say that it might not matter.  Table 3 appears to show a preference for professional>casual>lab coat, and professional attire and lab coat make gains with the older subjects when the subjects are separated into two age categories.
  • Ingram D, Fell N, Cotton S, Elder S, Hollis L. Patient preference, perceived practicality, and confidence associated with physical therapist attire: a preliminary study. PTJ ‐ PAL. 2011; 2‐8. I don’t have access to this paper, but their paper is included in Dr. Ingram’s NSC 2013 presentation What You Wear to Work: Appropriate Attire and Professional Image for Our Doctoring Profession.  The most preferred attire by patients was scrubs, though OP’s and college educated patients preferred collared polo and khakis.
  • Finally Mercer E, MacKay-Lyons M, Conway N, Flynn J, Mercer C. Perceptions of outpatients regarding the attire of physiotherapists. Physiother Can. 2008;60:349-357. In ranking photographs of professionalism and preference of attire for a male model, for professionalism it was lab coat>tailored dress>scrubs>jeans, and for preference of attire it was tailored dress>scrubs>lab coat>jeans.  For appropriateness of attire, it was tailored dress>scrubs>lab coat>jeans.  Interestingly “in comparison to their younger counterparts, more respondents aged 56 years and above perceived scrubs on the male model as appropriate.” (note – appropriate, not preferred or professional).  Also, “In contrast to the findings from medical literature, which indicate the lab coat as both most professional and most preferred, respondents in the present study unambiguously preferred tailored dress, despite regarding the lab coat as most professional.”  Also, “Extent of exposure to this therapeutic interaction appears to influence patients’ perceptions of the appropriateness of attire.  The study found that perceived appropriateness of lab coat and scrubs decreased and perceived appropriateness of jeans increased with increasing number of physiotherapy visits.”

So where does that leave us?  First of all, you obviously have to follow the employer requirements.  If you are in a hospital, you have no choice – scrubs are the standard, likely color-coded nowadays.  Some of the large corporate OP clinics have a standard polo/ khaki combo.  But if you are in a TCU/SNF or smaller OP clinic and there is just general guidance, what should you wear?  I have chosen to wear professional attire (khakis and a button-down shirt) for two reasons – for the patient, and for me.

I would agree with Angell et al that it is more the characteristics of the therapist, not the clothing, that makes a difference for (at least) the HEP, but probably even from the moment we first meet. Still, I think that clothing does play a part in the interactions, for me and for them.The literature hints at patients preferring professional clothing (Angell), or certain segment of the population preferring it (Ingram), or they consider it to be more professional and preferred (Mercer).   I also believe in dressing the part so to speak, and I think that is what Roush hints at.  I know that I felt different Monday-Thursday than on a casual Friday when I used to wear jeans.  Am I a better practitioner M-Th in professional attire than on casual Friday or M-F if I wear scrubs?  Absolutely not!  For me, I take my profession and my job more seriously than I do if I wear scrubs or jeans, and I feel more engaged.

I leave you with this from Mercer that I found interesting – “professionalism is a multifaceted construct that, in the health care field, encompasses the traits of competence; engagement (e.g., communication skills and empathy); reliability; dignity toward patients, peers, and self; placing the patient above self; and concern for quality of care.  In more practical terms, it is ‘an image that promotes a successful relationship with the patient,’ such that the patient feels confident in the capabilities of the health care provider.  Although professionalism is the single most important trait that can be enhanced by dressing appropriately, professional attire is only one means of achieving a successful relationship.”  Personality traits and interactions play a significant role in the PT-patient relationship, and I want to use professional attire to help me maximize the interaction, for them and for me.

Picture is from Otis Historical Archives

Aging and Population Health

2910912489_bf07d7809b_mI’ve been thinking for some time now (starting during PT school, because of my father and grandfather getting older) about the aging population – including illness, chronic illness, health and wellness, the changing of demographics in the communities and what is needed, or better yet, what might be expected and how to get ahead of the changes.  It was one of the reasons I did the residency and earned my GCS, and with continued changes to healthcare I’m realizing that instead of responding to just a major or minor illness (in my daily practice), I also need to get ahead and do something to help address population health.  From what I’ve seen communities are becoming more aware of this as well as their population ages, including Washington County and the Twin Cities overall.

Dr. Michael Riley has written a great challenging blog post Can We Jump the Fence? which I encourage you to read as a starting point.  One thing he writes is “Given the current health climate we are not seizing the opportunity to work as the entry point to better health. People change for two reasons, desperation or inspiration… I have been inspired to change the way I think about the future of this profession and the value we possess.”

Practice Level:  How can we do this at a provider level?  For PT’s working with older adults, we need to be inspired to be the entry point, and to view our position as a both-and (prehab/wellness, rehab, and post-hab/ wellness so to speak), not as either-or (PT or personal trainer, for lack of a better term).  The issues I see for those working with older adults is that Medicare won’t pay for wellness, there is an annual limit for MedB (and a rather tight scrutiny if you go over), and the limited fixed income most seniors are on create limits in some way.  Even if all these were answered to our patients’ benefit, there is a significant issue with adherence to exercise in the older adult population.  So how can we jump the fence and be “the entry point to better health”? We can advocate on our own, but having the support of other providers and current and former patients will be important.

  • Get buy-in from other providers.  They need to know what we can do, both for injuries and to address chronic diseases.  We need to show we know what we are doing by challenging our patients (which we don’t do often enough) to demonstrate good results.  Two PT’s who stick out in my mind in challenging the strength of their older patients or clients are Dustin Jones of the Senior Rehab Project and Christina Nowak of STAVE Off.
  • Get buy-in from our patients (the customer) that we are THEIR therapist, not just for this POC but anytime the need arises.  How can we do this?  Practice at our best, every, single, time; don’t give out a generic HEP, but target it to the patient’s most significant impairments (and emphasize this); and provide home assessments if they are interested.

Community LevelThis will largely be a pro-bono effort initially (though some customers may come your way through your interactions), but it is greatly needed, though others have found a way for it to work for the general population (see the link below for Pro-Activity Associates).  Having the support of providers and older adults may help you get a program started or give you ideas for promoting healthy aging in your communities.

  • For older adults:  support or even teach programs for falls prevention and strengthening; teach a class at your community center or local gym on a wellness topic or recovery from [x]; make or find and promote low cost technology to encourage physical activity in the older adult population.  An example of a good community program for overall health is Mike Eisenhart’s Pro-Activity Associates (What might a geriatric version of this look like? I’m intrigued and excited by the idea).
  • For their families: advertise how your program or classes can help their loved one function better; offer home assessments to help them age in place.
  • For communities and businesses: first, ask older adults what they see that they will need as they age!  Second, you can provide input at city, county or state meetings (zoning, transportation, and parks are a few areas that come to mind) where issues may come up that relate to older adults.  You can also provide comments to businesses on how to be senior friendly, and offer input to senior centers and ALF’s on design changes and fitness facilities.  Eagan, MN is redesigning their town (which is great for those who can move), maybe your community will redesign a part or all of it to accommodate older adults.  If you aren’t sure where to get started, contact your community’s public health department, and help out where your community may note needs (Washington County seems to have a good grasp of where the needs are and what they have in place already).

With a new baby I’m not taking on anything new at the moment, but I’m mulling all this over in my mind.  How can I help position physical therapy as “an entry point to better health”?  Can we therapists network with each other and with other disciplines and organizations to elevate the health and wellness of our aging population?  I think the answer is yes.  I’d love to hear your ideas either in the comments below, on social media, or via email.

Picture by Mendhak

Thoughts on “productivity”

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There has been a recent discussion on the geriatrics listerv about productivity (and a recent PT in Motion article about productivity), but you can probably read it anywhere on any discussion forum for rehab professionals – productivity requirements continue to rise, and it is making professionals frustrated. I said in a tweet it makes me sad, angry, and a little scared for our profession. I want to write a bit more on that.

First, how productivity is calculated: I work in a facility that calculates productivity based on minutes billed divided by hours present per day, minus any CEU time (if it takes me 30 minutes or 90 minutes for an eval, I bill 30 minutes or 90 minutes – I would take issue with some place that only allows me to bill or account 45 minutes for an eval if it takes me 60 from a professional perspective).  In my career I’ve worked in 3 SNF/TCU facilities where I’ve done sub-acute/ OP/ LTC, and interned in one other, and have had multiple friends and colleagues who have worked in similar facilities, mostly for the major companies, and the only way I have encountered productivity billing is the way I described above.  I can tell you that productivity demands that I have seen, experienced, and heard of take into account the hours paid that you worked, not your vacation time, CEU, etc, and it ranges from 65% to 92%.  If anyone else has had a different experience in how productivity is calculated they can comment on that and the impact on them; again, I want to comment on what I’ve seen and experienced.
Why it makes me sad:

Productivity is often what we are judged by, and it is often all about the money, not about the patient or outcomes. I understand this is a business (see my previous posts about the WSJ article on “copious therapy”). But seriously, productivity of 94%? To me, that sounds like a company looking at a bottom line with such a myopic view (for shareholders?) that they don’t see what they are doing to their staff.

Why it makes me angry:

What to fit in the minutes left over in the day: Using the productivity calculation above, in working an 8 hour day, if you factor our your LEGAL two 15 minute breaks (who really takes those?), and you DON’T document on your lunch, and you don’t overlap patients (which you can do with commercial insurance, but not Medicare): at 65% you have 138 minutes left, at 70% you have 114, at 75% you have 90, at 80% you have 42, at 90% you have 48, at 92% you have 8 minutes.  In those remaining minutes, you need to get ready for the day, go between patients (hopefully your patients aren’t spread out in a large facility), document to facility and payor expectations (or at least complete what you didn’t do during point of service documentation), return phone calls, respond to emails, talk to families who stop you in the hallway, talk to other disciplines you work alongside, breathe, and wrap up for the day (bathroom and water breaks are covered during your personal breaks).  I forgot to mention staff meetings (which may be factored out for efficiency, but not productivity), supervising PTA’s and co-signing their notes, waiting for nursing to give meds or finish toileting or dressing, finding patients unavailable due to an MD/NP seeing the patient, the patient refusing for a variety of reasons, the patient being out of the facility, finding OT or SLP has your patient, and answering the occasional call light, and I’m sure there is more that I’m not thinking of at the moment, all while trying to keep your focus on service, patient satisfaction, and good working relationships and not allowing your productivity requirements become the focus and becoming self-centered/ serving.

Would I rather have 138 minutes to do all that, or 8 minutes?  Some companies use transporters, which helps.  There are questionable suggestions/ recommendations I’ve heard that give me pause in even considering working for a national company that requires the higher levels of productivity.  And if a therapist can’t achieve those levels, their options would to: a) be fired, b) document off the clock, or c) try to find a company more in line with their views (my boss and her boss will probably read this – Brenda and Amy I love our company, have no issues, have no intention of leaving, and welcome a discussion on how to improve my productivity!).

Why it makes me scared:

We have done this to ourselves, and I see no end in sight. We as therapists have valued and needed a paycheck, and not stood up and said enough is enough. And for those that have said enough, someone has always been willing to come behind and take the job (at less pay such as a new grad with their student loans coming due).

What can we do?

For the benefit of therapists and our profession:

  • Refuse to document off the clock.
  • Do not work for companies with productivity standards that are so high that we document off the clock or be unethical in practice. I personally have limited who I work for to companies that put people before profit (people being patients and staff), while still encouraging their therapists to ethically do and be their best. For students interested in geriatrics, I don’t give company names that I won’t work for, but I offer suggestions of what to look for and questions to ask any employer.

HOWEVER!  As altruistic as we want to be, healthcare is a business.  Whether big business and answering to shareholders (ala RehabCare/Kindred) or a non-profit, you can’t run in the red.  We as professionals need to determine (and stand up for) what is ethical, but also be aware that this is a business; companies, it may help to show us the business numbers for better understanding and buy-in.  We need to ethically (and legally) be as productive as we can.  That may be structuring our day better (not checking/ answering emails except at specific times, seeing patients in a “geographic” sequence to limit getting our 10,000 steps a day by lunchtime, etc), thinking about using a productivity system or framework at work (Getting Things Done, Six Sigma, Kaizan, etc) not having non-work discussions during non-break time, trying point of service documentation as much as we can, giving our employers ideas on how to improve productivity to address roadblocks we encounter, etc.

I wish things were different, and hope things get better for the sake of our patients and our profession.  In the meantime if we are having a difficult time with productivity demands, we need to follow our ethical principles while either working with our employer to see the issues or look for another job that will value us and what we bring to the table, not just the number we generate (and be thankful when we find that job!).

Sorry for the length of my thoughts and opinions – I would be interested to hear other takes on productivity calculations, how to be more productive, ethical considerations in productivity, etc, be it on a listserv, FB, Twitter, or the comments section below.
Photo credit: Productivity by Sean MacEntee

Part II: “Copious Therapy”: Ethical Considerations

Again, a disclaimer before I go further – I work at a wonderful place that listens to its therapists’ recommendations regarding level of minutes. They respect our professional recommendations and encourage evidence-based practice, and we work together to deliver what is appropriate, adjusting levels as needed. I am very thankful to be working there; this blog especially this post and the last one are my thoughts and do not reflect the thoughts, positions, or practice of the staff or management.

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Read this first: Part I: “Copious” Therapy in Nursing Homes – Financial Gain or Good Therapy? (or both?)

It seems that some days, therapists can’t win, and these days can stick in your head. Patients or families are unrealistic about outcomes and appeal the decision to discharge, managed care limits your number of visits for a patient and you know if you had more visits you could accomplish more, Medicare (or the RAC) audits your records to determine if your documentation supports your billing, your company insists you need to get the minutes and you insist the patient isn’t appropriate for that much that day, or that an article in the WSJ calls into question what therapy companies do so you get included in the suspicion by patients and families that you are doing too much. What is a therapist to do? Two things come to my mind: we need to be professional and ethical when it comes to visits and billing (the visit as a whole), and we need to practice according to the evidence as best we can (the parts of the visit).

Visits/ billing: Billing can be made harder because as the article notes, there is a pressure on at least some therapists to achieve minute expectations (not to mention productivity – a different topic and post!). If you read the APTA’s Code of Ethics for the Physical Therapist, several principles appear to be applicable in light of the article (underlines are my emphasis):

  • Principle #2: Physical therapists shall be trustworthy and compassionate in addressing the rights and needs of patients/clients. (Core Values: Altruism, Compassion, Professional Duty)
    • Physical therapists shall adhere to the core values of the profession and shall act in the best interests of patients/clients over the interests of the physical therapist.
      • I would add “or the employer.” With the financial conflict of interest, are more minutes in the best interest of the patient? If it is quality therapy (evidence-based – see below), then yes. If not, we need to stand up for our patients.
  • Principle #3: Physical therapists shall be accountable for making sound professional judgments. (Core Values: Excellence, Integrity)
    • 3A. Physical therapists shall demonstrate independent and objective professional judgment in the patient’s/client’s best interest in all practice settings.
      • Therapists should be recommending the minutes, not management. We should be open to being challenged in our thinking, but we are the ones doing the evaluation; the patient is our patient.
    • 3B. Physical therapists shall demonstrate professional judgment informed by professional standards, evidence (including current literature and established best practice), practitioner experience, and patient/client values.
      • This is the therapist’s experience, not the minute manager’s; the patient’s values, not the company’s; the current literature and best practice, not the company’s practice.
  • Principle #7: Physical therapists shall promote organizational behaviors and business practices that benefit patients/clients and society. (Core Values: Integrity, Accountability)
    • 7A. Physical therapists shall promote practice environments that support autonomous and accountable professional judgments.
      • PT’s are professionals, and it is our judgment of what therapy the patient needs. Bowing to pressure of the company when the level is not appropriate is giving up autonomy and professionalism, but you will still be accountable.
    • 7E. Physical therapists shall be aware of charges and shall ensure that documentation and coding for physical therapy services accurately reflect the nature and extent of the services provided.
      • If you are providing exercises just to get the minutes, is your billing accurately reflecting the nature and extent?
    • 7F. Physical therapists shall refrain from employment arrangements, or other arrangements, that prevent physical therapists from fulfilling professional obligations to patients/ clients.
      • I would argue that if there is a pressure at your facility to provide therapy just to get the minutes, you should leave if that pressure continues. There are other facilities and settings that can use your talents.

The long and the short of it is that the reimbursement system is flawed, and being based on levels of minutes there can be a pressure to achieve these so we have a job. However, we as physical therapists need to stand up for what is right – what is right for our patients, and what is ethical toward the payer. I know therapists may be pressured into getting those extra minutes by any means necessary on a patient who is not appropriate, but we are not technicians.

Evidence-based practice: The other issue that comes to mind in reading the article is quality of therapy in the SNF/TCU setting. Several years ago I came across a PT Advance article (the link I had back in 2012 is broken, and I can’t find it for citing now), which said in part:

Being a specialist in geriatrics has a down side at national meetings, at times. We see our peers in sports medicine and manual therapy projecting a veneer of being the “best” in the profession. When we encounter them after many years and we are asked our specialty there is an uncomfortable somewhat condescending moment. We feel like our specialty is not as rigorous or deserving of praise. This is a bad feeling. When we reflect on the complexity of our patients, their multiple co-morbidities and medications as well as challenging functional levels we wonder why anyone would not think we are the brightest and hardest working of the profession?

As I have said elsewhere in the blog, “I love my specialty – it combines medical complexity with patients who really need help to function better.  But are we in SNF/TCU settings challenging ourselves (or students), let alone our patients?  And I mean really challenge.  Could that be a major reason why we feel that way?”

I suspect the author of the 2012 article still feels that way. Recently the APTA acknowledged that physical therapists need to challenge their older patients , and a current student notes the disconnect between evidence and practice in skilled nursing. In my six years of practice, we still seem have the reputation of not challenging patients. We need to step up and utilize the evidence (and the outcomes) out there, otherwise one could make the argument that we are providing an inferior product and not being responsible for health care resources. The following principles from the APTA Code of Ethics seem to relate:

  • Principle #3: Physical therapists shall be accountable for making sound professional judgments. (Core Values: Excellence, Integrity)
    • 3B: Physical therapists shall demonstrate professional judgment informed by professional standards, evidence (including current literature and established best practice), practitioner experience, and patient/client values.
      • Read up on the evidence for strength training in older adults, the use of ultrasound, number of repetitions for recovery from a CVA, the intensity for balance training (or the theories of balance), or any number of other approaches to treatment, then compare that to what we do. I know I continually need to be challenged and challenge myself – I know I can do better for my patients.
  • Principle #8: Physical therapists shall participate in efforts to meet the health needs of people locally, nationally, or globally. (Core Value: Social Responsibility)
    • 8C: Physical therapists shall be responsible stewards of health care resources and shall avoid overutilization or underutilization of physical therapy services.
      • To be responsible stewards of health care resources, we need to ensure we are not providing subpar therapy. Otherwise we are really overutilizing by having to provide more therapy minutes to get the same outcome.

We are professionals, and we have a responsibility to our patients, our payers, and our profession to provide high quality therapy influenced by the evidence and measured by standardized outcomes.

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Now I’m not advocating abandoning creativity or “out of the box” thinking (I use this in the best possible sense, not in a “how can I get my mandatory minutes?” way; for another post maybe), nor am I against being challenged in my approach and thinking. What I am advocating is that our primary responsibility is to the patient (one could argue our second responsibility is to the payer, in this case ultimately the tax payer). If we are looking at the whole patient and their situation, and practicing in accordance with the evidence, an RU may very well be the most appropriate and I’m fine with that. What I’m not okay with is ignoring or minimizing our responsibilities to the patient and to the payer in regards to practice and billing to “get the minutes.” We owe them, and ourselves, more and better than that.