Category Archives: Uncategorized

“Responding to the Reluctant Patient”

How do you respond to a patient that doesn’t want to participate in therapy?  This is a paper from the August 2016 PTJ, but I only read it just recently.  I had my current student read it, and would highly recommend anyone in the SNF/TCU or acute care (or even HH) read it.  It really opened my eyes to how better interact with the reluctant patient.

Delany C, Anderson L.  From Persuasion to Coercion: Responding to the Reluctant Patient in Rehabilitation.  Phys Ther (2016) 96 (8): 1234-1240.

If you are thinking of working in a SNF/TCU…

I’ve had some students recently ask me about searching for work in the TCU.  I love the TCU setting – the medical complexity, the rehabilitation for all different diagnoses (ortho, cardiopulm, neuro), getting people back home.  If you are looking at TCU’s, these are some of the things I’ve considered when looking for work:

  1. The Medicare rating – 4 and 5 stars is a good starting point; I’ve worked at a 3 and where I was at until July was a 1 for a while (upgraded to a 2 currently) and I would still willingly work there, so I wouldn’t automatically cross one off your list because of this. [edit 5/2: my Dad is now in a TCU in Tennessee – tough searching from a distance.  Consider looking at the ratings also for health inspections and for outcomes – the ones I looked at I’d rather have a higher outcomes rating than a health rating as it looked like the health ratings were issues with documentation, food temp, etc and tended to be isolated incidents vs percent of residents with pressure sores, not returning to prior functional level, etc).]
  2. In-house vs contract therapy:
    1. Productivity will probably differ; from my observation in-house productivity is relatively lower (see my blog post https://geriatricpt.wordpress.com/2016/01/28/thoughts-on-productivity/ ).   Find out what their productivity expectations are, and what they might have to help you achieve it.
    2. Employee satisfaction: I work at a place with low turn-over – we could get more pay elsewhere possibly, but at what cost?  What is employee satisfaction like? (ask current employees away from the interview time – if you know any prior grads at a TCU ask what they think of their company, or go to a PT Pub Night, or ask classmates what companies and locations they interned at and what they thought about the corporate culture).
  3. Will you be at one site, floating as needed between sites, or doing HH as needed?
  4. Get a sense of how important rehab is to the facility – if they put money into the rehab dept (as it is where a facility makes its money) it makes a real difference.  If the gym is in the basement with no windows and little equipment, it may be depressing to you and to the patients.
  5. What is the con-ed budget?  Companies may offer CEU’s through ACP (the modalities company) or Medbridge and have less of a discretionary con-ed budget.
  6. Mentoring – is there a PT you can turn to as a new grad if you have questions or need help?  Ideally an official mentor, but that doesn’t happen really in this setting (or rarely).
  7. Will you be all alone as a new grad?
  8. Will you be responsible for a PTA (or two???) as a new grad?
  9. What is the typical day like – treatment times, diagnoses generally seen, etc.
  10. How much is TCU vs LTC vs OP?  (I have been in a combined setting most of my career thus far).
  11. Holidays and weekend – how many do you have to work, or are you on call, etc?
  12. Dress code?
  13. Weekend pay differential if you are required to work weekends?
  14. Do they reimburse licensure? (pretty rare in TCU)
  15. What is the nursing: patient ratio (and the NAR: patient ratio)

Compendium for teaching professional level PT content (neuro focus)

From an email I received earlier this month.  If you are an instructor this is a great resource for neuro-related coursework ideas.

*************************************************

The Academy of Neurologic Physical Therapy is pleased to announce the
release of the updated *“Compendium for Teaching Professional Level
Physical Therapy Content, v. 2016”*. This compendium is an update of the
previous compendium published in 2000 and edited by Margaret Schenkman PhD,
PT and Kathleen Gill-Body, MS, PT, NCS.

The purpose of the Compendium is to provide examples of high quality
teaching and learning strategies that have been developed and refined by
the contributors. Some activities include detailed patient cases and/or
grading rubrics, which can be difficult and time-consuming to write. These
will be useful for novice faculty who are seeking innovative ways to
deliver content. In addition, experienced educators will find new ideas
and alternative teaching strategies.

The compendium is online, and open access
http://www.neuropt.org/education/compendium. Activities may be searched by
elements of the patient management model, by pathology, or by type of
teaching activity. *Activities can be downloaded individually, and
educators may freely adapt or adopt the learning activities while providing
recognition to the Academy and the original authors*.

The Compendium co-chairs would like to recognize the hard work of authors,
editors, and Academy leaders in developing this resource. We hope you find
it useful in planning your curriculum!

*Jody Cormack, PT, DPT, MS Ed, NCS*
* Sue Perry, PT, DPT, MS*
Compendium v.2016 Co-chairs

I have a bias toward therapy

I’m on a flight to go visit my father in the hospital. He had significant SOB, had a TEE which showed significant mitral regurgitation. We’ve had end of life discussions so know his wishes, and he wanted to have a valve clipping done (given his age and PMH it was recommended he not have open heart surgery, and this was the other option given to him). This is a relatively new procedure and I do have some questions I want to ask (including why no palliative care consult yet, will this reduce readmissions, change mortality, it drastically improve quality of life, and what are the complication rates).
I personally am questioning how much impact will this procedure have on dad’s life – cost benefit or risk assessment I guess; given that I work with sick people, have read Being Mortal, and have seen sad cases, I’m a little hesitant about surgery for him. I don’t want to see my Dad suffer either way. How do surgeons decide when to counsel conservative management, something other than what they are trained to do? ( His previous cardiologist knew of this problem and had recommended managing symptoms, but my parents just moved last month and had to reestablish health care providers, so this is definitely a different take on the situation).

Better yet, do I do any better? As PT’s we hear and agree #getPTfirst or #choosePT – we know we can make a great impact on people’s function and quality of life We talk about avoiding surgery if you can and avoid opioids. I want to bring hope. I hate it when I have to admit that i can’t restore function, return the patient home, etc. Most of the time it is easy – yes or no. But in the gray area, how long do you spend working at it? The patient with a CVA. The patient who has poor motor planning that isn’t responding to everything you can think of to help with mobility. The patient with pain you can’t really touch no matter what you do. These are the things you want to know as a student, and even as a practitioner there are ones that stick in your mind – did I do everything? Would a bit more, or something different help? I want to give hope, and I hate it when I have to say I’ve done all i can and we need to stop. Even therapy can’t fix everything. To a man with a hammer everything looks like a nail – i have a bias toward therapy and I need be aware of that for the sake of my patients, their families, and even myself.

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Student Debt – Get Rid of the Albatross!

7214450550_7545c96770_mFirst, a disclaimer.  I served in the Navy which meant I had very little undergrad loans, and I had assistance for grad school.  So I didn’t graduate with the massive debt that so many students are graduating with these days.  However, I wanted to write a brief post for some resources that I and others have found helpful if you find yourself in debt.

Why focus on debt?  And not just student loan debt, but also credit cards, car payments, and mortgages?  Because it is a burden that limits people – what you can do and even where you can go in some ways, it makes you a slave to the lender, and causes worry and sleepless nights (and arguments with your significant other).  Work hard at getting rid of it.  Here are some personalities that have helped me and others I know to do that (both therapists and non-therapists).   Please note this is not an endorsement of any of these – read and investigate on your own.

  1. Dave Ramsey – I know a few PT’s from Twitter who have used the debt snowball idea and are making major dents in their loans (and my parents used it to pay off a huge amount of credit card debt in a few short years, while Dad is retired and Mom was working part time).  We are using his steps as a template, and are also using his budgeting app EveryDollar (I recommend something like this as it makes you more hands-on, vs Quicken which is very easy to set and forget).
  2. Mr. Money Mustache – Some great (and challenging!) ideas on how to gain financial freedom and better yet live a full life.
  3. Budgets are Sexy – an interesting personal finance blog.  Not only does he put his net worth up each month so you can see how he lives out “saving, hustling, getting rid of debt, early retirement, and …. growing [his] net worth.”  Great ideas to save and hustle.  He also recently started an interesting podcast, The Money Show.

If anyone has any other helpful links or resources you can post them in the comments below or start a conversation on Twitter (#PTdebt as a hashtag?).

Addendum: Dustin Jones recommended Radical Personal Finance and You Need a Budget.

What do you say if your patient says “I’m careful”…

but their Tinetti is a 12/28, it takes them 10 seconds and several attempts to get out of a chair, and they demonstrate unsafe behaviors? The CDC’s STEADI program (Stopping Elderly Accidents, Deaths, and Injuries) website has a great handout about talking to patients depending on their stage of change. I have an interest in exercise adherence, and last week I heard the “I’m careful” and the “bad luck” reasoning. Unfortunately it seems an uphill battle for educating the public that just because you are older it doesn’t mean you can’t get stronger or improve your balance. I want my patients (and family!) to live a full, active and independent life. Adherence to exercise is important, but we have to meet our patients where they are at.

Returning to the blog (and life)

Extension Plans

I have been away from the blog for about 6 months. Six months of early morning coffee, studying for the GCS, and of coming to and through personal and professional crises and realizations of sorts. It has been a tough road, but I’m glad I’ve done it (and even more glad it is over!). After the test I was just thankful I was done, but now I’m anxiously waiting for the results, as well as waiting for spring here in the Twin Cities.

Now I’m back to the blog. I’ve recently taken a very interesting course on surgery and back pain, which has stirred my interest in pain science. You can expect to see reviews of articles about pain as well as articles I’ve come across in reviewing the literature for patient cases, thoughts on aspects of the profession (such as my review of the iPad in the clinic for documentation and education, G-codes, social media, and reflections on the residency), and occasional tangents on therapy-related topics. I also plan to update and revise various links on the blog, so stay tuned as the blog continues on!

Photo credit: Extension Plans, originally uploaded by MarkyBon