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.

 

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

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.

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