Author: Hobohealth

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Home Health as a Travel PT

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home-health-travel-pt-hobohealthI never considered working in home health when I was a new grad fixated on my career as a sports PT. But, when I started traveling, I quickly noticed there were a lot of home health gigs available. As I began yet another home care assignment a few weeks ago, I realized I was starting my 5th contract working in home care. When did this happen? How did this happen? How have I allowed this to happen!?

Turns out, home health is a pretty good shtick for traveling therapists. As I launch into this blog about “home health,” I’ll make a clarification up front: I’m going to use “home health” and “home care” interchangeably – I feel like most people prefer “home health,” I personally prefer “home care.” Whatever, it’s semantics, don’t worry about it.

I think of home care as more of a lifestyle than a job. With the right employer, home care can offer a flexible schedule that is great for people in a variety of stages of life. Flexible schedules typically bring to mind new parents or late-career therapists looking for per diem, but, for me, in 2010 in Hawaii, flexibility meant completing all my patient visits by 3 PM, then surfing for a couple hours before going home to finish paperwork with a cocktail in the evening. The right employer will allow you to control your own schedule – this can be a great way to get more out of the daylight hours in a work week. Paperwork and case management (calling doctors, other clinicians, and patients) do account for significant time during your work day – the good news is that you can do paper work and case management at a coffee shop, outdoors on a sunny afternoon, at home, or where ever you feel like it.

Productivity

The flexibility does not come with every home health job, it is essential to ask about productivity expectations during the interview.

The two major factors that will affect how busy you will be are: a. how many visits you are expected to make weekly and; b. whether more complex visits are weighted to be worth more than one normal follow-up visit.

Basically, without getting into the nitty-gritty jargon of home health, an evaluation visit may be worth more than 1 regular visit (ideally 1.5), but an admission, which can easily take 3 hours of your time, should definitely be worth 1.5 to 2 visits. This is called weighting – where a visit that requires more work counts more on your total productivity. A job with a company that doesn’t weight any visits, is a job worth walking away from.

Number of visits: 5 daily is perfect, 6 is usually fine, 7 is just too many – think about the weighting of eval and admission visits when you think of these numbers (i.e. 7 with heavy weighting may be OK, 6 without any weighting could be a lot of work, 5 with weighting is a great job to have).

The distance and amount of time you’ll be driving plays heavily into the pseudo-equation as well, so ask about your territory during the interview. Also consider looking at a Google Maps of the area you could be working in during rush hour to get an idea of traffic.

Home Health Lifestyle

I got to do some visits inside the famous gingerbread houses of Oaks Bluff (Martha's Vineyard) in the summer of 2015. Strange sitting in my patients' living rooms with tourists going by the windows taking pictures of the houses... neat, strange houses with a fascinating history, but try gait training someone on narrow, steep stairs built in the 1800s' version of tiny homes.

I did some home health visits inside the famous gingerbread houses of Oaks Bluff (Martha’s Vineyard). Strange sitting in my patients’ living rooms with tourists going by the windows taking pictures of the houses… Fascinating history of how these houses came to be, but try gait training someone on narrow, steep stairs built in the 1800s Victorian version of tiny homes. The challenge and adventure of home care was very apparent.

Enough of the boring logistics of home care. It is full of action. You will go into people’s homes and see how they truly live. Truthfully, you will be completely appalled at how these people live. Hoarders, live chickens in houses, 8 people sleeping in a room with one bed, beautiful mansions, family situations that are wonderful, and family situations that are incredibly ugly – I will NEVER say I’ve seen it all, because in home care, you see stuff you would never ever see anywhere else. It’s a crazy adventure going into people’s houses. It’s also really educational. Home care will forever change your perception of what kinds of living situations hospital patients are being discharged to. It is wild out there… usually in a really fascinating way.

Professional Challenge

Clinically, home care can offer a stimulating challenge. Frequently, you may be the only clinician visiting a patient’s house, and you will have to make important decisions like whether to call 9-1-1 or not. I have called 9-1-1 from patients’ houses a number of times. Typically, it’s a pretty low-drama experience, but you might be the first to come upon a patient whose blood pressure is too low to ignore, or whose blood glucose is too high to wait it out, or who is just too medically complicated to be left at home alone. Home care does make you use a lot of clinical skills and judgments to make decisions that matter, and that’s one of the coolest things about it. It’s worth mentioning, that because of the judgement calls you will have to make, it is worth getting a year or two of experience as a therapist before venturing into home care.

A Setting You Might Consider

So, think about it. Consider home care even if it seems far from what you normally enjoy. It has aspects that will challenge your clinical skills, and it will most definitely change your outlook on how people actually live on a day-to-day basis. Not to mention, there’s a ton of available jobs in home health, and it pays well.

This is 100% true about today: For me, it was a pretty cool day at work. I worked in the mansion of a business man and sat across a very important-looking wooden desk from my patient discussing his mobility and what he wanted out of therapy (business meeting style, he wasn’t coming out from behind that desk unless he had to). I went to a small shed in a backyard to treat another patient, while she is actively in the process of being evicted from the shed… by her mother. In between, I enjoyed some moments outdoors during the work day and even paused for a moment beside the road to soak in a view of the ocean. I took an afternoon bike ride before finishing paperwork, which I wrapped up just before sunset. To summarize my work day, I went into a mansion, positively affected the life of someone near-homeless, and drove around an island …Not a bad way to make a living.

This piece was originally published in the summer of 2015 through thegypsynurse.com

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Time Away – The Traveling PT Lifestyle

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As I write this piece, I’m on a plane flying back to Hawaii from a couple weeks off work visiting with friends and family in New England. This flight is non-stop from JFK airport to Honolulu. While it is highly convenient to not have to make a connection on the West Coast, 11 hours in one seat is incredibly uncomfortably, and the lady in front of me is driving me nuts. The trip away from Hawaii was planned this winter while working in Aspen at my annual winter job there. My wife and I knew we were going to Hawaii for the original 13 week assignment, but weren’t sure if we would be extending our contracts for the fall. All the right things fell into place and we’ll be working in Hawaii until Thanksgiving. The break from work was a great 2 weeks away and got me reflecting about the traveling physical therapist lifestyle. As we fly back to Hawaii, the reality is setting in that we have another 3 months ahead of exploring some beautiful islands. I’ve been flipping through the pictures on my phone, looking at the last 3 months in Hawaii, and I feel fortunate to be getting back to a more peaceful and simple lifestyle than the last few busier (but awesome) days we just spent hanging out with friends in Boston, my home town.

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The front yard at the cabin in Maine. (Or “Upta Camp” as any Mainer worth his salt would describe it.) Mountain, water, and a lack of people – what more could I possibly want!?

I don’t know when I really began to like a slower pace of life, but I’ve definitely grown away from being a “city guy”. The highlight of the vacation I’m currently returning from was a week up at my wife’s family cabin in the Northern Woods of Maine. Time spent just beyond where the paved road ends and out of reach of cell signal was a nice re-set to return to work feeling refreshed and ready to push through the next 13 weeks. The relaxation centered around daily dips in the lake and a few steep hikes in the surrounding mountains which I’ve become more-and-more familiar with over the years. Sure, I’m returning to work in a beautiful, peaceful place, but it’s still work and I believe strongly in regular time away to refresh the mind and stave off burn-out.

On the seat-back display here on the plane, I can see that we are cutting a South Westerly line across the country and that we are passing right over Aspen, the place I now consider home because of our yearly return there for work each winter. If I could get to a right hand window seat, I think I could look down and see town or some of the familiar valleys, or at least I-70. While skiing in the winter, I have frequently wondered where those high up planes might be going as they pass over the mountains, and now I wonder if anyone I know might be out hiking today looking up wondering where this plane is going. Strange to be so close, but so separated – if I could, I’d hop on the phone and call a couple people to let them know I’m waving down at them. Weird feeling.

Enjoying the Aspen back country with friends. "Traveling Physical Therapist" is really just a euphemism for glorified ski bum.

Enjoying the Aspen back country with friends. “Traveling Physical Therapist” is really just a euphemism for glorified ski bum. (Aspen Mountain in the background)

The Aspen connection was indirectly made through another “get away”. Growing up, my family would  travel in the summer to a rugged family cabin in the mountains outside of Colorado Springs. This cabin, also, is beyond the end of paved roads. It was my favorite place growing up and has been joined on my “favorite places list” in recent years by the cabin in Maine – along with handful of other special places. Visiting in the summer as a kid was my introduction to Colorado, and it is what eventually led me back to the mountains and to Aspen. I initially enjoyed Aspen primarily for the great access to culture without living in a city. While I still enjoy the concerts, the culture, and all the action Aspen has to offer, I now appreciate it more for the great access to extreme wilderness. Within a couple miles of walking out my front door, I can be deep in the mountains, away from much of the busy nonsense of life in the 21st century.

Another one of my more recently acquired favorite places is the island of Molokai where I will return to work tomorrow morning. Hawaii is the most geographically isolated place in the world, so it’s only natural that you can get off the grid pretty fast in many parts of the islands, but Molokai is even more isolated than most of the other islands. It offers a rural life that doesn’t have the conveniences of box stores or instant gratification through being able to get exactly what you want right when you want it, but I’ve learned to embrace that – sometimes it’s an easier life when you have to get by with what you have. I don’t know what the future holds for my relationship with Molokai (work? vacation?), but I believe it’s a place that will be a part of my life in the future. I often joke that I can’t stay in Molokai because the snow skiing is awful – I don’t think this joke ever goes over that well, but it’s the truth. I do need a healthy dose of slippery hills in my life. Skiing is my favorite mode of exercise and my favorite way to get my adrenaline fix. I don’t ever hoot and holler doing anything the way I do skiing on a great day.

We got invited back to camp in one of the valley's that Audrey Sutherland swam to in her book Paddling My Own Canoe. Unforgiving ocean, rugged land, beautiful place.

We got invited back to camp in one of the valley’s that Audrey Sutherland swam to in her book Paddling My Own Canoe (great book about getting away from it all). Unforgiving ocean, rugged land, beautiful place.

While visiting the Maine woods last week, I was reading a book by a woman,Audrey Sutherland, who had swum and paddled to many of the most remote valleys in Hawaii and later to many remote islands in Alaska. While she lived and worked on the more-busy island of Oahu where Honolulu is located, the book was mostly about her time away and the quiet and loneliness she needed to reset. I don’t necessarily crave loneliness like she did, but at times, I need the quiet for sure. When I read the book up in Maine in a quiet and peaceful place, I couldn’t help but think how connected these isolated places can be. That connection seems to be amplified as I fly from Maine to Hawaii while passing directly over my winter home in Aspen. For a small island with a population of only 8,000, I find it bizarre that I know at least 3 or 4 people on Molokai with a connection to the small town of Aspen, Colorado (also <8,000 residents).

I got to visit another one of my favorite places on this vacation. But this belongs in a different blog...

I got to visit another one of my favorite places on this vacation.

Sorry for the long blog, but I have nothing but time today – just about 3 hours until we land in Honolulu. I’ll run out of computer battery before I run out of words. I’ve taken the long way around on this story, but this is a blog about why I am a traveling Physical Therapist. I am not OK living a life built around working a job that keeps me from the places I love for all but a few days of the year. I want to constantly be surrounded by the places I love and to have easy access to the wilderness and quiet time that I am craving more and more often. The flexibility offered by the traveling-lifestyle and the opportunity to intimately discover and explore places that Kate and I love is the greatest reason to travel. I hope if you are considering traveling therapy that you too will seek out the places you really want to be. If there are great cities you want to experience, landscapes you want to explore, or beaches you want to lay on, go work there!

It has been a wonderful vacation. I saw a lot of people and places that were great to visit with. Time to get back to work this week, but I know when the work week is done, next weekend holds another adventure in the mountains and ocean right outside my door. For me, that’s what it’s all about, working where I want to live and not the other way around.

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DPT and Physical Therapy’s So-Called Identity Crisis

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DPT identityI have recently heard a lot about “physical therapy’s identity crisis”. That phrase, “identity crisis,” is uttered by those I know personally, by other leaders in the profession, and by PTs across the interweb. Collectively, we have labelled ourselves as having no consensus on what our role in health, wellness, and prevention. There’s in-fighting about the superiority of treatments centering on pain theory, manual therapy, movement science, and other guru-isms that insist, of course, their way is the best way. But, I don’t think we have an identity crisis. We firmly know who we are and what we do – we may have varied methods of treating our clients, but we do have a central, shared focus. I personally believe our percieved identity crisis has everything to do with a large part of our profession not owning their level of expertise, being shy to demonstrate their full expertise to patients and colleagues, and as cliche as it is, not “being the change”.

10 years ago, we were a profession in flux. I was graduating with my Master’s degree from Northeastern University and almost immediately re-enrolled for my transitional Doctorate, because that’s where the profession was headed. Since the 90’s, things have moved very quickly for our profession from a role as a technician, carrying out Doctor’s orders, to an autonomous profession evaluating patients and safely dictating our own treatments.  In a span of about 20 years, universities have propelled us from a 4 year undergrad education to a point where all PT students are trained as DPTs. This relatively quick transition from a 4 year education to a 7 year education did leave us poorly defined for a period, because our knowledge and role did change over that time. Now, it’s about time we get over it. As a profession, we are not at all confused about who we are anymore. APTA’s branding project has been proclaiming since 2009 that we are the human movement experts. The Guide and Vision 2020 had earlier defined what it is we do on a daily basis with our patients and clients. No matter your practice setting or population, human movement is central to your practice – occupational health, sports medicine, acute rehab – even in the realm of cardiopulm, the human body’s ability to move blood and air are central to care. There are some specializations and niches in PT that start to stray from the precise phrase “human movement” – i.e. wound care or veterinary care – but human movement is truly at the core of what the vast majority of Physical Therapists do at work on a daily basis.

So we have had a defined identity for the better part of a decade, why do patients continue to come into the clinic surprised at our education level? Because as individuals, not as a profession, we have refused to embrace the DPT and everything it stands for. I know that somewhere, right now, there’s a private practice owner griping about a patient who has come in expecting to get a massage. This weekend, that same private practice owner will go to a 5K race and give simple, boring, unskilled massages! This is the kind of thing that kills us. Stop giving massages at road races – why not offer gait analyses instead? Or offer mini-consults for ongoing injuries, which there are plenty of in the 5K community. Injury prevention, nutrition, running gear, pain – these are all topics we can consult on with authority. If you give massages at a race, then that is the snapshot of your practice that you are displaying to your community, and people will continue showing up at your door expecting nothing more than a massage. I’m sure you can get more creative with what your practice can do to engage your own community than I can, but please, stop giving massages at races – that’s not Physical Therapy!

We need to be shouting our knowledge from the mountain tops in all of our own communities. Get interviewed on local access cable about injury prevention, write letters to your local and not-so-local papers every chance you get, throw a fit every time physical therapy is forgotten on a TV show, radio program, or news article when we are the experts that should be leading the conversations on musculoskeletal health, not an afterthought. Get verbal, show off your knowledge. Participate in community planning to advocate for healthy and accessible community planning. Even as a traveling PT who is only in communities for a short time, I have hopped on local cable, written letters to local papers, and encouraged others in the community to contact their congressional representatives on topics that matter. It doesn’t take a whole lot of effort to positively and productively promote PT in your community.

Why are we so scared to call ourselves Doctors? I don’t know, but I’m as guilty as anyone else of shying away from routinely using my earned title. We really, really need to embrace “Doctor”, we have each earned it. The Chiro’s sure don’t shy away from the term, and we’re a lot more qualified in providung safe musculoskeletal care than they are. Ever thought twice before calling your Psychologist, Optometrist, or Dentist “Doctor”? These are all non-MD clinical Doctorates – the same as the DPT. In education, even High School, teachers with a Doctoral degree are called Doctor. I really don’t know what our problem is, but we each individually, and collectively, need to get over our phobia and embrace our advanced level of education that matches and surpasses plenty of other professionals who have no qualms with being called Doctor.

Stop looking to leadership for answers on what our role is. Stop looking to APTA to make that one Suberbowl ad that will change the world’s knowledge of PT – that’s not how this works. It’s time more individual clinicians embrace the unique and unmatched work they do in the clinic everyday and demonstrate it to their external community. There are many communities across the country where people do think of their Physical Therapist first when they have an injury. If you think we have an identity crisis, it’s time you changed your identity in your own community. That’s how this works.

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Health Insurance As a Traveling Therapist

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As a traveling therapist, there are all sorts of things you can, and should, insure. This may end up becoming a multi-part blog, but for now, I want to focus on health insurance and the options you have available. Getting and maintaining steady health insurance can be a challenge when you change jobs, and possibly employers, every few months. Other than going uninsured (awful idea), there are three potential options to keep yourself insured.

traveling therapist health insuranceEmployer Sponsored Health Insurance
If you are working steadily for a single travel therapy staffing agency or for a combination of agencies, taking your employer sponsored program is clearly the way to go. All the agencies I have worked for factor your health program into your pay package. So, if for any reason you are not taking your employer’s insurance, ask if you can get more hourly – I typically get a dollar per hour extra for carrying my own insurance… more on why I carry my own insurance later.

Typically, what agencies have available for choices are good plans that cover you with providers nationally. When you accept a plan from your employer, you are not subject to pre-existing conditions or other demographic categories that might cause your rate to be higher – you pay into the group price that the insurance has contracted with your employer, simple and right to the point.

A staffing agency that I worked for when I first started traveling physical therapy would drop you from their insurance if you weren’t actively working for them for 14 consecutive days. This used to scare the heck out of me and force me to get right back to work quickly. If a job wasn’t coming together within 2 weeks of the last assignment, I felt the pressure to take anything that was available so I wouldn’t lose my insurance. The truth is, it doesn’t matter if they drop you from their insurance, COBRA (federal gap insurance) covers you. What COBRA does is extend your employer sponsored program when your employment ends. You have up to 60 days to accept COBRA coverage and it works retroactively. This means, if you are taking anything less than 60 days off between assignments, you can go without insurance and if something happens, you can adopt COBRA after-the-fact and you will be covered under your previous plan. The catch is that COBRA is not cheap – unless you need it, then it is a great deal cheaper versus the medical bills you would otherwise incur. Once you have adopted COBRA, you can keep it active for up to 18 months, but in most cases, if you need insurance for more than a couple months, it will be much cheaper to go get a plan on the open market.

I’ve said it before, I’ll say it again: Always look for jobs with 2 or 3 agencies, it helps you get a handle on the local markets and gives you more options for assignments that could be a better fit to your needs. One of the big downsides to jumping between companies is all the “new hire” paperwork – which includes a few healthcare enrollment forms. Don’t worry about the paperwork, the benefits of searching with a few companies outweighs the burden of a couple hours of paperwork every few months. Paper work, JCO quizzes, and constant TB tests are a part of being a traveling therapist, deal with it.

Pros: Everything. Take this option if you are consistently working through agencies. You pay the employer rate and are not subject to rate increases for pre-existing conditions.

Cons: Becomes expensive and complicated if you take more than 60 days off between assignments or do independent contracts. You may have to take short-term insurance to fill these gaps.

Short-term Insurance

Doing a single independent contract? Taking a few months off from therapy to just travel? Unexpected circumstances keeping you out of work for >60 days? This might be the option for you.

The job I work every winter in a Colorado ski town is arranged directly with the hospital and does not offer health insurance for my seasonal position. This can be more common that you would think, especially with seasonal positions in resort towns. Frequently these facilities will not hire through agencies and rely on independent contacts for their seasonal hiring. The first couple of years I worked in Colorado, I got temporary insurance plans, and they were the perfect fit for my needs.

These plans last up to 6 months, are cheap, and are available through most insurance brokers. I got mine through eHealth.com, but I really have no allegiance to them and you should be able to get a temporary health plan through any insurance broker. The downside to these plans are that they only cover conditions that happen during the 6 months you have the plan. Any pre-existing conditions are not covered. If you have an injury or illness that extends beyond the 6 month period that is insured, payment will stop after the last day your plan covers. Also, there is no gap coverage, like COBRA, that would help you if you ended up with no insurance and an injury immediately following the completion of your temporary plan.

Pros: Cheap. Keeps you are covered for any 6 month period where you don’t have other insurance.

Cons: Covers only that 6 months period. Nothing that started before that 6 months, nothing that extends beyond that 6 months. No preventative care coverage.

The Open Market

If you find yourself, like myself, doing frequent independent contracts or in a repetitive rotation to a facility that doesn’t provide health insurance, then the open market might be your only choice. The open market can be unforgiving in its cost. I choose to find insurance through a broker who can compare rates and plans of multiple companies, or you can just go online and start searching rates by individual companies. You’ll find different insurance companies available in different states, and even certain companies are conspicuously absent from specific zip codes due to local laws or other factors. You should always apply for health insurance in your home state and at your home address. It may be tempting to get insurance in a state you are working in if they have lower rates than your home state, but by getting insurance at your home address, you are ensuring the insurer (pun intended) will cover you when you travel temporarily for work. Also, having your insurance based at your home address is one more feather in your cap if you ever have to defend the location of your tax home. It’s worth mentioning that when buying an insurance plan in the open market, there are some plans that only have in-network providers locally. You should make sure that the plan will cover you and has providers nationally – especially when buying from a state’s healthcare exchange marketplace (state Affordable Care Act plans). If you do end up with a plan that has providers nationally, but you happen to be in an area isolated from those providers, there are typically ways of getting your care covered in-network  by contacting your health insurance company – I have had success getting in-network coverage with United Healthcare when working in “far out” places.

State healthcare exchanges offer a good place for you to go and find a plan – so whether you are looking for a subsidy or not, you may want to start there and see what’s available. I almost hate to even mention the subsidies available through the ACA. I don’t think traveling therapists are who the subsidies are intended for, but at the same time, buying your own insurance can be expensive, so you might as well get as much help as you can. I know, with my half year working fully-taxed in my home state of Colorado, that my taxed income is too much for me to qualify for a health insurance subsidy. However, those of you working the entire year in situations that are heavily tax-free and for therapists that are recently graduated from school, I bet you’ll qualify for a subsidy to help with your health insurance plan. The one catch with the subsidy is that even though it’s called a subsidy, it’s really a tax credit that you’ll receive when you do your federal tax return, and if your income is more than expected through the year, your actual subsidy can be decreased. Proceed with caution. Here’s a link that provides good, easily understandable information about the health insurance subsidies: http://obamacarefacts.com/obamacare-subsidies/

Pros: It might be your only choice. It will travel with you where ever you go.

Cons: Can be expensive, rates are even higher if you have pre-existing conditions. You must make sure your plan covers you nationally.

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A Tale of Two Cars

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After 9 years of working as traveling Physical Therapists together, my wife and I have found cars a lot of interesting ways. When we started traveling, we would each drive a car cross country to get where we were going, but in time found road trips were a lot easier when we shared the driving in one car. This has led to us buying a lot of random vehicles on Craigslist when we arrive at our destinations… and later selling them on Craigslist. Throw in a handful of assignments in the 49th and 50th states, and the resume of vehicles we have owned is, from my viewpoint, impressive: A 1984 Chevy RV in AK, a VW Passat in Hawaii that broke down within 2 weeks, a subsequent 3-month rental car in Hawaii, and a Honda Civic in Maine that the entire exhaust system fell off of gradually piece-by-piece to be collected in the trunk and eventually sold to the next owner – so many memories too: the power back window of a 97 4Runner (best SUV feature ever), the Camry with the cockroach infestation, strapping 2 kayaks right onto the roof of that same roach-infested Camry, and living-in/maintaining/improving a camper all last summer back East on Martha’s Vineyard.

I take any opportunity I can to share pictures of the camper we lived in last summer. The ends pop-out, so our living space was slightly larger than it appears here. We'd eventually set-up a tent room on the deck and made it look a lot more homey too.

I take any opportunity I can to share pictures of the camper we lived in last summer. The ends pop-out, so our living space was slightly larger than it appears here. We’d eventually set-up a tent room on the deck and made it look a lot more homey too.

There’s so many vehicles, homes, and vehicle-homes, I can’t even remember each one. For now, I do want to share the two very different stories of the two vehicles we have right now in Hawaii.

We were working in our usual winter jobs in Colorado when we secured our jobs way out here in the Aloha State. Having worked previously on the rural island we’re currently on, we knew we wanted to have a 4-wheel drive vehicle. It can be tough to get a decent 4×4 here, because everyone who has one drives it into the ground. Lucky for us, we already owned the perfect vehicle for the trip. Our 2007 Toyota Highlander (“McLeod” – there can only be one Highlander), has been an awesome car, but we’ve started to pull more and more toys that are above its towing capacity. A Highlander is a great SUV offering a comfortable ride and good handling on rough road and in the snow, but it is definitely not meant to tow campers over 12,000 ft mountain passes – and we like to do that sort of thing. So, it was decided, McLeod would come to Hawaii with us, we would enjoy having a 4-wheel drive vehicle to access the off-the-grid mountains and beaches. We hope to sell McLeod here at the end of of our time in Hawaii – he will live out his retirement years in the islands. We will then return to Colorado and buy a truck.

A lot of research went into the logistics of getting McLeod over to Hawaii from Colorado. We (Kate actually) learned a lot about the vehicle shipping business. We have friends who shipped a car from Colorado to Florida for about $800 a few years ago, which sounds very reasonable to me – I’ve recently heard similar prices from other travelers. There’s a lot of different ways to try to find a good deal for shipping the car cross country. You can ship by rail which I think offers the best deals, but seems to be inhibited by the time it can consume in transit and the need to drop off and pick-up the vehicle at a major hub. It’s not unusual to have a narrow window of time to drop the car off with several weeks wait to receive your car on the other end. Shipping the car by truck is more common and, in theory, easier, but is didn’t mesh with our schedule.  The way the trucking system works is that the shipping companies you contact simply act as brokers between you and the truck drivers. You set a price you are willing to pay as a bid, and truck drivers are able to accept or negotiate the price – there are numbers available to give you an idea of what a typical car transport from, in this case, Aspen to San Diego might cost. Basically, you submit a bid and if there’s a driver headed West that likes the price and wants to swing by and pick up your car, they will accept. Also, if you live in an isolated place, you can offer to bring your car to a place closer to a major highway and this will cost you less as it’s more likely to be on the driver’s route. Because of this arrangement, you can find a trucker to take your car on pretty short notice. It’s a great system, except that you frequently don’t know exactly what day the driver will show up to take the car, and you need to have someone available to drop off the car and then receive the car on the other end. For us, it just didn’t work. We only had one week between work in Colorado and work in Hawaii and needed to dump the car quickly and get out to Hawaii.

Last year, we were leaving Colorado and wanted both cars back in New England. But, we wanted to share the driving. Our solution was McLeod towing our un-named Celica on a U-Haul dolly. I'll never do this again. The dolly made such a racket, and we couldn't pull off the highway in any cities where parking might be an issue - might not sound that bad, but, trust me, it was pretty awful.

Last year, we were leaving Colorado and wanted both cars back in New England. But, we wanted to share the driving. Our solution was McLeod towing our un-named Celica on a U-Haul dolly. I’ll never do this again. The dolly made such a racket, and we couldn’t pull off the highway in any cities where parking might be an issue – might not sound that bad, but, trust me, it was pretty awful.

We eventually set a plan to drive to San Diego and ship McLeod from California out to Hawaii on a boat – it costed us about $1000 to Honolulu, another $400 for the transfer to the island we’re currently working on – reasonable as far as I’m concerned. A few days before we were set to wrap up work in Colorado and get on the road, our boat was cancelled (with our money already paid), and an alternate boat had to be scheduled. We ended up having to leave a little early and make a sprint straight from our last day of work in Colorado on a Saturday to San Diego for a Monday car drop off. We ended making the trip with time to spare and saw some of the South West which I truly haven’t seen a whole lot of. Then, we were off to Hawaii! Unfortunately, the car would take 3 weeks in transit, so we had to come up with another way to get around the island in the meantime.

We had considered having a second vehicle – for the time until McLeod arrived and for the occasional times we would want a second vehicle. Maybe just a moped or dirt-bike would do for traveling the short island distances. There’s some rental cars available on the island, but they would cost us $200-$300 for each week we had to wait for McLeod to arrive. By some stroke of fate, it turned out the PT traveler before us had been driving a car around for the last 7 months that he wanted to sell for $1000. Honestly, I didn’t need to hear anything else – a $1000 car that drives? Sold.

I spoke with the traveler on the phone about buying the car, a 1982 Cutlass Supreme. The traveler was a real relaxed guy who I would later get to know personally – he clearly fits in with with the island lifestyle. Side note, he would explain to me, “I like to get in the ocean at least twice a day.” He had bought the car for $2000 from a traveling RN, and after his 7 months of use, he felt he had gotten his monies-worth out of it, and he was willing to let it go for 1000 bucks. He had no trouble with car, it always started up. The windshield wipers could occasionally get stuck in the on position on a sunny day which could be embarrassing, but other than that, it was a great buy for $1000. The travel PT had told me that the car only had 25,000 miles on it, “after all, it’s been on an island its whole life”. Upon further investigation, there is no 6th digit on the odometer of this car, so who knows how many times it has been past the 100,000 mile mark. But this 1982 Cutlass Supreme does drive. It likes to go. It’s a Brougham edition – I’m not totally sure what that means, I think Brougham might be the company that did the interior of the car (upholstered front bench seat and all) – naturally we have named him “Brougham”.

Jai, the previous travel PT still trying to sell me Brougham, even as I'm returning from getting cash out of the ATM. Awesome car.

Jai, the previous travel PT still trying to sell me Brougham, even as I’m returning from getting cash out of the ATM. Awesome car.

Brougham has been a blast. Great beach/island car with real street cred. We know the local guy who originally owned the car for its first 20-or-so years. He occasionally stops me in the middle of traffic in town to harass me about taking care of the car. It floats like a boat around corners and over speed bumps – Brougham is pretty awesome. I was able to restore some original glory through re-attaching the hood ornament and some of the original insignias to the trunk that had fallen off over years due to rust and who-knows-what else.

After about 2 weeks of work, McLeod finally rolled in on the Monday barge – barges come on Monday and Thursday with all the supplies for the island, including everything you could end up buying at a store. The barge is a nice reminder of what an isolated place we live in, how all packaged food and supplies come from somewhere, and that the waste we produce has to go somewhere as well. McLeod has been the 4-wheel drive beach-and-mountain-mobile we have needed him to be. It’s also nice to have A/C on an 80 degree day. Even with McLeod here and offering a smooth, cooled ride, Brougham has not sat idle long. The Cutlass Supreme is just a fun car to drive and gets us enough puzzled looks that we take it out frequently.

We hope to extend this contract for another 13 week stint before returning to Colorado for the winter. If for some reason we can’t extend, then we need to get For Sale signs on these cars soon and let the cycle start over again. When we get back to Colorado, we’ll be looking to buy a truck – preferably something from this decade with some good towing capacity. Until then, McLeod and Brougham will keep driving us in circles around this island, up in the mountains and down to the beaches. I suspect we’ll create some good memories of each of these vehicles between now and then.

Aloha! See you out on the open road!

 

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It Takes a Village

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Even the restroom lego characters are dressing formal.

Even the restroom lego characters are thinking #NoPolo.

I just finished packing my bag to head off to Nashville for the American Physical Therapy Association’s House of Delegates meeting. To quickly sum up what that is for those of you who might not know: about 500 PTs and PTAs representing different areas of the country, clinical specialties, and/or other interests get together for 4 days to make big decisions about big ideas that will drive the future of the APTA and ultimately the practice of physical therapy. When people talk about APTA doing or deciding this or that, that’s us, this week, and the PTs, PTAs, and Students that attend are all volunteering their time away from their daily jobs. As I pack my two suits and shiny black shoes into my suitcase for the upcoming meetings, I notice how much they stand out in contrast to the rest of the wardrobe I have here in rural Hawaii. I have scrounged together enough  black mid-ankle cotton sports socks to get through the week of meetings – I hope they’ll come high enough to gel with the suits. The most dressed up I’ve gotten in the last month is the polo shirt I put on daily to go to work (Is the #NoPolo crowd throwing a fit right now? More on this later.) Each Friday, I throw on an Aloha shirt for an even more formal Friday – here, in this local culture, an Aloha shirt is considered dressing up. The main Hospitalist wears an Aloha shirt every day. The Vice President of the Hospital wears an Aloha shirt every day. As an average Caucasian male, I’m already in the minority here. If I were to show up in anything more dressy than an Aloha shirt or polo, I would be a serious outsider. Dressing in a shirt and tie would, without doubt, affect my ability to connect with my coworkers and my patients. The culture I was raised in has no bearing on the social norms here and formal wear is inappropriate.

On my very first PT job in 2006, a job I took in a private practice that I had done a clinical with, we looked good. Just 3 guys from Boston practicing PT in the farm fields of Vermont wearing button down shirts and nice ties. Aside from our dress, we were goof-balls. Our staff had some really good chemistry there. We were always rambling on about anything and everything to keep our patients entertained and enjoying their time at the clinic. The schtick was constant and super-funny – “the PT will cost ya, the show’s for free.” In that clinic, not too far from Boston and not too far from New York City, we felt great in our shirts and ties, and it was the right thing for the right place – it did, indeed, take our appearance up a notch and add some professionalism to our otherwise juvenile behavior. But, when I left that practice 6 months later for the vast world of traveling PT which would lead to 10 years on the road, I realized that one size does not fit all, there’s more than one way to skin a cat, and, most importantly, rehab can be done best a lot of different ways.

I've got a couple patients here from outrigger-canoe-related-injuries. I finally took this canoe out with 5 other paddlers the other day. It gave me a whole new appreciation for the biomechanics of the sport. Most kids here grow up with paddling as one of the primary sports. "Doing is knowing" in both biomechanics and culture. Whoa, deep.

I’ve got a couple patients here from outrigger-canoe-related-injuries. I finally took this canoe (the Kula’ela’e) out with 5 other paddlers the other day. It gave me a whole new appreciation for the biomechanics of the sport. Most kids here grow up with paddling as a part of their upbringing. “Doing is knowledge” in both biomechanics and culture. Whoa, deep.

Later on, Colorado would become my home base, but I still continue traveling out of state on contracts most summers. Several years ago, we had word coming down from the top of the hospital that each department would need to decide on a uniform – I believe this stemmed from a JCO initiative for patients being able to more easily identify who is coming and going from their rooms. I advocated that the rehab department dress more formally – button downs, nice slacks, perhaps ties for the gentlemen. But, this is a mountain town we’re talking about. A place where the wild west is still alive and well. I have seen surgeons make inpatient visits in bike shorts, there’s an anesthesiologist that occasionally roams the halls wearing a cowboy hat, people do not care what you are wearing, they just want the best care from someone who understands their activities and lifestyle. Colorado mountain towns are full of aggro weekend warriors – nay, not weekend warriors, they have come to the mountains to make a lifestyle of outdoor sport and activity – for this reason, the mountains of Colorado respect  and understand the role of PTs more than anywhere else I have ever worked. A PT referral is always the first line of defense for all the patients that want the most direct line to getting back out in the mountains and doing what they love. Ultimately the dress code decision was made, there would be no formal dress, the final decision had been made made – black scrub bottoms, white tops, grey (sporty) vest.

I don’t know how I ended up in this place in this blog post. Polos, ties, and sporty vests have nothing to do with the point I’m tying to make.  What I’m trying to get at is that things we may accept as simple, given standards in our world may be very different from those held by someone else. I’ve written about local culture before and the great differences geographically in what the norm is, but I’ve been thinking of culture differently lately as I find myself living in more and more rural places. We so often are all encompassing in what we say – when someone says “the world works like this……”, they typically only know about their own experiences. People are so focused on their own world, that they can’t open up their minds and think about how someone lives their life in a community that has less resources, or that is isolated from all major cities, or that doesn’t want their community to be developed into something bigger and shinier. We are all so different from town to town, city to city, state to state, and especially internationally. We often think our own way is the best way, but the truth is that people are so different across our country because of their individual environments, experiences, and upbringings that we are all destined to value different things than our neighbors. We have a lot in common as well, but it’s the differences that can be divisive. I don’t mean to single out the crowd that thinks we should all dress up for work to make ourselves stand out as the autonomous practitioners that we are (I used to be firmly in that camp), but it is just one example that I can grasp tangibly to say dress standards can vary greatly place-to-place, culture-to-culture.

A few of my Aloha Shirts. Flowers and tikis are culturally appropriate. The Red Sox Aloha Shirt is not culturally appropriate unless you are dressing up as two-time World Series Winner Shane Victorino, "The Flyin' Hawaiian".

A few of my Aloha Shirts. Flowers and tikis are culturally appropriate. The Red Sox Aloha Shirt is not culturally appropriate unless you are dressing up as two-time World Series Winner Shane Victorino, “The Flyin’ Hawaiian”.

Another area that I have been thinking about culture in recently is research. You hardly ever read an article that breaks down the differences in effect of an intervention on subjects by cultural differences. In research, you frequently read something like, “this study was performed on subjects without confounding past medical histories and the results cannot be generalized to all patient groups.” Why don’t we see cautions like, “this study was performed primarily on New England Suburbanites and cannot be generalized to people of varied backgrounds.” I’m having a  little fun here, but I’m serious about the message – people are different and interpret the treatment we administer unto them differently. We cannot hold everyone to our own personal standards and should not expect everyone to have the same values that we do.

I hope that as therapists, we consider the widely varied backgrounds of our patients and that we respect our patients when our best practice patterns don’t align with their priorities. I hope as hundreds of us gather this week to discuss the PT profession that we can open our minds to see how different ways of practicing PT can all be successful for the people who are receiving the treatment and to embrace that difference. Finally, I hope in the greater scope of life that we don’t see people with different political and world views as lesser than ourselves and acknowledge that they merely come from a different set of life experiences.

Travel safe if you are headed to Nashville for the big meeting, I look forward to disagreeing with you all when we get there from our very different places. (just kidding, gosh don’t be so serious)

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Working 40 hours is Overrated

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I’ve come to believe that 40 hours per work week is just too many to be working. There’s so much going on in the world, so much more I could be doing than hanging out indoors for 40 hours each week. Who came up with 40 hours being the magical working amount anyways? On one tougher-than-average day at work, I once asked this question out-loud, more to myself than to anyone else, but someone within earshot replied, “Henry Ford”. I’ve never fact-checked this answer, but I was told with such confidence that Henry Ford had set the standard of the 40 hour work week for his workers, that I have accepted this as cold, hard fact. Despite my distaste for a full 40 hours at work each week, I have been finding myself accruing overtime more and more frequently.

Here I am complaining about how hard I worked this winter. This is one of the views from the PT gym at work, it could be much, much worse.

I used to insist on having a 40 hour guarantee on my travel contracts, meaning that even if there weren’t enough patients, I was contractually allowed to spend 40 hours at work each week and get paid for it. Of course, if you find yourself in the cooshy position of having more guaranteed hours than actual work, it behooves you to keep busy however you can – cleaning the hydroculator, scrubbing a whirlpool, updating facility rehab protocols, etc. Sitting around at work reading a book or surfing Facebook is not a good look on anybody, no matter what your contract says. When I reflect on the last few years, I don’t ever remember sitting, twiddling my thumbs. I remember working for hospital departments that would unload their fulltime employees schedules and pack mine – it’s part of the gig as a traveler, you are a grunt-worker hired for the purpose of easing the load on the facility. None-the-less, having that 40 hour guarantee is a concrete way to make sure you’ll be gainfully employed during your contract. It’d be a shame to show up to your job in a far-off town expecting and needing 40 hours worth of pay and coming up short, so I still recommend securing a 40 hour guarantee in your contract whenever you can.

The job that I work every winter in Colorado (7 years running), has never offered 40 hours guaranteed. They used to guarantee nothing, but somewhere along the line adopted a 24 hour/week guarantee – the truth of it is, if therapists are consistently getting anywhere in the neighborhood of 24 hours, someone’s contract is getting canceled, because the department is overstaffed. It’s a unique situation there. The hospital has a view of 3 of the 4 ski mountains in town. If a lot of people are getting injured on the mountains, we’re busy; if tourism is down, or the ski conditions are forgiving to injuries, we can have our slow months. In past years I’ve frequently come in around 36 hours per week with a few weeks significantly higher and a few weeks lower. This year I worked my tail off. I worked a lot of 42-45 hour weeks this winter. That probably doesn’t sound like a lot to many people, especially anyone working in a field where there’s a machismo about hard work at the office – long hours, late nights, early mornings, and postural dysfunction are signs of dedication to the company! For me, 45 hours is my hell-on-earth. A standard week consists of 168 hours – 40 to work, 8 hours of sleep per night gives you another 56 hours gone – we’re already down to well less than half of our living, breathing hours after only work and sleep (I do appreciate my 8-hours-square per night). These calculations don’t even take into consideration the hours spent getting ready for work, the time commuting, and the time when you’re too pooped to do anything else because you’ve been working so damn hard. We’re in a work-centric society and I don’t care for our society’s priorities one bit. Take a hike, Henry Ford.

Traded in my winter view for a summery one. This is from the parking at lot at my current assignment - working a few too many hours... #HawaiiProbs

Traded in my winter view for a summery one in Hawaii. This is from the parking at lot at my current assignment where I’m not in the ocean nearly as much as I’d like… #HawaiiProbs

I have been looking forward to  coming back to my island oasis here on Molokai in Hawaii to have some good time to relax and get away from the fast pace of a >40 hour work week. My wife, Kate, had been guaranteed the 40 hour position out here, and I took the second-position at only 20 hours guaranteed per week. There were some other PT opportunities that I looked into, but nothing panned out. I was kind of looking forward to filling some of my spare hours working at the bike shop, or on a boat somehow, or as a pool cabana boy, or just having time to do more with this website. This week was my second week of work and I worked 6 days for about 45 hours. So much for relaxing. The island around me is most definitely running on serious Aloha-time while I’m busting my rump during the vast majority of the sun-filled hours. Last time I worked on the Big Island, 2 years ago, we ran into a similar situation – Kate had a 40 hour contract and I had set up an independent contract with no guaranteed hours. On that job, I had a full schedule with a couple weeks. …a developing pattern? As the summer moves along, I hope my work hours come back to earth and that Kate and I can each work 36 or 38 hours, not over the dreaded 40.

I’m going to continue asking for 40 hours guaranteed in my future contracts, but have grown more open to accepting contracts with less certain work hours. I’m beginning to wonder whether this pattern of always being busy at work is just something I’m experiencing, or is it a symptom in a larger, growing healthcare trend as the baby boomers age and as healthcare professions fail to keep up with the growing demand. I guess time will tell as we all slowly, but surely, burn out from long hours of high productivity.That’s kind of a bummer of a thought, and I hope it’s not the direction we’re headed. But the numbers don’t lie, everyone in rehab is going to be pretty busy for longer than the next 15 to 20 years. This means one thing for sure – travel therapy and temp employment will be an option for therapists for quite a while. So, if you’re looking at traveling, but not quite there yet, take your time, it’ll be here when you’re ready and you’ll have a blast when the time is right.

Well after all of that, I don’t want to sign off on any sort of sour note. I’m in Hawaii, making a fruitful living and very happy for it. A couple extra hours of work each week isn’t really what I want, but doing physical therapy in Hawaii is a fine way to spend 40-something hours each week – there are far less meaningful and satisfying things to be doing with my day, so I’m thankful for that.

More blogs to come soon. I plan to write lots. See you on the open road!

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A Tale of Contract Negotiation

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travel PT contract negotiationAfter a few hours of skiing this morning, I had one heck of a day wheeling-and-dealing a travel contract. I ended up with a couple extra hours and thought I would quickly share the experience.

Kate and I are trying to return to a small, remote community hospital that we worked at a couple years ago. We absolutely loved the community and would love to return this summer for 3 or 6 months. We’ve been speaking with the rehab director over a few weeks and have established that there are 1.5 jobs (60 hours/week) available for the two us this summer. We’ve just been waiting, and waiting, for some details and pay numbers to come through. We had previously worked for this hospital through an agency, but the hospital requested we do an independent contract if we could. Finally, this past week, the ball got rolling, we filled out applications with the hospital and a proposed pay package came to us. I was pleasantly surprised with what the package offered – a rental car and housing included but a little too modest hourly pay. I sat down to crunch some numbers and with my estimates of housing cost, rental car, etc, the package fell well short of what we would be making at the same facility through an agency. I figured there was some wiggle room and while a rental car was a nice perk, we don’t really need a rental car and could perhaps negotiate it into a higher hourly pay. When I got on the phone with HR this morning, I was briskly informed that there was no room for negotiation – the offer we received was the final offer. Could we remove the rental car and turn that cost into hourly pay? No. Could any of the money be offered as tax-free per diem? No. How much are they paying for the condo? …a lot more than we would pay for a condo on our own. Bottom line, there was no wiggle in the pay package and I had to insist that we figure out a deal through a staffing agency because we would make a lot more moolah working the same exact job. But, the insanity wasn’t finished yet – just inform our recruiter to work with the hospital to set up the gig, right? No, the hospital has a policy that travel jobs must be posted publicly through a “vendor management system” (more on this later).

That’s the story on how this contract has come to be, but there’s a lot of nuance to break down and comment on that I believe offers some insight into the travel industry. First, non-negotiable!? Why wouldn’t we be able to negotiate a different pay package? While I did enjoy what was offered to us directly by the hospital, a lot of the value of the total compensation was spent on things I don’t need. Also, the tax free benefits available through an agency give them an edge on what the hospital could offer me. Here’s the factors that I believe led to the breakdown in the hospital’s ability to offer Kate and I jobs directly:

  1. A rental car. This is a huge cost. When going to remote areas, we tend to buy a Craigslist car and sell it at the end for minimal loss. If the money the hospital was pouring into renting us a car was converted into hourly pay, we  would have completed a deal directly with the hospital.
  2. Housing – When working for an agency, we typically take the housing stipend and find our own housing rather than taking housing offered through the agency. We do this, because with a little footwork, we can find housing that is better suited to our needs and costs less than the generic, supplied housing. This is exactly what happened with the hospital’s offer – we had budgeted $1200/mo for housing, and they were estimating $2000/mo. Sure it’s convenient to have housing set up for us, but not at a total of $2400 above our budget over the course of a 3 month assignment. (post-script update: We secured housing for $1100/mo – in the same exact condo complex the hospital was offering us housing in. This works out to $2700 more dollars in our pocket versus our initial  contract offer from the hospital.)
  3. Tax advantage – The hospital told me they had looked into their ability to do tax free payments (like per diem) and that they had chosen not to take it on for the tax difficulties it presented. When a portion of your pay is tax free, it really ads up. That was one reason I initially liked them supplying the housing. When they rent it for us, it’s like getting money before it is taxed. A great benefit!
  4. The nail in the coffin: HR literally told me, “We only pay a few more dollars per hour when we work with an agency, so we’re fine with that option.” A few dollars per hour!? That really ads up. Offer ME that money, man! Come on.
Kate and I enjoying the waning moments of our spring-time skiing before jetting off to the next contract in a couple weeks.

Kate and I enjoying the waning moments of our spring-time skiing before jetting off to the next contract in a couple weeks.

While I believe those are the main factors that ultimately led to the breakdown in our ability to work out an independent contract, the insanity was not finished. I mentioned that they had to use a vendor management system (VMS). There are several big VMSs and our contract was posted through the one I am most familiar with – if you have traveled for a while, you have probably had a job that was posted with this system. What exactly is a VMS, you ask? It’s the 4th party in a 3 party contract. VMSs collect job postings from facilities by handling a large portion of the foot work for the facility. These VMSs blast those jobs out to a bunch of different staffing agencies who subscribe to be a part of their listings. Have you ever had multiple agencies post the same job at the same time? If so, that job is posted through a VMS. Some larger companies that own multiple staffing agencies also own a VMS so that they can collect exclusive postings from facilities and post them solely through the staffing agencies that they own – big, shady business. The VMS that this job was posted through (where the facility, the clinician, and the recruiting agency were all known entities) charges a price of 4% of the total contract. So, again, rather than just paying the therapists, more money is being thrown at paying another company a good chunk of the available pay.

Lunacy, complete lunacy. But, you know what? Kate and I are returning to the jobs we want this summer. The contract eventually worked out through a staffing agency and we’re happy with the deal. It’s too bad that when you have a facility and a clinician that want to work together, it takes two other private companies to organize the employment. But, as long as facilities refuse to pay clinicians the money they are willing to pay to outside companies, traveling therapy will remain a strong industry and a great career choice for therapists all across the country.

There might be a second chapter to this story. We only have 60 hours of work between the two of us this summer. I’m currently working on establishing a contract with the state to do some part-time work in a very cool, very unique consulting situation. They are a little concerned with my temporary status, but I think I could do some great work for them in the time that I do have. I know, I have given you no details here …top secret… for now. Hopefully this part-time job will work out and I’ll have some very cool, very unique stories to share with you all. See you out there on the open road!