What’s Next?

If you’ve read this blog over any sort of extended time, you should notice a pattern: May to November, really good at writing frequently; December to April, really infrequent writing. I came into the winter this year with a head full of steam and several partially-written blogs. I had desires to reach out to more Occupational and Speech Therapists, and I also had the intention of voicing my strong opinions of PT-specific topics. But, as usually happens in December and January, I’ve had too much damn fun in Aspen and haven’t written a damn thing.

The mountains of Aspen have kept me aptly distracted from writing this blog.

The mountains of Aspen have kept me aptly distracted from writing this blog.

So, it hasn’t snowed a meaningful amount in several weeks, I got a quick ski session in this morning that was reminiscent of my days back skiing on the blue ice of the Northeast, and I’m left with a full afternoon to produce something meaningful for you. After procrastinating a couple hours by clearing a couple items out of my Netflix queue, I’ve sat down at the computer to write. In my mind, I’ve abandoned the two possible topics I had intended to write about and have forgotten what my partially-written blogs from November are even about. This will be stream of thought entry, proof-reading may be marginal, and I’d like to just get some of my current thoughts out to you. In these ramblings, I hope there’s something useful about being a traveling therapist that can be a take-away for you. If not, I’m sorry – at least my blogs are short.

The football playoffs started out with a lot of different potential outcomes for me. As a Native New Englandah and now as a Colorado Resident, the prospect of a strong Broncos’ team scares the heck out of me. It seems that in most of recent history, the Pats inevitably meet the Broncos in the playoffs – rivalries are fun, until it pits you against everyone around you. This year, we snuck by, the Broncos were eliminated early and my friends and co-workers (sorry, guys) were silenced. Crisis avoided. Then, two weeks ago, I realized my Pats were up against the Indianapolis Colts – Indy is also the home of this year’s CSM conference which is to be held 3 days after the Superbowl. If the Colts got past the Pats and went on to win the Superbowl, I would be in Indy for the victory parade…. Not a pleasant thought. Luckily, the Pats have prevailed beyond the Broncos, beyond the Colts, and are on to play in the Superbowl against the defending champions, the Seattle Seahawks. The NFL has once again stirred up controversy to make a good-guy/bad-guy scenario: Last year, the terrible Richard Sherman was portrayed as an out of control brute who can’t control his emotions, this year he is the intelligent tough-guy who will be playing through injury to take on the New England cheaters. I imagine by the time most of you read this, the NFL will have cleared the Pats of any wrong doing – it was trumped up controversy, folks, the NFL choreographed the whole thing to make you care about the Superbowl, just saying.

::segue coming::

The current center piece for our living room. A Hawaiian coconut painted with the Patriots logo. Below that, a series of books from Colorado, Hawaii, and Alaska.

The current center piece for our living room. A Hawaiian coconut painted with the Patriots logo. Below that, a series of books from Colorado, Hawaii, and Alaska.

Anyhow, let’s move along to the topic of therapy and travel. Did I mention I would be in Indianapolis for a conference next week? For those of you who may not be in Physical Therapy and may not know, CSM is our biggest conference each year, it moves from city-to-city each February, and over 10,000 PTs, PTAs, and students attend. Everytime I attend a conference, I come away incredibly motivated and excited for the future of our profession. I’ve written in the past about the need to gain knowledge and continuing ed while traveling (Traveling Doesn’t Have to Mean Professional Sacrifice – 4/11/11). Attending this conference accomplishes learning at a very high level and so much more – hanging out with old friends, meeting new colleagues/friends, discussing the future of our profession, meeting other travelers, and having a good time.

In the past, I have felt like the opportunity of being a traveling Physical Therapist may be some sort of compromise. Traveling frequently from place-to-place has limited me in creating real traction to move forward to the next stage of life (whatever the hell that is)! The approaching of CSM and some recent conversations with friends has brought this thought of the balance between travel-life and being established to the front of my mind again. This thought apparently comes to mind frequently around this time of year (Community Chest – 3/1/14). I was speaking with a co-worker, who is also a travel PT, and she was wondering what is “next” for herself. For me, “next” usually comes in the form of a 3-month plan that my wife and I spontaneously put together over a couple beers in mid-February. (Perhaps back home to New England for a few months? (and maybe catch some Red Sox games?)) (Who uses parentheses within parentheses? (Weird.)) But, this traveler I speaking with was asking the bigger question, “What’s next in her CAREER?”

Oh man, the “C”-word for travelers: “CAREER”. This word is only surpassed by the “S”-word: “Settledown”.

The life chosen as a traveler is unconventional. Kate and I, my wife, have chosen to roam fancy-free and mostly without any agenda other than to see as many different, awesome things as we can. We’ve been at this for 8 years and aren’t done yet, but it seems that through our meanderings, some sort of career-traction is being established. 1. I have had several requests for meetings at CSM this year, mostly about and due to travel (the total of all requests for meetings in previous years is zero). 2. I’ve inserted myself into conversations legislatively about licensure issues which has opened some big doors in the last couple of months. 3. Traveling just feels good to keep doing – after all, it’s what everybody does once they are retired and no longer hindered by their work schedule. Could it be possible that a career could be made traveling? Just writing down the words makes me feel uneasy, you’d think there would be some stop to this crazy travel-life. Who knows. For now, I’m excited for the Superbowl, CSM, and the next three months – but I should come up with a solid plan for the following three months soon. The three months after that? Not important, I’m doing jobs that I like, where like, with people I like.

Whoa, well I certainly got on a roll there. Hope it wasn’t too manic for you and sorry for blabbering about the Superbowl, be thankful I didn’t go on-and-on about the Rob Gronkowski dream I had this week. I’m just glad I finally got around to the topic of travel therapy. Have a wonderful winter and I promise I have more poignant topics soon.

Why I AM a Manual Therapist

A few weeks ago I read a blog that really caught my attention. The author explained why, as a sports and ortho Physical Therapist, he chooses not to use manual therapy. I’ve been thinking about his blog ever since I read it – it has frequently been the last thing I think of at night, the first thing I think of in the morning, and I think of it many times throughout the day as I work manually with the vast majority of my patients. My curiosity about this author and his stance against manual therapy has lead me on a bizarre journey finding other blog posts claiming manual physical therapy is a “sham,” “quackery,” and “pseudoscience”. Many of these manual therapy nay-sayers claim it doesn’t do anything meaningful. They say manual therapy is only a way for a clinician to act compassionately and/or cause indirect effects through being attentive to their patients. Essentially, they claim manual therapy’s benefits are an elaborate placebo.

When I came upon the first internet post that introduced me to the world of manual therapy nay-sayers, the post had already been out there on the web for 8 months. I came across it when someone in the online PT circles reposted it on Twitter. This reposting is one of over a dozen, and many more people comment on Twitter sharing their support and agreement. Apparently, there is an international network of physical (and physio) therapists who go from blog to blog verbally patting each other on the back about their distaste for manual therapy. They frequently refer to themselves as “recovering manual therapists,” they reassure each other with confident words about how novel each of them is to have stepped out of the populist belief that manual therapy is a good thing. The worst part about it is, many of these people are involved in professional leadership, research, blogging, and teaching – these people consider themselves leaders.

In this, my first introduction to the world of manual therapy nay-sayers, I was worried and confused and shot a quick email to a colleague. He is a leader, researcher, educator, and blogger – I knew he would know more than I did. In the first day I sent him the email, I heard nothing and nervously began to think, “Oh no, he’s one of them!” I woke the next morning and was comforted by his reply. He’d had experiences in talking directly with the manual therapy nay-sayers about their ideas – he described it plainly as, “a disturbing growing trend.” He is not a fan of these folks and their ideas. Frankly, neither am I.

If you’re like me, this is the first you are hearing of Physical Therapist researchers speaking out against manual therapy. Manual therapy is a corner stone of orthopaedic rehab… right? One of the articles I read over the past few weeks is a blog that has a robust comment chain following the article. The blog is a summary of a research article that claimed to be the end-all of spinal manipulative therapy research,

“Prof Menke concludes that more research is clearly NOT needed… That which is already known about SMT [spinal manipulative therapy] for back pain is quantifiably all that is worth knowing.”

Did you catch that? Th, th, th ,th, that’s all folks! Nothing more to see here. What an asinine statement: This guy summarized spinal manipulation in his research article and has it all handled for us! Here’s the link to the blog: (Spinal manipulative therapy: a slow death by data?) If you are an orthopaedic PT, I recommend you read the comments, they are scary – I, however, do not recommend you dig deeper to further posts and links, it gets downright frightening. One commenter on A Slow Death by Data states,

My favorite ‘hands on’ technique is what most people call a ‘handshake’.

He goes on to explain how his superior attentiveness and compassion to his patients are the secrets to his success without manual therapy – to his credit, he admits using his hands for “seeking more serious pathology.”  He then is repeatedly praised for his comments from the world of anti-manual therapy. How can these obviously intelligent and seemingly forward thinking people who are strongly rooted in Evidence Based Practice (EBP) believe that manual therapy is unimportant and, further more, that their treatments performed without manual therapy are superior!? This goes against everything I have ever learned and experienced as Physical Therapist working with orthopaedic patients.

I keep asking myself what could possibly be motivating the manual therapy nay-sayers. From what they write in their posts and comments, I believe many of them have had bad experiences with manual therapy in their careers, and I do not mean that as a slam. Some of these internet authors openly write about past experiences interacting with colleagues who claim manual therapy as a way to keep clients dependent on their services. If this is why they have grown so cynical of manual therapy, I am so sorry for the experiences they have had in the past that soured them to manual therapy. I have experienced similar misconceptions in my own PT career. I started out working in only high-volume sports and orthopaedic clinics through many of my student experiences and many of my jobs early in my career as a traveler. I once saw a clinic owner treat 8 workman’s comp patients in one hour. In the last 5 years, I have worked almost exclusively for clinics that book one hour treatments for their patients. I don’t think I could ever go back to the rat race of 2, 3, and 4 patients per hour, no way! I broke out of my bubble by seeing other models for delivering PT. I would suggest that a therapist who believes that manual therapy is no more than a pacifier go out and gain new experiences in manual therapy. There is a vast, vast majority of us manual therapists out there who use our hands because our patients get better faster and stay away longer – not to feed patients’ dependence on us.

Maybe these nay-sayers have only been exposed to manual therapy styles that they don’t see the value in. I have to admit, there’s a group of manual therapists that I don’t see eye-to-eye with either. I once worked for a private practice that had a manual therapy fellowship program built on a chronic pain background. The treatments were based on the smallest minutia I have ever seen in my life – for instance, a “pelvic ring instability” causing shoulder pain. Yikes! Way too many of the patients the other clinicians treated were getting SI belts to “stabilize their pelvic ring.” The therapists at that clinic – all brilliant, motivated, and extremely well intentioned people – were looking at the smallest details in human kinematics as their manual therapy targets. I am very much different. I consider myself much better with concepts than with the tiny specifics. If something is abnormally stiff, I want to move it. If something is hypomobile in the spine, it’s going to be a whole section of the spine, not a single level that I move. I do not believe in improving extension of one side of one segment of the spine – you just can’t do it, and our hands are not that specific – the research supports me in this belief. As clinicians, we are bad at determining joint mobility beyond three categories: hypomobile, normal, and hypermobile. If you find yourself frequently describing subrankings of these 3 categories (mildly, moderate, etc), research does not support our ability to be that discerning. Our hands may not be as specific as some will claim, but they are beneficial to a patient far beyond a handshake. My point is, I could get on board with a faction of PTs saying, “Hey gang, all this specific mumbo-jumbo is a bit much, lets get back to basics – move what’s stuck, stabilize what isn’t, and manipulate a group of spinal segments when indicated.” ….this is not the message I’m getting from the nay-sayers. Do not lump manual therapy together as one intervention. Manual therapy is many different, specific interventions. Some are more effective than others and the experience of the person providing those interventions matters very much.

OK, it is time to get back to the title of this blog.

So, why am I a manual therapist? Because it works. Not, “In my experience it works,” but because the research shows it works. It does!!! Patients get better faster for longer with manual therapy than without. What could be more mechanical and tangible than putting your hands on a restricted knee and straightening it, then performing a joint mobilization and straightening it further. If someone’s neck hurts, I’m going to see if manual traction helps – because it’s what the research indicates I should do, and because by using my hands, I am less likely to cause an increase in symptoms than traction performed mechanically. Then, if indicated, I’m going to manipulate the patient’s thoracic spine, because the research shows it will probably decrease their pain immediately. The use of hands-on techniques to decrease adhesions in skin or tendons through something as simple as transverse friction is undeniable (and well supported by research). These techniques are all specific things that require skill to apply and have very direct and mechanical effects. If you think the examples I’ve just given are too passive for your liking, and you want a patient more involved in their own rehab, let’s do some mobilizations with movement (Mulligan Concept) – how about some manually resisted PNF patterns? And, I really hope even the most radical of the manual therapy nay-sayers are putting their hands on patients to cue them with exercises and to improve harmful mechanics.

This is truly a case of throwing out the baby with the bathwater. Manual therapy is not one thing, it is a collection of many different techniques. If there are certain manual therapy techniques that don’t work, let’s address those specifically. I’ll gladly accept an argument for specific techniques over others. I’ll also gladly hear arguments that particular manual techniques are working differently than we currently believe they are. But don’t lump all manual therapy together and say it doesn’t work, it’s very well documented that much of it does. Let’s change this manual therapy versus no manual therapy conversation into a what manual therapy works best and when conversation. Those of us having this conversation already, should stop tolerating those that are absolute manual therapy nay-sayers, they make all of us look really bad and inhibit any productive conversation from happening.

As a Physical Therapist, if you’re not using manual therapy with your sports and orthopaedic patients, what the hell are you doing!? You’re not doing physical therapy. Physical Therapists are restoring function, motion, and abilities to hundreds of thousands of people every day – the ones doing it best are using their hands, a lot.

Let’s hug it out, the comments section is below. Please share your thoughts.

-By James Spencer, PT, DPT, OCS, CSCS,

Jack of All Trades

On my very first travel assignment, almost 8 years ago, I quickly started appreciating parts of PT that I never thought I would be working in or ever need to recall from the most doodled-on pages of my college notes. But, there I was, 6 months into my career – that I had originally intended to be as a professional sports PT – and I was standing by a whirl pool doing debridement on a homeless guy. Alex, an experienced PTA with a crazy amount of passion for Physical Therapy, had recently taught me the ins-and-outs of the simple wound care we were performing and why we were doing what we were doing. On this first travel assignment, I was also baptized into the world of prosthetics. Alex taught me about shrinking the stump and different techniques for wrapping and making simple adjustments to the prosthesis itself. Alex was a neat guy who took a “non-traditional” path to being a PTA and was one of my best early mentors. Along with Alex, there was a handful of PTs with varying degrees of experience who were all willing to help me through my first travel assignment. Me, Non-Traditional PTA Alex, and a few other PTs were conquering all the issues of the good blue collar people of Lowell, Massachusetts – and were definitely not doing professional sports PT. The funny thing is, I enjoyed it. Prosthetics was a cool field. Wound care wasn’t anything I cared for, but it was different and new. I even got some early ER experience and found some excitement in the mayhem I would find every time I walked through those doors – cops, crooks, drunks, and broken parts of all kinds. I ended up spending 10 months in Lowell getting some quality mentoring and all kinds of experience in a wide spectrum of PT. This was the first place I experienced the kind of place where you treat “whatever walks in the door” (or rolls in the door), it certainly would not be the last. After a few contract extensions, I triumphantly left that assignment, nearing a year and a half of PT experience under my belt – I knew it all, nothing could surprise me now!

[Just something to listen to while you read – enjoy! About Kaunakakai, where we currently live.]

I’m somewhere around 20 travel assignments now – I’ve worked in about 30 clinics. It amazes me that I have learned something significant and useful on every single assignment. My new knowledge on each assignment comes from both the things my bosses and co-workers are doing well and the things that could be done better. Much of the time, I’m learning something positive directly from colleagues who have become specialists in their own unique mixture of whatever walks in their door. Often my education is purely experiential in working with a new population, a new culture, or in a new setting – home care, inpatient rehab, private practice, acute care, hospital outpatient, ER. There is just so much variety of what you can do with PT and how you can deliver it. At the end of every assignment I make a note of what I may have learned and confidently think, “Now I’ve seen it all, I can’t possibly see something at my next assignment that I haven’t seen before.” I’m being a little sarcastic here, but seriously, after a while, there can’t be too many surprises left… right!?

I knew on this current assignment I would have to be a true generalist and pull from many different parts of my skill-set. On this island, there’s no OTs, no SLPs, no nothing other than one other PT working at a community health center up the road. To really up the anti, there’s just absolutely no where else to find any specialists, there is open ocean between us and anybody else – referring out to someone more equipped for a particular job isn’t an option. We are essentially the only option for whatever ailment you can dream up. I took a phone call last week from a case manager in the large hospital system we are a part of. The main hub of this system is over in Honolulu, and there are many smaller community hospitals throughout the islands that are a part of this health system – although, I can’t imagine any one of these small community hospitals being any smaller or more isolated than Molokai General Hospital (MGH). Anyways, this case manager in Honolulu was wanting to send a Molokai resident back home but wanted to make sure we had both PT and OT for her referral. I explained to her that we do not have an OT here at the hospital and there are absolutely no OTs on the entire island, but that we are used to filling many roles and can handle the patient. The case-manager seemed unimpressed with a reply of, “OK. Thank you,” and hung up. After the call, I realized that in a way, I am fulfilling a very Molokai role. Nobody expects to have every resource available on Molokai, but many people fill multiple roles and help the community as best they can by wearing many hats. Many employees in the hospital have their main role, but then serve an adjunct role as the as infectious disease coordinator, or employee health director, or any other job title you can picture being a full-time position in most hospitals. A funny sidenote: I was talking with someone who was one of 3 employees of the local paper, a transplant to Molokai. She described how word got out that she was decent with computers, and people (mostly older people) started showing up with their computer issues at the newspaper office for her to help. People here don’t expect to have every amenity or service, but they help each other out however they can.

Kate and I have enough years experience behind us in enough different settings that we are able to confidently carry out the vast majority of our responsibilities. At MGH we cover inpatient, outpatient, ER, and SNF (14 beds in the hospital – 7 rooms). We are serving as hand therapists, neuro PTs, the Ortho Specialists that we actually are, and essentially work in the role of rehab specialist on every condition from the age of 1 to 100 with only modest resources. We have a surprisingly great clinic, gym, and staff, but are routinely having patients order equipment they need online – there is a local pharmacy, but it’s pretty limited in the DME department. Kate has taken on the wound care, and while I appreciate having learned some about wound care in the ol’ days with Alex, I’ll pass, thank you. My learning experience on this assignment was revealed to me early on when I realized all the additional roles I would be filling:

Social worker – Kate and I both worked our butts off last week to get 2 SNF patients discharged. We called family members, called outside services, and essentially fully arranged and negotiated these patients’ discharges. Kate even went to her patient’s house to help her transfer out of her car and into her home. Not what you would call billable hours, but good work that achieved great results.We are also a part of a team that is charged with delivering a decision on whether or not to admit SNF patients. The list of variables to consider is huge, since to even get here as a SNF patient, you are typically flying commercial on a puddle jumper. Also, you have to be thinking discharge ahead of admission – there’s no home therapy services, there’s no long-term nursing home, there’s no assisted living. If a person can’t ride a commercial flight with a nurse or be expected to discharge home – they shouldn’t be admitted in the first place.

There are no surgeons. When someone cannot or will not go off island for an Orthopaedic or other surgical consult, we are the next best thing. The PCPs, many of whom we have gotten to know well in a short time, are quick to refer anybody with an ache, pain, or movement dysfunction to us for more specific diagnosis and treatment. We are determining weight bearing status for acute fractures, managing follow-up appointments, and suggesting when someone might need additional imaging. It’s a unique experience to be working with a patient that you know should have surgery, but that off-island surgery is just not a realistic option in his world. I could write another entire blog about performing PT in reality – treating within people’s financial limits, having realistic/sustainable goals for patients, knowing when someone has reached their own individual ceiling of health. When a guy shows up needing a metal plate in his ankle, but that metal plate is a plane ride away that he’s not going to take, that’s when some real-world PT is needed and when we need to decide what the best conservative treatment option is for the patient.

I do feel well equipped for this assignment that requires a wide range of skills and a certain depth of knowledge. I would not recommend this assignment for anyone without a few years experience across a few settings. It’s nice to be in an environment where we get to use a full range of our skills as PTs. Most of the time PTs will work in a setting that sees only a very small slice of the full scope of practice. Sports and ortho is still my bread-and-butter, but I have gained a lot of skills and knowledge in other areas over the years. When I am back in Colorado in the winters, I work for a hospital that practices orthopaedics at a very high level. The patients with various sprains, strains, and fractures are handed down from a team of Orthopods and ER docs that absolutely nail their diagnoses. It’s a nice luxury, but to be honest, my diagnostic skills atrophy severely in the winter from disuse. As I’m bending and straightening joints all day, patients ask , “You had to go to school for 7 years for this?” I defensively explain how making their knee bend is only a very small part of what I learned in school and that PTs are trained across a large variety of diseases and dysfunctions. But, back here, I’m using every last bit of those diagnostic skills and every ounce of my education across a very broad spectrum of pathologies. The health community here may not have specialists or surgeons, but to be as comprehensive as possible, everyone else must work their role to its limits. It’s fun, challenging at times, and definitely a new learning experience.

Continuous Education

I recently gave up my Alaska license because I didn’t have enough CEUs to renew. For a long time, all the licenses I held didn’t require CEUs, so it hasn’t been on my radar. Alaska is the first license I have had that has requirements, but some of the states I’ve been licensed in for years are adopting new rules for continuing ed requirements. I am based in Colorado, the continuing education tracking will start there after the 2014 renewals. I’m somewhat personally to blame for this, I have long supported CEU requirements and have advocated for states to adopt these requirements. I’ve heard people openly criticize these requirements. They claim that all continuing ed requirements do is drive people out to order crappy CEU programs that have little substance. I think this argument itself is crappy and believe that most PTs who have to purchase continuing education to maintain their licenses are going to reach for something meaningful rather than be the bottom feeders of their profession and community. In my case, I have 3 years to meet my Alaska continuing ed requirements and can renew at any point during that time. I have already order and started a HIGH QUALITY home study course from APTA’s Ortho Section that I previously intended to get but have been procrastinating for almost a year now. So, to you naysayers of continuing ed requirements, here’s one PT that was forced into getting high quality education by the very requirements you dismiss. And to those who believe that your years of experience are a superior substitute for structured professional development, you are wrong. I may not have been practicing for 20-30 years, but I have been practicing long enough to see huge progressions in practice – the way we assess and treat low back pain, the way technology has drastically changed total joint replacements, the proliferation of dry needling and manipulation – the list goes on… Each year that goes by, I realize how much more there is to learn, if you don’t see this, you’ve already fallen behind. People have been criticizing con-ed repeatedly in public internet discussions (I’m looking at you PT Twitterverse) and finally I get to candidly respond: You don’t know what you don’t know, and by fighting continuing ed, you are making yourself sound self-righteous and crotchety. The majority of your peers will consistently choose high quality education over the path of least resistance. Stop talking down on continuing ed requirements, they are a good thing for our profession.

Whew, sorry about that. I guess that’s been building up inside for a while. I hope smoke is coming out your ears from reading that last paragraph (my hair actually burst into flames). OK! Back to the story!

On the beach? Best place in the world to read a journal or home study course for CEUs. Continuing ed has never been better.

On the beach? Best place in the world to read a journal or home study course for CEUs. Continuing ed has never been better.

It’s not that I haven’t been learning. I read JOSPT every month, I read other articles when I’m not sure of something in the clinic, I go to coworkers’ places to knowledge-mooch when they have ordered a webinar. Travel PTs are ALWAYS learning. Different clinics have different techniques, different patient populations, and all kinds of people to learn something from. As a traveler you may work at one hospital that has the latest and greatest in surgical techniques and then you’ll work in a private practice that runs a manual therapy fellowship. A traveler is surrounded by casual learning opportunities, but we are not surrounded by funding for formal instruction – that is our challenge, our weakness. Unless you travel with one company for more than a couple assignments, you are unlikely to see more than a couple hundred bucks for continuing ed courses. But, there are opportunities out there – great opportunities! Great courses! And many of them are convenient for the traveler.

I have written in the past (Traveling doesn’t have to mean professional sacrifice 4/11/2011) about the opportunities for travelers to take larger programs like residencies and certificate programs. These are a big commitment, but force you to stay on path of continued education. Many can be completed through a series of weekend courses offered all over the country, so you can access your next stage of learning where ever you go. As I eluded to earlier, dry needling is a technique that has gained popularity and has some very high-level and quality learning opportunities. It wasn’t on my list in 2011, but it should be now!

There are smaller things a traveler can do for continuing ed credits throughout the year. Many reputable journals have read-for-credit programs where you can hop online for tests to demonstrate your knowledge on their articles. Credits are small, but add up over a year or two. The Independent Study Course I recently ordered from the Ortho Section, Applications of Regenerative Medicine to Orthopaedic Physical Therapy, has me fascinated in the first portion of a 6-part home-learning program. It is very high quality and written by THE experts. I will take a test at the end and get 30 hours of continuing ed – 30 hours! I have a co-worker who is finishing up a Foot and Ankle course this way. It’s a great means for people on the go or far away from a big city to get high-quality learning.

There are ways to get continuing ed without a huge hassle and without resorting to lousy courses that blindly dole out CEU’s for entry-level knowledge. Plan ahead, learn your states’ requirements ahead of time, and you’ll be fine. I’m well on my way to being able to re-instate that Alaska license should an opportunity arise.

Ask James

Hey everyone. It’s hit that time of year where April comes around and I realize I haven’t posted in 3 months. Don’t worry, I haven’t been working too hard, just skiing too much. 🙂

I thought one quick way to get back in the blog-habit is to post a recent email conversation I had with a new traveler. I think he was asking the right questions and made the right decisions in the end. Maybe our conversation can help someone else out there who is working on getting into travel PT.

Happy reading and happy travels! I’ll write again soon.

 

New Traveler: My wife and I have ventured out to begin traveling therapy. We left sunny SC and drove 2800 miles to cloudy OR last week. My wife had a for sure job but my opportunity fell through somewhere around Wyoming.

But now I have been contacted by a SNF and they want to offer me a contract directly.

They asked me to name a price and I asked to have time to think it over a while.

I have a little idea of what to say because I know what the travel company is paying my wife. But before I respond to them I am hoping to get some advice from y’all.

Here are my details: This will be my first job; I graduated in December. It’s going to be a 6 month contract. I have no experience in a SNF but I had 2 clinical rotations in outpatient (1 manual focused), 1 acute rotation, and 1 inpatient rotation.

One traveling company recruiter told me I should make 1400 dollars a week if they didn’t cover housing or insurance. I have both through my wife’s job.

Any thoughts?

Thanks

HoboHealth: Awesome to hear you guys are taking the plunge and hitting the road!!!

I have two thoughts. If the SNF job sounds like something you wouldn’t mind doing, then go for it. But if you’d rather be doing something else, then I think holding out another week or two may yield some good results if you’ve been seeing other opportunities in the area come and go. So, make that decision first… Is this really an assignment that’ll be ok for you? (Also, since you haven’t done SNF before, are there other PTs to help guide you? …the more the better.) Do you need another recruiter?

My 2nd thought is that $1400 sounds really low to me. I know therapists that made about $1500 wkly after taxes through an agency on their first assignment after only 6 months PT experience. Figure on top of that (or whatever your wife is making) that the agency is charging another $10-$20 an hour. That’s a lot of bargaining room for you. I would say as a new grad doing an independent contract $1600 is a very acceptable starting place for take home ($40/hr). I think you should aim higher $2000 ($50/hr)? I’ve heard of independent home health contracts going as high as $70/hr. Depends how ballsy you’re feeling…. Doesn’t hurt to ask. Also, just make sure you’re getting what perks and reimbursements you can.

Here’s some links in case you haven’t read them already (the second is some sample independent contracts):
The Job Search
Independent Contracts

New TravelerGonna give you a quick update. I went in for the interview on Friday and loved the facility as well as the other PTs and PTAs. I decided that it would be a great first job for me as a PT. The managers do a lot of the extra stuff like billing, etc so it will allow me to concentrate on solidifying my eval and treatment skills. As you know it’s quite different being an actual PT than a PT student. No one looking over your shoulder and checking behind you.

It is a unique situation. The clinic is considered an outpatient clinic because it is in a retirement village and serves an independent living community as well as a SNF so I will see a wide variety of patients.

The pay is good. It’s right around what we were discussing. I feel like it’s excellent for a new grad. $42 an hour initially and $48 after a month because I will decline the benefits. I am insured through my wife’s job.

Thanks for sharing the link as well. I used some of the pointers from your blog when negotiating the contract. The whole process went pretty smooth. My wife and I are planning to stay in Oregon for 6 months and then move on. We want to hit up Alaska in the next year. Maybe y’all will still be there and we can get a beer.

Thanks for the help. Hope to stay in touch.

HoboHealth: Thanks for the update. Sounds like a great gig and like you made some good decisions over the past few days!

Good luck and keep in touch when you start working towards AK!

THE Job Search

I promised a few blogs about how we got all our details settled on this current assignment. Given the location (Alaska) being so far away, the popular season we are here in, and a number of other unpredictable factors, setting up this assignment was tricky.

In the past, I’ve worked with a few travelers who have negotiated their own contracts, but Kate and I had never done this. I’ve had some interest in it, but not enough to actively pursue it. There are advantages and disadvantages to both using a recruiter and going the independent route. When you do have a recruiter from a staffing agency, they are your advocate, your negotiator, and your first point of contact for any issues you may have on contract. Also, while we typically choose to arrange our own housing and travel, many staffing agencies will handle this for you if you like.

On the other hand, as an experienced traveler, having the securities of a recruiter as a third party representative comes at a cost. …a real monetary cost. The idea that really attracts people into arranging their own contracts is that you eliminate the middle man and the cost that goes with paying the middle man. Therefore, an employer can dish out less and you get the same or more.

On this assignment, we had a friend in the Anchorage area who was willing to drop our names around town and find some potential employers for us. This worked, this worked very well. Kate quickly got a job offer with a private practice just outside Anchorage. There was a period of stress where she had to be willing to be her own advocate and ask for certain details in her compensation package. Now, she is making good pay and has many of the tax free benefits that a recruiter would be able to offer. The clinic she’s working for has even allowed her to use a car that different therapists have driven over the years, SWEET!

My contract took a little bit longer to develop. I continued to search with a few recruiters, but nothing was really working out. I found a lot of jobs that had repeat travelers lined up for the summer or were just too far from town. We had already started our road trip to AK when another contact of my friend called wondering when I was available. The job hadn’t popped up on any of the searches because the director didn’t want to work through a staffing agency. As it worked out, my benefits are comparable to what I would make through an agency, but by eliminating the middle-man, the clinic is likely paying far lower than they would pay a recruiter… WIN-WIN!

Ultimately, we’re pleased with the jobs we’ve found. The jobs are where we wanted, when we wanted, and are professionally/mentally stimulating. The story of our success negotiating private contracts on this assignment does come with a warning. There were additional stresses having to negotiate our own benefits without a recruiter as a go-between. Also, we would not have been able to negotiate if we hadn’t worked with so many recruiters in the past. Also, if something were to go wrong with the contract, the assignment, or anything it’s on us! The buffer through a middle man is a nice comfort that frequently comes at only a small cost to the clinician.

Here are a few things that I recommend are in your contract whether you go it alone or work through a recruiter:

-Guaranteed 40 hours pay

-A 30 day notice clause for either party to end the contract

-Travel, housing, and licensure fee reimbursement

-Negotiating any planned days off ahead of time

-Holiday schedule and pay

I do have friends and past co-workers who have made their own contracts. We did not do this, the places we were working for had used contract staff before and had their own contracts. I have seen some independent contract examples if you’re interested.

 

 

The THE Series

The THE series. Of all our travel assignments this one has been the toughest to find THE housing, most unique in finding THE jobs, and longest of THE roadtrips. We left our apartment in Aspen 4 weeks ago today, we have put 4,500 miles on the car, racked up 8,000 frequent flier miles, and will finally move into our new place in one more week in Anchorage.

As I’ve mentioned in previous blogs, I feel like one role of this site is to develop a knowledge-base of travel healthcare experiences in an environment not influenced by recruiting companies. Everything Kate and I have been through over the past 6 weeks needs to be shared with other travelers, and can be used as a template for how-to and how-to-not.

Expect in the coming weeks the THE series: THE housing, THE job search, and THE first few weeks (a working title). Thanks for tuning in, travel safe.

Travel Healthcare Websites

I had something I wanted to blog about, I have totally forgotten what that was. I got on a tear tonight. I’m excited, I’m on fire.

It all started when a friend wrote to see if Kate and I would be at the traveling healthcare conference that’s coming up in October in Vegas. I love the idea of it, I’d love to be a contributing part of it, and I know that no matter what, it’d be a great time.   …in fact, maybe we’ll go.

However, it led me on a little exploration of its organizers and the sites that are similar to HoboHealth. There are more sites than you would think and as best I can tell, HoboHealth is the smallest of these site that will turn up on a few basic google searches. What got me so fired up is that everyone else is fricken SPONSORED! Isn’t the purpose of our sites to help fellow travelers, to advise them in the ways to get the most out of their employment and travel experiences!? Let face it, staffing agencies are financed by us working in whatever job is available and willing to pay for us, not by us waiting around for our perfect assignment. While there are VERY GOOD staffing agencies, there is a direct conflict of interest in them paying us to give good advice!!! A site promising to aide travelers in their decisions cannot be funded by the very entities travelers are doing business with.

I have my own recruiters that I trust greatly, and I have plenty of companies that have failed at the task of holding their travelers’ needs at the center of their business. If you are one of the very few recruiters that works with me, know that Kate and I consider you within our personal circle and have the greatest trust in you. I wish I could plug my friends here, but it undermines the whole point of this website: To help travelers navigate the complicated business of travel PT and to help travelers have positive, well supported assignments in their own paradise.

I’ve spoken with some of my recruiters before about partnering, but never followed through, I never really knew why. I’ve visited sites identical to HoboHealth with 5 times the visitors and wondered how they got all that traffic. Tonight, when I realized those sites are advertising some of the very staffing agencies I despise, I figured out why this site has remained both independent and less visited. Our participants are real travelers just looking for tips from other travelers with no bias. Staffing agencies make their money on the work we do. They should be pleased to have us work for them and should work hard to keep us happy and protected. I love the opportunity here to help other travelers find the same joy in travel physical therapy that my wife and I have.

If you’re a site like HoboHealth without corporate backing, get in touch, let’s help each other help others. If you’re a traveler, ask questions and learn how to travel happily with companies that will support you, not companies only looking to earn their profit off your skilled work. I have found the companies that are willing to support me in my extravagant travels to awesome places with awesome people, I want you to find yours.

Oh man, I’m fired up…. and I finally feel like there’s a purpose to this very time consuming hobby.    🙂    Thanks for reading, I promise more light-hearted travel pictures soon.

 

Legality Schmeegality

I don’t really like blogs that are a pointless rant, so I promise I’ll try to keep this productive and at least a little informative for anyone who hasn’t yet been through  getting a new state license.

Kate and I are currently seeking our Washington and Alaska licenses for some potential work this coming summer. We have 4 licenses in common; I have Illinois and Vermont, and she has Florida, 7 states total. To simplify things, we’ve dropped being current in all but two states, our Home State which is the Vacation State (seems contradictory), and Colorful Colorado. Simplify? Yeah, I thought so, until both Alaska and Washington requested official license verification from every state where I hold or have ever held a license as part of their PT License Application. That’s a spousal-total of 11 licenses that need verifying through mostly snail mail and hand written checks. Who uses mail and checks!?!? Even the USPS has online options so that you don’t have to use the mail!

The Best:

1. Florida – $25 and an online submission will get you verified

2. Colorado – No fee and you may fax your request.

 

The Worst:

1. Hawaii – For only $15 per request you can have a verification sent within 20 days of receipt of your written request via mail.

2. Vermont – Written request. They’ll deposit your check and then have no record of your request.    <– happened to me

3. Illinois – Don’t bother calling, you’ll be on hold for 2 hours.

 

So, back to point, I’ve spent four hours getting these 2 applications together and probably have another 2 hours to go. Most of this time is a result of pre-internet legislation that dictates you do things as you would when mail and and personal checks were pretty much your only options. Part of the reason these laws have persisted is that no one likes to open their practice acts. When a practice act is modified, it offers a chance for other professions and interests to alter the law for their benefit as opposed to the benefit of PTs, PTAs, and patients. HOWEVER! Should you find yourself in a state with an open practice act and the chance to have your voice heard, please beg that licensure be brought into the 21st century, argue against the arbitrary barriers that keep well qualified professionals from practicing in a place that could probably use them, and educate your colleagues on the difficulties these laws place on state employees who must waste their time dealing with all kinds of paperwork for information quickly and easily available on the internet (fsbpt.org).

Really, I’m being a little melodramatic. Getting your license in a new state is generally a matter of paperwork, if your status as a PT/PTA is healthy, there’s no reason you won’t be licensed if you can get the paperwork to the right places in a timely matter. We’ve been licensed in many states now and have a greater burden because of it, if you’ve only worked in one state, it’s pretty straight forward.

Well I have to run, I’ve got some applications to fill out and an currently open Colorado Practice Act to leave my mark on.  🙂

Forest Gump and a New Clinical Prediction Tool

Firts, let me first start with 2 (two) apologies:

1. I apologize for writing so sporadically. I’m getting married next month and promise to be more consistent in August.

We passed this couple while hiking on the N Shore of Kaua’i. She was wearing the same shirt as me from Jack Quinn’s Running Club who we used to run with in Colorado Springs.

2. Sorry the comments don’t work on the blog. In addition, if you click around, you’ll find the entire blog portion of this site acts funky. If you wondering why I haven’t fixed this already, please see apology number 1 (one).

On we go:

I do like running in different places. I especially like finding a body of water on vacation (lake, ocean, river, irrigation ditch) and running along side it. While running on assignment, I learn my way around the neighborhoods I live in and see interesting things along the way. On a recent wrong turn that took me 6 miles out of my way, I realized how quickly I could get into vast farmlands and have beautiful valley views (it didn’t seem so close on the way home). I also got an up close look at a roadkilled-porcupine. The porcupine was pretty interesting, but more than I had bargained for.

The last time I went running a small happening that I think most runners can identify with inspired the creation of a new predictive rule for the field of psychology. So, the moment you have all anticipate, my first independently developed objective measurement tool:

The Spencer Societal Startle Test (SSST)

The subject should be sent out for a casual walk on a public street. The investigator should dress as a recreational jogger and begin running from a distance behind the subject. As the investigator approaches the subject from the rear, a cough and foot shuffle should be performed at a distance of 20 ft to alert the subject of an approaching person. The investigator should continue to run alongside and past the subject.

Scoring: Score 1 (one) if the subject yells out audibly in surprise. Score 0 (null) if there is no audible reaction. A score of 1 indicates the subject will likely benefit from professional psycological intervention.

Clinicians interested in studying the SSST should note that it should be expected that the test will have strong specificity, but fairly poor sensitivity. Meaning, a high percentage of subjects who test positive under the SSST will benefit from psychological counseling, however, a negative score may not truley indicate that a subject would not benefit from psychological counseling.

Enjoy the open road…. some day I’ll write about this whole barefoot/forefoot running thing, it’s really been driving me nuts.

James

James R Spencer, PT, DPT, OCS, CSCS

Current location: Skowhegan, ME