Know Your Role

I’ve had some trouble with delineating the roles in my life lately. I’ve always considered myself to have a variety of different personalities I can tap into – I initially come of as clean-cut, if not preppy, but my music interests lay primarily in heavy metal – very much at odds with my appearance. When on travel assignments, I have often heard I give an initial impression of reserved and quiet – but it doesn’t take long to learn that is far from the truth. For short periods, I have abandoned my clean-cut look for a shaved head and heavy goatee, which has served me well in scaring off tourists in Hawaii and has lead to fun nights blending into the crowd at biker bars in Maine.

I think we all have some multiple personalities within us that can come into conflict at times. I recently have experienced that conflict coming to blows between my personal and professional life… at least internally.

Me (far right) and several other Colorado APTA Members had the chance in early April to meet with my Congressional Representative (center). Central to our discussion was PTs’ Unique Role in the Opioid Crisis.

My Congressional Representative and I have very different views of our world. We disagree on most topics. I find him extreme in one direction, he would likely find me extreme in the other. Our district in Colorado, that I live in and he is elected from, is large and divided in its politics. I don’t think it’s moderate, but all the different extremes exist within it. I feel he should vote more moderately as to represent the average of his district, after all, he was re-elected with only 51.5% of the vote in the last election, hardly a landslide.

While my representative and I disagree on many topics, our lives and common opinions seem to be intersecting on one particular topic – the opioid crisis.

I currently serve as the Federal Affairs Liaison for the Academy of Orthopaedic Physical Therapist within APTA. Simply, this means I keep on top of the legislative issues affecting physical therapist and report back to the Orthopaedic Board. It also means I attend the annual Federal Advocacy Forum, put on by APTA, to meet with our Representatives and Senators in order to advocate for the bills and topics that will benefit PTs and our patients.

In the past couple years, APTA has targeted the opioid crisis. Afterall, Physical Therapists are positioned uniquely to help in reducing the amount of pain pills that need to be prescribed. We have extensive skills in decreasing pain (through exercise, manual therapy, and modalities), we are often the alternative to surgery or injection, and we do not prescribe medications. Every study I am aware of shows our ability to decrease the overall cost of a musculoskeletal injury in contrast to surgery or medication. A big part of Federal Advocacy Forum is PTs educating legislators on what it is we do in our daily work and how our skills can best be used to improve the lives of their constituents.

My Representative has championed responses to the Opioid Crisis and done a good job with it. We may not agree on much, but we agree on addressing the problems that have lead to Americans’ dependence on opioid medications to “fix” their pain or feed their addiction.

I have met with my Representative’s staff over the past couple of years, and very briefly with him. It’s an interesting exercise in burying my personal politics and focusing on what the priorities are for the Physical Therapy profession. I have heard other PTs at the Advocacy Forum ask about this conflict – personal politics vs professional role. The answer is always, simply, you put your personal politics aside for this role – but what about all the other days of the year outside of the Forum?

The whole group from Colorado at FAF. We divided and conquered to chat with as many of our Representatives and Senators as possible. #choosePT

For 3 days per year, at APTA’s Federal Advocacy Forum, I try to be the consummate professional advocating my my profession, my patients, and their causes. However, I only found myself in this role because of my interest in politics and policy. Obviously, I have some deep, deep disagreements with my Representative. How do I reconcile that? I see a scenario where I could end up at a fundraiser for him, funding his re-election through my professional priorities, all-the-while biting my tongue and trying to get everyone I know to vote against him. I’m having a hard time putting this internal conflict to rest.

PT-PAC raises money to contribute to candidates who are supporting PT-friendly legislation. One PT I know, deeply entrenched in these positions and topics, stopped his donations to PT-PAC. He felt his personal politics were so greatly at odds with some of the candidates PT-PAC was supporting, that he could not be involved. I get it – my representative is a personal foe, but a friend of the profession. Where do we draw the line? To what extent do I let my professional roles define me? I often feel strongly about large societal issues and want to act to improve them. But, often, I think I’m just tricking myself into believing I can have an effect – do I completely abandon those large societal topics for the professional priorities that I am actually in a position to affect through face-to-face conversations with my Congressional Representative? Uhg, I think so.

In a different position, I participate in APTA’s House of Delegates as the Delegate for Western Colorado (quite similar to the chunk of geography my Congressman represents). The House of Delegates is a meeting held each year to develop the policies for APTA, and therefor, the profession. Some of the topics are meaty and contentious, while others are snoozers for me. Luckily, there are over 400 Delegates representing every state and specialty area in PT. Someone in that group has a passion an expertise for every topic that is discussed.

I was at a PT conference earlier this year and ended up in a conversation with a longtime PT leader that I respected. We were casually chatting, and with legislative issues and House of Delegates topics on my mind, I asked him a question: “What are the topics we need to be taking on today to make sure Physical Therapy is a thriving profession in the future?” It was like he had been waiting all night for someone to ask him that question…

This aging leader in our profession talked on-and-on about Physical Therapists’ effect on society and our need to speak out on a wide variety of issues external to our profession. That as highly educated professionals, we have a responsibility to drive not only our profession, but also our society, in the right direction to achieve their optimal health and wellbeing.

I don’t know how this guy did it, but he predicted the future. Maybe another 30 years in our professional association will give me the same foresight. The House of Delegates is taking on a large breadth of topics that are societal (political) in nature this year. The topics include Medical Marijuana, vaccinations, naloxone use in PT clinics, and gun violence. You often hear discussion around these topics about whether we should be taking them on at all, or if we need to re-focus on PT-specific topics.

A portion of the ballroom at House of Delegates. I have yet to take a picture of this room that gives you the feeling of how big it really is. Walking into that room gives me tingles.

Within my Delegate and advocacy positions, I find a wild contradiction. In my position as a political advocate, I bury my personal beliefs to represent the priorities of APTA. In my Delegate position, I use my personal beliefs to help determine the priorities of APTA. To which extent do I rely on my personal experiences and values, and to what extent do I suppress my personal beliefs to act in a silo as a clinician-leader in my profession?

The most contentious of the House of Delegates motions this year is about gun control. I think it best articulates our involvement (or not) as a profession in social issues, and it illustrates my conflict between personal and professional priorities. The original idea for the motion is quite different from the current version because of collaboration between many PTs from different states and backgrounds. These motions can change and evolve up until the very moment they are passed or defeated. In my opinion, the current (June 1st, 2019) version of this motion is far less political than its original form. It does not advocate for any specific gun control, but would add APTA’s support to performing a CDC study on the health effects of gun violence.

At the outset of writing this blog, I wanted nothing to do with the House of Delegates’ motion concerning gun control, but after writing this out, I want to discuss this topic more. If you are an APTA member, you have access to all of the Delegate discussions leading up to the House. Also, if you are the rare bird who wants to be involved in it all, you can live-stream the house.

As someone who holds positions both in representing the priorities of the profession and determining the priorities of the profession, I’m curious where you think I should draw my line between personal and professional politics. Do I let my personal political beliefs shape the profession? Do I bury those personal beliefs to advocate more effectively for our profession? It all seems very complicated to me.

Links to info on all House of Delegates motions including gun control, House of Delegates motion discussions, and Federal Advocacy Forum. If these kinds of topics interest you, you should probably give to PT-PAC and contact me to get involved in this kind of stuff. Our profession needs more, opinionated clinicians who want to drive the future of PT.

It Takes a Village

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)