Scoot and I are buds from the travel PT days in Aspen. We talk often, it usually digresses in some PT shop talk.
We got on Zoom and talked for over two and a half hours recently. I was able to trim it down to about a 30 min recording. We think we’re hilarious. We think we have good ideas about PT. Give us a try – I think you’ll be entertained and maybe informed too.
If you’re into cable, we’re better than anything on there… and maybe half of Netflix. Play us in the background while you do dishes or something, but try us out. If you like it, we’ll do more in shorter format.
I’m not one of those people who writes, stops, crumples up a ball of paper, and starts over. Usually, I sit down at the computer, write whatever comes to mind and move on with a few edits later. This time, I just can’t get this blog going. I’ve started, stopped, started-over, and re-started over. There’s so many obstacles to writing this blog. The biggest barrier is that while many of us are finding ourselves with additional free time, we are so all-consumed with this virus that we can’t seem to get anything done – like writing this blog. Another huge barrier has been the speed things are moving at, every time I think I have a handle on what’s happening in healthcare and with the virus, it changes. Finally, I think I’ve been trying to fit too many ideas in one blog that truly contradict with each other.
Contradictions, that seems to be the hallmark of this crisis. While some facilities are laying off all their staff from lack of work, others are overloaded and woefully understaffed. One minute I’m convinced we’re all doomed to big, big trouble, the next I know we’ll be fine, then I swing back the other way. Should my last few remaining patients be scared of what I could spread to them, or should I be scared of what they will spread to me? I worry and I’ve had to quickly learn to manage that.
All those contradictions are why this has now become at least 2 separate blogs, maybe more if this isolation drags on. In this first one, I’d like to lay out the challenges that many travelers are facing in this crisis and some of the resources that are out there to help those challenges. In the sequel to this blog, I’d like to take a more positive note and look at some of the opportunities for change this crisis will bring. But I can’t write that piece without first writing this one that expresses the true graveness of this situation.
We’ll see if I get through writing this. Things will undoubtedly change before I can push that “publish” button. So please grant me some grace in knowing that what I write today may be outdated or completely inappropriate by tomorrow.
This thing is moving very fast. A few weeks ago, I was finishing up a paternity leave in Hawaii. The impetus for the trip was the wedding of an old travel PT friend. At that time in the beginning of March, the COVID-19 concern had started to build, but wasn’t doing much to affect every day life. The wedding went off without a hitch, was awesome, and was full of international guests and current/former Travel PTs and OTs from all over the country. I haven’t heard of a single illness from that wedding. Phew.
The next Monday, still in Hawaii, I had a meeting with some colleagues to decide whether to hold or cancel a PT event. While most of us agreed on a wait-and-see method, one colleague was not happy with the decision and had somehow anticipated or learned of the seriousness of this virus. Only 24 hours later, I would share his opinion that we absolutely had to call off the event (of course now, this is commonsense). In that one day, things had started to fall apart back in Colorado, and I had realized the gravity of what was happening.
All of a sudden, the Govenor was closing down everything in the state. Our county and town had also taken aggressive actions to stop large groups of people from congregating – first no more than 50, then 25, then 10, now 5. From a place of relative comfort in Hawaii where very little was happening COVID-wise, these seemed like drastic measures. Was our Governor OK? Or some kind of germaphobic lunatic?
Because of the craziness in Colorado, we decided to stay a few extra days in Hawaii. There were about 3 extra good beach days in Hawaii before the gravity of COVID-19 hit – then it became time for us to get out. Our flights all started getting cancelled, there were protests to shut down the local airport, quarantines for all arrivals were put in effect. As much as I love Hawaii, I didn’t want to get stuck there. Following many hours on the phone and internet with United and Hawaiian Air, we eventually ended up on a red-eye direct to Denver with a newborn and toddler. We safely made it home in time for me to return to work the next day.
I share this story to say that COVID has an interesting effect of people thinking they’re OK until they aren’t. That original colleague who wanted to cancel our event KNEW already, then the Colorado Governor KNEW, I didn’t know until a full week later. If you’re still out there thinking we don’t need to be social distancing yet, your time is coming. You too will KNOW soon. Please be safe.
Running parallel to my timeline in Hawaii, watching Colorado respond from afar, an interesting story was playing out back home in Aspen. A group of Australians had visited and brought COVID with them – even a month later, we only have 30-something confirmed cases in our county, 10 of them are those dang Aussies. Two of these patient-zero-Australians decided to quarantine-in-place at their 5-star slopeside hotel on Aspen Mountain, with the knowledge and agreement of the hotel staff. BUT, they did something no one could have anticipated – those awful, awful people snuck out and went skiing with the general public, putting everyone at risk.
It’s my understanding that their indiscretions is what closed down our city, county, and ultimately the state very early in this pandemic. Those arrogant jerks may just have saved us. Time will tell.
At work, I continue to be gainfully employed – at least as I write this, but nothing is certain. We have trimmed down to “essential” patients only, basically anyone who will be permanently disable if they don’t see a Physical Therapist right now, mostly post-ops. I have about 1-2 patients each day and am managing to stay impressively busy with projects. Administration indicates that they are keeping everyone they possibly can working in whatever capacity they can so that if a “surge” comes, our workforce is immediately ready. Hopefully that surge never comes. I have heard our anticipated peak is April 17th. So, the moment of truth draws near.
Our hospital held onto our travel PTs as long as they could until they finally had to cut them loose this week. In talking with the travelers, no one seemed to be surprised, they were happy to be kept on as long as they were. They were let go with a couple weeks of pay and free housing for a few weeks. It was nice to see the hospital treating the travelers well despite having to make some tough decisions at their expense. Which finally brings us to the point of this post.
This is an awful, awful time for many workers in this country, Physical Therapists included. I don’t have any hard numbers, but casually, it seems like 50% of PTs have been cut from their jobs. If you are a traveler and have had your contract cut short, you are not alone, there are many out there just like you. From what I hear, there are some jobs out there that still have openings, particularly in home health, acute, and SNFs. So don’t forget to open yourself up to the possibility of a new opportunity – just in case you can find one.
If you have suddenly found yourself without a job, I hope your agency or your employer is treating you well to the best of their ability. This time is putting a strain on everyone, and I think we all need to embrace a piece of the sacrifice, employers included. Some clinics will not re-open, many PTs will not return to the clinics that laid them off, PT practice and our society will be forever changed. We are living through a historic event the likes of which very few people have ever seen in their lifetime and hopefully we will not see again. This period in time will go down with the Spanish Flu of 1918, both World Wars, and 9/11 – it’s going to be rough, but it will pass. And some of those events of the past have been defining for our profession.
When this is all behind us, people’s knees will still hurt, their backs will still hurt, and they will still suffer strokes and heart attacks. Lots of people will need PT when this is all over! I hope for a very quick rebound, particularly in the realm of clinics needing temporary staffing. When people feel safe coming out of their homes, they will need our services. Hopefully that happens sooner rather than later.
In the Meantime… here are some opportunities to ease the pain.
Emergency License Waivers/PT Compact
There are still some employment opportunities out there. Many hospitals are overwhelmed at this time. It makes sense that as many thousands of people recover from the novel Corona Virus, they will require inpatient rehab needs in a SNF, or the will need home health. If you’re looking for work, it is these setting I would be looking in right now.
I’ve heard some people talking about a possible Federal mandate to open licenses across borders. The main challenge to this happening is that professional licensure is a state protected right by The Constitution. We are far more likely to see more state waivers on licensure like we are seeing emerge now.
The link below from FSBPT is tracking the measures states are taking to allow healthcare workers to come into their state to help in this crisis. There is a huge variation of waivers state-to-state, so your best bet is to click on the link below and see where you might qualify for temporary practice.
A couple examples of what is going on out there:
California – allowing people with inactive and expired CA licenses to re-activate within a matter of days.
Delaware – Allowing graduated, but not licensed PT and PTA students to practice under a licensed clinician.
New Hampshire – Specifically allowing out of state licensed professionals to practice telehealth.
There are a lot of people out there advocating for our role in this global emergency. Our profession evolved to resemble what it is today out of Reconstruction Aides during the first World War and from needs presented during the Polio Epidemic. Our success or failure in responding to this crisis will shape our profession in the future. If we want to be an essential service in the future, we better demonstrate the uniqueness and importance of our skills NOW.
There will be no one else mobilizing and strengthening the thousands of patients who recover from COVID-19 with significant lung damage that needs our skills. All the people that are sitting sedentary at home right now are going to need us badly when they try to leave their homes again. There will be major societal repercussions from this time of solitary confinement. Don’t be mistaken, if you don’t see our essential need yet, you will – it’s coming.
APTA has collaborated with others to develop a volunteer pool matching available professionals and students with needs for volunteers. If you are available, please consider signing up at the link below – while it might be a little scary, this is a great opportunity to be a part of the heroic response and gain some new skills along the way.
There is a tremendous amount of information available for free these days. There are existing resources and new ones that have been recently opened up. If you are finding yourself with extra time to occupy, here are just a handful of ways to expand your mind, but I encourage you to search for more. There’s a ton of stuff out there.
The Academy of Orthopaedic Physical Therapy has release a reading list that was previously a part of a paid course. This reading list is a greatest hits of Orthopaedic Physical Therapy literature and long enough to keep you occupied for months: ow.ly/Z4bT50x2xHT. AOPT has also decreased the price on many of it’s archived courses. You won’t receive official CEUs for these courses, but I’ve taken several of them and they are very meaningful learning opportunities produced by the absolute experts in our field. For $10 or $20 you can get some great education: https://www.orthopt.org/content/education/independent-study-courses/browse-archived-courses
Meditate. Headspace is a online service focusing on guided meditations. Now, they are offering their premium service for free to healthcare workers through 2020. This may be the single most valuable resource on this list. Whether you are under-worked or over-worked, some meditation could probably do you some good in this time. Mental health is so important in a time like this.
Many universities offer free courses on a regular basis including Harvard. I’ve always wanted to check out what they have to offer, now might be that chance.
Audio Books – Audible has over 1,000 titles available for free. With school being out, they have added a whole bunch of children’s books which includes many of the classic. Might be time to review some Mark Twain or Hemingway.
Learn a language. If you are, or live with, a student of any level, both Rosetta Stone and Babbel are offering 3 free months of courses in a lot of languages.
If you have been laid off, furloughed, or have had to step away from work to care for a loved one, you are eligible for unemployment benefits. Who is available has been expanded by Congress and they are supplementing the weekly benefit by up to $600. I’m not so polished on the details, but this APTA page explains some of the details and links to the Department of Labor who is ultimately in charge of implementing the changes.
Congress included the gig-economy and contract workers in this expansion. I have to imagine there are Unemployment Benefits that extend to travelers given those two area of focus. It is also likely further expansions of unemployment will come.
That’s all I have in me for now. I have the intention to write the second piece to examine what positive changes our profession and our society can take from this experience… we’ll see what comes of that as the next couple weeks progress.
This is a grave time, historic in all the worst ways. I hope our profession can pivot to meet this time’s needs and come out stronger on the other side. Stay safe out there. Take care of yourself. Take care of each other. We’re going to get through this, and PTs will be VERY busy in a couple months.
A couple weeks ago I found myself sitting at a small breakfast table with 2 past Presidents of the American Chiropractic Association (ACA) and some current ACA board members. For anyone who knows me well, this is a very unexpected place to find me – I am acutely aware of and involved in the many legal battles that have taken place between Chiros and PTs over the years. Now that I’ve had some time to reflect on the whole experience meeting with Chiropractors, I’d like to share it.
With the scene set, I must pause for a second and write a little about my writing process. At the beginning of a typical post, I have an idea and I start writing. Sometimes I don’t know where I’ll end up, other times I do, but I never know what the middle of the piece will look like. This time, I know I will end with a message of hope and collaboration between professions that have often been adversaries over a few decades. I only tell you this in order to convince you to read to the end. I can’t imagine I won’t disparage some Chiropractors along the way, it might get ugly – just stick with me, the end is positive.
There’s a local Chiropractor, who as with any other practitioner in a small town, I share some patients. She and I have never really met each other, but we’ve been in the same room enough times that we know who each other are. We share some great friends in common. Because of the people she is friends with, I can’t imagine that she is not a good person – but as a professional…. uhg. Her clients routinely come in believing they have “had Physical Therapy before”. I was shy at first when patients would come in telling me they already had Physical Therapy, but now I plainly reply, “You have not had Physical Therapy. She is a Chiropractor, you have had Chiropractic, not Physical Therapy”.
This single Chiropractor is emblematic of my relationship with the Chiropractic profession over the years.
My introduction to back pain was through an injury I suffered wrestling in high school. I originally went to see a Chiropractor who was the father of a soccer teammate. After my first Chiropractic treatments, I was hooked. Manual Spinal Manipulation feels good… but it didn’t fix what would eventually turn out to be a spondylolysis, a.k.a. decapitated scotty dog, a.k.a. fracture in my L5 spinous process. Chiropractic adjustment felt good, I loved it, but it wasn’t curing my spinal fracture. I eventually would wear a lumbar brace for 9 months, take some less-than-recommended time off sports, and get a short course of Physical Therapy that I hardly remember.
Fast forward several years, and I’m at Northeastern University in a pre-PT program bringing in Chiropractors to talk to our class so we can understand their profession, as well as ours. I was that guy. I was the guy who brought Chiropractors into school so we can all learn from each other and practice in a happy collaborative world of bliss.
Chiropractors ruined my positive attitude about them – there is no one to blame but them. I got involved in APTA in Massachusetts, then the states I lived in as a travel PT, and then nationally. One constant persisted across my experience – Chiropractors suing PTs across the country over pointless turf battles. The lawsuits centered mainly around two topics, PTs performing manipulations and PT Direct Access (without a Physician or Chiropractic referral). These lawsuits were not based on patient safety, they were only based on a perceived threat to Chiropractors’ bottom-line. These lawsuits developed a long, dense history of contention between the two professions that eventually led to last month’s Interprofessional Collaborative Spine Conference (ICSC) to start healing some wounds.
The ICSC brought together PTs, Chiropractors, and Osteopaths to discuss manual spine treatments.
The structure for the conference was essentially this: For two days, panelists presented topics, then opened up to audience questions for further discussion. The presenters and audience were largely leaders in PT and Chiropractic, (and Osteopathy). The questions were engaging and on-point – the presenters were the best-of-the-best in our fields. There was zero contentious discussion that was had. In fact, I found the formal content of the conference pretty underwhelming.
The good news is, there was a lot of time scheduled for social interaction and networking. This is how I found myself having breakfast with Chiropractic’s heavy hitters. The very individuals I have grown accustomed to battling against in state legislation over-and-over again, I was having a polite breakfast with, exchanging stories of insurance interference in our practices, and exchanging business cards. I think I behaved myself, and the conversations were enlightening for me.
The time in between the sessions was invaluable for me. It allowed for open, cordial conversation about a variety of topics. We talked about our education, our practice, our research training, and our common interests. It added to my understanding of the loooong histories that make the Physical Therapists, Chiropractors, and Osteopaths what they are today. Our current-day practices are deeply entrenched in the histories of our professional origins over the last 100 years and long before.
After digesting the conference for a couple weeks, I now more strongly than ever believe that the Physical Therapists have the higher ground on whose practice is more evidence-based. I hope that the Chiros and DO’s walked away saying to themselves, “Whoa, did you hear that content from the PT presenters?” That was definitely my reaction. But, more likely than not, their reaction, like mine, was something reinforcing their own practice beliefs. But, maybe they are onto something too. Chiropractors have a very effective model in making people feel good (if only for a little while). They don’t allow themselves to feel overly limited in doing exactly what the science dictates, they just manipulate and know it makes a lot of people feel good. They do have a point.
I could go on. And on. And on about how I believe PT is more superior in research based practice, that’s our training… but that’s not the point. They clearly have something good going on with the way they practice too. We will not align Physical Therapist and Chiropractic practices for a very long time – our histories are too different.
There was a great common thread of conversation that reflects the impetus for this conference. Research does, indisputably show, that patient interaction with a Physical Therapist, a Chiropractor, or an Osteopath decreases prescription medications, imaging, surgery, and, most importantly, cost. One phrase I heard in conversation at the ICSC that has continued to run through my head is, “A rising tide lifts all ships.” So true. Despite our different individual histories, and our many battles against each other, if we can unite to improve access to manual therapists before surgeons, we will save our patients from pain and from the cost of undue medications, radiographs, and surgeries.
I have learned that everything we think we have different with Chiropractors is justified. But we have one major thing in common – either of our treatments decreases more invasive and expensive alternatives. That is something worth burying the hatchet and uniting over.
Tennessee and Missouri share their borders with 8 states each, more than any other state in the nation. Both are compact states, and both are actively issuing compact privileges. Each has 6 of their neighbors in the compact, including each other. Tennessee has one advantage over Missouri – Tennessee’s neighbor, Georgia, currently has legislation proposed to adopt the compact later this year. Therefore, I hereby rule, Tennessee is the center of the PT Compact World.
You don’t need me to tell you where the center of the compact is. Just look at the most recent national PT Compact Map – you can easily tell we all revolve around Tennessee. Come on Missouri, “show me” I’m wrong. <— hehe, hope you caught the MO joke in there.
The compact has come a long way in the last year. 23 states have adopted the compact – 9 of those are active, issuing privileges to PTs and PTAs. If you’re in a state that has approved the compact already, but is not yet active, don’t worry. Most likely, if your state has approved the compact but isn’t active yet, they are actively working on making it happen.
The compact is a scripted piece of legislature that states are individually approving into their laws. Each state has to approve the exact compact language. Any changes in the language would void the compact – essentially, it’s an agreement between states to accept licenses from other states – each state’s law has to match. So, if your state has approved the compact, but isn’t active yet, your state board is working to align its requirements with those of the compact.
It’s complicated, I get it if you don’t understand yet. A great example of an existing state compact is drivers’ licenses. Each state has the exact same language in their laws acknowledging every other states’ drivers’ licenses. That is exactly what the PT profession is trying to accomplish – license reciprocity among all states.
What I have heard about the actual compact experience is very positive. The people I have talked to have gone online, paid their fees, and immediately have license reciprocity! If anyone out there has had an experience, good or bad, with using the compact, lease post in the comments. I think it’s important that we start to collect some info on how the compact is doing in the real world.
There are 23 states onboard and another 5 are currently working towards adopting the compact. There is a very realistic scenario that we could have over half of the country on the compact by the end of the year – that is a very big feat in a very short time! As more states sign onto the compact, the states who are not onboard will find themselves being the odd-man out. States without the PT Compact will likely suffer staffing shortages. In a world where we are expecting PT staffing shortages through at least 2030, I can’t imagine why a state wouldn’t want to decrease whatever barriers it can for workers to come work!
That’s all I’ve got on the compact for now. Please do share any positive or negative experiences you have had accessing compact privileges. Ask any questions you might have. I’ll be replying and writing on this topic in the future as things progress forward.
Stick with me, this isn’t your average tale of of international crimes committed in clandestine night clubs or amongst thugs with weapons. This is far more nerdy. Far less violent. But, it’s real, it’s effective, and it’s highly destructive. I think it’s super interesting – why would international crime choose physical therapy?
Looking for info on International Travel PT? Click here.
In 2006, I was a new grad serving on a committee within FSBPT (Federation of State Boards of Physical Therapy). The committee dealt with the administration of the PT liscensure exam. While we didn’t deal directly with the security of the exam, I got to be front row for some high drama taking place across the Pacific Ocean.
As I remember it:
Some test takers in the US territory of Guam had higher scores than they should have. Guam is a convenient location to take the test for foreign-trained PTs coming from across the Pacific. After statistical analysis of test results, a cluster of test takers originating in the Philippines was identified as having abnormally high scores. Upon further investigation by US and Philippines law enforcement, these abnormally high scores all seemed to be coming from people who had taken one specific test-prep course. This test review course had sent employees to take the NPTE and steal questions by a variety of methods – small cameras, writing down questions, memory, etc. Unsuspecting test-preppers had taken the review course with stolen questions and were unknowingly exposed to hundreds of actual test questions. These course participants then went and did REALLY well on the test… so well that the statistical anomalies drew some attention. Law enforcement bodies from both countries investigated and prosecuted those who had stolen test materials. FSBPT stopped offering the test in US territories and increased security to the test. In addition, the test was limited to several specific dates as it is administered now, rather than being offered throughout a portion of the year as it had been previously – making it harder to steal and re-use test questions. With heightened security of the test and scrutiny of specific testing centers, the test is again being offered in specific test centers in US territories including Guam.
Guam is is a location very far from the US – about 5,500 miles off the coast of California, almost 4,000 miles from Honolulu, but only about 1,300 miles from the Philippines.
From a 2011 FSBPT report¹:
In response to compelling evidence gathered by the Federation reflecting systematic and methodical sharing and distribution of recalled questions by significant numbers of graduates of physical therapy schools in Egypt, India, Pakistan, and the Philippines, as well as several examination preparation companies specifically targeted to these graduates, the Federation in 2010 temporarily suspended NPTE testing for all graduates of schools located in those countries, pending the development of a separate, secure examination. This evidence was obtained through extensive forensic analyses of NPTE performances, as well as a variety of legal actions brought by the Federation in the United States and abroad.
That’s crazy stuff, right? Who knew why security around the NPTE was so tight – there’s reasons, the incident I described is only one reason. People domestic and abroad make attempts to steal test data more frequently than you would think. The test materials are held under very tight security and the cost of protecting the test questions is very high – a major reason why the test cost hundreds of dollars to take.
I only share the above story to add some plausibility to what I am about to describe has happened on HoboHealth. Foreign entities have attacked the profession of physical therapy previously – and they’re at it again.
At this point, we’re all aware of the desire of foreign powers to sow discord through our society. “Foreign Bad Actors” as they are now frequently called are known to have participated in our online discussions, pretending to be normal, fed-up Americans. There are known warehouses of people in Russia and other countries sitting at computers where their only job is to interfere in American online discussion² ³. These paid trolls place misinformation all across social media and try to start arguments where ever they can. The ultimate goal is to make conversations within the US divisive – to pit us against each other and prevent us from being able to come together and do anything productive. It seems this strategy has been very effective within the realm of politics, but never did I think HoboHealth would be a target. Frankly, it’s flattering.
In July, two separate comments came through on HoboHealth blogs. My first reaction anytime I get an email notifying me of a comment on my blog is cautious excitement. It’s wonderful to have a conversation happening on my site, but more often than not, it’s spam – these comments stood out as a very different kind of spam. The two comments came through the same day (July 4th none-the-less) and each were well written but very aggressive. On closer inspection, it turns out each came from foreign email addresses – Canadian, I don’t know what to make of that.
Here are what the posts said:
“Manual therapists who self identify as such should spend time actually reading the current research and sober up. Those who refuse to do so will be marginalized as a fringe group, further eroding the credibility of the profession, something it can hardly afford. Unless you have super powers, maybe stop pretending you deserve superhero status. The legend is in your own mind, but only.”
“The DPT is a ginormous waste of money and its [sic] starting to look like the profession is willing to eat its young just to survive. Stuck in the past, too rigid and clinging to orthodoxy of the past to demonstrate the flexibility needed for change that they tell clients they need. Welcome to the slow swirl.”
These fake comments reflect real sentiments spread by a loud, but minority few who have blogs and participate extensively on Twitter. I have previously railed against similar real voices who preach anti-manual therapy (Why I AM a Manual Therapist). But the truth is these are fake posts, by people or computer algorithms that likely have nothing to do with physical therapy. It is wild to me that the body or government behind these posts is so desperate to create arguments that they would go after physical therapists. It makes me wonder, is it just another part of a foreign government’s efforts to sow discord in our culture where ever they can? Or has a competing profession gotten in the business of starting a troll farm? The topics they went after, Doctoral degrees and manual therapy, do seem like the type of thing a very specific profession we often compete with would want to have us divided on…
Don’t get carried away with anything you might read from any commenter on the internet. I have heard it estimated that only 10% of the physical therapy profession actively participates on the internet. Meaning, if you read a minority opinion on the internet (say from the anti-manual therapy camp), that opinion may be held by only a small portion of the 10% participating on the internet – a VERY small minority of the whole profession. It turns out, that some of the voices chiming in to support those minority, extremist opinions may not even be real – just paid trolls, specifically participating to create conflict.
I’ll never know the source of these posts, but I believe the moral is this – If fake accounts are being made to post on lil’ ol’ HoboHealth, then they are posting EVERYWHERE. Be very, very wary of where you get your information, who you debate with, and when you allow yourself to believe that a real, genuine person is on the other side of the computer screen. Paid trolls are intervening in every little innocuous conversation we have on any public platform.
A final tangential topic just came to mind: Fake research. I only recently heard about fake research, but I believe we’ll all be hearing about it much more in the near future. I first heard about fake research publications a few weeks ago on this short episode of PT Pintcast featuring Chad Cook. I have since heard about it on NPR in different arenas outside of PT. There are journals that are publishing completely unreviewed, unmonitored research – I find the phenomena totally mind-blowing. We need, in all aspects of our lives, to use reliable resources. Whether in research or news, there is too much information available for the average individual to vet it all. We need to insist our research comes from research journals with highest impact factors and news that comes from similarly reliable resources.
That’s my take. Be careful what you read. Treat each other kindly in person and on the internet.
In recent years I have gone out of my way to educate clients, colleagues, and others on the success of non-operative, conservative care for a variety of conditions. The #GetPT1st campaign has been a big motivator for me and is a great resource for PTs wanting to educate those around them on the potential to avoid surgery for a variety of conditions through PT. In my own clinical practice, in a ski town, I have become somewhat obsessed with the idea that the majority of clients with ACL tears should be put through a mandatory 6 week waiting period before electing surgery. Here, the tendency is for skiers to elect immediate surgical reconstruction for their ACL-deficient knees. The thought is “surgery will add stability and decrease the likelihood of premature arthritis,” “skiing is different than other sports, you need an ACL,” and “our population is just different here, everyone is extremely active.” I have been fighting these misconceptions for a couple years now, but change is slow – some of my PT colleagues still don’t buy that there is a percentage of people who can live an active, fruitful, physically elite life without an ACL (if you guys are reading this, I will get you eventually… you’ll see). I think the idea of the active non-surgical ACL is gaining some traction – if not yet with the medical community in town, at least more patients are starting to self-select a waiting period before surgery. Just to be clear, evidence tells us that there is a significant percentage of the population that can return to full function without an ACL – this percentage includes division I athletes and downhill skiers. Studies have specifically been done on ACL deficient elite athletes, there is a significant percentage who return to sport without an ACL – in fact, for those with a well informed sports medicine team, the non-surgical option can be a quicker way back to competition. Repairing your ACL does not decrease your chance of early arthritis – the life of a knee without arthritis following ACL reconstruction is about 15 years according to the literature. So there. People just don’t want to be patient and do 6 weeks of strengthening for a less than 50% shot at avoiding surgery – hey, if that’s the choice they want to make, I don’t really blame them…. But I feel strongly that they should be accurately informed.
We’ve had a couple injuries in the Spencer household lately and we’ve had to choose conservative care over surgical intervention.
Here I am pressing my thumb into the counter to keep it extended while I work to re-tape the splint for support. The morning ritual takes longer than you’d think and has evolved to my using 10 separate pieces of tape each time.
I had an unfortunate water polo accident (said no one else ever). Goofing around between actual play, I had a shot blocked and my thumb went tip first into a swatting palm. I immediately knew something wasn’t right – I instinctively grabbed my thumb. There wasn’t much pain at all, but I had heard a small pop and my thumb would no longer actively extend – I could easily push it straight with the other hand, but could not hold it there without assistance. I don’t do a lot of hand therapy (I’m spoiled by having some great hand therapists around me), but I knew enough to know immediately that some sort of tendon no longer existed. The next day, I got bootleg-assessments from one of our talented OTs and a trusted Orthopaedic Surgeon next door – the good doctor diagnosed mallet thumb. Mallet thumb? “Yes, it’s mallet finger but in your thumb,” he said frankly. This is not common. The extensor pollicis longus tendon is broad, thick, and fibrous – it doesn’t usually rip. Because it’s relatively rare, there’s not a whole lot of research on mallet thumb – but I did find some case studies. It seems I could surgically have a pin put down the length of my thumb bones for 8 weeks and have a return of most of my thumb extension pretty much guaranteed …or… I could wear a splint on my thumb for 8 weeks – no bending the thumb, ever. I can take the splint off to clean the thumb with the tip pressed against a counter-top for extension, but if the thumb bends, the 8 weeks starts over. Most people do well with the conservative treatment, but full return is not as guaranteed as with surgery. I figure with a small army of OTs, PTs, and Orthopaedists at my disposal, I should do well – we’ll find out in about 3 more weeks. The idea with both the surgical and conservative treatments is that the tendon will scar down to the bone wherever it is – hopefully it scars down somewhere useful. I’m just happy that I’m able to keep working, and, more importantly, continue skiing.
But my little thumb injury has been put to shame by Kate who went out and tore her ACL. I need to pause here and quickly explain that Kate is pregnant and we are excited to be adding a baby girl to our gypsy caravan in April! So, needless to say, many exciting changes ahead. I’ll do a separate blog soon about how this will affect our traveling life – for now, let’s stick to the current topic.
Kate had been skiing cautiously and picking her ski-days judiciously. She was simply coming to meet me for breakfast on the mountain and for one ski run. She was skiing on a wide open run 5 minutes after the mountain opened when she was clipped by another skier. The fall wasn’t bad, but it was enough to tear Kate’s ACL (no other injuries to momma or baby). After struggling through our planned breakfast, we called ski patrol, and Kate got a ride down the mountain.
What we have here is a situation where we have no choice, Kate won’t be having surgery (at least not until after the baby is born) – we must try our luck at conservative management of Kate’s knee. Although, I did receive a call at work this week from another pregnant woman in town who had torn her ACL. She had tried skiing on it again already, but “it didn’t feel right” so she stopped. Her OB, suggested that she should have the ACL repaired soon, so she would avoid crutches while super-pregnant or while caring for a tiny baby. I guess it just goes to show the persistence of the myth that an ACL is absolutely necessary.
Anyways, Kate’s knee swelled up pretty big and there was some visible bruising. Kate did get an X-ray just to make sure there is no fracture. As we have progressed only a few weeks from the injury, Kate has started formal PT with one of our coworkers and she is already hiking lightly without a brace. So, she’s doing all she can do and hopefully when this summer comes, more vigorous hiking is not a problem. Perhaps next winter, she will ski comfortably without an ACL – her early success at walking without a brace seems encouraging.
Onward we both go. We’re doubling down – no surgery here unless we absolutely need it. Surgery is, and should always be, a last resort.
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.
Employer 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.
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.
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.
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.
Here is a Hawaiian Monk Seal. Only 1,100 of these endangered guys left on Earth. We did not almost trip over this one like we did the one mentioned in the last blog – but there he was, just laying on the beach enjoying the sun… just like us.
I feel like we’ve graduated tiers of traveling on this assignment. We’ve reached a realm with only the other wild-ones. On this small, 8,000 person, 1 hospital island the two traveling nurses we’ve met are doing their work the rest of the year in places like West Sudan and St. Thomas. We have arrived. It’s just us and the other nuts who cannot fathom the inhumanity of a 9 to 5 in Pleasantville, USA. We have traveled far to the remote, quiet, pristine island of Molokai… only to continue working the 9 to 5.
In our first 2 weeks here, I have already found this island to be a place that will broaden my view on life and how life can and should be lived. Earlier this week, while out hiking, I said to Kate, “I think this assignment is going to be life changing.” She asked me why, and I quickly back peddled. OK, “life changing” may be a little dramatic, but this is a different place, and for 13 weeks I’m living a different life than I have ever known. It’s slower here, there are few people, much of the land is pristine – this is how the rest of Hawaii used to be. Last weekend, as we were walking from the local farmers’ market that takes over the center of town each Saturday, I had my arms full of local papaya, tomatoes, and avocadoes. I took a look around at the people and buildings – and the scenery – and knew that this place is very different from anywhere I’ve been before.
Up on our hike in the Forest Preserve. A beautiful jungle protected just behind the cliffs of the North shore.
This past weekend, we headed up to large forest reserve. Between off road driving from sea level, then mountain biking, and then hiking to an overlook at 4,300 ft, we covered 16 miles one way (pretty good on an island that is 38 miles end-to-end). We saw one group of hunters while we were on the roads. On the bike and hiking trail we saw no one at all and on Labor Day weekend! The lookout at the top was socked in with clouds, but we had heard that if we waited a bit, a hole would usually clear. As Kate and I waited, we talked about Molokai. We’ve done travel assignments in a lot of places and hiked to a lot of far-off summits, but decided we have never been in a more remote place than where we stood at that moment. The clouds later parted, and we were treated to one of the best views anywhere.
Somehow, through all this quaintness, the 14-bed hospital remains a part of the 21st century. People show up on time for appointments, the days are busy, and JCAHO and their misguided standards reign supreme. I find myself rushing through the hallways to patient rooms, back to scheduled appointments, off to grab equipment. It’s a great place to work and is full of extremely friendly people (the “Friendly Isle,” after all), but it’s a busy hospital like any other. The dichotomy of the two lives I’m living in and out of work were displayed for me full force the other day as I headed out for a quick errand at lunchtime. I had the time, but needed to move quickly to be back for my 1 PM patient. I zoomed out of the hospital parking lot and briskly down into town where the speed limit is 20. As I hit the first stop sign*, a man driving 7 mph pulled out in front. SEVEN. This guy was driving 7 miles an hour. On the weekends, or after work, I behave. I’ll drive slow, walk slow, pop into little shops, and have exceedingly long conversations with strangers. But, I had to get back to work for a patient, and this guy was driving 7 miles per hour.
Our view once the clouds parted. Likely, there isn’t a single person in that valley and the ocean beyond stretches uninterupted to the Aleutian Islands of Alaska
This life here is definitely going to change some perspectives for me because of its simplicity and the slow pace. To really make things interesting, we are going without TV altogether, and because of weak cell signals Netflix is really hard to stream. (Now, no cable, that’s life changing. I’ve already decided to put the hospital-supplied cable box away when we get back to Colorado… except for football… or hockey playoffs… or…) Despite the slow pace, the roosters waking me in the morning, the empty hikes, and the empty beaches, a hospital is still a hospital and there is work to be done. In fact, here, there is work to be done 6 days per week (yeah, more on that later). We’re working hard while at work and trying everyday to slip back into lazy island life within minutes of walking out the hospital doors – It’s pretty awesome.
More soon. I have some great blog topics coming, but getting them written down takes some time. Stay tuned, and get out on the road! As travelers, we are given an awesome opportunity to see the many different sides of this country and world – Enjoy it!
*They call it a one stop sign island – However, I have counted several. There are no traffic lights at all.