International Crimes Against Physical Therapy

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?

Traveling Physical Therapist

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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.

 

  1. https://www.fsbpt.org/download/2011DH_ExamDevelopmentCommitteeReport.pdf
  2. https://www.nytimes.com/2018/02/18/world/europe/russia-troll-factory.html
  3. https://www.foxnews.com/tech/insiders-russia-troll-farm-even-zanier-than-indictment-says

Doubling Down on Non-Surgical Conservative Care

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.

Health Insurance As a Traveling Therapist

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

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

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

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

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

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

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

Short-term Insurance

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

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

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

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

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

The Open Market

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

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

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

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

Why I AM a Manual Therapist

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jack of All Trades

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

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

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

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

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

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

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

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

Red light. Green light.

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.

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.

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.

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.

Continuous Education

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

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

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

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

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

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

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

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

How Should I be Paid?

With any job, there are a number of different ways you can be paid. There’s straight-forward salary, hourly, or some sort of productivity-based pay. Of course, when considering pay for a typical job, there are things to consider besides just the money – health care, retirement, life insurance, employment-related discounts, and the list goes on. In traveling physical therapy, the list gets a little bit longer and more complicated. A traveling therapist has more say in how he or she would like to be paid and needs to determine how much he would like to weight his taxed versus untaxed wages. There are IRS limits on how much you can take tax free in each zip code, but I have been told that taking those upper limits with low taxed pay can be a red-flag for an audit. So, I typically take $20-$30 hourly (taxed) and get the rest of the pay as stipends/reimbursements. I know a lot of travelers think hourly should be near the normal hourly amount a perm PT makes with the reimbursements being in addition to normal pay, but that’s just not the way it works. A more adventurous travel assignment can have some perks that can make the math of take home pay a bit more complicated: a loaner car from a boss, employee housing, a coworker’s mother-in-law apartment, or other non-monetary compensations.
Productivity arrangements in healthcare can get iffy real fast, think anti-kickback laws. I am not a fan of pay-per-code or percentage of billing situations. These can quickly turn an honest therapist nasty. It’s just too tempting to bill an extra modality or therex that may not be necessary when you know your own bottom line is linked to it – I don’t like it one bit. I’ve seen a number of positions, particularly for therapists in management, where bonuses (boni?) are paid for meeting certain productivity thresholds – number of patient visits or units billed. I occasionally see pay-per-visit systems go awry with a therapist seeing many patients at once, episodes of care dragging on, care extenders over-reaching their scopes of practice, patients getting less attention, and therapists getting burnt out. But, I can’t speak too harshly about pay-per-visit, since it is how I’m getting paid right now. Luckily I’m in a practice where all treatments are provided by PTs 1-on-1 for an hour. With the focus of 1-on-1 patient care, I find the arrangement ethically acceptable, but it’s definitely got its pros and cons. I’m well paid for my hour with a patient, but there is nothing worse than an initial evaluation that no-shows and leaves me unpaid with nothing to do for a full hour. I would encourage anyone considering a pay-per-visit position to first strongly scrutinize the care patients are receiving, and secondly, to ask for a little more money than you normally would, because the chances of batting 1.000 for attendance in any given week are slim.

Advance Healthcare Network

From Advance – Click to access their full report

New travelers are always asking me what they should get paid – I don’t know. Pay varies so much regionally and even town to town. It can be real tough to know if you’re making all you can of if a recruiter is taking you to the cleaner’s. Just find a recruiter you trust and get as much as you can out of each contract. I may try to establish a database where travelers can anonymously input how much they got paid on assignment. It would likely be a small sample size, but may provide all of us some information about what other traveling PTs are getting paid in each state. As I mull over that idea, here’s a nice piece that Advance puts out each year based on their survey results of PT pay. I just stumbled across the APTA Workforce Data page, not as sexy or user friendly as the Advance survey, but lots of good info in there if you click around (APTA Members only).

Some advice for the new traveler: Remember that your recruiter is working on commission and doesn’t get paid if you don’t get hired- it is in their best interest to get you on board even if it lowers their own bottom line. You are a temporary worker for a facility that needs help immediately, you are willing to pick up your life and move to that job to fill a position they desperately need filled – this has big value to it. With all these things working in your favor for higher pay, the costs of travel, furnished apartments, and miscellaneous other will likely cancel out a big chunk of the extra moolah. But, traveling PT can be an exceptional lifestyle that is worth so much in personal experience and growth – so get what you can financially out of a contract, but more importantly, just get out and see some more of this world.

In other news, a series of conversations this week have lead me to believe that the travel PT market is rebounding from a couple of more difficult years, I’m finishing up my SCUBA certification with four dives off the coast of the Big Island this weekend, and (in a crazy out of this world experience that only traveling PT could provide) a hospital has bought Kate and I plane tickets to fly out to interview for a possible once-in-a-lifetime travel assignment this fall – we shall see and more on this later.

Keep living the dream 13 weeks at a time!

Wiki Wiki

The increasing infrequency of my posts is a clear sign that my work hours panned out. Just a wiki wiki (quick) update on the travel and jobs in Kona.

A wave crashes near our campsite in Laupahoehoe last weekend. Real dramatic ocean on this part of the island. There was a tragic tsunami here not too many years back - interesting history everywhere you look.

A wave crashes near our campsite in Laupahoehoe last weekend. Real dramatic ocean on this part of the island. There was a tragic tsunami here not too many years back – interesting history everywhere you look.

The hospital gig, which was a wishy-washy thing from the get-go did not work out. I had tried to get something going at the hospital through one of my go-to recruiters. When he wasn’t able to come to an agreement, my recruiter gave me his blessing to try to establish a contract with the hospital on my own. So I tried. I spoke with the rehab director and later on the contract manager (the fact that they have a full-time position dedicated to manage contracts should have been a dead giveaway to steer clear). They were very encouraging that something would work out for me to be at the hospital. As they requested, I sent them a written proposal of what I would expect in my contract – 2 weeks went by and they requested I establish a contract through one of the recruiters I had used previously. The situation started to feel a little icky since my original recruiter had found the job, and working with another recruiter on the same job can start to cross travel PT ethical borders quickly.  Hesitantly, I went along with it. As everyone who has been doing travel health care for any period of time knows, credentialing for a job can take up a fair amount of time. So, I got underway on getting my paperwork and vaccinations all set for the staffing agency; I did the tedious skills checks online, I requested old varicella titre reports from my alma mater, I took a drug test at one facility, and I went and got my TB test up to date at another facility – all to find out just a couple days later that the contract wasn’t happening. Bummah. At least I got a free TB test out of it…. silver lining? Whatever, ainokea (“I no care”).

Waipio Valley - "Valley of the Kings" - We hiked here after camping in Laupahoehoe. King Kamehameha the Great was raised here and many Hawaiian royalty have had homes here.

Waipio Valley – “Valley of the Kings” – We hiked here after camping in Laupahoehoe. King Kamehameha the Great was raised here and many Hawaiian royalty have had homes here.

BUT, I got lucky, again, and landed on my feet. Everything is coming up James! The private practice prn job now has me booked 40 hours/wk and would gladly book me 50 hours if I let them. That job is doing just fine. And the kicker is that some of the staff at the clinic also work for a local coffee shop up the street, so I have found my Kona Coffee hook-up!

I have to get going, time to get to work. Upcoming island excitement includes a state holiday tomorrow, Kamehameha Day, celebrating King Kamehameha “the great” who united the Hawaiian islands which has previously each been under separate rule. He united the islands primarily through war and execution, and he also ended human sacrifice in the Hawaiian Islands right around the year 1800… different stories for a different day.

We will start SCUBA training this weekend, so that should lend itself to some good stories and pictures.

Aloha!

A Little Ketchup

One of the many beautiful sunsets this fall from our apartment looking back on Boston.

One of the many beautiful sunsets this fall from our apartment looking back on Boston.

Another travel assignment has flown by and I again have written far less frequently than I intended. I have a short list of meaningful topics I’ve been wanting to get to, but today you’ll have to settle for just an update on the travel life.

It’s been a great autumn in the Boston area. Kate and I got a killer apartment on the coast just north of the city and have made up for a lot of lost time with old friends. Lots of fun, a few shenanigans, nice cold evening sunsets, and being here for another World Series championship have made it a great fall! It’s raining right now, but its probably one of less than 7 days it has rained during our 3 months here. It’s been a fantastic fall… but, man, am I ready to get out of here and head to Colorful Colorado!

Highland Bowl

Highland Bowl, one more reason to get out and get acclimated… that bowl ain’t gonna hike itself!

This will be our 6th year working seasonal positions out in Colorado. I have worked for the same hospital out there for 5 years now – I am so excited to get to the mountains, see good friends and co-workers, start up the low-stress life of a professionally employed ski bum, and most importantly,get to laying down some powder turns. After a delay in finding a job for the fall, this contract is running a little later in the year than I’d like it to, and some weeks of the ski season are slipping by. I’m also losing out on some precious time for altitude acclimation that makes a huge difference for some mountain races later this winter – and just trying to keep up with the other locals around town – and not being out of breath sitting at my desk at work.

 

Accord

The ol’ Accord road tripping in all its glory.

I think part of my extreme anxiousness to get out there lies in a newly fine-tuned proficiency for getting ready to move. I have no bags packed, but I feel like I have been preparing to move for 3 weeks now. Just a few drawers of clothes to shove in bags and we’ll be packed up. To add to the ease of moving this time around, we have upgraded to an SUV. I sold my old Honda Accord that I had put 120,000 great miles on (plus 70,000 miles from its original owner). It drove some of the great roads in North America – made the trip up the Alcan Highway to Alaska, drove East through Canada to Prince Edward Island, and touched the Southern and Northern tips of Rt 1. But, for two people routinely moving cross-country multiple times each year, I can’t believe it took us this long to get a bigger car. I sold the Accord this weekend on Craigslist and I am driving a rental for my last week working in home care – 4 more days on this contract – head down, nose to the grindstone. Short-Timer Syndrome be damned!

I, of course, will be updating on the Facebook and Twitter (@hobohealth) pages all along the road trip, but this trip will be less of a meander out west than some of our previous trips. We will get to catch up with some friends in Chicago along the way, but otherwise this trip is going to be a straight-shot westward in just a couple long days of driving. Expect updates soon and travel safe! -James