Post 82: student loan debt

“Various authors have argued for and against the effects of several factors on increasing costs (of college education), including growing numbers of institutional administrators, increasing federal regulation, new campus buildings to attract students, rising costs of employee health insurance, costs of intercollegiate sports, and an increasing proportion of professors staying beyond traditional retirement age”
Debt has become a crisis not only among PT students, but across the board for students of all disciplines. Dave Ramsey, Author of the Total Money Makeover and other national best sellers, speaks of this problem frequently on his show. He notes that the cost of education has gone up not just because of administrators but also because of an increase in other personnel also, such as secretaries. I was about $80,000 in debt graduating from PT school and this is about half of what some of my current student’s debt load look like. This is scary. I can’t image the burden that these students will have coming out of college, especially if the increase was to go towards more secretaries and administrators throughout the university

“The result is that over the past 3 decades, tuition and fees have increased approximately 210% at 4-year public universities and by approximately 130% at private 4-year nonprofit institutions, while median household income has increased by approximately 2%.”

Something smells fishy here? If the average median salary has only gone up 2%, this is an income issue. Seems that those that have gone into higher education have not done much to increase their overall salaries. Let’s take a for instance. When I quit Sam’s club, I was making about $32,000 per year. This is a lot of money for no education or experience needed to start. I studied to be a teacher and raked up about $35,000 dollars in debt and this is with taking all available credits at a community college paying cash for the first two years. The average starting salary for a teacher in Illinois is about $37,000. Let that sink in, I went to school for 6 years to get an undergraduate degree (insert slow joke here). I worked full time through most of my college years. All of this would have been to make an extra $5K? Enough of that…Let’s go back to school! I accumulated another $50,000 in debt in order to make $62,000. Although I had a big hole to dig out of, I went out and bought a bigger shovel. After 8 years in practice, I am making north of 80,000. This is about a 29% raise over the course of the 8 years, averaging 3-4% raise per year. In that same time, the cost of school has increased at double the rate that my salary is improving. Again, Dave talks about this all of the time on his podcast. This just seems like a large hole for current students to dig out of, as the size of their shovel is proportionately smaller to their debt load than mine (This is one case in which size matters).

“Consequences of high student loan debt are reported to include delays in starting families, buying homes, or saving for retirement. Some evidence suggests that student loan debt influences decisions about where to work or live, with increase importance of salary and cost of living in decision making.”

One theme that I notice in my students is that they have no idea how much total debt they have. I encourage all PT students to pay attention to this number and try not to let it grow out of control. This number may dictate how you practice your craft for your entire career. If you are so focused on your salary, you may neglect mentoring opportunity. You may choose not to spend more money on continuing your education than you have to spend. You may choose to live a cheaper lifestyle in order to abolish your debt. Go check out another new graduates blog posts how he is going about financial independence.

I chose to live with my parents for the first 9 months in practice. This may not be the most attractive, but I was able to bank $25,000 to save for a wedding. I hear students talking about buying new cars and houses and traveling and chuckle to myself before dropping the financial hammer. All college students need to be aware how much their education costs and treat it like any other business transaction, find the best value for the dollar. 

“…the aggregate limit for graduate or professional students is $138,500. Aggregate loan limits for private student loans are $75,000 to $120,000 for undergraduate students and limits for graduate and professional students are higher.”

Shaking in your boots yet!? Think about these numbers! This is a mortgage…AND YOU STILL DON’T HAVE ANYPLACE TO LIVE YET! There are ways of making this blow a little easier to manage and I would advise all PT students to check out This guy has gone through your education and then some. If you don’t contact him, that’s fine, but at least Google some of the podcasts that he has done so that you are more educated on how your finances will affect your life.

“…since fiscal year 2004-2005 the mean total cost of physical therapist education programs has increased nearly 100% at private institutions (mean fiscal year 2014-2015 = $99.797) and approximately 50% for in-state students at public universities (mean in fiscal year 2014-2015 = $55,997).

Lets make a couple of points about this. First, in the previous 10 years, the cost of becoming a professional has increased about 10% per year. This is huge given that the average raise of a PT (using a N of one) is about 3-4%. The cost of education is outpacing the salaries of PTs.

The next huge example though is to take the total cost of public in-state universities compared to private universities. The difference between the two is about $43,000. This sound doable over the course of 20 years, it’s only about an extra $2,150 dollars per year right??? WRONG! You can add an additional 23,000 dollars on top of that difference. The choice between in-state public compared to private school is $66,000 dollars! That would be enough money to pay for in-state school twice! This money would be very helpful when one gets to retirement age. It’s the equivalent of one year salary for a first year graduate.

The point of the matter is that school choice matters, which is also spoken of on the Dave Ramsey podcast. Dave Ramsey college choice

“Eighty-six percent of doctor of physical therapy (DPT students graduating from one state university program in 2005-2007 financed their education with student loans, and more than 13% had student loans of more than $80,000…physical therapist program graduates 1 to 5 years out of school had an average cumulative student loan debt of approximately $96,000.”
Can you hear me now? This number should scar you so much that your drawers have an odor! We are not dumb people. We have to be smart to even get into PT school. Financially, on the whole though we aren’t that bright. Every PT student should know what an amortization calculator is amortization calculator. Interest can either be a reward as an investment or a punishment as a debt.

“Financial experts recommend that cumulative student loan debt not exceed a graduate’s starting annual salary or that monthly student loan payments not exceed 10% of monthly salary…on average, in 2013 physical therapist up to 10 years post graduation did not make more than $80,000.”

Lots in this statement. First, a new graduate demanding more than $80,000 better be able to bring in the business. As a therapist, I have spent 5 years building my brand. My brand travels wherever I go. I had to work hard to create a reputation in the community and based on the blog across the world. As of today’s writing, it has been seen in 37 different countries.

It makes sense that the average therapist is not making more than $80,000 dollars because the average therapist is not going to follow these basic principles: leave the cave, kill something and drag it home. 
 Excerpt taken from: 

Jette DU. Physical Therapist Student Loan Debt. Phys Ther.2016;96(11):1685-1688

Post 80: Org chart

“Org charts are critical to efficient business operation, and form the foundation for growth through clear delineation of responsibilities and reporting assignments.” 

An org (organization) chart is similar to a flowsheet that directs the companies hierarchy. For instance, when I worked at Sam’s club I knew my role. As a cart guy, I was at the bottom of the barrel. No one was below me and I had a huge organization of people above me. As I moved up to cashier, at least the cart guy was below me in the organizational chart, but there was still the cashier supervisor, front end manager and general manager above me. As I continued to advance in the company, there were more people under me than above me. Without a working knowledge of he hierarchy, I would never know who is senior and who is not in the company.

Taking this to a hospital- based setting, a staff therapist answers directly to a shift manager or site manager. The only person below them are PTA’s and physio techs (if the company has any). There are only so many positions available in a hospital-based setting, so in order to move up the org chart, usually one person has to quit or retire.

In a small private practice based clinic, it may only be you and the owner. In this case, you definitely aren’t moving up the org chart. Not moving up doesn’t necessarily mean that you are stuck at your current salary, but it means that you may be stuck at a specific set of minimal requirements. Obviously, you could always do more, but you will never be mandated to do more.

“An org char is your road map. It’s a top-down and bottom-up char that provides each member of your organization a direct reporting relationship to someone else within your company

I hope that I explained it well in the above example, but if not…here’s another go. One person should directly report to one person. If that person is unavailable, then that person should report to the one person above the initial superior. As you move up the chart, there will be fewer people to answer to. For instance, at Sam’s club there were about 40 people that worked on the front portion of the store (cashier, carts, door etc). These people all answered to the COS (check-out supervisor). The COSs all reported to the Front End Manager and the Front End Manager reported to the GM. One person reports directly to one above them until you get to the top of the organization and there is no one left to report to. This is an example of an org chart

“Start at the top. Somebody-possibly you-is ultimately responsible for the entire company…Continue down the organization until all leadership roles are identified”

Everyone must know who they report to. It doesn’t make sense for a supervising therapist to look for approval from a volunteer. This reminds me of a line from Saving Private Ryan

Captain Miller: “I don’t gripe to you, Reiben. I’m a captain. There’s a chain of command. Gripes go up, not down. Always up. You gripe to me, I gripe to my superior officer, so on, so on, and so on. I don’t gripe to you. I don’t gripe in front of you.”

This is another example of an org chart.

“Respect the ‘one boss rule’”

Essentially, there should be no confusion about who a person reports to. A person should never have to decide who is his/her superior. If this has to be a guess, then the organizational chart is not very specific.

“Publish, Publish, Publish. You’ve got a beautiful org char, but it is only as good as those who rely on it.”

Doing all of the work to create an org chart is only beneficial if that information gets passed to all of the employees. There should not be any confusion regarding the organization. If there is confusion, then the staff employees need to speak to the top supervisor in order to educate them. A supervisors/manager’s job is not to supervise/manage, but to serve those that they manage in order for the employees to perform their job duties to the best of their abilities.

Excerpts taken from:

Quatre T. FIVE-MINUTE FIX: Mastering the Org Chart. IMPACT. Oct 2016:16-19.

Post 79: Movement Impairment System and hip pain

Post 79: Hip pain
“Hip pain is a common complaint for which people are referred to physical therapy. The prevalence of hip pain in adults over the age of 60 ranges from 9.7% to 19.2%”

Hip pain…think of a pain that is around the groin region that radiates down to the knee (but on the front/inner part of the thigh). Sometimes pain in the buttock could come from the hip, but other areas that could cause buttock pain should be ruled out first. For instance, the SI joint can also cause buttock pain, but if the person is elderly it is probably not the cause. The spine could also cause buttock pain, and in a majority of “pains in the asses” that I see are coming from a spinal referral.

Hip pain is not the most common ailment that I see in the clinic, but it is not rare either. There are a lot of structures surrounding the hip that are innervated (have a nerve source), which means that there are a lot of structures surrounding the hip that could cause pain. I don’t think that our job as therapists is to find the exact tissue that is causing pain (although there are some patients that just need to know), but our job is to classify the symptoms and place the symptoms into a puzzle that makes sense for us. We do this mostly by pattern recognition (at least for therapists that have seen patterns over his/her careers), but we may also have to do this by using the HOAC method (smart way of saying: “give it a shot and see if it works”).

“Abnormal or excessive loading of the hip has recently been recognized as a potential cause of anterior hip pain and subtle hip instability”
I partly agree with this. For those that don’t know me well, I am certified in Mechanical Diagnosis and Therapy, which was proposed by Robin McKenzie in the 1960’s. He proposed a syndrome called the postural syndrome, in which healthy tissue, abnormally loaded, will create pain with the possibility of becoming a dysfunctional tissue over time. In short, I agree with the above statement.

“Femoracetabular impingement is present in 10% to 15% of the population…symptoms are commonly manifested as insidious groin pain.”

I had to look up the three different types of FAI (the long words from above). This means that the ball and socket portion of the hip is not working appropriately. When thinking of a hip, think of a golf ball and tee. The ball is the ball portion at the top of the thigh. When it is round like a ball, it can spin on the tee without falling off. Now imagine that your tee is a little deeper and larger and can encompass the ball. This portion that would encompass the ball is the acetabulum. It is a piece of cartilage that makes the tee deeper so that the ball can sit in without falling off the tee (think dislocated hip if the ball falls off of the tee). So one type of impingement is if the ball is no longer round, but shaped in a different fashion that makes the ball a little bigger on one side. This would cause the ball to pinch on the acetabulum with certain movements (more on this later).

Another type of impingement is when the tee is malformed. This could cause the tee to pinch on the ball, also causing pain.

Either way, groin pain is the chief complaint typically seen in the clinic.

“Combined hip flexion, adduction, and internal rotation movements (FADIR) along with maximal hip flexion most commonly replicates the pain…catching, clicking and feeling of ‘giving way’.”

Picture a little kid doing the “W” sit. This is what the above sentence describes as FADIR. I know…you’re thinking I can’t do that any more…GOOD! That’s not good for you anyway. Now close your eyes and imagine yourself going up stairs. When you go up stairs, do your knees collapse inwards? Don’t answer yet! Imagine yourself slowly sitting down onto a soft couch (you know what I mean…the ones that you sink down into). Did your knees cave in? DON’T ANSWER YET!! Finally, imagine that you are getting up off of the toilet. Do you have to lean far forward or better yet, rock forward and backwards a couple of times in order to get up off of the toilet? Now you can answer. Did you answer yes to any of these? If you don’t know, that’s alright, my imagination sucks also. Go try it. If you have these things happening, YOU HAVE A PROBLEM!

The first step is simply admitting that you have a problem. Unless you admit that you have a problem, you’ll never get to asking for forgiveness from your hips and knees. I thought that the analogy was good.

Anyway, when the knees cave in, this is a poor position for the knee and the hip when in a hip flexed (knee closer to chest) position.

“Hip joint forces are altered by hip joint positions and changes in muscle force contribution”

“I love it when a plan comes together” Hannibal Smith from the A-TEAM.

This describes another of MDT’s syndromes: the derangement syndrome. This is simply a change in the normal resting position of a joint. It may cause muscle inhibition. This a lay term for “shutting down”. On a side note, there has been major debate on Facebook for the terms used to educate society. For instance, in Supple Leopard, Dr. Kelly Starrett describes a muscle as turning off (he means that it is not working to its fullest potential), but some therapists have a hard time with this phrase. This is why I used the phrase “shutting down”. Maybe they won’t have a as hard of a time with this terminology. I don’t know, but if you don’t get the point…please ask.

When a joint’s position is changed then the muscles that act on the joint will change also. Quick example: my dad used to take me out to plant trees in the forest every year. We would tie the tree down using 3 stakes in order to ensure that the tree grew straight. Now imagine if we used the same 3 stakes, but before driving them in, we placed the tree at a 45 degree angle to the ground. (Think leaning tower of Pisa/Pizza). If we pull on the strings in each scenario, there will be a different outcome on the tree. In one, it will be stabilized and in the other it will fall over even further. This is what happens when a joint is altered in its position. When the muscles contract (the strings are pulled), the joints movement will be altered from normal.

“The 2014 clinical practice guideline on nonarthritic hip joint pain recommends interventions such as patient education, manual therapy, therapeutic exercise, and neuromuscular education, but the strength of the evidence for all of the recommended interventions are at the level of expert opinion”
This is important for all of the PT students that may read this blog. We have entered a world with buzzwords such as evidenced based practice/medicine. We are supposed to be using the highest form of evidence or using “best practice” when treating patients. For this ailment, nonarthritic hip pain, the best we got is a bunch of people coming together to give us an opinion. Granted, the people are really smart, but for a profession that is trying to sell itself as “movement specialists”, we should have more than opinions to sell to patients.

“However, Byrd and Jones report that FAI is not necessarily a cause of hip pain; it is simply a morphological variant…”

Wait… You mean to tell me that having a problem on an image, such as an x-ray or MRI does not correlate to having symptoms?! Obviously I jest. An image alone does not indicate a problem for most musculoskeletal problems. The image must be correlated with clinical signs and symptoms. A person without signs and symptoms is healthy, as some problems noted on an image are correlated with age related deformities. Think of this as a wrinkle. For instance, as we age our muscles go from the texture of filet to the texture of beef jerky. Things start wearing down. We are the ultimate machine, but we have yet to figure out how to keep the machine from breaking down.

“While physical therapists can not change the morphology of the hip joint, they can address movement impairments, muscle strength deficits, and certain aspects of joint range of motion to decrease stresses on the anterior hip joint”

I will not make your bones longer or shorter. I will not change the depth of your joint capsule. I will not make you into something that you’re not. But what we can do is address the issues that you have at that point in time, that aren’t structurally unchangeable. Here’s an experiment I want you do: squeeze yourself into the smallest suitcase that you have and I want you to hang out there for 5 hours and then try to get out. It doesn’t feel so good. I didn’t change any of your structures, but I probably created symptoms. Not all symptoms are related to the structural change, and not all structural changes related to symptoms.

“…movement system impairment syndromes described by Shirley Sahrmann,PT, PhD. The movement system impairment approach places less emphasis on identifying the source of the symptoms and more on identifying the pathomechanical cause.”

I’m always reminded of an old research study, I don’t remember the author, when we give you a diagnosis based on pathoanatomy, we (medical professionals) are right 10% of the time. I can’t specifically tell you which structure is causing your symptoms. What I can tell you is you have symptoms when you move. Maybe if we move a different way your symptoms all go away. It’s my job as a therapist to understand the different ways that movements may affect your symptoms.

“27-year old female…left anterior hip pain July 2014 after doing Miri-directional lunges…continued despite pain…after one week discontinued the multi-directional lunge but continued with deadlifts, squats to 90 degrees…sprinting/walking interval training prior to her injury…discontinued in August due to pain. Before July…she was pain-free…did have clicking, snapping and pinching in both hips…main goal was to return to lifting weights while doing squatting and lunging movements without pain.”
The biggest thing to take from the above is that the patient is active. She is not a couch potato.. This patient is the perfect patient to come into the clinic. I love trying to help these patients get back to their active lifestyles. This is the patient that I am going to go over and above in order to return them back to the gym. I AM A MEATHEAD. I see that as a term of endearment.

“…stood with swayback posture and displayed increased hip medial rotation on the left compared to the right… Had increased pronation bilaterally as well as a positive “too many toes” sign… Range of motion of the lumbar spine was normal and pain-free… Adequate hip flexion range of motion during forward bending but the majority of the motion came from the thoracic and lumbar spine… positive Trendelenburg sign bilaterally.”

 Essentially, description is that of a person with poor usage of the hip muscles and a lazy stance. Could indicate some tightness and she stands with the swayback, but it also may mean that she needs better motor control and a better understanding of what appropriate standing posture actually is. Just from the above description, she seems like many of the females that I see in practice.

“During single leg stance, the patient displayed contralateral hip drop during single leg stance bilaterally, increased hip medial rotation on the left, and decreased balance on the left… Able to squat just passed 90° of hip flexion, but displayed increased forward trunk flexion and reported pain at and range. Hip flexion range of motion at her and range squad was 104° in the flexion range of motion was 92°.”

What this is describing is a partial squat. She is unable to go to full depth because of pain. She also has significant weakness in her hip muscles as noted during single leg stance. If you stand on 1 foot, and you notice your opposite pocket falls significantly compared to when you’re standing on both feet, then you probably have a problem in your hip ability to generate force. Sometimes we’ll see this when a person, specifically female, is walking away from us. This looks like that infamous hip wiggle. Not that I’ve ever watched! I love you babe.

“patient displayed overall hypermobility throughout the exam and had 8/9 Bieghton score for increased ligamentous laxity.”
This is otherwise known as the contortionist scale. If you could dislocate your joints at will, they probably aren’t very stable.

The intervention was actually pretty good. The authors describe meso and microcycles for endurance and strength training. This takes me back to my days as a personal trainer through the International Sports Science Association. I have yet to hear physical therapists discuss mesocycles, until this article. Essentially, they placed the patient on a progressive 2 week cycle that built upon itself over the course of 6 weeks emphasizing core stability, endurance exercises, and the addition of plyometrics.

“At the end of 6 weeks, a second reassessment was conducted. The patient stated she was now able to perform a full squat.”

Nuff said!

This is a good article because it describes that patients can improve rather quickly from functional limitations and pain when issued the appropriate interventions. One thing to note from the article is that although it took 6 weeks to improve, the patient was not treated frequently due to her schedule. The idea that a patient needs to be seen three times per week for four weeks is a tradition that needs to be questioned. As a therapist, I must place my patient’s values and health above my own needs. This is one of the core values of our profession. When I start treating you like a dollar sign, then I no longer am treating the patient according to their needs. Don’t get me wrong, some patients may need to be seen 3 times in a week, but these are few and far between in our clinic.

If you have an questions, comments, concerns or good jokes please feel free to let them fly. I can be reached through comments on this blog, @movementthinker on Facebook or at my personal page on Facebook.

Vince Gutierrez, PT, DPT, cert. MDT

Excerpts taken from:

Smith A, Brewer W. Management of Anterior Hip Pain Using a Movement System Impairment Approach: A Case Report. Orthopaedic Physical Therapy Practice. 2016;28(4):226-235.


Post 78

Post 78: Day one expectations 
“Before any revenue can be captured, managed, or collected, these new patients must arrive for their first visit.”

All barriers to a patient walking through the doors need to be addressed. This starts with the phone call to the patient. Is there any reason why they wouldn’t come in? Are they caring for kids? Is your business able to accommodate a child in the clinic? Can they drive or do they need a ride? If they need a ride, does your company offer ride sharing? Once they are able to come, is there adequate parking (this is a big issue for some patients that can’t tolerate walking a certain distance). I have noted that this is a larger issue for a bigger company or a PT practice located in a shopping center. Stand-alone clinics don’t seem to have this as a problem. Does the patient know where your clinic is located? All of the above issues need to be addressed during the initial phone call with the patient.

“Scheduling staff need to understand their goal is not only to schedule a patient but also to ensure they arrive for the initial evaluation.”

 We all have had those patients scheduled for an evaluation that haven’t shown for the appointment. Depending on your facility, you either jump up and down for joy for some breathing room to get paper work done or you slump because you won’t meet your productivity numbers for the day. I personally have never been slow enough that a lost evaluation has affected me much, thankfully. I almost always have something else on the stove to work on.

“’Have you been to physical therapy before? Do you know what to expect? Would you like me to provide directions? Are there any reasons why you may not be able to come to your first appointment?’”
 This is basic customer service! The patient is the consumer/customer and we have to start looking at health care in this fashion. I want the patient to be so at ease prior to coming to the session that the evaluation seems like “old hat” for the patient. If there is any apprehension on the patient’s part prior to the first visit, then I did not do a good enough job of training my staff to prepare that patient for the visit. The front desk staff should be able to answer any and all questions regarding the “first day experience” minus any clinical information.

“…it is essential to have a person in this role who represents your practice well and has impeccable customer service. The scheduler must also be able to explain to the patient the value of physical therapy…Be aware of the scheduler who describes physical therapy when asked as “exercise, massage, and dry needling”
 OMG! I would flip if my staff described therapy as the above. First, I take ownership over all experiences that patients have with me. I answer all of their questions and will speak to patients prior to that patient coming in for an evaluation in order to appease their needs and questions. Previously working in a private practice, I understand the value of a front desk staff for ensuring the smooth operation of an initial evaluation. The front desk staff is more than just a “scheduler”. The office must be an extension of me! This means way more than just my name on the door or my sense of the importance of therapy. Dave Ramsey talks about values. The person that works for me must represent my values, ethics, and morality. Dave Ramsey speaks of the hiring process in multiple episodes of EntreLeadership podcast and I highly recommend business owners start listening to the podcast or read the book of the same name.

“A professional and informative brochure representing your practice is more likely to result in a patient calling to schedule their initial evaluation.”
 This may be true for some more so than others. For instance, I currently work in a hospital system in which the number of patients is endless. This is a good problem to have, but working for a hospital system brings other challenges. When working for a private practice, we would use the MDT brochure to give to patients and doctors. I can remember typing up a bulleted list of benefits that patients can receive from physical therapy. This paper, plus a small book to educate the physician on MDT, a brochure, and script pads would all go out in the mail to prospective physicians.

The above is the opinion of Dr. Vince Gutierrez, PT. If you are looking for advice on treatment options or a consultation please leave a comment in the comment section or leave a post at my Facebook page @movementthinker.
Excerpts taken from:
Collie M. Low Arrival Rate is Lost Revenue. Impact. September 2016:77-78.