Barefoot influence on arch height

Barefoot influence on arch height

 

“Our aims were to establish the prevalence of flat foot in a population of schoolchildren in rural India and to determine whether this prevalence varied between shod and unshod children”

 

First, it is hard to translate this research over to an American population. Just because it is the prevalence in India, doesn’t mean that it will be the prevalence in other countries. Until I have other research though…this is all I have to work with.

 

Unshod means not wearing shoes. Therefore, shod means wearing shoes.

 

“…2300 children between the ages of four and 13…static footprints of both feet were obtained from all 2300 children”

 

This encompasses a large age span from the time prior to arch formation to post arch formation. I remember learning in school that the arch starts to take shape around the age of 8, but this may just be a tradition that has carried through the ages of PT students. Anyway, this is a large sample size to look at.

 

“The footprints were classified as normal, high-arched or flat. Some form of footwear was worn by 1555 children and 745 never used shoes.”

 

It’s still hard to believe that there were this many children that hadn’t used shoes. The children in the study were between the ages of 4 and 13. We sometimes take for granted all of the “needs” that we have here in the states. Anyway, here is a link to give an idea of what the arches would look like on a static footprint. One way to think of it is to get your foot wet and go walk on a wood floor or deck. You would have an imprint of your foot as follows: picture of arch height.

 

“…1551 were considered to have normal arches in both feet, 595 had a high arch in one or both feet and 154 had unilateral or bilateral flat foot. The prevalence of flat foot progressively decreased with increasing age.”

 

This last statement is what is taught in PT school. There are so many facts that are taught in PT school, but we don’t learn the research behind the facts. A majority of children go on to develop normal arch height. There needs to be a further breakdown of the children that go on to develop an “abnormal arch height”.

 

“There was a significantly higher prevalence in children who wore shoes (8.6%) than among the unshod (2.8%)”

 

There is a large difference between the two populations of children, but we also have to consider the small sample size of 154 children. I would love to see this study take it one step further and search for all children in a larger radius with flat feet and see if the same types of prevalence rates are present. If this is the case, then we can start to make some assumptions regarding footwear affecting arch height. There are so many other variables that are not accounted for that could also play a role in arch formation, so this study has to be taken with a grain of salt. It does though make a statement that kids wearing shoes may not develop a normal arch compared to those not wearing shoes. It literally states: “…shoe-wearing predisposes to flat foot”.

 

“It seems that closed-toe shoes inhibit the development of the arch of the foot more than do slippers or sandals. This may because intrinsic muscle activity is necessary to keep slippers from falling off.”

 

This is a good theory, but would have to be proven. As a PT, we tend to recommend against sandal or flip flops because of the same reason: we have to work differently to keep the shoes from falling off. There is something called the windlass mechanism that can be altered when wearing shoes that can easily fall off. Again, more research is needed in order to figure out which party is right.

 

Excerpts taken from:

 

Rao UD, Joseph B. The Influence of Footwear On the Prevalence Of Flat Foot. J Bone Joint Surg [Br]. 1992;74-B:525-527.

 

Link to article

 

 

 

 

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 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.

Post 77 keeping the doors open

“We must now have 12% to 15% of our weekly visits as new patient visit… There is an increased financial responsibility being placed on our patients to higher co-pays and adaptable, less resulting in fewer visits per week causing the potential for greater noncompliance with their prescribed plan of care.”
I guess I never really thought about this. When I was in private practice if we had 10 patients per week for me and for new evals, then we knew that we would remain busy for the next four weeks. With patients coming in for fewer and fewer visits, the rest of the week needs to still be filled with patients otherwise they will be therapist sitting around feeling their pumps. This means that we have to get more patients in the door for new evaluation. I don’t know if I agree with the fact that a patient coming into therapy for fewer days per week will lead to a lack of compliance, because compliance or better yet therapeutic alliance is more related to the communication that takes place between the therapist and clinician while the patient is in front of the therapist. I have many patients that I’ve been very compliant and active with her home exercise program even though I may only see them once every other week.
“If your therapist are not 85% efficient according to their schedule, maximizing their productivity per visited , and getting raving feedback in writing from both her patient in your referral sources, then you have found a good place to start.”
Again, it has to be said that productivity is not a bad word. Businesses need to keep their doors open. The only way that they can keep their doors open is to make money. The only way to make money, is to have your time settled with activities that actually make money. This is the definition of productivity. How much money are you making per hour for the company. When you consider that the average cost per session is $70 and the reimbursement from Medicare ranges from $9200, there is not a large margin when you are treating Medicare patients. So if your therapist is not busy making money all day long, this is a good place to start. The people who generate income must be generating income. Know the people on the team must be excellent. Period when I want their communication skills have to be excellent, their clinical skills have to be excellent, and their ability to work within a team must be excellent. Obviously, not every therapist is at that point yet. If I work for a team that has therapist that aren’t at this level, then I hope that this team is doing its best to coach everyone up to that level.
Gallagher BJ. Scheduling the next visit: Ensure your patients follow through with treatment with one simple task. Impact. Sept 2016. 33-36.

HR 101

“We must recognize that each one of our employees comes to us with a unique personality and a backlog of experiences that will influence the way they work.”
My experience at Sam’s Club plays a large role in my choices as a physical therapist. Sam Walton was still alive during my first years working for the company. There were some major rules that we had to follow as employees of Sam’s Club. The first rule is the 10 foot rule. This means that any time that I come within 10 feet of a Sam’s Club member I must make eye contact an acknowledge that person. It seems so simple to just give a hello, but we all know that customer service is lacking in many companies. Customer service is the reason we are doing what we are doing. Without the customer we have no income. In healthcare, we can substitute the word customer with the word patient. Without the patient I have no income. I need to ensure that that patient is well taken care of, and that starts just by acknowledging that the patient is a person. Other things that I learned from Sam’s Club is that hard work is rewarded. I was given many merit raises during my first three years at the store. In 2003 I was the best employee out of the 200 employees. This is not subjective on my part, but I was awarded with the employee of the year award. At that time I knew I had to quit. This is another thing that I learned about myself while working at Sam’s Club. I have a drive to improve and to consistently and constantly get better. Once I have reached the top of a certain position, then it is time for me to try new things and strive to be the best. 
“… More than 30,000 physical therapy jobs that will go unfilled in 2016, it is difficult to understand why a practice owner wouldn’t make the effort to appropriately care for their therapist.”
It is easier to take care of the good people that you have working for you than to find a good person In the sea of applicants to a business.  
“Daniel Pink, In his wonderful book, Drive: the surprising truth about what motivates us, point out that people want to believe they are contributing to something meaningful.”
When I worked for Sam’s Club, we had a core group of people that we would go to bat for. We worked hard in order to make up for any shortcomings of the people that were around us. When everybody is pulling in the same direction, great things can be done. I believe that. At the time I worked at Sam’s Club we were doing great things. I currently work with a group of people at small community-based hospital in which we all have our niches. We are all really good at our specific specialties and it is fun to be a part of this team. We don’t have the newest equipment, but we are all share a passion for patient care. It is demonstrated in both our outcomes and our patient satisfaction. We are playing our part in the changes that are occurring in healthcare, which emphasize patient outcomes and improving overall health status.
“Creating strong company values, and a clear mission statement, are necessary to motivate and engage staff. Period. More than 70% of all employees were disengaged at work. Disengaged employees tend to create drama… And subtly communicate their unhappiness to patients.”
This correlates with the old saying idle time will provide for the devils handiwork. If we have something to do and are passionate about doing that activity, we will provide customer service. We have to be engaged more with our patients van with our cell phones or Facebook. 
” Pink suggest that most people are innately motivated by autonomy. Essentially his philosophy is that we should hire good people and let them do their job.”
I love this quote! The problem though is that not all companies hire good people. When you surround yourself with people who are going the extra mile, they push you to go the extra mile. I would much rather play on a team with scrappers, then play on a team with a bunch of superstars. My job is to make my teammate better in their job is to make me better, in the end the patients get better because of the team.
“Too often we repetitively train, and retrain, an employee who is falling short rather than letting them go in order to preserve the overall atmosphere within the clinic. As difficult as it is to terminate an employee, we must put the needs of the whole clinic above the negative behavior of one person.”
This couldn’t be said any more clearer. Politics unfortunately cloud judgment. Legalities cloud judgment. Dave Ramsey has said it many times over if I wouldn’t re-hire that person, then that person should no longer work here.
Excerpts from:

Stamp K. HR 101: The art of managing people. IMPACT. Aug 2016:29-30. 

HR 101

“We must recognize that each one of our employees comes to us with a unique personality and a backlog of experiences that will influence the way they work.”
My experience at Sam’s Club plays a large role in my choices as a physical therapist. Sam Walton was still alive during my first years working for the company. There were some major rules that we had to follow as employees of Sam’s Club. The first rule is the 10 foot rule. This means that any time that I come within 10 feet of a Sam’s Club member I must make eye contact and acknowledge that person. It seems so simple to just give a hello, but we all know that customer service is lacking in many companies. Customer service is the reason we are doing what we are doing. Without the customer we have no income. In healthcare, we can substitute the word customer with the word patient. Without the patient I have no income. I need to ensure that that patient is well taken care of, and that starts just by acknowledging that the patient is a person. Other things that I learned from Sam’s Club is that hard work is rewarded. I was given many merit raises during my first three years at the store. In 2003 I was the best employee out of the 200 employees. This is not subjective on my part, but I was awarded with the employee of the year award. At that time I knew I had to quit. This is another thing that I learned about myself while working at Sam’s Club. I have a drive to improve and to consistently and constantly get better. Once I have reached the top of a certain position, then it is time for me to try new things and strive to be the best. 
“… More than 30,000 physical therapy jobs that will go unfilled in 2016, it is difficult to understand why a practice owner wouldn’t make the effort to appropriately care for their therapist.”
It is easier to take care of the good people that you have working for you than to find a good person In the sea of applicants to a business.  
“Daniel Pink, In his wonderful book, Drive: the surprising truth about what motivates us, point out that people want to believe they are contributing to something meaningful.”
When I worked for Sam’s Club, we had a core group of people that we would go to bat for. We worked hard in order to make up for any shortcomings of the people that were around us. When everybody is pulling in the same direction, great things can be done. I believe that. At the time I worked at Sam’s Club we were doing great things. I currently work with a group of people at small community-based hospital in which we all have our niches. We are all really good at our specific specialties and it is fun to be a part of this team. We don’t have the newest equipment, but we are all share a passion for patient care. It is demonstrated in both our outcomes and our patient satisfaction. We are playing our part in the changes that are occurring in healthcare, which emphasize patient outcomes and improving overall health status.
“Creating strong company values, and a clear mission statement, are necessary to motivate and engage staff. Period. More than 70% of all employees were disengaged at work. Disengaged employees tend to create drama… And subtly communicate their unhappiness to patients.”
This correlates with the old saying idle time will provide for the devils handiwork. If we have something to do and are passionate about doing that activity, we will provide customer service. We have to be engaged more with our patients than with our cell phones or Facebook. 
” Pink suggest that most people are innately motivated by autonomy. Essentially his philosophy is that we should hire good people and let them do their job.”
I love this quote! The problem though is that not all companies hire good people. When you surround yourself with people who are going the extra mile, they push you to go the extra mile. I would much rather play on a team with scrappers, then play on a team with a bunch of superstars. My job is to make my teammate better and their job is to make me better, in the end the patients get better because of the team.
“Too often we repetitively train, and retrain, an employee who is falling short rather than letting them go in order to preserve the overall atmosphere within the clinic. As difficult as it is to terminate an employee, we must put the needs of the whole clinic above the negative behavior of one person.”
This couldn’t be said any more clearer. Politics unfortunately cloud judgment. Legalities cloud judgment. Dave Ramsey has said it many times over if I wouldn’t re-hire that person, then that person should no longer work here.
Excerpts from:

Stamp K. HR 101: The art of managing people. IMPACT. Aug 2016:29-30. 

Our we worth it?

“First, we must actually prove the value of our services, ourselves, and our profession. And we must do so objectively – with outcomes data. ”
I agree to a certain extent, that we need to prove our value with outcome data. Patients, so need to be educated on what this data actually means. We are slowly transitioning to a point in which patients are paying for a majority of their healthcare when compared to insurance companies. Co-pays are rising. Outcome data needs to be measured, but explained to patients in a way in which it makes sense. We do need to prove our value, but proving our value to patients will be completely different than proving our value to insurance companies.
“That that that tracking patient outcomes… The demand for this type of data collection has amplified in the last few months…”
The demand for this type of data is increasing from insurance companies. Do you think insurance companies are demanding this data in order to increase our pay? I highly doubt it. They’re demanding the data to determine whether or not therapy in actually valuable. I, as the therapist, sometimes question the value of physical therapy. Not all therapists practice alike, so is there one best practice? As a profession, we have clinical practice guidelines. Not all therapists are utilizing clinical practice guidelines. Can we weed out those therapists that are not using the guidelines, or can we coach up these therapist to ensure that they are practicing in a way that is supported by the evidence.
“… The federal government is not wasting any time and it’s quest to reduce healthcare spending that ”
We all know that our country is broke! if we ran our household in the same manner that our government runs the country, we would all be filing for bankruptcy. The government is trying to find ways to reduce costs. Healthcare appears to be one way in which to reduce costs. I am not saying I totally disagree, because as a country we spend a great deal of money on healthcare, but do not get the results commensurate with the spending. We have to find a way in which to incentivize good care to ensure that patients are no longer getting sick at the same rate they’re getting sick currently.
“So, in all likelihood, most – if not all – payments will be linked to value within the next few years quote
This same line has been stated year-to-year for at least the last six years. At some point I am waiting for the boy to stop crying wolf. I welcome the day when pay-for-performance actually takes place. Therapy consists more than simply ultrasound,hot pack, electrical stimulation, and massage. The best evidence we have is regarding exercise. It’s sad because not all therapist coming out of schools are proficient at analyzing, providing, and creating exercises in order to address the limitations seen during the initial valuation. I spend a great deal of time with the students that I have teaching them how to create and how to analyze movement patterns. They do not learn this very well in school.
“… There is a big difference between merely recording numbers and generating meaningful, actionable insights, because when you do the latter, you can achieve three really important things: ”
As a profession, we need to start by “merely recording numbers”. I started as a therapist in 2007, and during those first few years recording numbers was not happening. We have come a long way in utilizing functional outcome measures, but this is because insurance companies have forced our hand in order for us to receive payment. I do not believe that our profession would have policed itself into using outcome measures.
Excerpts from:
Jannenga H. IS PT VALUABLE? ONLY OUTCOMES DATA WILL TELL. IMPACT. June 2016: 46-51