Category: medical ethics

 

 

  1. Lumbar spinal stenois (LSS)…defined by any narrowing of the spinal canal and/or nerve root canals…In patients with severe LSS, a space reduction of 67% has been found in the spinal canal.”

 

Spinal stenosis is the narrowing of the holes of the spine. The spine has 3 holes in it in the lumbar region. Each hole carries a nerve. It could either be the nerve of the spinal cord down the middle, and larger, hole. It could be the nerve roots out of the holes on the side of the spine. Each hole needs to be big enough so that it doesn’t irritate the nerve that it allows to pass through the hole. Picture a water pipe. If you put too much stuff in the pipe it will clog up. Sometimes there are tissues that can make their way into the holes of the spine to clog the holes. When the hole is clogged, the nerves don’t have as much room to do their job (transmitting signals to and from the brain). Now take that same pipe and come back and look at it over decades. There will be sludge and stuff built up around the pipe. This is essentially creating a smaller diameter on the inside of the pipe. This smaller diameter due to sludge is also creating a smaller hole. This could happen in the spine with severe arthritis or degenerative disc issues in which the hole gets smaller. A visual is much better so maybe this will help. image for spinal stenosis

 

  1. “…estimated the incidence of LSS in Denmark to 272 per one million inhabitants per year”

 

In other words, it is not very common in Denmark.

 

  1. “…it is important to discriminate between LSS and disc generated pain since these conditions have different prognoses and the range of evidence based treatments are different, as well.”

 

The treatment between the two issues, discogenic back pain and stenotic back pain, is very different. A thorough evaluation can start to correlate symptoms with either discogenic pain or non-discogenic pain. Many patients believe that an MRI will be the answer to why they have pain, but unfortunately this isn’t so.

 

  1. “a valid and reliable clinical assessment protocol for identifying LSS would be valuable in terms of choosing relevant treatment and informing the patient about the prognosis as early as possible.”

 

This article was written in 2009. The medical profession has existed for eons. There is still not a valid way to assess a patient in order to determine spinal stenosis. There are biologically plausible ways, meaning that when I assess you, I can make an educated guess from some of the findings in the history and physical, but it is not a valid (proven) way of coming to a conclusion.

 

  1. “The high sensitivity and specificity of MRI suggests this is a good test for ruling in and out the disease.”

 

The MRI does a great job of telling us what is abnormal, but it doesn’t do a great job of telling us if the abnormal finding is causing symptoms. As seen in the link above, there are abnormal findings in a population without symptoms. We have to take the imaging findings and see if they make sense after performing a physical exam.

 

  1. “…history will provide strong clues to the presence of spinal stenosis…more than 65 years of age…prolonged history of low back pain and intermittent radiating symptoms having developed gradually…limited walking capacity…Movements or positions involving flexion e.g. sitting or stooping, will often abolish symptoms…total loss of lumbar extension range is usually found, while flexion most often is well preserved.”

 

The typical patient with lumbar spinal stenosis will notice that the ability to walk has gradually reduced over time and there is a need to sit due to back or leg pain. Sitting will typically turn down or off the symptoms rapidly. This patient will have limited motion into extension (think of looking over your head to see the stars or bending backwards while standing).

 

  1. “…stenosis from zygapophyseal joint hypertrophy, ligament thickening or other degenerative changes, it cannot be expected that physical exercise or manual treatment will create a lasting change in the degree of space reduction in the spinal canal or intervertebral foramina”

 

In the presence of physical changes to the bones, ligaments or loss of disc height, there is nothing that a PT can do to change these back to the way that they were previously. These have been described as wrinkles on the inside. If we look at your face we can start to see how much age you have based on the wrinkles in the face. This is also done on the inside in that some “degenerative” changes are normal. Wrinkles are normal; they are not symptoms of anything sinister. The same can be said for physical changes on the inside. They don’t have to be pain generators. It takes a physical exam to determine how your symptoms respond and whether or not this matches the images on an MRI or X-ray. Even then, we can’t say that movement won’t help, only that we won’t change the physical “inside wrinkles”.

 

  1. “The main purpose of this pilot study is to evaluate the validity and intertester reliability of an algorithm of physical examination tests, in relation to identifying symptomatic lumbar spinal stenosis.”

 

This is good. A pilot study is like a pilot for a t.v. show. This is done to see if additional episodes should be done. This study will conclude if additional studies on this topic should be done.   What it hopes to find is a reliable (consistent) way of determining validity (actually seeing what the test hopes to see) in testing for lumbar spinal stenosis. A test that is both reliable and valid should be able to test for spinal stenosis regardless of who is performing the test and who is measuring the test.

 

  1. “Two patients were classified as “LSS” and five patients “Not LSS”, meaning a 29% prevalence of “LSS” Intertester agreement for overall diagnostic conclusion was 100%”

 

There are so few patients that this study will likely not yield any results that are actionable. The interesting thing is that the examiners agreed 100% of the time. This is not common in the medical field to have 100% agreement on near anything.

 

  1. “…the algorithm in its present form can not be used as a screening test to rule out LSS, although it may be able to diagnose the condition.”

 

There were so few people in the study that it is hard for any clinician to put it to use in the clinic. It may be able to diagnose the condition in that it demonstrated a specificity of 1.0, which is really good.

 

 

Excerpts taken from:

 

Lengsoe L, Lyhne S, Melbye M. An algorithm for clinical identification of spinal stenosis-a pilot study of validity and intertester reliability. International J of MDT. 2009;4(2):21-28.

 

Can’t find the abstract to the study, but it is listed under the author’s CV http://pure.au.dk/portal/en/persons/martin-melbye(ed4ee688-2d9e-4c17-b0b1-44a5b4b59ada)/publications/an-algorithm-for-clinical-identification-of-spinal-stenosis–a-pilot-study-of-validity-and-intertester-reliability(6d714ee0-d910-11de-9e3b-000ea68e967b).html

 

 

 

 

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. 

Outline to back pain presentation

žCentralization

žCentralization, although first described by McKenzie14, has been replicated in multiple research studies15,16,17.

žCentralization is the movement of symptoms from an area distal to the spine to a more proximal segment14,18.

žPeripherilization is the movement of symptoms, originating from the spine, from a more proximal and central location to a more distal location14.

žThe centralization phenomenon, when produced in patients, correlates with good outcome9,10,18,19.

žPatients presenting as non-centralizers are six times more likely to require surgical intervention19.

žCentralization is shown to highly correlate with a discogenic lesion20.

žOTHER CONSIDERATIONS

  • Spinal Stenosis= reduction of the surface area of the spinal canal or foramen

–No clinical feature or diagnostic test can confirm that stenosis is the cause of symptoms

–A literature review determined that “all studies favored decompressive surgery for improvement of pain, function and quality of life, as well as in terms of patient satisfaction” compared to conservative care24

  • The advantage of surgery was noted within 3-6 months and remained constant for up to 4 years.
  • Surgery is more cost-effective for this group of patients
  • Appropriate for patients that have not improved with 12 weeks of conservative care.

žEPIDURAL STEROID INJECTIONS

žThere are multiple systematic reviews demonstrating that ESI’s can be effective in the short term and long term for managing back pain for both discogenic pain and stenotic pain21,22

žFollowing an ESI, about 45% of patients then demonstrate centralization and report 90% satisfaction of results after 1 year23

žAny questions?

žreference

1.Garzillo MJD, Garzillo TAF. Review of the Literature: Does Obesity Cause Low Back Pain? JMPT 1994;17(9):601-604.

2.Hill JC, Whitehurst DGT, Lewis M, et al. Comparison of stratified primary care management for low back pain with the current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378:1560-1571.

3.Walker BF, Williamson OD. Mechanical or inflammatory low back pain. What are the potential signs and symptoms? Manual Therapy 2009;14:314-320.

4.Fritz JM, Cleland JA, Speckman M, et al. Physical Therapy for Acute Low Back Pain: Associations with Subsequent Healthcare Costs. Spine 2008;33(16):1800-1805.

5.Shin G, Mirka G. An in vivo assessment of the low back response to prolonged flexion: Interplay between active and passive tissues. Clin Biomech 2007;22:965-971.

6.Kelsey JL, Githens PB, White AA, et al. An Epidemiologic Study of Lifting and Twisting on the Job and Risk for Acute Prolapsed Lumbar Intervertebral disc. J Orthop Research 1984;2:61-66.

7.Pople IK, Griffith HB. Prediction of an Extruded Fragment in Lumbar Disc Patients from Clinical Presentations. Spine 1994;19(2):156-158.

8.Natural history of lumbar disc hernia with radicular leg pain: Spontaneous MRI changes of the herniated mass and correlation with clinical outcome. J orthopedic surg 2001;9(1):1-7.

9.Long A, Donelson R, Fung T. Does it Matter Which Exercise? A Randomized Control Trial of Exercise for Low Back Pain. Spine 2004. 29(23):2593-2602.

10.Long A, May S, Fung T. Specific Directional Exercises for Patients with Low Back Pain: A Case Series. Physiotherapy Canada 2008;60:307-317.

ž

  1. Kovacs FM, Urrutia G, Alarcon JD. Surgery Versus Conservative Treatment for Symptomatic Lumbar Spinal Stenosis: A Systematic Review of Randomized Controlled Trials. Spine 2011;36(20):1334-1351.
  2. Urquhart DM, Bell R, Cicuttini FM, et al. Low back pain and disability in community-based women: prevalence and associated factors. Menopause 2009;16(1):24-29.
  3. Konstantinou K, Dunn K. Sciatica: Review of Epidemiological Studies and Prevalence Estimates. Spine 2008;33(22):2464-2472.
  4. McKenzie R, May S. The Lumbar Spine: Mechanical Diagnosis and Therapy. 2nd ed. Waikanae, New Zealand: Spinal Publication Ltd;2003.

15.Delitto A, Cibulka MT, Erhard RE, et al. Evidence for an extension-mobilization category in acute low back syndrome: A prescriptive validation pilot study. Phys Ther 1993;73:216-228.

16.Donelson R, Silva G, Murphy K. The centralizaiotn phenomenon: Its usefulness in evaluationg and treating referred pain. Spine 1990;15:211-215.

17.Donelson R, Grant W, Kamps C, Medcalf R. Pain response to sagittal end-range spinal motion: A multi-centered, prospective randomized trial. Spine 1991;16:S206-212.

  1. Werneke MW, Hart DL, Cutrone G, et al. Association Between Directional Preference and Centralization in Patients with Low Back Pain. JOSPT 2011;41(1): 22-31.
  2. Skytte L, May S, Peterson P. Centralization: its prognostic value in patients with referred symptoms and sciatica. Spine 2005;30(11):293-299
  3. Laslett M, Oberg B, Aprill C, McDonald B. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine Journal 2005;5:370-380.

ž

  1. Manchikanti L, Kaye AD, Manchikanti K, et al. Efficacy of epidural injections in the treatment of lumbar central spinal stenosis: a systematic review. Anesth Pain Med. 2015;5(1):e23139.
  2. ManchikantiL, Buenaventura RM, Manchikanti K, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician. 2012;15(3):E199-245.
  3. van Helvoirt H, Apeldoorn AT, Ostelo RW, et al. Transforaminal Epidural Steroid Injections followed by mechanical diagnosis and therapy to prevent surgery for lumbar disc herniation. Pain Med. 2014;15(7):1100-1108.

ž

One school’s take on educating the future

One school’s take on educating the future.

 

This was a refreshing article regarding the creation of a progression to a doctoring program for a school in Australia. Although this school is a world away from my practice, they face the same situations that we do here in the states. I was impressed with the thoroughness of the article’s message and am excited to see the students that graduate from a program like the one described. I would love to see this type of program offered in the states, as I personally don’t feel that this type of education is being offered. At least I haven’t seen many students that possess these traits in my clinic yet. Those that do, I am uncertain if they were learned in school or through inherent characteristics.

 

  1. “Chronic disease management requires holistic, patient-centered care, with collaborating and respectful teams of interdisciplinary providers (physicians, nurses, pharmacists, and allied health workers).”

 

I see where the authors are going with this, in that they are creating the lead in for the rest of the article. On a side note…I can remember in 6th grade reading/composition learning how to make a house in order to get a point across. You had to start with the roof, which is the overall theme and then build the house down from the roof by adding in the thesis and supporting points. Mrs. Hart..I didn’t forget. With that in mind…that analogy doesn’t apply to this type of writing, as I simply brainstorm and just try to keep up with my thoughts on paper.

 

Back to it. We should be collaborating for all patients, not just chronic illness based patients. All patients should expect the same high level of care, which involves calling other professionals with results if need be. I see way to often the lack of communication when working with patients in the clinic. Luckily, no one has suffered greatly from the lack of communication, but luck shouldn’t be my basis of success.

 

  1. “health care ‘now requires large enterprises, teams of clinicians, high-risk technologies, and knowledge that outstrips any one person’s abilities’”

 

I beg your pardon?! I am very capable mind you…just kidding. No one person can know all of all things. It is important for a PT, or any one for that matter, to know his/her weaknesses and place him/herself in a position to leverage strengths, while hiding weaknesses. For instance, I am very good at orthopedics, which means that if I work in a clinic that sees more than just orthopedic patients (which I currently do), then I have to partner my skills with those of someone that is very good at everything else. Luckily, I have. If I were to ever leave to open up my own practice, I would have to either 1. Work on my weaknesses (I’ve never been a fan of that) or 2. Be so good at treating orthopedic conditions that I can refer those patients that encompass my weakness to a colleague or a friend at another clinic. WHAAA?! Turn away patients…sacrilegious! I wouldn’t want my mother to see me if she had Dandy Walker syndrome…it’s not my specialty.

 

  1. “The Centers for Medicare & Medicaid Services recently implemented bundled payments for hip and knee replacements…the hospital that performs the surgery will be accountable for the costs and quality of related care for the episode of care…The payment structure incentivizes better coordinated care”

 

SIGN ME UP! Accountability paired with incentives to improve patient outcomes. This is a great thing. Some people are scared of this bundled payment thing, as they talk only about loss of profits. I only see rewards for fixing patients quicker, with fewer complications, leading to increased pay.

 

EVERYONE NEEDS TO WAKE UP THOUGH! This is happening. You need to do a better job of choosing your provider. If you ask a friend and learn that the friend got crappy care from their provider…don’t go there! Even if others (namely health care professionals) are trying to push you in that direction, make more informed decisions. Get a second opinion before going there.

 

  1. “The curricula need to engage students to develop the necessary attributes, knowledge and skills in health leadership, policy, advocacy, and research…physical therapy curricula need to be forward thinking and innovative.”

 

AWESOME SAUCE! Now…I’ll believe it when I see it. I totally agree that PT’s need to be better trained when coming out of a Doctorate program, but unfortunately tradition appears to be taught more so than forward thinking…or thinking in general. We have come past the recognition and regurgitation aspect of therapy. We need to do a better job of teaching how to think.

 

The rest of the article went deeper into the curriculum for the program. I highly recommend any and all teachers of health care to read this article. It touched on some very important points and I look forward to practicing alongside those that graduate from a program like the one described in the article.

 

Quotes taken from:

 

Dean CM, Duncan PW. Preparing the Next Generation of Physical Therapists for Transformative Practice and Population Management: Example From Macquarie University. Phys Ther. 2016; 96:272-274

HOT DOG…GET YOUR HOT DOG! Health care sales

Hot Dog!…Get your hot dog!

 

This article highlights how we, as healthcare professionals, are salespeople. Some points I don’t agree with and others I would take a step further. Enjoy!

 

  1. “Be patient: ‘the purpose of a pitch…is to offer something so compelling that it begins a conversation, brings the other person in as a participant, and eventually arrives at an outcome that appeals to both of you’.”

 

I reminisce about my few marketing experiences that have produced major referrals. In one instance, I (there were three of us, but I did a majority of the talking) was sitting in front of a medical group (around 12 physicians) and just gave my pitch. It was great! Those that know me, know that I can be verbose and a salesperson…especially when it comes to back pain. It just so happens that it was my opportunity to tout our clinics greatness when it comes to treating back pain. I was writing checks that my a$$ couldn’t cash at the time, but in the end it worked out so well that we have more patients than we can handle.

 

  1. “Be present: Be in the moment in your encounter”

 

This holds true for every encounter throughout the day. This doesn’t apply just to “the sell”. My patients can tell when I was up late writing…like tonight. I just don’t have the same sharpness that I normally do. I try to be in the moment as much as possible and do my best to clear my head during the workday by taking a nature walk in the short time I have for swallowing my meal. Do what you have to do to make the person in front of you feel like the only person alive.

 

  1. “Be prepared: Physicians are just like everyone else, and they typically love to discuss things like football, golf, and pop culture.”

 

Look…I disagree with this to my very heart. If I have to learn about how Taylor Swift broke up with her latest boyfriend…(this statement seems to be timeless throughout the years)…in order to have a conversation, then I consider myself a failure. If I can’t make my topic of interest so compelling that I lose the physicians interest, then I need to work on my knowledge or performance of my knowledge. I go a little different direction with be prepared. Know so much about your topic that the other person actually learns something that can be helpful to your audience. If I provide a physician with information that can help his patients…I have physicians now call my personal cell phone for a quick phone consult…then I will have done a good enough job to have that physician’s trust to send me patients.

 

  1. “Ask questions” Referring to personal questions.

 

I don’t look to this as selling, instead this is simply “not being a douche”. I know as much about my referrals as they want me to know. I don’t pry, but I don’t shy away from a “normal” conversation either. Be real…be you…and if you are a douche…act like someone else.

 

  1. “Be cool: …this is a way to show off your bedside manner”

Again see number 4. I thought that this point was redundant.

 

  1. “Be punctual: Which really means, be early.”

 

Again, this goes back to not being a douche. If someone takes the time out of his/her day to meet with you, in order to further your agenda, at least be respectful of his/her time. I’ve heard that in the military if you are 10 minutes early, then you are late…but if you are 15 minutes early, you are on time. Take this to heart.

 

  1. “Be human: Give them a chance to highlight their accomplishments or current work they are doing.”

 

I don’t know how much I agree with this, especially for the first encounter. I would be just as happy to say hello…My name is movementthinker and here’s my card. If there is anything that I can do to assist you with a problem or if you have a patient that has tried everything else…give me 3-5 visits to prove myself. Wow them!

 

  1. “Be awesome: …always point out the things that you have that no one else has”

 

I think that this is a very superficial definition of awesome. Writ a check that you will difficulty cashing! Make statements that you will have trouble backing up. Push yourself to be better by putting pressure on yourself to get better.   You had better live up to the hype though. If you can’t cash the check…don’t bother even having the discussion. As a matter of fact, if you can’t cash the check…go listen to the following:

Entreleadership, Spartan up, PT insiders, the Tim Ferriss podcast.

 

  1. “ Do your homework: Find out where they went to school, where they did their residency, and most importantly what their Starbucks preference is”

 

This is infuriating! Drug reps sell drugs to physicians, but really they are just the closer. The commercials pitched the entire game and the lunches, “business trips” and other perks are acting as the Mariano Rivera of drug sales. I would rather find a good starter and have them pitch the entire game. When I need a closer, I will look into it. Give me a Nolan Ryan over Kid K. I will be advertising…no…selling to the patients. They are the ones that make the health care decisions, because as time moves on…they will be the ones paying out of pocket. I will give value.

 

  1. “The most important ingredient we put into any relationship is not what we say or what we do, but what we are.” Taken from Stephen Covey.

 

I have had many conversations with private practice owners and this seems to be the overarching message. Provide good care, be a good person and allow the patients to see that. The attitude of “if you build it, they will come” no longer applies in healthcare. I take pride in the fact that patient’s refer me friends and families, I will take my attitude towards providing service to whatever avenue life brings.

 

Quotes taken from:

 

Lee A. Top Ten Tips: Selling strategies for the nonsalesperson physical therapist. IMPACT. April 2016: 63-64.

The age old question (for healthcare providers at least)

The age old question

 

How do we get patients in the door? Many therapists, especially the mom and pop clinics, struggle with this question. Some physicians are spoken for by specific companies, which makes getting a referral from the physician difficult. Some insurance companies are making it difficult to see a physical therapist of choice, at least without you paying $$$$ out of pocket. So how do we get patients?

 

  1. “…marketing to physicians-would not provide the expected revenue stream. Instead, a direct-to-consumer marketing strategy was needed and needed fast!”

 

Why does it take so long for PT’s to catch on to this concept? I have heard it all my career; “patient’s need a referral in order to come to therapy, so we should market to physicians.” There’s a great documentary done by a fellow meathead called “Prescription Thugs”. Drug companies realize that if they can sell their drugs to the patients, that the patients will go to their respective physician and ask for the prescription. The question is where do we want to spend our marketing dollars or time? I have seen over and over again, the physical therapists takes coffee to the physician and tries to grab the physicians ear for a couple of minutes. THIS WILL NOT WORK! Think about it. When you go to the physician, how much time do you actually see the doctor? What…5 minutes…maybe 10 max? How much time do you think that the doctor has to offer you…for free? Not much. With that said, there are some companies that have doctors ears. I will let you make the conclusion about how they are able to get into the doctors ears for 5 minutes.

I think that a good t.v. commercial would look like this…dream with me.  A father picking up his child and having a big red throbbing circle radiating from his back.  Black screen. A mother breast-feeding her daughter and a big red throbbing circle radiating from her neck. Black screen. A weekend warrior doing pull-ups with a red circle radiating from the shoulder.  A different weekend warrior playing basketball with the circle from the knee.  Black screen.  DO YOU HAVE ANY OF THESE SYMPTOMS?  Go talk to your doctor and then see movementthinker.org.

My biggest referral source is previous patients. I have so many patients requesting me at this point that I am unable to satisfy the need in a 40-hour work week. There are many private practices that would kill to have this problem. I see this as a major problem though because I stand for very personalized care to each patient and if I can’t get the patient in the door…it’s not very personalized.

 

  1. “1. Clearly define the customer”

 

Who is my customer? Anyone that I come in contact with knows about my blog. Everyone is my customer. This is where you define your elevator pitch. What do you do? I can tell you what I do. I offer specialized care in which I take the puzzle that is your problem and break it down into smaller pieces that you can understand and teach you how to aide in not only fixing yourself, but preventing your problem from returning. I am a teacher, disguised as a physical therapist. My customer is anyone that has a problem…puzzle…that revolves around movement based pain or limitations.

 

  1. “2. answer the question, ‘Why should the consumer come to our clinic specifically and pay cash at our practice”’

 

I will give you value. Within a short number of visits I will teach you about your problem. I will guide you and teach you how to fix your problem. I will educate you on why this may have started and how to keep it from coming back again. I will ensure that you understand the basics of human movement. I will guide you to resources that you can read if you want to learn more than you can in a short number of sessions. I will tell you if therapy will help you. I will tell you if you are more likely to respond to surgery than to therapy.

 

Not only that, but I will do this in a short number of sessions in order to save you money in the process. It would be cheaper for you to pay out of pocket to see me than to go through your insurance company. I will give you value.

 

  1. “3. Determine how to effectively reach that target market”

 

You’re reading the first way that I am answering this question. I just realized that I have reached over 900 “visits” over the previous 4 months. Officially, this blog now reaches more people than I can care for in the clinic. This is my start of marketing myself and my knowledge to others. Whether you choose to come see me or not, you will be better after having read the blog.

 

Quotes from:

 

Clinton SC. OVERCOMING MARKETING OBSTACLES: A cash-based practice perspective. IMPACT. April 2016: 52-56.

 

 

Put UP or Shut UP!

lean-scatter-480x240

 

What are you doing to make your company better? If you are employed, then it is your company. Take stock in your employer. If you can make your company more efficient, then you deserve a raise. None of us should be getting raises for time served. It is not prison, at least it shouldn’t seem like prison. Find your passion and follow it. If you don’t have passion for at least one part of your job, then reassess your career path. Once you find IT, then make yourself valuable.

 

  1. “Process changes entails ‘looking for changes we can make within our system to become more efficient’”

 

If we believe that no system is perfect, and we can look at our own system (regardless of the profession or business) to ask ourselves ‘How can we be better’, then this will open Pandora’s box. For instance, I recently asked myself what can we as a department be doing better. There were a lot of suggestions that were thrown out. We delved into one suggestion and it a brick wall when we broached a certain subject. Pushing further, it turns out that another department limits our department. Our conversation didn’t go any further than this, but I would love to be in an upper level position to be able to bring the two departments together in order to demonstrate to the two departments how closely entwined they are with each other. This was just one suggestion of improvement that I discussed with my supervisor. In my opinion though, things will never change if they are never analyzed.

 

  1. “’In the end, whether it’s a clinical process or an operational one, anything you do that is part of that process must create value for your customer’”

 

Who is our “customer” in healthcare? The easy answer is the patient, but that answer is too easy and cookie cutter. I would challenge that answer. That is one of our customers, but maybe not THE customer. When we look in terms of retail, who is the customer? Is it everyone that is in the store…in an ideal setting, the answer is yes, but realistically our customer is the one that is spending money on our wares. In PT, the wares are PT. The customer (the one giving us the money) though is not the patient as much as it is the insurance company. How do we best create value for our payers? We fix our patients, which some believe to be our customers. This is not to demean the patient by any means, but we have to understand who feeds us. If the patient’s had to pay our of pocket, then I would say that the patient is the customer and that would create a different set of values.

 

  1. “Michael Porter, PhD, in The New England Journal of Medicine…defines value ‘as the health outcomes achieved per dollar spent.’…’Value should always be defined around the customer, and in a well-functioning health care system, the creation of value for patients should determine the rewards for all other actors in the system…value in health care is measured by the outcomes achieved, not the volume of services delivered…”

 

What this is saying is that the health care providers (therapists in this specific example) should get paid for doing a good job (meaning the patient gets better and avoids other costly procedures such as MRI’s, surgery, prolonged loss of work, etc) instead of getting paid for DOING a lot of stuff to the patient. In my opinion, this means that if you have back pain, then the therapist should get paid a certain amount for a specific outcome. If this outcome occurs in a short period of time, then the therapist makes more money per visit overall. There is value though in identifying patients that will not benefit from therapy and the therapist should also be rewarded for getting this patient to the proper practitioner to fix the problem. Another way to say this is that the therapist should be “punished” by having to refund money to the payer if the patient needs to undergo a surgery that the therapist though was avoidable. If we save the health care system a lot of money by avoiding surgery, then we should see a percentage of that health care savings. On the flip side, if we stated that the patient would do well with therapy and the patient did not do well, or needed surgery, then the money that we were paid should have to be paid back in order to help pay for the surgery. This is opening up a box, but as I stated before, the cream will rise to the top and those that are good at their job will learn how to maximize income by becoming better at fixing those that can be fixed and referring those that can’t be fixed on to someone else that can fix the patient.

 

  1. “Companies are seeking ways to reduce costs in response to health care reforms and in anticipation of the ever-closer move away from fee for service and toward value-based care”

 

This is all fine and dandy, but the companies need to inform the employees what is happening in the health care world. There are many companies, mine included, that have cut jobs, which has created a more stressful environment company-wide. We all hear, do more with less, but what should be said is that “we are getting paid less and have to get creative in order to continue to stay solvent”.

 

  1. “…the patient is the customer. Value, therefore, depends on patient experience…outcomes are greatly influenced by the amount of time the patient spends with actual caregivers”

 

My company does some things right and some things wrong. We need to assess the patient experience. This starts well before the patient is actually sitting in front of us for an evaluation. When the patient pulls into your business, is the entrance marked appropriately? Are you easy to find? Did your receptionist ensure that the patient had directions to get to your clinic? Now that the patient has found it, how easy is it to park? Does the patient have to walk a long way in order to see the clinician? Is the waiting room busy? Is the waiting room cluttered? Is the waiting room clean? Is there coffee? Is there demographic based reading material in the waiting room? Is the front desk staff warm and receptive? Does the front desk staff make an effort to remember patient names? When the patient registers for the first visit, are they simply handed paperwork to fill out, or does the receptionist offer to help? After registered, does the therapist come to the patient, or is the patient brought back to wait for the clinician? Is it a long walk to get to the clinic? Are there private rooms (or at least a private area) available to talk candidly with the patient, without the patient feeling stifled due to outsiders? Are the beds clean? Is the room inviting to the patient? Does the clinician have all the tools needed to take care of the patient?

 

This only describes the first 5 minutes of a patient experience and it can go on and on? Are companies still thinking about the patient experience, or simply the $$$.

 

I can say that my company does not ask me to violate any ethical considerations and as long as the patient is in the clinic, I am with the patient and caring for the patient. That patient is vulnerable, that’s why they are there, and I do my best to ensure that the patient understands that they are in a caring environment. This doesn’t always mean that I can help or “fix” the patient, but the patient understands that they will learn, be cared for, and get their money’s worth in the session.

 

  1. “The goal is to minimize the amount of time any patient must wait to be seen once he or she has called to make an appointment…3 days or less”

 

I have seen wait lists of up to 2 weeks to see the practitioner of choice. This is absurd. If the patient has to wait, the therapist better be fantabulous. This is uncalled for to have a wait list longer than 3 days. My first job, we prided ourselves in getting the patient in the clinic within 24 hours if the patient wanted to be seen.   It meant sacrifice at times, but the patient was always my priority.

 

  1. “…examining the department’s intake procedure, its insurance verification process, and even the performance of individual PT’s who might become more efficient by changing some of their protocols”

 

All businesses, healthcare is not an exception, could stand to become better. There are many avenues in which to improve, as I listed many instances, which could be evaluated in the first 5 minutes of a patient experience. Could the therapist be better? Of course! Is the therapist doing something to become better…highly unlikely…unfortunately. (This is simply my observation over the course of 8 years in practice. Once we start getting paychecks and life happens, the professionalism and giddiness that we entered the profession with starts to get pushed down by other priorities)

 

  1. “Lean…all about continuous improvement-taking every functional area of your practice, business, department, or organization and continuously challenging everyone who is part of it to do things better.”

 

This can be scary. Imagine having someone telling you that “you suck”. Scary right?! It will never happen, but unfortunately, it’s what we hear when we are told that we have to change. We can all be challenged, but how we are challenged is what matters.

 

Story time: Sam’s club 8298 Joliet IL. The year was about 2002 and a new GM came to the store. David was a good leader. I was working in Tires at the time and there were about 4 of us in the department on this day. He asked me to do one job and report back to him when I was done. No one else was asked to do anything more, so I was the only one working while everyone else waited for the next customer. After the first job, he gave me another…and another…and another. Six hours later, I was frustrated and angry because I was the only one working. I confronted him about it after 6 hours and he said something along the lines of wanting to see how much he could push me before I pushed back. He was surprised that it took 6 hours, as he though it would take much less. I respected him more for that, only because he told me his end-game.

 

 

  1. “It (Lean) allows you to find the steps that are not providing value so you can eliminate them.”

 

Change is hard. It is hard to change what has always been done, but if no one looks at “what has always been done”, then we will never know if it can be done better, or needs to be done at all.

 

  1. “incremental changes are made to a process and either accepted or rejected depending on the results”

 

This is similar to what we do in an evidenced based version of healthcare. We attempt to change one variable and note the result. If the result was bad, then we change back to what we were doing originally and attempt to change a different variable in order to make the patient better. This is the same concept, just applying to business instead of patient care. The trick is to allow the variable some time in order to allow itself to show its change. For instance, if I were to offer valet parking, I couldn’t assess it in one day. It may take time for my patients to realize that this is offered and even longer still for it to become an everyday occurrence. When it is established, I can then take inventory on whether it is good/bad/indifferent and if the valet needs to be improved or eliminated.

 

  1. “You’re continuously making changes, but they’re easy to reverse…if you do something that doesn’t lead to significant improvements, you go back to what you were doing before.”

 

This is very self explanatory, but I rarely see it put into practice. Complacency is the killer of excellence.   Unless we are constantly striving to improve, then we will be passed up by those that are.

 

  1. “if you want to come in and start your therapy today, you can, and you can make your appointments for whenever is most convenient for you. You just have to be willing to see different therapists”

 

This is a very simple concept, but if the patient is never made aware that they will be seeing different therapists, then the patient may not be as happy with the convenient time as they would with the same PT. This is something that my current company has tossed around, but has not taken 100% initiative with.

 

  1. “I would encourage any PT to see the journey in their setting from a patient’s perspective”

 

What would my patient’s think about their experience? I believe that the clinical aspect is covered thoroughly, but is there something else that I could be doing to enhance the experience?

 

  1. “Patient’s were starting late because it was taking too long to do all the paperwork. In that case, she says, ‘We brought everyone together to look at all the ways we had patients register. We then figured out what was absolutely necessary-as opposed to what we were doing just because we’d always done it that way…managed to reduce the average intake time by almost 10 minutes”

 

This is huge for me. I hate that I have to wait for a patient to complete all of the paperwork on the initial evaluation. When I have to wait for the patient, I am left with 2 options: cut the session short so that my next patient doesn’t have to wait, or make the next patient wait. Who is more important at this stage? It would be ideal for the patient to be completely registered prior to coming in for the first appointment. Why can’t this be done when the patient comes in to schedule?

 

  1. “’…quiet the external noise’ that too often exists in workplace environments…When we reduce that volume of noise, we free up our clinicians and frontline workers.”

 

This is interesting because this exact line was used in a previous e-mail from an employer. Unfortunately, just saying it doesn’t do much if the “leadership” doesn’t follow the same line. Noise could be anything from rumors, complaints, internal bullying, and anything that makes the frontline dissatisfied.

 

Excerpts taken from:

 

Hayhurst C. Why Physical Therapists Are Embracing Lean Management. PT in Motion. December 2015-January2016:24-28.

Cream will rise

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I recently became a member of the private practice section of the APTA.  I have illusions of grandeur, which include working up to 70 hour weeks in order to sustain a small private practice.  We will see if this is just a mirage, but in the meantime, I will also be providing commentary on articles in that magazine.

This will be another short one because it comes from a short article.

 

  1. “We recommend building a program to mentor your existing staff to become those next clinic directors”

 

I can’t ever remember a job in which mentoring actually took place formally. I have worked for Wal-Mart, and although it was a great learning experience, the learning wasn’t formal. I learned more by watching the culture from the top down. When looking at the top, there was the GM. I can remember my interview with the GM as a 15 year-old. He asked me about school and I was very cocky back then. I told him that I wasn’t worried about school. He made the comment, “that either means you’re really smart…or really stupid.” Looking back, that was a memorable moment. As a kid, I just blew it off, but as an adult I hope that my kids never make such a shortsighted comment.

 

I learned a lot while at Sam’s club and made friends that are still friends to this day (20 years later). I made huge mistakes and should’ve been fired for some of them, but I wasn’t and I learned from them. I kept learning through the years and quit the same year that I earned employee of the year. That’s the same year that I got accepted into PT school.

 

From there I went to World’s Gym Joliet. Again, I learned a lot, but not formally. The owner did not have a way of promoting talent. When a person has no direction and no way to succeed, then the person will slowly sink back to mediocrity. At this job, I became a great student of PT, as it gave me plenty of time to study, but I was a horrible employee. I only did what was needed to get the job done because I didn’t know what else to do aside from the list at the desk. This was horrible management because we didn’t have a way to excel. Needless to say, the gym is closed.

 

In none of my PT jobs do I have a way to become management. I have specifically asked this of my jobs (all of them to be exact) and the answers are almost all the same, “we don’t know how to promote someone to management” or “we don’t have any room for additional management”. This doesn’t make sense. A manager is someone that takes on more responsibility than those they serve. Although it typically comes with additional resources, it doesn’t always. I don’t think that those above me see the loss that takes place when I am pigeonholed into a lesser role.

 

I can’t give a good reason why a clinic director would not take the time to develop those they serve to take their place. I can think of many reasons, but none of them good.

 

Fear: If I groom someone to take my place, then what stops him or her from taking my place? I groom many students to do what I do in the clinic. None of them will be as good as I am with the information that they received from me. This is not an arrogant statement, but I spent thousands of hours studying the information and understanding the information in the studies. The students simply get PowerPoint presentations of my knowledge. This is much better than what they get in school regarding specific topics, but at no point will they obtain my understanding through PowerPoint alone. The same can be said for a clinic director grooming an understudy to be a director. I can obtain the same information, but I shouldn’t know as much as the director regarding the information…unless the director didn’t spend the same amount of study to learn the information.

 

Power: If only one person can do the job, then all else must bow down to that person as an authority figure. There are certain things that only the director can accomplish, because only the director knows how to accomplish certain things. It can never be delegated because then the director will have slightly less power than prior to delegation.

 

Lack of talent: This is not a good reason to not develop a person. This is the poor management to begin with, as if a “person wouldn’t be rehired, then the person should e fired”. I don’t know who said it, but I heard it from Entre Leadership podcast.

 

  1. “Develop a career ladder in your business that points to a staff therapist growing to become a manager”

 

This seems logical. Those that want to succeed will then have a structured way to climb the ladder to the top. Not everyone wants to be at the top. Not everyone wants the responsibility or the time constraints that come with moving up the ladder. Those that do though…should have a written way to climb the ladder so that one’s wheels aren’t spinning.

 

Excerpts from:

 

Martin P. FIVE-MINUTE FIX: Build Bench Strength. IMPACT: Private Practice Section of the American Physical Therapy Association. 2016;May:17.

Not That Type of Quickie

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This is a quick statement of sales. In healthcare, we are preprogrammed by administration, or bosses, to take your money. It doesn’t always sound this sinister, but it may sound like one of the following:

  1. Make sure that we don’t have a waitlist. We don’t want people to have to wait to get in an appointment. This sounds very altruistic, but what we could hear if we fine tune our frequency is: don’t let this patient get better over time or make sure that this patient doesn’t hang up and go somewhere else.
  2. If you have something else to work on, make sure that the patient is completely satisfied with their stay. This could also mean that you haven’t treated the patient for enough visits to make as much money from the patient as the doctor has enabled us to make. For instance, if the prescription says 3x/week for 4 weeks, but you are better after 3-5 visits, then any visit not seen up to 12 is considered loss of potential revenue.
  3. There is nothing wrong with making patients feel good in order to get them to do what we want them to do. I hear: modalities are easy to apply and we can get paid to do them so…why not?

 

  1. “A good salesperson works hard to ensure the answers are all just different shades of ‘yes’”

 

If you want something, don’t take no for an answer. As much as I agree with this, I also have to disagree with this. You have to be willing to establish how important it is to “sell” your wares. For instance, regarding physical therapy that “ware” that we are selling is the new evaluation. It pays the most and leads to many additional visits. We have to ask ourselves if we are willing to sacrifice and what are we willing to sacrifice in order to get that new evaluation? Are we willing to sacrifice a lunch break? Are we willing to pay our employees overtime (most companies have gotten around this by going salary)? Is the employee willing to stay late? Are we wiling to sacrifice patient care by double booking a patient? We have to establish our priorities, so sometimes it is okay to say no if it doesn’t “make the boat go faster”. Again, Google this phrase…it’s that important.

 

This was a quickie, but still needs to be said.

 

Excerpts taken from:

 

Quatre T. WHY THEY BUY: Because They Cannot Say No. Impact: Private Practice Section of the American Physical Therapy Association. 2016;May:13

Feelings…Nothing more than feelings

Feelings…Nothing more than, feelings

 

This weeks article speaks to the importance of choosing your provider. Writings may be few and far between, as I am getting married the afternoon of this writing. Because we will be taking our honeymoon soon, there will be a pause in publishing more articles. FEAR NOT! I will return.  Thanks for reading

 

  1. non-specific “LBP (low back pain) where it is not possible to diagnose a specific cause”

 

This accounts for about 90% of back pain issues as stated in previous research. When a doctor tells you “you have a herniated disc”, “you have arthritis”, “you have spondylolisthesis” (sorry, I wanted to sound smart), they are simply telling you what another doctor saw on an image. What does this mean? It means that you have lived a life on this Earth and are no different than a majority of the population…okay the spondylolisthesis is not that common. Aside from telling you that you are normal compared to most people, they are telling you that your picture on an image (x-ray, MRI, CT scan) is not the ideal that is in the textbooks. The picture alone can not tell you with certainty that this is what is causing your pain. In other words, your pain is not specifically coming from anywhere, but it may be coming from any structure that senses pain and refers pain to that area.

 

Think of a heart attack. I picture George Costanza (Cant standja) from Seinfield. His imagined heart attack was complete with left arm pain and chest tightness. This is what we mean by referred. The heart, when upset, can send pain signals to other portions of the body…even though there is nothing wrong with the left arm or jaw or any other location that the heart tells the brain.

 

  1. “…experts have questioned whether the current paradigm is flawed”

 

We are right about what structure is causing your pain in about 10% of the cases..do you think that there is a flaw in the system somewhere? The first flaw is that the structure causing the pain actually matters. I know…I know, you want to know why you feel a knife slicing your spine in half or ants crawling on your skin, but in the end, if we turn off the pain…Does it matter?

I think the primary flaw is trying turn non-specific low back pain into something specific. There is plenty of research that demonstrates this: once you have an “answer” to the cause of your pain, you are quite willing to start blaming all of your problems on your disc or stenosis or arthritis or spondylolisthesis. “Sorry honey, can’t do the dishes…my disc bulge is acting up.” Actually…I may need to use this later. I RECANT ALL I JUST SAID. Joking of course…don’t take anything I write seriously.

 

  1. “Guidelines for the rehabilitation of patients with persistent NSLBP (that non-specific low back pain thingy from above) highlight the importance of practitioners encouraging patients to remain at work and stay as active as possible, with a key focus on self-managing their condition”

 

I of course will tell you that back pain will not kill you. It could in a very small percentage of the population be something so serious that it will kill you, but in reality it’s probably not you. (again, I am not a medical doctor, but a doctor of physical therapy, so if you think your back pain will kill you…go see your medical doctor). I can understand that some people just want a break from work. If this gives you good reason to take a break from work…Shhh…I won’t tell. Aside from the mental health days that you may want to take, don’t let back pain keep you from working. You are highly unlikely to make it any worse, or better for that manner, by working. Back pains due to disc herniations (bulges) are not the result of one massive injury, but the result of multiple small injuries over time. It’s like the old saying, “the straw that broke the camel’s back” (HAHAHA…it literally fits).

 

  1. “It is not known why physical therapists do not follow guideline advice”

 

This is my complete opinion here, but the patient’s don’t know any better. If the patient’s can’t tell the difference between good therapy and bad therapy, and if we then let the cat out of the bag and say that bad therapy pays more than good therapy, why don’t YOU think that the guidelines aren’t followed? There are some therapists that know the guidelines like the back of there hands, such as myself. You can see a previous blog in which I summarize the guidelines for low back pain, but there are other therapists altogether that don’t know that these guidelines don’t exist. I make this statement in a general sense and I extrapolate it from previous research that states that older therapists don’t have either the time or expertise to find a research article. If they can’t find it, then like the tree in the forest…it didn’t happen.

On an aside, I have to keep touching on the bad therapy pays more than good therapy situation. Our profession has historically been paid for what we do to you. Meaning if we give you an ultrasound…cha ching$$$. If we give you e-stim…cha ching$$$. If we give you a rub down…cha ching$$$. If we have you do exercise (whether we are watching you [the ethical thing] or a high school graduate aide is watching you [the pay is the same]…cha ching$$$. If we do all of the above and add traction…$$$. You get the point. We are finally starting to move to a system that if you have a knee replacement, then we will get paid a specific amount, regardless of what we do to you in that process. You will slowly start seeing all of the above disappearing over time because the effect is questionable and we would then be getting paid less per treatment approach that we use. ITS ALL ABOUT THE BENJAMINS BABY!

 

  1. “Practitioners’ attitudes and beliefs about LBP have been shown to influence their advice and treatment recommendations”

 

What this tells me is that we are treating based on tradition instead of the current evidence. Again, if you go to multiple doctors, you will get multiple opinions. The same thing holds true for PT’s. If you see a myofascial specialist…then you have a myofascial problem. If you see a manipulator…then you have a facet (back joint problem). If you see a MDT specialist…then you have a disc problem. We as practitioners have to know more than one system, but we better be good using at least one of the systems; otherwise we will just start mixing and matching systems.

 

  1. “Results have shown that practitioners’ professional group and practice setting appear to be associated with their attitudes, beliefs, and advice”

 

$$$$$$$$$!

If the practice setting values money over results, then the people working in that setting will have to reflect the values of their employers. It’s rough out there in this profession because it is hard to figure out which employer you are walking into until it is too late. There is such a huge pressure financially to make a living and pay off the hundreds of thousands in student loan debt, that the new graduate doesn’t know the difference between an awesome environment and one of financial manipulation.

 

  1. “ I would probably explain to her that it was most likely postural strain…there could be an underlying facet joint degenerative problem evident”

 

How confident are you in this practitioner’s opinion of your problem. It could be this or it could be that? I don’t really have a good reason for either, but “Hey, it’s usually this or that…so why not now?”

 

  1. “They believed that patients who exercises and kept active were more likely to avoid future episodes of NSLBP”

 

For future reference, please read Audrey Long’s article about the right exercise.

What if I told you that your therapist could be making you worse? If we don’t keep up with the research…it is possible. Not all exercise is good exercise. More on this in another blog.

 

  1. “Empowerment through education and pain control were clear subthemes…”

 

People…IT’S YOUR BODY! TAKE CONTROL. We can hold your hand, coach you, be compassionate towards you, but WE CAN NOT FIX YOU! You have to play a role. We can give you the tools to fix yourself, but if you don’t use the tools then WE failed TOGETHER. I didn’t fail, you didn’t fail…BUT WE FAILED!

 

  1. “’passive attitudes’…Therapists found working with these patients demanding, as from their perspective, patients with these attitudes were difficult to communicate with and, therefore difficult to educate and empower”

 

Please see # 9.

 

Excerpts taken from:

Jeffrey JE. Foster NE. A Qualitative Investigation of Physical Therapists’ Experiences and Feelings of Managing Patients with Nonspecific Low Back Pain. Phys her. 2012;92:266-278.

 

As an aside, I just saw that Nadine Foster is one of the authors. I absolutely adore this lady. I had to opportunity to hear her talk at the MDT conference in Austin. I really adore smart people, and she was impressive.