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It’s how winning is done!

“…distress among clinicians had been understood primarily through psychological concepts such as stress and burnout, which, although relevant, were not sufficient.”

Part of the reason that burnout is not purely psychological is because this model dictates that the person doesn’t have the tolerance for the mental aspect of the game that is being played.

My game of choice is physical therapy.  Burnout is happening in this profession and it still baffles me at times, but I am starting to have a more thorough understanding of it as I apply research from other sectors to our profession.  For instance, there are therapists that pride themselves on treating multiple patients per hour.  Some therapists are able to handle the load of multiple patients, but once they understand the purpose of treating multiple patients at once, said therapist may no longer feel proud of doing this.  Some clinics need to treat multiple patients per hour to keep the doors open, which is noble for the therapist to feel like he/she is greatly helping the clinic, whereas others are doing it only to fatten a pocketbook.

“shortages of resources, such as shortages of time and staff, led to dispiritedness, a lack of respect, and an absence of recognition for both patients and staff, all of which severely diminished the ability of staff to provide high-quality care.”

In healthcare, it’s all about how much work can be done in a specific time period.  This is measured by patients seen/hour or units billed/hour or dollars made/day.  We are always being asked to do more with less.  Guess what? Us and almost every other industry out there.  This is not just healthcare, but in a limited scope its what we focus on here.  Because of this, some may feel unappreciated and believe that the big bosses (administration) don’t see our struggles.  We can either play the victim or we can take action.

I don’t know if I agree with the last part of the statement “diminished the ability” etc.  The ability has not changed.  The skills have not changed.  The personal drive should not have changed.  I have worked in environments where morale was down because of this exact scenario and still never understood it.

We make choices everyday.  We made a choice when entering this profession that we would place the patient’s needs above all else.  I made that choice.  I have to live with that choice and can’t allow other outside influences to impede the decision that I made.

I think that more in the healthcare profession need to go back and examine their personal mission. Mine is short and sweet.

“The consequences of moral distress for nurses and other health care providers include feelings of anger, frustration, guilt, and powerlessness.”

I’ve seen this firsthand.  People stop caring.  It’s sad to walk around in an environment where the employees don’t feel heard.  If things in an specific environment always remain the same, then where is the impetus for change? Are you a flea?

“…moral distress can also occur when clinicians internalize external constraints to such a point that their own moral values begin to shift, causing them to disengage morally, compromise their integrity, and possibly engage in harmful practice.”

I have had conversations with those that enforce the rules (read that as members of the department of justice) and there was something said that has stuck with me all these years. To paraphrase: people don’t start out with the intention to deceive, but they may slightly overbill every once in a while.  If they don’t get caught, then there is no external pressure not to do it and then other vices take over such as greed.

Understand the why behind actions and it is easier to understand the actions.

“…moral resilience, which can be understood as ‘the capacity of an individual to sustain or restore [his or her] integrity in response to moral complexity, confusion, distress, or setbacks.'”

Some people are just stronger.  That’s not wrong to say.  It holds true in many aspects of life.  I am a bigger guy, so I am in the bottom half of runners.  I’m just not a strong runner.  I have seen people get shot.  I’ve had friends killed.  I’ve had family in prison.  I’ve seen bad stuff.  I have a stronger resilience to bad stuff than others and I don’t tend to panic quickly.  I know…I know… “I have a high pain tolerance.”  I hear it all the time from patients, but I believe that my moral compass is on point because of my experiences.  I don’t believe that there are many in healthcare with my experiences.

Question of the day:

Do you have moral resilience?  This means can you stand up for what you believe in or are you going to get knocked down and not have the ability to stand up for yourself again?

 

Excerpts take from:

Rodney PA. WHat We Know About Moral Distress: Looking over three decades of research and exploring ways to move the concept forward. AJN. 2017;117(2):S7-S10.

 

 

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Moral Distress and Moral Resilience

“At the individual level moral distress may cause burnout, lack of empathy, and job dissatisfaction, while at the organizational level it may lead to reduced quality of care, increased staff turnover, and poor patient outcomes.”

Moral distress is essentially knowing the right action to take, but being unable to take that action due to external conflicts.  For instance, in therapy we may believe that a patient only requires one visit per week, but the corporation may place pressure on the therapist to see the patient more often during the week.  Again, this decision may be due to corporate pressures to make more $$$.  If you are the therapist, you are now in the middle of doing the right thing by the patient (at least what the therapist believes to be the right thing) and doing the right thing by the company.

You can see a quick link here speaking to some of the pressures felt by staff PT’s to keep patients longer than “needed”, in the therapist opinion.

When employees feel this pressure, they start to believe that the initial reason for getting into healthcare, “to help people”, becomes trumped by the need to make more money for the company.  This difference of personal moral code and corporate code has been shown to lead to moral conflict.

Can you see how this could lead to staff turnover? Of course, when the therapist’s personal mission is not in alignment with corporate mission, it may cause the therapist to find a new job that best matches personal mission.  It has been said that Millenials are very concerned about a corporate mission matching a personal mission.

One can logically make the jump from a lack of empathy (not listening or understanding the patient’s position) and job dissatisfaction to worsening clinical outcomes.  All of this makes sense to me.

“Generally, resilience refers to ‘the ability to recover or healthfully adapt to challenges, stress, adversity, or trauma'”

I love using this when talking to patients about tissue ability to absorb force and unexpected events.  When talking about moral issues, it has to do with a person or therapist’s ability to absorb stress without significant setbacks in emotional or physical well-being.

The article went on to create recommendations for addressing moral distress and moral resilience.

“Institution leaders need to value and create a culture of ethical practice and commit resources to support individuals in cultivating moral resilience”

Many statements can sound great, but creating a culture of ethical practice may be near impossible in all practices.  From the top there is a culture that leaks downwards onto the worker bees.  This company will assume the “culture” of the owner, if not in whole, at least an iteration of the owner.  This is where I believe that having a thorough understanding of one’s own personal mission is vital because otherwise one may assume another’s mission and waste years or decades on a mission that one doesn’t own.

“Encourage accreditation bodies to mandate that curricula for all health care professions include content addressing ethics, moral distress, and moral resilience”

I fully disagree!  Whaaat?!

I don’t think that the curricula should include ethical content, but ethics has to be embedded within all of the curricula. Here’s my rendition of an ideal program set-up.  The ideas on the periphery can always change, but they must center around creating an ethical professional.

ethical curriculum

The ethical issues that are noted across the lifespan will differ and the ethical issues noted in business are a completely different animal.  Because of this, it is important that topics are brought to the students attention so that they have some background from which to make a decision.

I also don’t think that this should be taught by the professors at the universities.  In terms of treating in the trenches, most of academia that I come in contact with haven’t practiced full time in a clinic in a long time or ever.  Because of that, there is a lack of “street cred”.  It’s hard to discuss and own a topic if there is no experience in the topic.

We had a teacher in PT school that would always say refer to Reese and Bandy (authors of a book), whenever we brought a question.  At first, I thought that she wanted us to obtain the answers for ourselves, but over time I learned that the professors (plural) teaching that class 1. didn’t know what was in the book and 2. couldn’t rationalize the ideas that were in the book.  They had me refer to a different teacher altogether in order to have him explain the concepts in the book that were contradictory.

Ethics has to be taught from experience…in my opinion.

Excerpts from:

Rushton CH, Schoonover-Shoffner K, Kennedy SM. Executive Summary: Transforming Moral Distress into Moral Resilience in Nursing. AJN. 2017;117(2):52-56.

Why Rush

I came across this quote today in Black Belt Magazine. (Read topics from other fields because you will expand your knowledge and may find information that applies to your mastery).

This quote is perfect for the profession of physical therapy.

Are you in this profession for the long term?

If so, study every day. Learn a little bit every day. Master a topic every day. You have time to reach that mastery. You have you’re entire career to become a master at physical therapy.

If this is a stepping stone to something else (I ain’t gonna hate ya for it), then why bother to master anything at all?

If your goal is to go into the business of owning a clinic, teaching courses, becoming a professor, then it doesn’t matter if you “master the profession”. It only matters that you master that which is your goal.

Happy thought for the day.

Moral Distress

“Unfortunately, information about moral distress and its consequences is often inadequate in healthcare provider education.”

This topic of moral distress was never spoken of in our physical therapy program, but I am unsure if this has changed with time.  Moral distress occurs when someone knows the morally right thing to do for that person, but the individual feels like they are unable to do the right thing for one of many reasons.

These are topics that are not addressed well enough in PT school.  If a person doesn’t have strong moral resolve, then the person may work to appease the reason that he/she feels constrained instead of fulfilling his/her own moral code.

 

“Moral distress as ‘psychological response to morally challenging situations such as those of moral constraint or moral conflict or both’…experience moral distress and burnout in situations such as patients receiving non-beneficial treatment, patient suffering, care not consistent with patients’ preferences, lack of administrative support, perceived powerlessness, and competing obligations.”

For those that are new grads reading this…WELCOME TO THE WORLD OF HEALTH CARE!

Burnout is a topic that has apparently been taboo to talk about in previous years or there hasn’t been a platform in which healthcare practitioners felt comfortable releasing their thoughts.  I can’t remember in my career, albeit only 11 years, in which burnout has been such a large topic as it has been in recent months.

Moral conflict can happen from providing care that is not beneficial.  WHY IN THE WORLD WOULD ANYONE EVER GIVE THIS TYPE OF CARE?!

Enter Shane McMahon

Unfortunately, there have been many therapists that I have spoken to across the country that are performing treatments that they do not personally believe to help the patient, but are trying to stay out of trouble with higher-ups in the company that they are employed.

 

If you are a patient reading this, close your eyes for this and skip to the next paragraph…Companies are trying to get their hands in your pockets.  (YOU WEREN’T SUPPOSED TO READ THAT!)

“Poor work environments…associated with a higher frequency of nurse-reported healthcare-associated infections. Persistent moral distress can progress to burnout, which is also associated with increased incidence of hospital-acquired infections.”

So…who do you want treating you? Do you want to be treated in an environment that increases your likelihood of developing an infection?

If not…pay attention to your surroundings.  Are your healthcare professionals happy, energized, empowered and fulfilled?  If so, you are probably in a good spot.

“Nurse leaders provided insights on risk factors that increase the possibility of moral distress. System-level factors such as work environment, lack of strong ethics resources, and heavy workloads prevailed.”

If you are practicing in healthcare, does this sound familiar.  A lack of ethical resources and heavy workloads describes most institutions in which I have worked and hear from others in the field of PT.  At no time should money trump patient care, but it happens all too frequently.

I get it…I am trying to run a business.  I have heard the phrases that we need to keep the lights on.  We need to make sure that we are making a small profit.  I get it, but at no point in time should we allow greed to take precedence over patient care.

Seek it out

Understand it

Pay attention to workplace climate

Promote receptive environment and engagement

Open opportunity for dialogue

Reflect, Evaluate, Revise

Transform Environment

Link to article

Thanks for taking the time to read this synopsis.  It would mean a lot to me if you would share this for others to see the state of healthcare in today’s environment.

Burnout

“The interest of this project is assessing the prevalence of BOS (Burnout Syndrome) among physiotherapists who work in the Estremadura region (Spain)”

 

I can already hear the arguments from other PT’s, “Why are you reading research from Spain?” and the answer is because we don’t have enough research from America.  We will have to try to extrapolate some of the information from this article to see if it applies to our work environment.  In the end, people are people and no one article will apply to everyone, but maybe some bits of knowledge can come out of this article to help many.

 

Let’s start with burnout.  It exists in healthcare and this sector has one of the highest rates of burnout among sectors (think like education, healthcare, transportation, law enforcement etc).

 

From the other research articles that I am reading, burnout is characterized by emotional exhaustion, depersonalization, and low professional (sense of) accomplishment.

 

“LPA (low professional accomplishment) is clearly higher in the case of split shift working day as well as in private practice”

 

A split shift, in this study is defined as just that, a shift that is non-consecutive. For instance, there was one job that I was interested in that would take a two-hour lunch in order for the people working there to go to the gym next door.  As much as I was in favor of it, it would have meant another hour away from my family…so I politely turned it down.

 

Private practice is private practice.  We have this here in the states.  Private practice is traditionally seen as a capitalistic venture, in which the owners are trying to make as much money as possible.

 

“…more than 40 hours of direct attention (patient contact) is linked to higher scores in EE (emotional exhaustion), and that more than 20 patients treated per day is associated with higher scored in both EE and Dp (depersonalization)”

 

Are you surprised?

 

We treat sick people day in and day out.  We treat people in pain day in and day out.  We are constantly taking the burden of others in trying to help these folks.  It can be exhausting.  The other option that could happen when a person becomes emotionally exhausted is to just “shut it down” and then depersonalize work and simply “go through the motions.”

 

Is this what you want in a health care provider?

Be on the lookout when you go to therapy to see if the therapist is seeing one patient at a time or more than one patient at a time because it can start to give you insight into the PT’s mindset.

“Physiotherapists included in our study had a moderate level of BOS (burnout syndrome) in its three dimensions: EE (emotional exhaustion), Dp (depersonalization) and LPA (low professional accomplishment).”

Although I don’t believe that I fit into this category, it is becoming more obvious from talking to other PT’s in the profession that this is a major problem that will have to be addressed in the not-so-distant future.  Think about it! The population is becoming older, we have a shortage of PT’s and there will be a higher demand for our services.  There are only so many of us to go around and if the PT works for a company that values $$$ over quality, then the PT’s will be asked to see more and more patients per day.  This appears to be leading the charge for burnout, based on the conversations that I have with other PT’s.

 

I did an informal survey on FB to determine the primary cause of burnout among the professionals and the primary answer was productivity demands.  For those of you that aren’t in healthcare, this means how many patients are you billing per hour.  WE DON’T MAKE WIDGETS!!!! We can’t treat people like WIDGETS!  It makes sense that some PT’s are getting their ethical buttons pushed and start to depersonalize.  One PT that I spoke to literally said that he was exhausted from TREATING PATIENTS!

 

Are you kidding me?!

 

It’s only getting worse out there.  As a patient you need to know what’s happening in the profession and choose a PT that is giving you undivided attention when you are in the clinic (THAT’S WHAT YOU ARE PAYING FOR!) and as a PT, you have a choice to work in a place that is asking more from you than you can deliver or you can leave and find something different.

 

“…the age of physiotherapists does not seem to have any influence in the syndrome. However, there is an adjustment period, at the beginning of the physiotherapist’s professional development, where they are especially vulnerable to the development of BOS (burnout syndrome).”

 

Old and young alike feel stress.  We all have ethical buttons.  Some that have swam the waters of this profession for years have learned to live with it, but those coming out are facing challenges that are considered taboo to speak of in school.  It’s only due to social media that these topics are becoming more mainstream for students to learn about.

 

“…physiotherapists who work split shifts and more than 38.5 hours per week are those who present the highest level of BOS (burnout).”

 

I don’t know any PT’s, minus those that don’t choose to work full-time, that are consistently putting in less than 39 hours per week.  I am personally putting in a ton of hours per week of direct patient care and indirect care through notes, blogging and doing videos.

 

“Burnout syndrome reaches its highest levels in those who dedicate more than 40 hours per week of direct attention to patients…”

 

Should we even bring up student loan debt?

 

If you want a comfortable/stable life, then you will work more than 40 hours per week.  Otherwise, you will pay your student loans off over decades.  That ball and chain will always be there.  Click  here to learn more about the ball and chain.

 

I personally receive income from three different companies, which I wished that I did sooner instead of waiting almost 10 years to work multiple jobs.  On the flip side though, had I done this sooner, then I may have experienced burnout and not be in the position that I am in today.

 

“…more than 20 patients per day have the highest levels of EE (emotional exhaustion), Dp (depersonalization) and BOS (burnout)”

 

PTs: Does this fit the description of the person and therapist that you want to be? If so, go forth and treat 2+ patients per hour.  Just know that you are making that decision and there is no sympathy for you in the end.

 

Patients: Does this describe the person that you want treating you? Emotionally exhausted, depersonalized and burnt out? If not, look around.  How many patients are there per therapists.

 

YOU ARE NOT A WIDGET!

 

Excerpts from:

Gonzalez-Sanchez B, Lopez-Arza MVG, Montanero-Fernandez J et al. Burnout syndrome prevalence in physiotherapists. Rev Assoc Med Bras. 2017;63(4):361-365

You got a choice: right or not so right

As a father and husband, the topic of ethics and morals has a deeper meaning for me.  I need to make choices that will allow me to sleep at night.  I can’t afford to be passive in my profession because I have multiple sets of eyes watching my every move.  The best way to influence the future is through decisions that I am making today.  My wife may not like that I am posting this picture, but it’s done with love so that should override all.

Enjoy today’s article.

Moral Distress is knowing the right thing to do but being unable to do them because of internal and external constraints.

Flood gates are opening now. This profession is full of good people that want to do what is right, but are torn between collecting a paycheck or doing what is right for the patients.  This is a huge deal!  I hear from therapists all over the country that after long conversations just shrug their shoulders and say, “what can you do?”

 

What you can do is stand up for what is right.  In print, it doesn’t come across as well, but either stand up for what you believe in or bend over and take it.  If you chose to bend over, just know that you have a choice! You are not forced to make the decisions that you are making! There are other places that offer a paycheck!

 

I walked out on a job at lunch, albeit not the most professional thing to do but the right thing for me, because I could never wrap myself around to performing the acts that the corporation wanted me to perform.

 

The meek shall inherit the land…don’t take this literally.  Stand up for what is right for the patients! Stand up for what is right for the patients! Stand up for what is right for the patients!

 

The profession of physical therapy has the potential to be a great career choice, but unfortunately so many are experiencing burnout, helplessness, and exhaustion because of this moral distress.   Can we stop doing this to ourselves?

33% of nurses will consider leaving their profession because of moral distress

I’ve already read about PT’s leaving the profession and spoke with PT’s that left because of this issue.  I don’t feel bad for them.  They stood up and walked out.  That was right for them.  I feel sorry for the people that don’t have the ability or internal strength to make that decision, but instead struggle in silence.

“When students encounter microethical dilemmas, the risk for moral distress is present because they are confronted with making a decision between two choices: speak up and advocate for quality patient care or remain quiet and permit the substandard practice to occur.”

I left this in as a quote because it goes well beyond schooling. If you are a member of the public and reading this…I apologize for what I will say.  If you are in healthcare, you already know this.  Shady stuff is happening in healthcare.  People are asked to do things that aren’t ethical.

example 1

example 2

example 3

I got tired of copying and pasting, but I could do this all day

Those choices never go away.  If anything, the chasm between the choices grows with each decision made.  For instance, standing up for one thing, in my opinion, will allow you to find your voice and draw your line in the sand.  It will be easier to draw that line and that line will become deeper each time it is drawn.  You learn more about yourself from standing up, which makes your ethical radar stronger over time.  It will become more apparent when your ethical button gets pushed and again you will have to make a decision.  Long story short, it never gets easier.

Top two reasons for having ethical dilemmas among nursing students was 1. I wasn’t in charge and 2. I didn’t have enough information

Unless you are the founder or an executive, I got news for you   YOU AIN’T IN CHARGE! This feeling of being subordinate never goes away until you reach the top of the mountain and there is only so much room at the top.

I get that some people don’t want to make decisions because they feel that they don’t have enough information, but there is a solution to that…go get the information needed in order to make a decision.

It’s not hard people…it takes a little more work.  As a PT, we spend hundreds of thousands of dollars to enter this profession.  We study for 7 years to become doctors.  No one is afraid of work.  We may be afraid of learning the information because then it will force us to make a decision that makes us uncomfortable.

It’s my opinion, based on multiple conversations with other professionals, that there are a lot of PT’s that are comfortable.  Unfortunately, those that are comfortable also have a lot to complain about.

Thanks for reading.  I appreciate that you took time out of your day to read my rants and hear my thoughts.

 

Excerpts for this blog were taken from:

Krautsched L, DeMeester DA, Orton V et al. Moral distress and Associated Factors Among Baccalaureate Nursing Students: A Multisite Descriptive Study. Nursing Education Perspectives. 2017;38(6):313-319.

Monk and the Merchant: a personal perspective

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Part 2 of the Monk and the Merchant.

five “Take responsibility for problems that are the result of your own bad decisions. Don’t displace the blame”

 

I’ve taken accountability for my actions for as long as I can remember.  Growing up, my dad was a huge influence on me.  There were many sayings that he would consistently use and I’ll list them here to give you an idea what growing up in a household with my dad was like:

  1. If it was after 6 AM and I wasn’t awake, this phrase would always come out “You’ve already slept away half of the morning…Are you planning on sleeping your life away?”
  2. “Either get busy living or get busy dying”
  3. “We send you to school, buy you books and THIS is what we get?!”
  4. “I just don’t understand…and I don’t think I ever will”

Mind you, I started hearing these phrases at an age of 5, probably sooner, but that is the earliest recollection of these phrases.

 

I haven’t always made good decisions.  When I was 13 I was caught shoplifting.  I was a chronic shoplifter and I kept it hidden from everyone.  I would steal for no other reason than the thrill of the challenge.  It didn’t matter what I would steal, as I would typically throw it away or give it away later.  Mind you, these were bad decisions and I don’t condone it.  I was making mistakes and it took getting caught to actually see the error of my ways.  I was actually proud of myself for getting away with it for so many years prior to getting caught.  My mother couldn’t understand and we had a long discussion about this.  She tried to understand the motivation.  My dad on the other hand didn’t even try to understand.

 

Let me paint you a picture.  My dad is a Vietnam Veteran.  He was a Medic for the 101st Airborne (Screaming Eagles).  He was a light sleeper and would wake up every night at 1 AM to do a check throughout the house.  He would wake up between 3:00 AM and 3:30 AM every day, even on weekends.  When I got home from getting caught shoplifting, my mom woke up my dad to inform him of what happened.  He pulled me into the room and had a short conversation with me.  There was no punishment.  He simply said, “Son, I’m disappointed in you”

 

You have to understand my background.  I am the youngest of seven and the one that was supposed to stay out of trouble.  Those words that my dad, my Superman, said to me that night completely changed my life.  I have never done anything and would never do anything to make my dad feel disappointed in me again.

 

I had to pay back a $2,000 fine to the place that I was caught and have been straight-laced since.

Principle six “See challenges as stepping stones, not as obstacles”

Joliet Junior College is the oldest community college. One of the few classes throughout my academic career that was my bane was Chemistry 101 with Dr. Matthews at JJC.  I dropped this class twice, although the second time was because someone stole my lab work for the semester and I wasn’t able to complete all of the work on time.  I was working 2 jobs (Sam’s club from 3-9 PM and Eagle [no longer exists] from 10PM to 6AM).  Because of all the hours that I was putting in, I chose to take one semester of just chemistry with Dr. Matthews and made it through with an “A”. Knowing that I could tolerate discomfort made the rest of undergraduate “easy”.

Principle seven, “Be meek before God, but Bold before men.”

Getting back to some of the prayer conversations that I had with God (I highly recommend the series  of books regarding conversations with God), I was humbled before God when making my decision for a career. In this career, I have had to stand my ground many times.  As someone that cares deeply about the profession of physical therapy, I stood my ground many times and lost multiple jobs because I wouldn’t sacrifice my morals.

Principle eight, “Live debt free and below your means”

Hello Dave Ramsey! This is where the Ramsey influence comes into play.  I actually purchased this book at EntreLeadeship One Day.

 

You know that saying, If I knew then what I know now then there would be so many changes in life.  Like many, I am coming out with student loans and made some poor financial decisions over the years.  I am now digging out of the hole of debt.  Luckily, we have a big shovel to start digging out of the mess.

If you are in debt, this is a great plan to start following.  I paid off more debt in the previous year than I did in the 5 prior.

 

Principle nine, “Always keep to your budget”

This is something that is very difficult and takes practice.  It takes time to understand fixed and variable expenses.  Trying to cut fixed expenses is hard, but there are companies out there that work to reduce fixed expenses such as Bill Shark.  This company reduced our internet and phone bill.

Variable expenses such as going out have been greatly reduced as my family is attempting to get out of debt.  I’ve been out of school for 10 years and still have student loan debt around my neck.  We are planning on getting out of debt in the next two years, all except the mortgage for now.

 

Principle ten, “Loaning money destroys relationships”

I’ve never borrowed more than $20 dollars from friends or family because the guilt of being in debt to them changes the relationship.  I don’t think that it affects everyone the same way.  My brother has owed me $100 dollars for years and it’s just never going to be paid back.  I realize that, and it was the best $100 dollar lesson I could’ve learned.

Principle eleven, “set aside the first ten percent to honor God”

I have been much better at this over the years, but am no where near tithing.  Honoring God doesn’t mean that I have to give to the church.  I now donate to so many of the local charities and purchase gifts for kids in need during Christmas.  This was the first year that I did the kid’s gifts, but it felt great.  The thought that a kid wouldn’t have a gift to open is heartbreaking.  Pairing that with the fact that the only gifts that this particular kid wanted was winter clothes, jackets and boots made me sad.  Knowing that there are kids in this country that don’t have the basic necessities is heartbreaking.

I realized that giving to others is selfish in that the way that I feel after giving hasn’t been recreated by anything else I’ve done.

 

Principle twelve, “Understand the power of partnership”

The ship that won’t sail is a partnership. Understanding the power of partnership is important.  This principle goes beyond business.  A marriage is a partnership in which both individuals work to make the unit stronger over time.  I am still curious as to the power of the business partnership because one person always has more leverage than the other.  This leverage can be dangerous to the partnership because it can always be held over the other’s head.  If there is a 50/50 partnership, which includes 50/50 work ethic, I may be convinced otherwise.  I just haven’t seen it yet.

 

Thanks for reading and I hope you get something from the links provided in the article.

McKenzie Method and back pain

I recently just read a case study, which I will be referencing a lot in the future paragraphs, regarding the use of MDT in the treatment of a patient with pain.  This is not uncommon, but what makes it special is that that the patient has a diagnosis of recent transverse process fractures in the spine.  Hope you find it interesting also!

 

First, Mechanical Diagnosis and Therapy (MDT) is also known informally as the McKenzie Method.  You can read more about the method with this link.  Also, this method is used by therapists all across the world as seen  here. Finally, if you are looking for more in depth information on the method, it can be found here.  There is so much information out there regarding MDT that there is no need for me to go back and explain it all again.  Read the previous stuff that I did. 

Patient characteristics

  1. 24 y/o female referred with left sided back pain
  2. 10 week previous involved in accident in which she was hit by a car while walking
  3. Transverse processes fractures from L2-L4
  4. Evaluation occurred about 10 weeks following accident

Examination:

  1. PT and MD agreed to patient generated forces only
    1. This is important! The most important part of this statement is the communication that is taking place between the PT and the physician prior to the patient entering the clinic. Also of importance to note is the trust that the physician has in not only the therapist, but also the method, as the patient was specifically referred for an MDT assessment. 
  2. Left low back tightness and numbness constantly
    1. Pain was intermittent
  3. Sometimes worse with sitting and tenderness when sitting against a hard-back chair, sometimes worse with activity and waking a few times per night due to pain
    1. The above is also important as this indicates high irritability as the symptoms can be constant and pressure can increase the symptoms. Also, the patient is waking during the night, which is historically correlated to an inflammatory process, but can also be position related. 
  4. The patient was better with standing, walking and lying
    1. This could mean that the patient has a directional preference for extension, prefers to be unloaded or is better with movement. The only way to figure out how these variables play a role in her symptoms is to start playing/manipulating the variables and watch the outcomes.  This is no different than any other science-based projects.  We have the opportunity to work with patients that trust us.  We have a responsibility to work with the patient in order to educate them as to the process of attempting to narrow down the variables at play regarding the symptoms.  Once the patient is agreeable to working together, we can change the inputs to the brain and assess the outputs in terms of physical changes and perceived changes from the patient. 
  5. Worse with postural correction, but no worse with using a lumbar roll.
    1. Postural correction, when performed according to the book is a hands-on technique and in doing so may be too much for the patient to tolerate. The fact that the patient is no worse with a lumbar roll means that extension, in and of itself, may not be bad but increasing the range in a loaded position may not be preferable at this time.
  6. Patient was issued back bends, repeated extension in standing, after the first session due to her complaints with flexion based movements and improving with standing and walking.
  7. Visit 2 overall unchanged and the patient was instructed to lean against a countertop to provide a fulcrum to lean against during the movement. This is, theoretically, to allow for increased force during the movement.
    1. The worst response to any movement that I can see in the clinic is “no overall change”. If we can’t change the patient’s symptoms or movement patterns, or strength, then it is hard to predict if the patient will respond to therapy over the course of care.  If the patient gets worse during the evaluation, it is not good/bad, just a response.  The thought is that if the patient is able to change for the worse, then the PT should be able to create a change for the better.  It’s simplistic thinking, but in the presence of a mechanical and not chemical issue, it is a common response to see in the clinic.
  8. Patient was better with either the countertop version of backbends or when doing pressups
    1. This is a version of progression and alternative versions of the same exercise. For example, the thought is that during a pressup, the patient is able to move further into the range of extension than during a back bend.  This may be because of eccentric loading of the global flexors or because of gravity assistance during the pressup on the lumbar spine.  I haven’t seen any research that definitively states why, but these are the thoughts.
  9. By the third visit, the patient reported 80% improvement with no pain.
    1. This is very common to see when a patient presents with a mechanical response and is categorized as a derangement (see all of the links above). It’s not uncommon to reduce symptoms in less than 7 visits. 

 

The big picture lessons from this case are:

  1. Don’t be afraid to assess a patient systematically.
  2. Communicate with other members of the health care team.
  3. Be willing to change your plan when something isn’t progressing accordingly.

Elenburg JL, Foley BS, Roberts K, Bayliss AJ. Case Report: Utilization of Mechanical Diagnosis and Therapy (MDT) for the treatment of a lumbar pain in the presence of known lumbar transverse process fractures: a case study. JMMT. 2016;24(2):74-79.

If you are having back pain and want to be evaluated by a certified MDT therapist, you can find me here.

What’s it mean to be a PT part I

 

 

As professionals, we are all supposed to practice in accordance with the core values and within the Code of Ethics.  Having conversations with PT’s all over the country regarding unethical situations makes me think that some in the profession could use a refresher.  Especially those (me included) that may not have been paying close attention to this information while in school.

Principle #1: Physical therapists shall respect the inherent dignity and rights of all individuals.

It’s unfortunate that there are people that make bad decisions in life.  There are cases of PT’s acting inappropriate with patients. Here’s a recent article regarding a PT that was found to act inappropriately by his state board.

Moral of the story: patients have inherent rights as people.  Although we are in a position of trust, we must never do anything to compromise that trust that patients place in us.  Patients are coming to us at a vulnerable time in his/her life and we must acknowledge that.

  1. Physical therapists shall act in a respectful manner toward each person regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability.
    1. It’s been published that some students receive lower grades during a clinical correlating with race.
    2. PT students may not feel comfortable treating the older patient with the same principles as the younger patient per this
    3. Another study speaks to the disparities among races for receiving medical care for knee

 

I guess that I have been naïve all of these years.  As a minority that comes from a blue-collar family, I never paid attention to this and have not seen it personally.  We have to take into account our  implicit bias at all times.  For instance, I recently attended a health fair at the local Spanish Community Center and the people were so surprised that a Mexican from “the neighborhood” was able to earn the title of Doctor.  This type of bias affects every generation that gets infected with this negative thinking.

  1. Physical therapists shall recognize their personal biases and shall not discriminate against others in physical therapist practice, consultation, education, research, and administration.
    1. I thought that a lot of these principles were common sense and part of being a good person, but apparently there are a lot of people who have these biases in healthcare.

 

 

THIS IS THE FIRST IN A SERIES OF POSTS THAT I WILL BE DOING ON THE CODE OF ETHICS AND CORE VALUES.  FOR SO LONG, I’VE ATTEMPTED TO LIVE THESE CORE VALUES OF OUR PROFESSION, BUT THEN I HAVE COME TO REALIZE THAT SO MANY OF MY STUDENTS COULDN’T RECITE THEM.  TO ME THIS MEANS THAT THEY HAVEN’T BEEN INTERNALIZED.  AS PROFESSIONALS, WE NEED TO ACT LIKE PROFESSIONALS AND AT LEAST BE AWARE OF OUR CORE VALUES AND CODE OF CONDUCT.

Right hook

If you’ve never heard the saying that one works for decades in order to become an overnight success, then you’ve heard it here first.

I’ve been in PT for 10 years and am now getting mentioned in conversations with people that I’ve looked up to for years. At one point, someone was shocked that another student didn’t know who I was. I find it comical.

As the son of a laborer, especially one that worked in the sewer systems, I have always had a strong work ethic. For 10 years I’ve kept my head down, avoided causing any waves and just worked. I worked through a divorce. I worked through a fainting episode. I worked through a cardiac issue. I worked. It’s what I’ve always known. I guess I’m just too dense to know any different.

One thing that I am realizing after all these years is that I gained a lot of knowledge by working with patients, working in study groups and working at night by reading journals. I worked hard and now I’m starting to speak out more from behind the computer.

I have a lot of passions for this profession, but this profession is just that…a profession. At some point I will leave it and move on, but while I’m here, I want to have an IMPACT.

Jim Rohn said “If you let your learning lead to knowledge, you become a fool. If you let your learning lead to action, you become wealthy.”

I’m starting to take action. For those that follow my blog, keep your eyes and ears opened because I am creating a CEU that will encompass our profession, but I believe that it will transcend our profession.

I am not doing this for the money. I am sick of hearing the negatives of our profession. I chose to look at these negatives systematically to try to determine how I can help. I think I know how to create waves and make an IMPACT.

see you soon…hopefully in a class near you.