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My journey is not your journey

“don’t you dare compare your beginning with someone else’s middle“

I can see how this happens frequently, even in my own profession as a PT.

I hear it from new graduates, “we can’t all know as much research as you do.”

I hear that and I get pissed.

I wasn’t born with research inputted into my brain.

I wasn’t spoon fed the research through lectures.

I spent hours per week reading.

When I hear others tell me that they can’t do it…I think that you have other priorities. That’s fine, but don’t attempt to demean my priorities. Don’t try to knock me down so that you feel better about yourself, because I won’t have it.

My need to become better at my profession was a stronger force than most other priorities in my life, at the time.

Needless to say, my priorities weren’t well organized for the person I am today.

The issue that I see is that I looked at others in managerial positions and thought, I could do that.

I looked at people that were owning businesses and thought, “I could do that”.

I don’t want to do that.

I don’t want to be tied to my profession with the same short leash that I had my first 5-8 years.

I want more freedom to spend time with the kids (in small doses of course).

I want more freedom to be able to watch 3-4 hours of wrestling per week (don’t judge, we all have our indulgences that we would rather not do away with).

Now, I only have to do what I need to do to take care of my family and what I want to do to be happy. It took decades to grow into this person.

Don’t compare your journey to mine and I won’t compare my journey to others.

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All hustle, no talent: pushed by hate

“ for me, it was always through achievement that I was able to receive notice from my parents. What does taught me at a very early age was that in order to be loved I need to do things to earn it. But to a child for whom notice is the outpouring of love, the absence of any leads to a desperation to learn what she can do to receive it.“

Rachel Hollis

I don’t resonate with this saying at all.

I need to let people into my world for a second.

I am the youngest of 5. The youngest by far. My next oldest brother is 8 years older than I. You know what that means right?…OOOPS.

That’s right, I was an oops baby.

I wasn’t planned. By the time I came along, my mom was tired. She was done from what I’ve heard.

I say that because I don’t have many memories of my birth mom after the age of 8. My parents got divorced and my dad took all of us.

Now I got three of my own and I don’t know how the hell he did it! I struggle with the three while my wife works on the weekends. He had to take care of the kids financially and emotionally (as best as he could). Again, I say this because at the time my Dad was an alcoholic. Don’t get me wrong…my Dad is my Superman. He would come home from work and we would go to the bar. Again, I am much younger than the others, so mostly I would be the only one that would go to the “club” (a bar that you had to pay membership to get into). There weren’t a lot of kids at this bar, but the kids that were there became like family because we all had the same story. Our dads all drank and drank almost every night.

I became the “Pinball Wizard” and my name was always on the board.

Again, my Dad did his best to take care of me, as he was just trying to stay afloat and teach me lessons throughout my life. He coached baseball, he never missed a game from the time I was 8 up to when I was 17. He took me to my bowling league. He stood up against a major street gang when they attacked our family (and they backed off). He eventually married my Step-Mom (Aida), which completely turned my life around. He no longer went to the bar. We moved out of the gang and violence that I grew accustomed to and moved to a farm town.

Interview with Dad

I digress.

The reason that I never used achievement to feel loved is because I was full of hate and self-worth issues.

I had to be the best…not to get the attention of my parents because my Dad didn’t value accomplishments as much as the work out into any accomplishment. He didn’t care that I only struck out three times my senior year of baseball, but he praised the hours that I would spend at the field hitting into the fence.

I had to be the best…because I needed to prove my value.

Remember…I was an oops baby and I knew this.

To make matters worse, my mom left me and walked out of my life when I was young. The person that gave birth and was supposed to have inherent trust because of that…walked away.

I had a self-worth issue.

I’ve seen it happen many times in life, a situation like this either breaks a person and they search for whatever acceptance they can find or it drives the person with a chip on the shoulder.

I had the chip.

I didn’t care what I was doing, I had to work to be the best at it. I would look at people that had all of the opportunities and talent and just never reached potential and I would shake my head.

I created a catchphrase that I still follow today.

“All hustle, no talent”.

It was that rejection that I experienced early in life that led to the work ethic that I have today.

It was that rejection that led me to become the employee of the year at Sam’s Club. It was that rejection that led to me graduating with a 3.8 GPA from college. It was that rejection that led me to push myself in the career that I have.

There has been closure from that rejection. I no longer harbor the hate that I had for decades.

I had a long conversation with my Dad when I was about 24 years old that allowed me to dispose of the hatred.

I wrote a letter to my birth mom, which allowed me to close that book.

Aida filled the gap of raising me, but she could never cure the resentment that I had for decades.

Now, it’s because of that rejection that I try to never do something like that to my kids.

Loyalty to those I love is the reason why I push myself so hard now. I have nothing to prove anymore, but I have to set an example for my family.

Work/time = something

“ I mean that you focus in on the dream you have, you do the work, you put in the hours, and you stop feeling guilty about it!“

I quit the hospital the second time to move to Virginia. It was a great time! It lasted a whole weekend (seriously my address was Fairfax, Virginia for a whole two days). I quit the hospital on a Thursday. I was back on a train to Chicago and then the Rock Island to Mokena by Sunday.

Needless to say, I called FW at Palos Hospital and was back to work at the hospital the next week. Although it seemed like a short vacation that I was away from the hospital, because I put in my notice, I lost all of my seniority, which included vacation time. Not a huge deal though because they hired me at the hourly rate i was receiving when I quit. I got a 90 day raise after my probationary period ended.

Another small detail is that I returned home having filed for divorce.

This whole story was to tell one small detail. I actually obtained a job in Virginia, one in which I never started but did the interviews. Virginia was, at the time, a direct access state for anyone that had a DPT. Without a DPT (doctorate degree in physical therapy) a PT could not see a patient “off the street” unless he/she took a differential diagnosis course.

I realized that the DPT has a little value. At that point I decided that I was going to obtain a DPT degree. (In hindsight, I could’ve just as easily taken the differential diagnosis course, but having moved back to IL without any furniture or television set, I had nothing better to do with my time. Literally, I thought to myself…I got some time to kill and the hospital agreed to pay $3,000 per year…I might as go get a Doctorate degree). The coursework for the DPT was relatively easy, but time consuming. I am proud that I did this and obtained the DPT. Not because of the title, but because now I can argue both ends of the argument regarding the DPTs worth; it only cost me $5K over three years.

In the end, I keep it simple.

“Just keep swimming. Just keep swimming”

Money, money…yeah, yeah

The payment model for PT has been failing over the previous decade that I was in practice.

The amount of reimbursement per hour from Medicare isn’t bad, it’s about $90/ hour. Let’s do a quick breakdown of how that money gets spent.

The average therapist is making about $40/hour. Add the employee taxes and we will call it $44/hr.

Still not bad, the company is left with $46/hr.

The company has to pay for liability insurance, which can cost about $0.30/hr.

Now down to $45.70/hr in profit. So far so good.

Rent is consistently going up and averages about $2000/month in my location for a small clinic. This comes out to about $12/hr

This still leaves $32.70/hr of treatment.

Wait…we still have to hire a front desk person due to Medicare regulations. That’s $15/hour plus employer taxes = 16.50/hr.

There is still $16.20/hr profit.

If the company offers health insurance and vacation time, it further reduces profits.

What happens if a patient cancels?

That $129.60 profit ($16.20 x 8 hrs) per day quicky vanishes.

We are seeing large corporations reporting 6-8% profit per year.

Some smaller clinics (without using ancillary staff) are making upwards of 20% profit per year.

Students need to understand that the company needs to make a profit in order to stay open.

This is the reason that they will get lower offers year to year. Expenses are always rising (rent, fuel, water, liability insurance) and reimbursement has historically reduced with time.

This equation really sucks for the individual when you add in $150K+ in student loan debt.

I don’t recommend anyone come into this profession unless youcan do it under $100K all in (this includes 6-7 years of school plus living expenses).

During this pandemic, I enjoy being the light that shines on good news 😂

Stay safe everyone!

Taking a jump

“ in fact, when you understand that you don’t have to justify your dreams to anyone else for any reason, that’s the day you truly begin to step into what you’re meant to be.“

I’m going to agree to disagree on this one. As you heard before, I made quick changes in my career without consulting my then wife…that relationship ended.

Although I don’t have to justify my dreams, I have to justify my decisions to my family. Making a quick jump, or even a well-thought-out jump, to satisfy my dream may not be worth it if the dream adversely affects family finance or security.

For instance, I quit the hospital the third time (that’s right, they took me back a second and third time) in order to chase a dream of managing my own clinic. I took a stupid pay cut in order to do this. I chose to cut my own pay by almost 20%. Not only that, I quit the cushy hospital job to go manage a clinic that was easily losing $100K per year. After 6 months of following my dream…reality set in. My wife said that I had to make a decision of opening my own clinic and leaving this one or going to find a job.

That was a smart move on her part. Although I increased the number of patients that were coming into the clinic by a little over 10%, it still wasn’t enough to justify the overhead that I inherited and the salary that I was getting. I was averaging about 28 visits per week, but that amount of money barely covered the overhead. There was no chance of profiting any time soon. Because of that, there was no chance of getting a raise any time soon. Mind you, during this time period I was also ranked in an honorable

https://www.google.com/amp/s/www.updocmedia.com/2017-top-40-influencers/amp/

Class by my peers. This was my opportunity to advance my lot in life. I am now making about 10% more than when I left the hospital and this year will mark my break even point. Every week after this year marks a betterment than where I was when working for the hospital. The cool thing is that I am still following my initial dream because I now have my own company, am managing patients the way I feel appropriate, and have created close relationships with many physicians and the community I serve. This was what I set out to do when I initially left the hospital.

Don’t get me wrong, Palos Hospital was a great place to work. I worked with an unbelievable team in which we all respected each other’s strengths and there were no egos on the team. (I say that because I may have had the biggest ego at the time so no one else appeared to have an ego in comparison.) None of us would hesitate to reach out to another PT or PTA if we were stuck with a patient. I have always recommended anyone to take a job there if they have the opportunity. My chief complaint with the hospital was that there was no chance of advancing one’s career, and I was looking for more.

If I never took that chance to chase a dream, I would still be in a job that I was frustrated with, although more changes were made after I left which may have satisfied my need for change. If my wife didn’t have that conversation about the reality of finances, I may still be trying to steer a sinking ship that I inevitably had no control over.

I now am in a spot to have more control and am avale to support my family while advancing my career, community involvement, and education of peers.

Play on words

If group based therapy is no worse than individual one-one care, should we perform more group care for total knee replacement based patients?

I think that this is one opportunity that our profession would jump on, if we had enough patients to create a waiting list consistently.

If we know that we can get similar effects in a group setting, should we bill patients one-one, which we know is more expensive of a healthcare burden for both the insurance and the patient.

What are your thoughts?

Que será será

“ as long as you’re not asking anyone to give you approval, then you don’t need anyone to give you permission.”

This reminds me of the saying “it’s easier to ask for forgiveness than permission”. I heard this phrase frequently from one of my former bosses at Palos.

Man I miss that guy.

You know that type of relationship? The one that only two guys can have with each other in which they share ideas, for better or worse. They share their day. They are just open and honest with each other. Those relationships are few and far between and I’m just blessed that I got to share that relationship while at work, because that’s where I spent a majority of my days.

Back to the point of the story:

When I believe that I am doing the right thing, I have no reason to ask for permission. This has gotten me into hot water at times during my career. There was one job that I quit over lunch. I did what I felt was right, but what was right wasn’t what was best for business. After the second time the owner pulled me aside to have this conversation… about doing what is best for business…I quit on the spot. Mind you, this is not the most professional thing to do, but I had to stand up for my moral belief system.

Since I didn’t care about the owner’s approval…or the job for that matter…I walked out.

Let’s talk about that job. I made a mistake in taking that job. I quit Palos Hospital, this was the first time that I quit the hospital job.

I quit a decent paying job, at the time I wasn’t making much at the hospital because I hadn’t served my time. Sometimes working at a hospital is like a prison sentence. You get cred (more money) for time served. Unfortunately, it was hard to get raises based on achievement, extra-curricular activity, or simply by producing the most money for the department. The secret to getting the highest pay was simply outlasting the next fella.

I made a mistake in taking that job, after leaving the hospital, because I just took ANY job. I didn’t thoroughly research the company, which is something that I do now. I didn’t shadow the clinic multiple times, which is something that I do now. I didn’t talk to the employees about how they enjoyed their job or if they could do it again…would they, which is something that I do now.

I took that job because the commute was wicked short. It only took me 4 minutes to get to work and home. It was so awesome that I actually bought a bike and rode to work. That stint lasted a whole 8 weeks. I bought a commuter bike, GIANT brand, which cost me about $900. I didn’t work at this job long enough to recoup the money I spent on the bike.

Oh well…you live and learn.

Anyways…I quit over lunch and the hospital took me back (second time being hired) that afternoon.

The point is if you don’t need anyone’s approval, then you don’t need permission.

Funny story…I was married at this time.

When I quit Palos (the first time) I literally walked into FWs office and said that I was giving my two weeks notice. I had no plan. I had no job waiting for me. There was no pot of gold at the end of the rainbow.

I quit Palos (the first time) because I signed up to make an impact. I wanted to change the way the hospital was doing therapy. I wanted to be innovative and create new programs. I eventually accomplished all of this…just not the first go around.

The second go around did not last much longer, but that’s a different sorry for a different day.

I remember walking out of the office and going outside to call my then wife at the time to tell her that I just quit my job, after less than a year on the job.

If you don’t need approval…you don’t need permission. Needless to say, that marriage didn’t last long. We were both so career oriented that neither of us asked permission before making major changes.

Que será será.

Functional movement screen norms

“However, the common misconception that screens by themselves can prevent injury has been challenged because they only provide individual information that is often based on standardized exercise recommendations, and may or may not suit an athlete’s specific needs”

Screening tools can be helpful in terms of setting up expectations and who should be monitored over time, but so far a screening tool is not a good measure of who will get injured.

For instance, I’ve written extensively about the Start Back Screening Tool, but this tool is used after a person experiences an injury or pain. It doesn’t attempt to predict who will experience an injury or pain.

“Assessing basic fundamental movement provides an opportunity to create a more individualized training program that focuses on changing or modifying movement patterns, instead of focusing on the rehabilitation of specific joints and muscles.”

Assessing basic fundamental movements…let’s stop here. Who gets to judge basic fundamental movement?

If we listen to Paul Chek then we would include walking, running and pulling movements into an assessment.

If we listen to USAW, then the screen looks eerily similar to the movements that will be performed in sport, only with less speed and weight.

The goal of screening an athlete, or anyone for that matter, is to determine if the person has characteristics that would prevent them from participating in their life activities due to injury.

I also believe that we can modify movements and change motor patterns, but only to an extent.

For example, someone with biomechanical issues, such as a different angled neck of the femur, long femur or short torso will not squat/lunge in the same fashion as those with different levers.

Meaning that we can stretch the ankle until we are blue in the face, but at some point a person just runs out of dorsiflexion due to joint mechanics.

“The FMS (TM) was developed as a comprehensive pre-participation and pre-season screen, and consists of seven tests/movements which challenge an individuals ability to perform basic movement patterns that reflect combinations of muscle strength, flexibility, range of motion, coordination, balance, and proprioception.”

This sounds great! Unfortunately “pre-participation” in curling requires different mobility, strength and balance when compared to wrestling or archery. We can’t just hang our hat on a one-size-fits all approach.

“Five of the seven FMS (TM) tests are scored separately for left and right sides, and can therefore be used to locate asymmetries which have been identified as an injury risk factor. An FMS (TM) specific cut-off value of 14 or below is suggested to indicate an elevated risk of injury”

I don’t have data for this, but some sports are inherently asymmetrical. Look at tennis, bowling, curling, baseball, golf and so many others…would we increase risk of injury by making these players symmetrical?

I know that there is follow-up research on the FMS stating that the asymmetries on the test are more predictive than the score cut-off, but I would like to see a specific study done on a mostly asymmetric sport, one that limits forward running, but maybe emphasizes lateral movement and only use of 1 arm or leg.

“…small sample size…ability to generalize this cut-off value to other sport and recreation participants may be limited”

The ability to generalize the results from one study is limited to the participant demographics within that study attempting to cite. For instance, the FMS (TM) has a cut-off score of 14, but this only applies to profesional football players. That’s a very narrow field, with which to apply the results.

“To date, there are no published normative values for score on the FMS (TM) to help sports physical therapists, coaches, and athletic trainers interpret the raw data collected during testing”

Typically, we would see normative data or studies performed before we see abnormal, or predictive of injury studies, performed.

An example would be this:

If the norms for the FMS is 15, but injury risk increases at 14, there is a very narrow window of error on the tester’s ability that could take one from healthy/normal to high risk for injury.

“convenience sample…approximately 200 females and males…between 18 and 40 years…recruited from tertiary population”

“Exclusion criteria…use of mobility aid or prophylactic device, or if they had reported a recent musculoskeletal or head injury”

“Each participant was given three trials on each of the seven tests (deep squat, hurdle step, in-line lunge, shoulder mobility, active straight leg raise, trunk stability push up, and rotary stability)”

To be certain, I do like some of the movements in the screen, but I’m not sure if I like the scoring and I believe that the screen is limited in scope. Here is a video of Grey Cook describing the movement screen. I enjoyed the video and I included it for your viewing pleasure.

“The combined composite mean score on the FMS (TM) was 15.7 with a standard deviation of 1.9 and a median of 16.”

Let’s break this down. Many people, both Physical Therapists and personal trainers, were taught to use the cut-off score of 14 as a sign of dysfunction.

The mean (average score) was 15.7, but the standard deviation could actually place the average in the same range as someone considered dysfunctional. If this is the case, then this testing is not very specific for finding dysfunction because the norm is dysfunctional.

“31% of the participants, had a composite score of 14 or below which indicates a heightened risk of injury according to Keivel et al.”

One-third of normal-healthy people are considered dysfunctional based on this test. We can’t extrapolate (assume that data from one study can be used on other people that don’t fit the study from which we obtained the data).

We can’t state thy this population is at risk of injury because of their score. Just because they scored 14 on the test doesn’t mean that they are at a higher risk for injury. They are not professional football players and can not be held to the same standards.

“The cutoff score of 14 was determined in a study on 46 professional football players…used with caution. “

The reason it has to be used with caution is simple.

This test is purportedly used to determine if someone is as risk of injury.

The average person doesn’t put themselves through the same type of activities and stresses as a professional football player. They shouldn’t use the same testing procedure to determine if they are at the same risk of injury.

Link to article

Deductibles

Let’s start with the basics:

Premiums: the amount of money that comes directly out of your check to pay for insurance

Deductible: the amount of costs that the patient has to pay before the insurance agreement (80/20 plan, 70/30 plan or 90/10 plan) kicks in.

How much money are people paying in premiums per month.

I’ll speak for my self. We pay $900/month for our family. We have a $3K deductible if we stay in network and a $6K deductible if we go out of network.

Let’s do some quick math…it won’t be exact, but pretty accurate.

In premiums per year we pay $10,800. We have an additional $3K deductible, which we meet yearly.

We spend at least $13,000 before the insurance ever has to pick up part of the bill.

If healthcare costs were priced appropriately, we may never come close to $13,000 in a years worth of spending on doctors appointments and medications.

One of my physicians charges $350 per 15 minute session, only to get reimbursed $115. Essentially, we are paying the insurance $13K to make it look like we are saving a couple of hundred dollars per session.

In PT, I’ve seen charges in private practice range from $300-$1000 per session. This is to get reimbursed on average $100 per session. Again, we overcharge in order to get a specific reimbursement. It makes it look like the patient is saving a ton of money by having insurance, even though we don’t ever expect to get paid what we charge when dealing with insurance.

Sometimes I see the whole system as a scam and we are all simply pawns.

En español:

Comencemos con lo básico:

Primas: la cantidad de dinero que sale directamente de su cheque para pagar el seguro.

Deducible: la cantidad de costos que el paciente tiene que pagar antes del acuerdo de seguro (plan 80/20, plan 70/30 o El plan 90/10) entra en acción.

¿Cuánto dinero pagan las personas en primas por mes?

Hablaré por mí mismo. Pagamos $ 900 / mes por nuestra familia. Tenemos un deducible de $ 3K si permanecemos en la red y un deducible de $ 6K si salimos de la red.

Hagamos algunos cálculos rápidos … no será exacto, pero sí bastante exacto. En primas por año pagamos $ 10,800. Tenemos un deducible adicional de $ 3K, que cumplimos anualmente. Gastamos al menos $ 13,000 antes de que el seguro tenga que pagar parte de la factura.

Si los costos de atención médica se tasaron adecuadamente, es posible que nunca lleguemos a cerca de $ 13,000 en un año de gasto en citas médicas y medicamentos. Uno de mis médicos cobra $ 350 por sesión de 15 minutos, solo para recibir un reembolso de $ 115. Esencialmente, estamos pagando al seguro $ 13K para que parezca que estamos ahorrando un par de cientos de dólares por sesión.

En PT, he visto que los cargos en la práctica privada oscilan entre $ 300 y $ 1000 por sesión. Esto es para obtener un reembolso promedio de $ 100 por sesión. Una vez más, cobramos de más para obtener un reembolso específico. Hace que parezca que el paciente está ahorrando una tonelada de dinero al tener un seguro, a pesar de que nunca esperamos recibir el pago de lo que cobramos al tratar con el seguro.

A veces veo todo el sistema como una estafa y todos somos simplemente peones.

Patients pay for services

Anyone that says that people won’t part with money are delusional. We know that people are paying cash for PT services. We know that people are meeting their deductibles and paying copays/coinsurance.

As professionals, we have to figure out how to educate patients on

1. Solving their problems

2. Understanding the true costs of healthcare.

Patients first purchase our services because of a few reasons

1. They were referred to us by their physician.

2. They are referred to us by their friends/family

3. They hear about us from internet searches

4. They choose us blindly

Regardless of how they find us, we have to give them value when they come to us.

For instance, my mom had therapy at one of the big chains a few years back. She said that she would only be able to attend PT twice per week, but the PT has her sign up for 3x/week. What do you think happened?

She canceled her appointment once per week…because that’s exactly what she said that she would do when asked about frequency.

Instead of listening to the patient and scheduling 2x/week, they scheduled 3x/week and after 3 weeks they discharged her for non-compliance.

Who was in the wrong? Was the clinic providing value…maybe? Did they listen to the patient and establish expectations and alliance…nope.

The value of the session always lies with the receiver and not the giver.

Many of us tho I ourselves to be rockstars…me included, but take this piece of advice from “The Rock“.

What matters is what the patients think and how they perceive the service. They are the ones paying for the service. We have to establish the expectation with the patient and then…deliver.

They will part with their money in these situations. We just have to follow the basics.

Cualquiera que diga que la gente no se separará del dinero es delirante. Sabemos que las personas están pagando en efectivo por los servicios de PT. Sabemos que las personas alcanzan sus deducibles y pagan copagos / coseguros.

Como profesionales, tenemos que descubrir cómo educar a los pacientes sobre

1. Resolviendo sus problemas

2. Comprender los verdaderos costos de la atención médica.

Los pacientes primero compran nuestros servicios por algunas razones

1. Nos los remitió su médico.

2. Son referidos a nosotros por sus amigos / familiares

3. Se enteran de nosotros por búsquedas en internet

4. Nos eligen ciegamente

Independientemente de cómo nos encuentren, tenemos que darles valor cuando vengan a nosotros.

Por ejemplo, mi madre recibió terapia en una de las grandes cadenas hace unos años. Ella dijo que solo podría asistir al PT dos veces por semana, pero el PT tiene su inscripción por 3 veces por semana. ¿Qué crees que pasó?

Ella canceló su cita una vez por semana … porque eso es exactamente lo que dijo que haría cuando se le preguntara sobre la frecuencia.

En lugar de escuchar a la paciente y programar 2 veces por semana, programaron 3 veces por semana y después de 3 semanas la dieron de alta por incumplimiento.

¿Quién estaba equivocado? ¿La clínica estaba aportando valor … tal vez? ¿Escucharon al paciente y establecieron expectativas y alianza … no?

El valor de la sesión siempre recae en el receptor y no en el donante.

Muchos de nosotros pensamos que somos estrellas de rock … yo incluido, pero tomo este consejo de “The Rock”.

Lo que importa es lo que piensan los pacientes y cómo perciben el servicio. Ellos son los que pagan por el servicio. Tenemos que establecer la expectativa con el paciente y luego … entregar.

Se separarán con su dinero en estas situaciones. Solo tenemos que seguir lo básico.