Talking PT with Dr. E

Dr. Erson Religioso and I had an awesome Google Hangout yesterday. Check out the blog entry at: The Manual Therapist!

And, of course, the video below:

New Grad Career Strategies

Perhaps one of my biggest pet peeves in western educational systems is the lack of career guidance and preparation. I feel in professional, graduate programs - there have been more improvements. Nevertheless, it's always helpful to hear from someone who "was just there" - in a manner of speaking.

For the purpose of this post, I will be delivering all content in reference & address to the newly licensed physical therapist with their shiny (and very expensive) Doctor of Physical Therapy degree.  In this post, I make some pointed comments regarding some views of the DPT degree, and, want to express that I hold such comments on the VIEWS, not upon those who hold such views. Finally, I want to thank you in advanced for being patient with this post of generous length. I do hope that you find this helpful in your career path.

New Grad Career Strategies for Physical Therapists

In my opinion, there are three basic career strategies for the new graduate #DPTStudent:

1. Make Money!
2. Go Into Business
3. Get REAAAALLY Clinical

1. Make Money!

Face it. You have loans. We ALL have loans. Whether its student loans, loans for a home, car, and/or other - modern economy is a debt/credit based economy.... LOANS are a part of life. The student loans you have sum to a small fortune which in all reality, makes for a physical therapist's license (the right to work) and a little "D-Envy" for your undergraduate peers. Without going into what the "doctor" means in the life of a physical therapist, ECONOMICALLY, you are in a market position where many employers think that:

• You really don't know that much since you are a "new grad"
• They shouldn't pay you all that much since you still learning as a "new grad"
• Since you have zero experience, there is no where else you can go for work to pay off said student loans and they can bully you into accepting a position for terrible pay.

I don't know about you, but THAT... is a sucky deal.

Besides... "they" are WRONG. There are several segments of work that pay VERY well and offer you the exposure & experiences which will raise your market equity as a physical therapist. Home health agencies, contract work for skilled nursing facilities, general registry companies, and, travel agencies (pay the most!) all tend to have pay which is immensely superior to the common 40 hr a week acute care, acute rehab, pediatric, and/or outpatient gig. In fact, the pay grade at such aforementioned companies tend to be comparable to time-and-a-half of the typical entry-level pay for larger health system positions.

Given that in late spring of 2013, rehab therapists in Southern California have earnings ranging from $33/hr to mid $40's/hr with 20+ year clinicians asking for $50/hr, working at as an entry-level-traveler for $45+/hr certainly sounds more worthy of a pay grade for you, doesn't it, doctor?

The reality is, to make money: work for someone who values your labor, NOT your education.

2. Go Into Business

I've had a range of shocking, infuriating, depressing, enlightening, saddening, and encouraging revelations when speaking with healthcare administrators, executives, and leaders in regards to physical therapists contributing at the corporate scale in healthcare. While they fully understand the scope of knowledge, training, and abilities required of a physical therapist, nearly all have communicated that the healthcare market simply does not see physical therapists as healthcare leaders. Why? Because "you're therapists...you're not a nurse... you're not a physician."

The inference is this: a physical therapist's background is insufficient to understand the breadth of human health the way a nurse or physician would. In fact, there are still segments of the market that esteem that physical therapists know muscles and movements but generally know nothing about medicine. Therefore, we would prove poor candidates to serve as a hospital administrator - say for example, the chief operations officer of an acute care hospital.

That's poppycock. POPPYCOCK, I say!

This is a MASSIVE market perception problem that we've carved for ourselves during the various evolutions of our profession. There is a hope, however. To rise in the chain of command in a corporate health system; to get into hospital operations; even to own your own clinic and be held respected by your investors/stakeholders, etc... EVERYONE RESPECTS STRONG BUSINESS SENSE.

Solution: Get Into Business!

If you look at the physical therapists who have risen the ranks to health system leadership, nearly all of them have some type of business background or adjunct degree. Whether it is an MBA, MPH, MHA, etc. - this additional academia positions the individual as one who is "not just a clinician"; this person has business potential! And, business means money - money means leadership.

Unfortunately, it's not that simple. As I mentioned in #1 "Make Money!" - you're a new grad. Say you apply for a job as a new grad DPT, MBA. And, let's be honest here, the respect level for you will still on the shallow end of the dream pool because of cultural barriers in the workplace inclusive of jealousy, insecurity, lack of faith/trust in your freshness... whatever it may be, just remember, it's a "sucky deal" (SEE ABOVE). But, guess what? ALL entry-level-professionals have to pay their dues and climb the totem pole. It is ALWAYS a sucky deal for new-comers. Junior associates for law firms and fellows under training from senior physicians... they all have to pay their dues.

My best advice: Get into a place; get really good; get supremely liked... loved even, by your co-workers & C-level-executives; and... LEAVE.

From what I've seen, it is very difficult for new-hire, new-grads to be seen as anything but a new-grad for the entirety of their tenure at any employment. It's even worse when new-grads have worked as rehab aides as prior employment. Earning your stripes quickly for an employment and leaving is the best way to demonstrate your worth on a CV, with your references, and with the company. The funny thing about human nature: people tend to miss you (and value you) when you are gone.

With that, you are able to better position yourself as an "experienced clinician" to another employer. This is a quick way of rising the chain of command at other ventures. This may also leave an open door at your prior employment to return as a higher ranked employee, maybe even return as a manager. In any case, I would suggest that to take this route, find a really good place to learn from and grow. Once you've reached the ceiling, its time to move on.

Also, if you have any aspirations in business operations or healthcare administration, start looking into online programs. Honestly, its probably the best hope you have of realistically making a difference at the corporate health system level as a physical therapist. Hopefully, over time, this perception of the physical therapist will change. Maybe, we will even see an ending of the in-fighting and intra-professional "D-envy" or even "D-hate" that is sadly still very evident in the workplace today - forcing us to climb the ladder with only one good hand.

3. Get REAAAALLY Clinical

And, I do mean, REALLY clinical and credentialed. I encourage you to get your board certified specialty, get your MDT credentialing, or FMS/SFMA, or additional certification in manual therapy, spinal manipulation, dry needling, NDT, PNF... anything and everything goes!

Go for a residency so you can get that OCS in a year's time. Invest in fellowship training. Even get a Ph.D. if you wish! Regardless of what your perceptions or your colleague's perceptions are of alphabet soup credentials - it still says something to the consumer when a practitioner has a list of credentials for which they could write Shakespearean prose. Many of these credentials represent weeks, months, and years of post-graduate training. And sure, there is no guarantee that a slew of credentials makes you any better of a practitioner - BUT - here's the thing... career = business & marketing position = level of demand. *WE* in the physical therapy world know what most credentials are and mean. The consumer may not. However, consumers can certainly see alphabet soup and can infer for themselves the level of value. Finally, while your first employer may not value (see #2 "Get Into Business) the fact that you are an OCS, Cert. MDT, FMS/SFMA, FAAOMPT within 3 years time & after you LEAVE... let me tell you, your NEXT employer will absolutely care!

When you reach 3-5 years of experience and you come to me with all the above credentials, dry needling background, credentialing in NDT, PNF, DNS, wound care, etc. and more - I WILL HIRE YOU - AND - I will try to find a way to make you a clinical educator; a veritable teacher of teachers.

Now while I've harped on negative view points of the DPT, the same criticism goes for any potential scenarios that would present should the DPT had been a PhD, PhDPT, DPTSC, DScPT, ScD, ... it really doesn't matter what the degree is. What I feel is truly a workplace travesty exists in the disdain, harassment, belittling, and under-valuing of new graduates. In the same vein, I have no tolerance for new graduates, regardless of time/era/degree coming out of school - waving a diploma with a superiority complex. ESPECIALLY in the world of social media, there are colleagues who I consider so highly that I do not feel that it is within my professional lifetime to achieve the levels of expertise that they have achieved. Their years of experience and a legendary era of training have yielded a smooth operator of human function that is likely to become a lost art in the coming years. However, I've also encountered their chronological counter-parts where I've sat in continuing education courses for medical screening by which the term "deer-in-headlights" couldn't begin to encompass how lost they were in current times.

I suppose my angst in this post is truly directed at intra-professional degradation. Physical rehab professionals are the only group in healthcare that I see overtly bash on their new colleagues for graduating with shiny degrees. So many other professions couldn't be happier that their new-grad-colleagues are receiving higher degrees that more accurately reflect where the profession has been, should be, and is going to be. However, our profession seems to have tolerance to those who behave from the view point that "doctor" is giving new-grads far more credit than they deserve.

Now, more likely than not, if you are reading this post, you simply don't hold these negative views in any array or permutation. Therefore, what I do ask of you is to stand up in defense of professional unity; rebuke & restrain those who take negative light to the new-grads who represent our future and the general future of healthcare & society at large.

UNIFORMITY IS THE FACE OF FAVORABLE CONSUMER PERCEPTION.

The profession must advance & we can only advance together. And with that, I leave you until next time in which I have plans on blogging about my first month as a rehab director as well as creating value through content marketing.

With the Most Sincere, Respectful Regards as Yours in Humbly Service,

-Ben Fung

Competition vs. Collaboration

Greetings!

Please consider the following tweets:

@mjcdpt @jerry_durhampt Much agreed! PT needs to function in concert to raise demand; in fighting will weaken our market position.
— Dr. Ben Fung (@DrBenFung) May 19, 2013

And now, please consider this most intriguing inspiration

Other versions of the same clip:
http://www.youtube.com/watch?v=uAJDD1_Oexo

http://www.youtube.com/watch?v=2d_dtTZQyUM

HMMMMMMMMMM!!!!!

Competition in a perfectly competitive market is one where firms would need to "worry" about gaining, maintaining, and fighting for a competitive edge. A perfectly competitive market has two main characteristics:

• The goods offered for sale are all the same.
• The buyers and sellers are so numerous that no one buyer or seller can influence the price.

Physical therapy is NOT a perfectly competitive market.... not by ANY means. Therefore, we need a lesson from microeconomics. In this particular case, the Nash Equilibrium. Most commonly portrayed in the Prisoner's Dilemma (as seen below) or popularized by the movie, "A Beautiful Mind" (as was seen above) - the principle states that if all individual parties in a group does whats best for the individual AND the group, THAT point will be the most advantageous for all parties involved.

The Prisoner's Dilemma: Best Choice is staying silent - cooperating.

For the physical rehabilitation & wellness business, we NEED to learn from this economic principle. The level of demand for our service and expertise is far below where it could be. Competing amongst ourselves will only be damaging to our market position in comparison to referral-for-profit models, alternatives to our services, or the very simple choice - NOT GOING to the physical therapist (or allied rehab professional).

In healthcare, related scopes and similar disciplines gain from collaborating, cooperating, strengthening in concert, and marketing in unison. Sure. Not all *insert professional service here* is made equal. But, just as I've been saying since the New Year's posts aka. the Mickey Mouse Moment series - unity is the only thing that will elevate our profession as a whole. When the entire profession is better positioned, all of our individual firms will be that much stronger in the marketplace.

My suggestions are these:

• See another rehab therapy professional that is doing something similar? Make a business alliance; share ideas; cross-market; and, refer to each other.
• See another hospital that is doing excellent work? Request for their expertise and wisdom gained from stumbling across the wrong paths of choice so you avoid the same mistakes.
• Conversely, see a facility that is struggling? Share your success stories. Help them avoid the pitfalls you've already conquered.
• Notice someone on social media who is positioned in a similar vein of expertise? Make for a combined and expanded presence. One of the earliest expressions of this concept that I've noticed is with Dr. Erson Religioso's Physio Answers and Physio Pics. As you can see, each participant is made better for their collaboration.
• Are you already involved in a larger group, association, club, or fellowship? How about create a physical therapy marketing combine? Use your strength in numbers and associated financial power to create a marketing campaign to identify, position, and advocate physical therapists as the practitioner of choice for all things related to health, pain, movement, performance, sports, and graceful aging. A health specialist that serves as an ever supportive friend who can give guidance for finding a live-worth-living; one of longevity, fulfillment, and well-being.

Competition? PLEASE... not with one another. We're a team; a unit of professionals. The "enemy" isn't each other. There are far more dangerous foes that we must face. The best thing we can do is to strengthen each other such that we as a whole are then stronger.

Just like this scene from "The Gladiator"

"LOCK YOUR SHIELDS. STAY AS ONE!" - Maximus, The Gladiator.

Marketing vs. Advertising in Rehab Business

There exists this interesting perception that much of the expression of a good marketing program is seen in good advertisement. I'd like to disagree with this.

The way I see it, marketing is creating demand.

Advertising is simply getting your name out there.

Creating Demand vs. Flashing a Name

IMHO, the key difference between true marketing and simply advertising is this facet of business. When marketing, a firm wishes to make their product/service/brand more desirable to the consumer. When advertising, a firm wishes to make their name/brand/product/service known to the consumer. The funny thing is, in order to market to a segment of consumers, knowledge of a brand is inherently part of the working. Advertisement tends to be more passive. However, a good marketing campaign utilizes advertisement in strategic manners that not only makes known a name/service, it also positions that firm in superior elements - much like a top shelf alcoholic spirit is positioned above the generic competitors.

Advertising is a projection; Marketing requires introspection.

In advertisement, firms tend to tell others what they think of themselves. This can be a total shot in the foot when the consumers think something ENTIRELY different than the firm's self-perception. Something recent that floated up of generally relative connection: Abercombie & Fitch.... #FAIL!

https://www.youtube.com/watch?v=O95DBxnXiSo

A good marketing approach thinks on what others think of you. Therefore, in this approach, marketing creates a discussion with a target segment; advertising is plain talking at said segment - and really, no one likes being talked at.

Marketing makes an emotional connection; Advertising creates an intellectual connection.

Laughter. Tears. Anger. Outrage. Love. Hate. These emotions are critical elements of the human experience. This are also the critical elements of what makes a good marketing campaign "good".

Remember that Old Spice commercial? The Man Your Man Could Smell Like? Sure, this was an ad, however, the entire campaign of Old Spice was shifting its market position from "the smell of grandpa" to "the man your man could smell like." It was so simple! It was so easy! It was so genius! This campaign combined humor, complete randomness, female desire, male jealousy, and amazing film-works which made Old Spice relevant again.

Compare that to something on the extreme bland... something like this:

Or this.....

Seriously?! Does anyone really expect consumers to respond to stuff like this? Do you? I sure don't. In essence: Marketing "entertains"; "advertisement educates." Good marketing causes an entertainment factor (emotions), and, in the end buying into something is highly emotional - not always intellectual.

Marketing is a purposeful study of the market environment, the firms involved, the customers at hand, and the climate of the economy.

So how does this apply to the business of physical rehabilitation?

To answer this, we must keeping in mind that most people don't care about outcomes and care mostly about the experience at hand. How do we present ourselves to the market, as if we were on that retail shelf and better position ourselves in reference to competitors? A strategy from Proctor & Gamble comes to mind:

“Who am I?  What am I?  Why am I right for you?”

                          - Questions every P&G package MUST answer.

So then, what can/does physical rehabilitation (and wellness) provide? The following comes to my mind:

• Pain relief and physical comfort
• Enhanced mobility of joint, muscles, and movement
• Solutions for recovering from injury and illness
• It addresses pre/post surgery considerations
• It can help where drugs (pharmaceuticals) have failed
• A present friend to help during your time of need; restoring your ability for life
• Expertise in health, fitness, and longevity of well-being

Not good enough? CORRECT! We must segment descriptions of service strategically:

• For seniors that wish to avoid nursing homes and hospitals, we are the preventists - experts in helping you keep out of the hospital and rehabilitation facilities.
• For the elite athletes, we are specialists of human performance, strength & conditioning, and recovery from injury.
• To the third-party-payers, we are the most cost-efficient, time-efficient, practitioner of choice who can bring people back to their livelihoods and prevent them from needing recurrent care.
• To individuals with chronic pain, we are compassionate clinician who will spend the time you need to deal with the stressors, triggers, and causation factors that have made for a life of discomfort.
• To those who are generally healthy, well, and active - we are providers of  well deserved comfort; a luxury service to pamper to the physical, the mental, and perhaps even the spiritual.

I hope that this post has been helpful in creating sparks of business solutions for your rehab marketing needs. All too often, the healthcare industry is too obsessed with the outcome of the service and not the experience of the service. Additionally, the industry is far too inclined to talk at our customers rather than talk with them. Making an emotional connection during a highly emotional experience (being cared for in healthcare) is a terribly important need. We should position ourselves as serving those in need rather than making patients taken as situational victims.

When the public at large views physical rehabilitation services as a highly desirable, accessible, and favorable enrichment to their life's experience - we would have met success in the marketplace.

Make demand. Fill the demand. Scope for change. Plan for the future.

Acute Care: Preparing Students for Direct Access (Part 4)

Continued from Acute Care: Preparing Students for Direct Access (Part 3)

Alright! We're at the conclusion to this blog series on Acute Care! Here are the results of the last three case studies:

Case #6: To Move or Not To Move...

As mentioned many times, there is a definitive culture of stigma - fear - uncertainty - and/or anxiety in regards to intensive care. BUT! I always ask, "what bad may come if I do NOT see the patient?" In this case, my answers are these:

• Yes. I move the patient.
• Yes. I will attempt to mobilize this patient out of bed per his response to exertion.
• Yes. The risk is worth it. The hazard of this patient further declining in musculoskeletal function with a decreased lung capacity is far worse than should this patient (once again) de-saturate to critical levels of oxygen.
• And, what IF this patient crashes into the 70's? We've already been here. Worst case scenario is that the medical team must now pursue more aggressive oxygenation; the same place they just came from. Albert Einstein is famed for saying that "Insanity is doing the same thing over and over again and expecting different results." If we wish for the patient to return to health, he needs interventions other than bed rest and supplemental oxygen.
• The discussion with the RCP & RN should include mentioning the risks and concerns of prolonged best rest. It should also include the above mentioned expectations of status quo versus active intervention. This discussion would also benefit from assurance that should the patient respond poorly to exertion, that such discovered limits would be expected & respected. Much of the time fear of change drives decision making more than goal of outcomes; every discussion with the above in mind for this setting has always lead to agreeability on all sides for mobilizing patients in the unit.

Ultimately for this patient, he was muscularly quite strong given two weeks of bed rest. He was able to transfer to a chair at moderate hand-held-assistance and was also able to participate in airway clearance, diaphragmatic breath, breath sequencing, and some gentle therapeutic exercise of the UE, LE, and trunk control. His saturation (surprise surprise) moved from the high 80's/low 90's clear into the mid-90's after 10 minutes. We were even able to wean off from 10L to 6L without any decline in oxygen saturation.

My vote on this one: TO MOVE!

Case #7: ICU, Ventilated trauma patient

Similar to the above case, the rationale I saw for this patient was fairly straight forward: if the patient doesn't maintain his physical capacity, he will lose it. At this point, the "only" barrier to function is really the physiological function of the lungs due to the trauma sustained. The patient was following commands and appropriate in mentation - I saw no danger and could gather no valid reason NOT to mobilize this patient. While the nurse expressed her nervousness regarding moving a ventilated patient, she respected my expertise and had confidence that I would not cause harm to the patient after a detailed explanation of my evaluation plan. I requested that she be present in the room as a second pair of eyes & hands to manage lines - and - off we went. The patient was able to stand, step, transfer, work on balance strategies for UE, LE, and trunk. He wrote on a piece of paper how thankful he was to be out of bed. Imagine the disservice of NOT having this patient be active during this state when all other systems are perfectly functional and safe!

I think there needs to be a cultural re-working of the ICU. In my opinion, the ICU is literally the SAFEST place a patient can be while staying in a hospital. Compared to other units, there is far more frequent and closer attention by the medical team than in any other unit - this includes the technological monitoring of patient status. Anecdotally, I can attest that the majority of the unanticipated events that befall rehab staff  during patient care tends to occur in their encounters outside of the ICU, where the monitoring is not as detailed.

I feel that the lesson of these first two cases in the ICU is that there must be a legitimate reason NOT to engage the patient in physical activity for physical therapists to defer evaluation and treatment. Otherwise, we are simply practicing Einsteinian insanity.

Case #8: Lumbar Disc Protrusion > 5mm; SURGERY?!
For this patient, I had a quick conversation with the nurse regarding MDT and the evidence behind early intervention for low back pain by physical therapists. About two minutes later, I was in the room introducing myself to the patient. I spent significant time educating the patient regarding the biomechanics of the spine, pain science, and expectations of the evaluation should the patient choose to proceed.

The patient expressed that he really did not want to have surgery. I explained that it is quite possible for us to avoid it should we be successful in reducing pain and restoring function. I started this patient with extension in lying on pillows then eventually moved onto full extensions while prone. Copious education and ice was to follow; the nurses were EXTREMELY helpful in reminding the patient not to position in spinal flexion as well as to encourage icing during the overnight short stay.

The next morning, a colleague of mine followed up with extensions in standing and the patient was able to ambulate pain free (minus a mild central soreness) as well as perform two flights of stairs. Surgery PREVENTED (at least for the moment) - the burden for a health system then would be to make sure this patient followed up with an outpatient physical therapist. Nevertheless, the lesson here is that even if imaging highly suggests the need for surgery, imaging is still imaging - the patient's response is what guides the direction of care.

Case #9: ATV Crash, Arm in two pieces?

Before we get anywhere: ALWAYS be your patient's #1 advocate! When patients start to complain that something doesn't quite feel right and you've screened out secondary gain, start looking deeper! Further investigation of the shoulder complex would have revealed that the patient was able to rotate the proximal humerus INDEPENDENT of the rest of his upper extremities.

Do NOT recommend this patient to be sent home. A closed reduction needs to REDUCE the fracture into one more-or-less "functional" piece; this patient felt like his arm was hanging out by itself - apart from his shoulder joint. If you feel the rotator cuff muscles shorten AND feel the greater tuberosity of the humerus move AND appreciated ZERO movement distal from the fracture site... the fracture was NOT reduced.

The orthopedic surgeon was paged and informed. He expressed much gratitude and after surgery, stated that this fracture site was SO clean that it was as if a laser cut the bone in two - reduction was impossible. The humerus was openly reduced and pinned. After the surgery, the patient was exuberantly thankful that someone intervened on his behalf. At first, the physician, nurse practitioner, and floor nurse were all trying to pass off the closed reduction as stable and good for home. The job of the physical therapist isn't necessarily to go with the flow - the job is to advocate for the patient's best interest.

Some closing thoughts:

I hope this blog series demonstrates the intensity, the breadth of scope, the situational awareness, and some of the political/communicative savvy required to be a consummate clinician in the acute care setting. These case studies were but a snapshot of some of my experiences and some of my colleagues experiences which is a DAILY part of acute care physical therapy.

Dr. Kyle Ridgeway expressed his concerns that should the profession truly move into an unrestricted direct access environment, the only realistic way for graduates to be able to recognize such complex and intense medical situations is through the exposure and training gleaned from the acute hospital environment. How else would one recognize a hypertensive crisis? How else can a graduate gather a sufficient auditory sample of auscultations to identify an S3 heart sound? I think its fairly clear that an acute care rotation should be a mandatory part of the #DPTstudent academic experience. Surely, we need to change the model of education for the acute care setting, both for the student and for the clinical instructor. I feel that acute care, with the medical complexities and instabilities involved, requires a graded exposure. I mentioned in PT TV Episode 12 that it should be much like a martial arts experience in training. Students start out as a white belt and are exposed to the simpler and less unstable situations. The content is then made more complex and intense over time. Also, much like martial arts, there is typically one teacher with several students. This is a prudent model for the acute care setting as schools can logistically operate for greater numbers of students per site, and, it would allow students to develop collaborative skill sets. Besides, so many other healthcare professions are ALREADY operating in this manner and have demonstrated much success. We should move forward as well.

In closing, I hope that this series has inspired some students to request and seek out acute care rotations. I can tell you from my personal experience, the acute care internship was the iron that sharpened the blade of my clinical judgment to its finest point as a new graduate.