The Profession's Path

[Barrett Dorko]

It’s been a quiet week in Cuyahoga Falls…

I haven’t typed those words in a while. For several years I wrote a column, journal entry, diatribe, description of travel or semi-true story that came out roughly once each week, and they all began this way. The line of course is a corruption of one invented by Garrison Keillor.

It was a blog before such things existed.

In the interim I began to embrace brevity and thought Range of Motion would satisfy my desire to speak briefly and with a harder edge. It has, and traffic to the spot has grown steadily. But I found that too often I wasn’t being insightful; I was just bellyaching.

I want to stop that. No, not the bellyaching (an interesting term given what we now know about pain) – I just want to stop writing about it there. Instead, I’ll do it here.

I’m about to begin my fourth year as a full-time contract therapist and have now worked in 14 different venues. I’ve seen a few things, and I want to write about that separately.

This will be the place.

If you’ve an observation about the realities of clinical life you’d like to share, vent or ask about in light of our profession’s path toward, well, I don’t know what, bring it here.

More soon.

[Barrett Dorko]

I think it begins with the concept of fungibility. Click on that.

You’ll find that if therapy is nothing more than a commodity, it really doesn’t matter which of the licensed personnel provide it as long as they bill for it. If the people in some distant city that actually own and run the company worry about this I’ve seen no indication.

Everything follows from this.

[Frédéric]

GPs' certainly think our profession has this fungibility «quality».

I, considering the current state of the buisness of PT, am inclined to think the same way, sadly.

[zimney3pt]

Is it safe to say that all health care has some form of fungibility to it.

IMHO the general public sees health care as having fungibility or the individual person may be a raving fan for some form of therapy (proven effective or not). Usually it is one or the other.

It is a horrible struggle to change the masses. How do you change those that see no difference that one might exists when we have no measurement tool. And how do you change someone "culted" to believe something even though science says otherwise?

[Barrett Dorko]

I agree with both of you.

These are the issues that lie at the heart of present day practice and reversing the attitudes that have grown more pervasive may never be possible. The effort certainly makes for an interesting time however.

I listened to an interview about the business of Hip Hop this morning. One of the originators (about '78) left the industry saying, "It's no longer about the music, it's about getting paid. I didn't leave Hip Hop - it left me."

[Barrett Dorko]

The word fungible stays with me. If in fact this commodity (customarily something from the earth) we call therapy is just that, we shouldn't complain and neither should our patients.

But there's copper mined legally and there's copper stolen from buildings, some still occupied. There are diamonds and then there are blood diamonds.

Are these all worth the same?

[zimney3pt]

It would depend on the measurement tool for value to determine the worth. There is no universal "currency" in therapy to determine worth.

[Jon Newman]

Maybe modalities are fungible but therapists are not. I'm of the opinion that health care, in general, is not a commodity.

[nari]

IMHO the general public sees health care as having fungibility or the individual person may be a raving fan for some form of therapy (proven effective or not). Usually it is one or the other.

GPs' certainly think our profession has this fungibility «quality».

I also agree with these statements from Bas and Kory. There are some GPs who do discern quality care amongst physiotherapists and select one over the others, but that is sometimes just a hand in glove setup.

More importantly, in Oz where PT autonomy is nationwide, it is the clients/patients we need to educate in some way and that is extremely difficult too.

In the situation where PTs use modalities, plus education, plus exercise, plus whatever else is trendy, there is no hope of educating them in defungibilisation (sic).

Nari

[Diane]

Maybe we can call this place the defungification zone. I worry about our defungifiability too.

[Barrett Dorko]

Brick walls are there for a reason…to give us a chance to show how badly we want something.

Dale Carnegie

In post #22 of this thread I likened therapy to a fortress and listed the walls we face:

1) A wall called Traditionally Established Notions
This contains powerful and ancient memes (well, 75 years old or so) like “effort relieves pain,” "effort is essential for recovery,” strength and posture are related,” “posture and pain are related,” “pain is generated peripherally” etc. You know the drill.

2) A wall called Clinical Prediction Rules

3) A wall called Evidence Based Practice

4) A wall called Financial Considerations

Look at the thread for more about each of these walls. Here I’d like to write more about what life is like inside the fortress.

Each day I enter through the fortress gates. There I’ve learned to leave my voice.

Soon, a description of the courtyard.

[Diane]

Fort PT.

[nari]

Excellent, Diane!

Where's the moat to keep out unwanted neuroscience invaders?

Nari

[Barrett Dorko]

In the courtyard I’ve found that the therapists are often hard to tell apart. They all dress pretty much alike (nothing fancy) while I stand out like a giant flower in a wheat field. (See this)

They practice similarly too. Many are of the glad-handing, goodwill, raucous juvenile humor-laughing-cheerleading school of thought. This lasts until a patient “moves wrong” or doesn’t follow the amazingly strict procedures that are supposed to be safer than what ordinary people do. Plopping into a chair is something I’ve done countless times. Man, would I be in trouble (Well, I’m in trouble anyway, but for reasons far more profound than that).

Mainly what I see is a willingness to engage personally with anyone else present that far exceeds anything I would feel comfortable with.

[Diane]

Originally Posted by nari

Excellent, Diane!

Where's the moat to keep out unwanted neuroscience invaders?

Nari

I made a new slide of Fort PT.
And I had a lot of fun (too much fun probably) with a new powerpoint program that can crop out backgrounds. So, check out the new fort complete with moat and crocs guarding it. I could put a harpy in there too, probably.

[Diane]

Harpies and a scared mean dog.

[zimney3pt]

And I had a lot of fun (too much fun probably)

If only more people could have too much fun, life would be a little better for most.

[nari]

I like the crocodiles addition.

[Jon Newman]

So is there an adjacent possible buliding? One made of bricks?

[Diane]

Does your brick building have a purpose? Barn? Toilet?

[Jon Newman]

What we have here is a description of PT as it exists versus a description of what it could be. Your picture features a wooden fortress. I'm curious what a possible building might look like like in terms of foundations and walls. I'm suggesting brick at a building material based on the Carnegie quote and to prevent the big bad wolf from huffing and puffing it down.

One suggestion I have is not to let shruggies guard the entrance.

[Barrett Dorko]

It’s a good question. Expansion toward the kind of imaginative and defendable thought many here think the profession might embrace can only proceed if the occupied room has been well-examined and declared fit. This is all detailed in Johnson’s book which I tried to write about here. I lost some steam, I guess.

Anyway, your question brings to mind my sense of this courtyard I’m allowed in each day. I know I stand out if only because of my dress, size and age, but other than that it’s as if I’m wearing some sort of cloak of invisibility. Quiet but intense with patients, I rarely speak to anyone else. Despite our proximity we have very little in common.

If there’s an “adjacent possible” in the form of a bricked space none of those working for “the man” in this place see it or sense that they are allowed to move toward it. I can though.

They are indentured servants.

I’m a migrant worker.

[Jon Newman]

Thanks for that thread reference. I didn't have the time to search for the thread at the time I used the phrase "adjacent possible." I've now included a link in that post.

[Diane]

How about something underground?

Or out on a ledge?

[Barrett Dorko]

Unless someone beats me to it I intend to draw the picture described below, scan it and then post it here.

Draw a triangle, shaped like a pyramid. Add dividing lines horizontally just beneath the top and again two thirds of the way down. To the right of the lowest level write “losers,” above that, “clueless” and next to the apex, “sociopaths.” Left of the pyramid write, “Corporate Hierarchy.”

From post 36 of Punch Potential

Since I'm not actually employed by the corporations running the fortress I'm not in there.

I've been asked to hire on several times of course. The problem is that then I'd have to take a starting position on the lowest level.

[Jon Newman]

On Philsophy Bites this week, Philip Pettit talks about group agency. It was a good conversation.

[Diane]

Originally Posted by Barrett Dorko

Unless someone beats me to it I intend to draw the picture described below, scan it and then post it here.

Something like this?

[Jon Newman]

The original source for that is Hugh Macleod

[Barrett Dorko]

Perfect. Thanks for the link Jon. I'd lost it somehow and don't want anyone to think I came up with this on my own.

I'm still waiting for someone to post this near their desk.

I don't have to. I don't have a desk.

[Jon Newman]

No worries. You referenced him in your post 36. He calls such things "cube grenades." I think he'd support people creating make shift ones but for the aesthetic minded, he does offer prints. I noticed that that particular print is particularly popular. It's offered in a variety of colors, some of which are sold out.

[Barrett Dorko]

The space within the fortress resembles nothing so much as a collection of fiefdoms.

That word is defined as “the domain of a feudal lord; something over which one dominant person or group exercises control.”

As a migrant worker I’ve learned to become immediately watchful for those bits of behavior that will please the overseer. In one place it was a willingness to work hard. Another placed great emphasis on social networking with other staff. Another only wanted the productivity standard met.

I do well with the first, I suck at the second and the third, well, while I certainly understand the need for this, I noted that I could have been a serial killer as long as I was billing over 95% of my time in the facility for this. No one cared what I was or wasn’t doing.

I’ve yet to find a department (read fiefdom) that placed any sort of premium on actual practice that made sense or could be rationally defended.

[Barrett Dorko]

Around me I always hear, “Move your feet like this” or “Sit down like this” or “Turn like this” blah, blah blah. Basically, people are being told how to do things they’ve done for about 80 years. I doubt most of it is necessary, but the therapist has to come up with something in order to fill the time. Without knowing it, they are using the logical fallacy, The Argument From Authority.

The argument from authority should come from someone who seems be an actual authority, or, at least, looks like one.

Perhaps this is the strategy behind talking to patients as if they were mildly retarded five-year-olds.

[Barrett Dorko]

I just re-read his thread. Nothing's changed since I started it. Maybe after I'm de...oh, wait.

“I think you have butterfingers.”

I heard this said to a man I’ve grown to like the past few weeks. Always glad to see me and committed to hard work and attention to his physical therapist, he never fails to remind me that in the midst of the craziness that passes for therapy these days a patient will save me if only I pay attention.

The comment was made rather off-handedly by one of the other therapists after some clothes pins hit the floor. She followed it with a laugh. The patient looks at me and my heart aches. He has Parkinson’s, not “butterfingers.”

In this place my boss spends most of each day staring at a computer screen. She’s buying and selling what she calls therapy, and the people such as myself who deliver it are little more than pieces of a puzzle she must solve to her boss’ satisfaction.


It’s got to be a tough job and I should feel sorry for her.

Well, I do and I don't.

[Diane]

Originally Posted by Barrett Dorko

In this place my boss spends most of each day staring at a computer screen. She’s buying and selling what she calls therapy, and the people such as myself who deliver it are little more than pieces of a puzzle she must solve to her boss’ satisfaction.


It’s got to be a tough job and I should feel sorry for her.

Well, I do and I don't.

I feel bad for her in that she is burning up her retinas with a computer screen and not learning anything for the sacrifice.

[Barrett Dorko]

I'd feel differently if the supervisor hearing a thoughtless comment like this would take the offending (sive) therapist aside and spoke with them.

She wouldn't ever do this because she doesn't actually understand what therapy is supposed to be. I'm not kidding.

I'd like to do this but, being a migrant worker and all, I hesitate to allow the other therapist an opportunity to make my life a living hell. I know she's fully capable of that.

Interesting clinical life I've got, don't you think?

[Diane]

Interesting country you live in. I think the two situations reflect each other. Speaking as a foreigner I mean.

[Barrett Dorko]

Since January of ’08 I’ve practiced in over a dozen venues. Each offered me an opportunity to observe a different supervisor and find a way of working beneath their gaze. Whether they knew it or not, I was also watching them.

Without exception, it seemed that they were overwhelmed by the work. Most were either occupational or physical therapy assistants who had been given the responsibility of “overseeing” the practice of someone more qualified. The conflict created is often palpable.

Aside from that, the pressure exerted by what I refer to as “the suits” from the parent company was constant, extreme and unfathomable. Their dissatisfaction with the numbers provided them (read money provided them) was evident in the streams of emails and calls that came in, the visits from regional supervisors and the long hours required of the person who was supposed to be watching me.

I had a boss who said “I waken each night crying” and many others who’d grown silent and sullen – staring at the computer screen for hours each day and never looking up. Once I watched as my boss was escorted from the building by a security guard. Our productivity had dropped too low and he wanted some new wheelchairs. I'm not kidding.

In one building I was in the tiny staff room with a colleague when the super walked in, gazed at the assignment board for a long time, made some notes and walked out. The other staff member looked at me and said, “It’s like we don’t exist.”

I couldn’t disagree.

More soon.

[Barrett Dorko]

There seems to be no escape. One day I watched as two prospective employees showed up for what amounted to an interview. Both were dressed as if going to work in the yard. One of them replaced me a few weeks later.

It wasn’t as if the supervisor had a choice. She was commanded to hire someone cheaper than me as soon as possible.

As many here know, I think that therapy is about context and relationship. The room in which we must practice is often loud and the talk has no earthly relation to therapy itself.

I’ve yet to work in a place where the supervisor or the supervisor’s vision of therapy dominated the department in any way whatsoever. Actually, if any had an opinion they could articulate it was wrung from them (or driven back into them) sometime before I got there.

The therapy departments are universally dominated by the therapist who makes the most noise.

I’m not kidding.

[Diane]

Would sure be nice if we could go find some unpopulated spot on the planet and make a new country where we could practice the way we want.

[tonyf315]

Originally Posted by Diane

Would sure be nice if we could go find some unpopulated spot on the planet and make a new country where we could practice the way we want.

My current job is pretty comfy in the freedom I have but I'm discovering even still that there's still pressure and scheming from "suits" to bill as much as possible to make as much $$$ as possible. I just hate all the financial BS in the health care field. If my own $ needs were met I'd do PT for free as a volunteer service.


I pretty much HAVE to keep working as a full time PT working for someone else for at least 6 more years but after that have more options (part time, change professions, open own clinic or even keep at it if I want). Anyone up for making up a "SomaSimpleSurvivalGuide" to staying in the profession long term?

[Diane]

Always make the point of what you do the interaction you have with the patient in front of you. And enjoy your interaction. Really, everything else is context, to be "managed". The patient is who needs to be set free (-er). And no matter how tame you have to act on the outside, cherish the wild on the inside.

[Luckbox]

I had a boss who said “I waken each night crying” and many others who’d grown silent and sullen – staring at the computer screen for hours each day and never looking up. Once I watched as my boss was escorted from the building by a security guard. Our productivity had dropped too low and he wanted some new wheelchairs. I'm not kidding.

Reminds me of One Flew Over The Cuckoo's Nest

I guess you would be McMurphy? Regardless, that's not a healthy environment....For anyone.

Would sure be nice if we could go find some unpopulated spot on the planet and make a new country where we could practice the way we want.

Diane, what good would that do? What's holding you back from having the practice of your dreams?

"Hell is the knowledge of opportunity lost; the place where the man I am comes face to face with the man I maight have been"
--Anonymous

[Diane]

Originally Posted by Luckbox

Diane, what good would that do? What's holding you back from having the practice of your dreams?

And what would ever make you think that is not exactly as I have done, and am doing, every day of my existence?
As for what good it would do, I can't imagine anything better to do. Really.

[Luckbox]

Would sure be nice if we could go find some unpopulated spot on the planet and make a new country where we could practice the way we want.

and

And what would ever make you think that is not exactly as I have done, and am doing, every day of my existence?

I must have mis interpreted your original quote. The two statements appeared to me, contradictory.

If you're doing exactly as you have done, are doing..etc. Why are you wanting to make a new country where we could practice the way we want.?

Just an observation, that's all.

[John W]

I think it's an illusion, if not delusional, to think that anyone could open "the practice of their dreams" that is also consistent with current knowledge, ethical and accessible to all those who need or would benefit from the care provided.

That last point is critical. There are not nearly enough Diane's around who have the wherewithal, experience and circumstances to establish practices that allow them to live the professional life of their dreams in order to meet the needs of the masses of people who would benefit from the way someone like Diane treats.

That's the other side of the equation that many fail to see- perhaps because it's more about them than the patients they treat.

We need a societal solution, not more herculean efforts, luck or geographic idiosyncrasies of a few isolated individual practitioners.

For every Diane Jacobs there's at least one Barrett Dorko. This should not be.

[Barrett Dorko]

Luckbox,

I think you need to read the book again, or maybe you're thinking of something else.

McMurphy was a sociopathic con man; someone with no actual understanding of mental health provision and bent on revenge, self-gratification and screwball comments.

That's not me.

[Barrett Dorko]

This happened once before after I’d been working in a place for six weeks and yesterday it happened again after six weeks on the job.

For some reason I always choose someone in the department to be wary of. Perhaps “wary” isn’t the right word. I seek to satisfy them with my movement and behavior. I know when they’re around and this serves to motivate me. This person reports to those higher up the chain of command in the company and my reputation will determine whether or not I’m chosen for another job in the future. After all, I have some competition.

Yesterday the question from this “chosen one” hit me especially hard. It was asked of me as if she were a clerk at the DMV and I was just another of the hundreds she needed information from. But this is a small department and I’m the only PT there. My productivity fuels the fires of corporate finances and pays her salary. She’s been my boss all this time.

Her question?

“What’s your name?”

[zimney3pt]

Interesting article by DANIELLE OFRI, M.D in the New York Times.

The Provider Will See You Now.