The Bus to Mediocre-ville

Jamie Lowy is an experienced physical therapist that has helped me tremendously. I value his perspective and willingness to speak up about a BIG issue in our profession that I've been guilty of - Mediocrity.

Here's the audio version if you'd rather listen:

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Disclaimer: My hope is that I offend a few off you, get some of you to think differently, and perhaps influence others to jump on this band wagon and help re-shape the direction of our profession.

A few months back I posted on Twitter one of my perspectives related to some earlier conversations with some fellow PTs (tip the hat to Todd Davenport, Sarah Haag, Karen Litzy, Sandy Hilton, Dustin Jones, Jason Falvey, Richard Severin, and Jerry Durham for keeping the conversation going).

What I posted was "The bane of the PT profession is not the health care system, but Mediocrity".

What do I mean by 'mediocrity'? Quite simply that we've traded the aspects of providing meaningful treatments to our patients in favor of being viewed as 'good employees'.
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A show of hands, how many of you listening right now can say that that in your present work situation, you are NOT judged by your productivity metrics?

​There may be a few of you with your hands in the air, and I imagine that you are the ones that have already started a journey on an alternate pathway. You might be the one taking a leap of faith and starting a cash-based business freed up from bonds of third party payers. Or perhaps you work on a per diem basis in which you see a few patients here and there, perhaps for a couple of different SNFs or home health agencies. But since you are not a benefited employee, you may think you are exempt from the influence of productivity metrics.

Think again. As rehab director for one of the larger national HH agencies, I can tell you we monitor that closely. If full time clinicians are slow, we don't give you work. However, if you're a real hustler, we notice and look to give you more work, since you're such a productive work horse. So for a manager, with budget goals based on how many new patients I can squeeze my field clinicians to bang out in a week or a month, we judge you primarily on your productivity.​

The bane of the PT profession is not the health care system, but Mediocrity. -@JPTLowy

By now you may be asking yourself, "So what? That just means I'm a good employee, right?"

​Yes it does!  Congratulations, you're on the bus! The bus to Mediocre-ville.

Think about it. If your reward for being a good employee based on your metrics is a better paycheck...What's your real motivation for showing up to work everyday?

Is it really about the patient?  Or is it now about having a job that pays the bills, the student loans, the vacations, the new car?

Before I digress along this pathway, I want to give you a better example of what I mean. As a manager, I used to supervise a PT by the name of . . . Let's just call him Joe. Now Joe is a good guy, he's friendly and respectful to his co-workers and his patients. He gets his schedule in the morning, gets everyone set up, then goes about his day. Moreover, Joe is a wiz on the EMR system and completes all his documentation either during the visit itself or by the end of the day.  Joe is a very good employee. One thing that does not stand out so much is that Joe's patients, while they do seem to get better, all seem to get similar treatment plans with similar interventions and goals, and similar ordered number of visits. Another thing that starts to stand out is that while most of Joe's patients do make some improvements, they're usually just enough to advance to the next level of function on our OASIS data sets at discharge. So the outcomes also seem to show that Joe is doing good clinical work. Patient surveys likewise describe Joe as respectful, polite, and generally a nice guy.

So why am I being so judgmental towards Joe? Because more than any other clinician, his patients seem to also come back on service a month or two later, or they end up returning to the hospital not long after services were initiated. Now we know that patients with chronic diseases are a complicated group of folks to manage. It's highly probable that some of the patients that Joe is seeing are very fragile and may have so many things going wrong at once, that a hospital re-admission is inevitable.

But I'm not really talking about those folks. I'm talking about the one's that are high risk for injury due to falls or perhaps pressure sores from just not moving enough. These folks get really basic exercises and interventions because perhaps Joe doesn't think they can tolerate more, OR, because Joe is so intent on getting all his documentation done timely, he does not take the time to fully assess all the patient's potential risk factors. He's choosing productivity and keeping the bosses happy, and not thinking about what's really best for the patient. This is the mediocrity that I'm ranting about, and I know that there are many of you out there who work like Joe. 

And I'm telling you now, stop killing our profession, and stop hurting your patients!!!!! 

So now that I've come off my soap box for a moment, what's my solution? It's easy to talk about change and not do anything else other than go on a social media rant. First, be realistic about your own expectations for change. When you ask your patients to change a lifestyle habit, such as sitting in the recliner all day, do you have them walk 2-3 miles that first session, or set reasonable goals for them to accomplish and build on over time?

Start with what's in your immediate control. You can choose to spend a few more minutes of time with your patient in order to establish the goals that are important to them, and use your assessment tools to figure out the best pathway. Don't just use a standardized test like a TUG, DGI, or SPPB and have the goal to simply increase the score. It would be good to look at the standardized test to find out how much progress indicates clinical significance.

Consider WHY that test is relevant to your patient in terms of function and safety. If your patient has issues with incontinence at night time because they cannot ambulate to the restroom quickly enough, why not use the results of your TUG as the basis to work on improving a sit to stand transfer, gait speed and turning safely in order to satisfy the patient's need to get to bathroom without having an accident or falling because he/she was in such a rush. It really is that simple.

My other suggestion is to take a moment to consider this question: What would your PT student self think of you today just settling for "good enough"? When you saw the world through those eager eyes, did you envision yourself just doing enough to get by, or did you have visions of taking your patients further and farther than they themselves could have ever thought possible? And when did you sell or trade your ideals for mediocrity? Was it to meet the ever growing demands for productivity or even dealing with empathy burnout? The thing of it is, we may all be susceptible to stress and and the mental/emotional/physical wear of taking care of people who are recovering from illness and injury. Perhaps it's time for a change of work setting like outpatient to home health, or to find a clinical mentor (some may be folks on social media) who can help you develop some strategies to break out of mediocre practice habits and be the PT or PTA that your patients deserve. Keep reading the research and stay skeptical of any therapy intervention or system that promises to fix all your patients.

And perhaps most importantly, and I owe this bit of wisdom the the aforementioned Sarah Haag, be focused on the shit we can change, not the shit we can't.

You're not going to cure your patient's Parkinson's, but you can make them move better, feel, better, and live better. 

Think on that, and get yourself back on the pathway that lead away from mediocre-ville, not the one that leads to it.
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-Jamie Lowy, MSPT