Navigating Challenges in Physical Therapy Practice

Alan Fredendall // #LeadershipThursday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses how to approach helping patients who don't want help

Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

INTRODUCTIONGood morning, everybody. Welcome to the PT on Ice Daily Show. My name is Alan, happy to be your host today. I currently have the pleasure of serving as our Chief Operating Officer here at ICE and a faculty member in our Practice Management in Fitness Athlete Divisions. It is Thursday. We talk all things leadership, business ownership, practice management. Leadership Thursday also means it is Gut Check Thursday. It is the 4th of July, so we have a gnarly hero workout planned for you all this week. The workout, I just finished it. It is called Glenn. Glenn is named for former U.S. Navy SEAL and CIA operator Glenn Doherty. He was killed in the attack on the U.S. Embassy in Benghazi back in 2012. And so this is a very long Very kind of moderate intensity piece with a bunch of different stuff thrown together. So the workout starts with 30 clean and jerks Recommended weight there for guys 135 95 for ladies that should be a weight that you can hit for smooth consistent singles getting done somewhere between maybe three to five minutes out the door for a mile run a 2k row for guys 1600 meter row for ladies or a 4k bike for guys 3200 meter bike for ladies After that cardio piece, you're back in the door for 10 rope climbs. That also looking to be done in maybe 3-5 minutes, a rope climb every 15-20 seconds or so. If you can't rope climb, we have some scaled options for 20 pull to stands. or 30 strict pull-ups, whether that's with actual strict pull-ups or with a band, but some sort of challenging vertical pulling motion that's going to get you done in three to five minutes. Back out the door, repeat that mile or that row or that bike, and then come in the door one final time for the coup de grace, 100 burpees. For a lot of folks, this is going to take maybe 45 to 60 minutes. It's going to depend obviously a lot on your mile run time, your ability to cycle that barbell, and your ability to motor through, more importantly, those 100 burpees at the end. Treat this workout just like a run where you're maybe aiming to decrease your split time, start slow, build up speed. The worst thing you can do is race through those clean and jerks in that first run. and then crash into a wall on those rope climbs that second mile and definitely you can hit the wall if you're not careful on those burpees and turn that into a really miserable end to the workout. So just pace yourself, go slow, get faster kind of mindset. So that's Gut Check Thursday. Today is 4th of July. We're kind of talking about a topic related to the 4th of July in the United States of America. The American mindset, the cultural mindset that we can and we should and we have to save everybody, right? We have to be the world's police and the world's diplomat and inside of America as healthcare providers and physical therapists, we have to save every patient. So the title of today's topic is You Can't Save Everyone. I don't want this to be a pessimistic episode where you leave feeling discouraged and like you should give up. I hope you actually leave this episode feeling maybe a little bit more relaxed, a little bit more empowered in your practice. This topic came from a question we had from a student at the Fitness Athlete Live Summit a couple weeks ago. So, on Sunday mornings of Fitness Athlete Live, we take Q&A. We get some really good questions, we get some really good discussion points. And a student named Trevor, Trevor Purcell, who's nearby me here in Clarkston, Michigan, had a question. He said, hey man, you know, you're doing the thing, you're using the symptom behavior model, you're finding out what's wrong with people. you're giving them manual therapy and exercise that's reducing their symptoms, you're trying to get them into loading and higher intensity exercise, you're figuring out what music they like, you're pumping the jams, you're trying to high five, like you're bringing it, right? In every aspect of your practice, the clinical reasoning, the manual therapy, the exercise, the personable skills, the DJ skills, you are bringing the heat And that person is just straight up not feeling it. Like how, what do you do, how do we get those people to get more serious, to get them to maybe transition to doing a maintenance program with us at the clinic, or maybe transitioning to a fitness program out in the community with a resource that you may have associated with your clinic. Like what do we do with those people who seem to, no matter what, no matter what value we're showing them, just really don't seem interested in picking up what we're putting down. And so my answer back to Trevor was be careful, right? Be careful that we don't try to save everybody, even people who don't want to be saved. And so today I want to talk about that. I want to unpack that answer in a little bit more detail. I want to talk about the numbers behind the physical therapy profession and how many people were expected to help. I want to talk about what I call the lie, how we learn to help people in physical therapy school. And then I want to finish and talk a little bit about the reality of what it actually looks like in practice to work with those people and some tips and tricks for that. THE NUMBERS So let's start with the numbers. Numbers are boring. As Jeff Moore, our CEO, would say, data doesn't change behavior, but I'm a firm believer that even though data doesn't directly change behavior, telling somebody they're going to die early if they don't lose weight or stop smoking or sleep better or exercise more, all that stuff, we know That just doesn't flip a switch in people and all of a sudden they change all of their less than optimal health behaviors. But that being said, even if data doesn't change behavior, I'm a big believer that data does inform decisions. And so knowing the data going into any situation can make us better prepared for that situation, even if it doesn't directly influence a decision in that situation. And so stepping back on a macroscopic level and looking at analysis of our profession, there are about 300,000 licensed physical therapists in the United States of America versus a population of 330 million Americans. So if we were to pair up one physical therapist with patients and say, this is your charge, this is your crop of people that you need to help every year, get moving, stay moving, stay with whatever fitness program they've been turned on to, you would need to help 1100 individual people per year. Now, the truth of that 300,000 is that those aren't all full-time practicing physical therapists. We have about 90,000 full-time physical therapists in outpatient. We have about 60,000 in acute care, skilled nursing, inpatient rehab, sort of the hospital side of the equation. and we have about 26,000 folks working in home health for a total of 176,000 full-time licensed practicing physical therapists. People getting up every day, putting on the uniform, and going out to man their post on the trench, right? So automatically that cuts our profession in about half. All the rest of those people are in academia, they are in management or ownership, they're no longer practicing, they are part-time, or even many of them are retired and they just want to keep their license because once you let it lapse, it's a lot harder to get it back than if you just keep it renewing. So that changes the equation a lot. That means every physical therapist now has to help about 1,900 patients, right? Almost double the amount of patients. And if we take a hypothetical scenario where you are an outpatient physical therapist, your productivity is maybe moderate. You see a patient every 45 minutes. You see about 12 patients a day, 60 patients a week. We know those are all highly unlikely to all be unique visits, each with a different patient, that a lot of those folks are coming maybe two to three times a week. And so if we assume that those folks are coming twice a week, then you're probably only interacting with 30 unique people or so per week, and then if the average plan of care is about 10 visits, or about five weeks of care, that we probably only interact with somewhere between 250 to maybe 500 unique patients per year, and that would be a very high volume productivity model. That would be a model where maybe you are seeing a patient every 15 minutes or so, or maybe even more. And so just thinking that statistically already the math doesn't add up, right? That puts us at about 20%. We're helping about 20% of the people we need to if our belief is that we should be helping and saving everybody with getting them moving, helping them stay moving, musculoskeletal rehab, performance, that sort of thing. It's not surprising to me that that number is exactly where physical therapy is at for utilization each year. Only about 20% of Americans seek the help of a physical therapist per year. So all things considered, we're at where we should be for the size of our profession. That if we wanted to reach more patients, we would somehow need to get even busier than we are, which I don't know how that would be possible. If you're only working with 500 people a year, seeing a patient every 15 minutes to see 1,900 people a year you would need to see 6 to 10 patients an hour you would have 3 to 5 minutes with each patient and so obviously that does not seem logistically possible and so the real truth is we either need more physical therapists or we just need to recognize not everybody needs the help of a physical therapist at any given time or wants the help of a physical therapist at any given time and that's okay. THE LIE OF ENTRY-LEVEL EDUCATION So moving away from the numbers and moving into the lie of why doesn't everybody need our help and why do we feel this disconnect between wanting to help everybody but maybe perceiving that not everybody is, again, picking up what we're putting down. We're bringing all the noise in the clinic and they're just not receiving it. In physical therapy school, we were shown a facade, right? We worked with a lot of paper patients, right? A lot of case studies and scenarios on a sheet of paper. We worked with a lot of mock patients who were usually our fellow classmates, our professors, or maybe paid actors who were likely just students in a different program at the college that we took PT school at. And the thing about these folks is that they always got better, right? We did an intervention, a manual therapy, or an exercise intervention, or both, or whatever. and those patients always got better. Not only did they get better, they were completely adherent with their home exercise program, and they miraculously restored their function, sometimes within minutes of care, right? And so the smack in the face is entering those clinical rotations and entering early practice and realizing, That's not how the majority of human beings respond to physical therapy treatment at all. And we get this buzzword that flies around social media as a result, imposter syndrome, right? I feel like I don't belong here. When in reality, I think imposter syndrome is this belief that we're not good enough and we have nothing to offer our patients and that we're not doing enough to save these people, right? If we could just shackle them down and force them to exercise, they would feel so much better And damn it, why don't they just do that? But in reality, what we're probably experiencing is this interaction of higher volume care than we were exposed to in school, right? I remember my mock exams being 90 minutes or two hours. I've never had that long for an eval in practice in my life. And we also had a lack of basic clinical reasoning coming out of school. and a lack of exercise prescription skills. So we're interacting in this high volume model where maybe we're not able to quickly figure out what's going on, correctly dose manual therapy and or exercise for that person to show them a symptom reduction, and also that they just tend to not get 100% symptom relief, even if we do nail it on the head. And so we leave the clinic every day feeling defeated, like we're not helping anybody, like we can't possibly help everybody, and then we come with questions like, What do you do when people just won't accept the treatment that we know is the best choice for them? THE REALITY OF PRACTICE And so that brings me to my final point, the reality, the reality of practice, that not every person needs or wants our services, especially in the span of an entire year. I think often of my own mother, who is a very unhealthy person, has been unhealthy her entire life, who is really a testament to the resilience of the human body, has never exercised, has never picked up a heavy thing, has never got her heart rate above baseline, who I don't think has ever eaten meat or anything that's not packaged or processed in a piece of paper or a piece of plastic, right, lives off Twinkies, and Ho-Ho's, and 7-Up, and lunch meat, and kind of the typical baby boomer diet of nuclear family processed food. Has been healthy her entire life, has done nothing about it, and this past December, having a string of three hospital admittances in about a month of being so sick that it was tough for even the doctors at the hospital to figure out what was wrong, having septic shock, having COVID, just really kind of decaying in a hospital bed. And me going down to that hospital, a two-way drive each way to get her some physical therapy, 10 to 15 minutes of movement, and seeing the kind of miraculous change that she made just doing 10 to 15 minutes of higher intensity exercise a day, right? Function restored, no longer needs a walker, no longer needs oxygen, standing on her own, back to kind of her baseline before she started to get sick and go in the hospital. And thinking that finally, by gosh, this is it. This is the light bulb moment where she's going to connect that the exercise she's doing is related to how much better she's feeling, how much more function she has, the realization that she can probably continue to live independently and she just has to keep doing this stuff. And then again, that lie, right? That getting smacked in the face moment of going back home and hearing, I don't want to keep doing that, I hate that, I'm never gonna do that again in my life unless I have to. And feeling that disappointment, right? Of gosh, why won't you let me save you? And finally, coming after a really bad failed intervention to say hey, you need to turn your life around, you could die, we don't have the time and money to continue to do this with you, I can't keep driving here four hours a day to make you do 15 minutes of exercise. And that moment of, oh, I don't want you to. I don't want to do this exercise stuff. I only did that because I had to. And that's really kind of what we hear a lot from our patients in the clinic, isn't it, right? We hear a lot of the reasons sometimes that they come to see us are extrinsically motivated. They have to come see us in order to get that image they want, in order to get an extension on that pain medication. maybe they're coming to see us so their spouse or their kids or their grandkids or their friends or whoever stops nagging them about going to get their elbow pain seen or their knee pain or figure out why you're falling. So a lot of times Patients can show up without the necessary intrinsic motivation on board that we know we need to see to really have a person make a significant lifestyle change. And understanding that real people don't behave like the fake patients we interacted with in physical therapy school. They don't always 100% get better all the time. They don't miraculously buy into our care. They aren't lifelong proponents of physical therapy just because we treated them once. That's not how real people behave. They have a number of different expectations, a number of different barriers, and a number of different motivation reasons to or to not come to physical therapy. I'm a big fan of the 90-10 rule. This is something I learned from our CEO Jeff Moore. Don't spend 90% of your time helping 10% of people, right? Do the opposite. Spend 10% of your time helping 90% of people because they have the motivation on board that you need to see, that they can make those changes we want to see them make, but they are also voicing and they are showing you and telling you that they want to make those changes. And now that's not to say that we abandon those other people, we abandon the 10%, but rather we reserve ourselves, right? We don't beat ourselves up that we haven't convinced a person who is maybe 85 years old, who has never exercised in their life, who has never eaten something that hasn't been processed, is not probably going to make a miraculous life change after coming to see us for physical therapy for just a couple visits. And so, letting yourself off the hook a little bit. The sooner you learn to recognize who those people are, again, you're not banning those people, you're not going to give them less care, you're not going to say, hey, you can't come here until your attitude turns around, but you're just a little bit more reserved. You're understanding that if you continue to dump a lot of energy and passion into a person who's not reciprocating it, it's unlikely that you're going to see that behavior miraculously change until something else changes in their life and there's no harm in that and there's no reason to feel bad about that because I would argue that you have cemented yourself as a resource in that person's life that if in the future they encounter another injury they're probably going to come see you which is great because it's better to come see PT 2.0 than PT 1.0 or surgery 0.0 or whatever, it's better for you to be the resource in their life for when that pain does pop back up. And if they are ready to make a change, they are ready to lose weight. get fitter, get stronger, stop falling, stop smoking, stop drinking, sleep better. Whatever might change in their life, once they get their own life figured out on their own time, they have you as a resource, and I think that's very, very, very important, and that's very, very, very noble and good work to be doing in your community, while you continue to pour the majority of your energy into the people who are reciprocating the things that you are trying to teach, the things you're trying to show, and the lifestyles we're trying to change and shape. SUMMARY So, you can't save everybody. The numbers support that it's not possible anyways. Recognize that we were kind of set up for failure from the start with school, of never encountering patients who didn't get better, patients who didn't want to come to physical therapy, patients who were soul-sucking sometimes in their physical therapy session. and I think it's a normal and natural reaction the way that entry-level schooling is currently run for us to get that smack in the face feeling when we leave school of, oh boy, this is much different than those fake actor patients and those paper case studies. And the reality, the reality of what can we do We can't dump our energy into those folks and expect them to change on their own. It doesn't mean that we abandon them. It doesn't mean that we discharge them. It means we continue to be a resource for whenever they're ready to change and we pour the majority of our energy into the folks who want and are currently trying to make those changes and need and want our help to do so. That's all I have for you all on this wonderful Thursday. I hope you have a great 4th of July. I hope you have a nice long weekend. Hopefully you have tomorrow off work. Have a great weekend. We'll see you all next week. Bye everybody.

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