Ten Things I’ve Learned About Therapy That I Didn’t Learn in School
Since Covid-19, like many of us, I’ve had lots of time to think. And what I started to find myself thinking about, is what it would look like if I could practice physical therapy the way I wanted to do it - without any corporate oversight or pressure to take more patients or schedules or guidelines or the rest of the ‘stuff’ that comes with being an employee. What would it look like if it was just me, and my patient, working together to meet their goals? During this exercise, I started to reflect on what I’ve learned in the past twelve years since PT school and how it impacts the way I practice. What I’ve come up with is the following - a list of ten insights I’ve gained about the provision of physical therapy that influence how I treat every day. The punchline? Not one of them has to do with exercises, range of motion or any of the other skills we had to master to become PTs.
Since Covid-19, like many of us, I’ve had lots of time to think. And what I started to find myself thinking about, is what it would look like if I could practice physical therapy the way I wanted to do it - without any corporate oversight or pressure to take more patients or schedules or guidelines or the rest of the ‘stuff’ that comes with being an employee. What would it look like if it was just me, and my patient, working together to meet their goals? During this exercise, I started to reflect on what I’ve learned in the past twelve years since PT school and how it impacts the way I practice. What I’ve come up with is the following - a list of ten insights I’ve gained about the provision of physical therapy that influence how I treat every day. The punchline? Not one of them has to do with exercises, range of motion or any of the other skills we had to master to become PTs.
Use your brain - literally. Use neuroplasticity to your favor. Learn about it, love it and make it a part of everything you do. To make change in the brain, you must perform activities intensely, repeatedly and specifically. They must have meaning to the person doing them. They must be specific; learning how to play basketball won’t make you a good swimmer. They must be intense; the typical ‘do a set of 10 ankle pumps’ isn’t doing anyone any favors. Activities must be performed in a way that provides challenge - if you aren’t working near the point of failure, neuroplastic change cannot occur. And the activities must occur repeatedly. This can be applied to every thing you do as a therapist, from strengthening, to functional mobility to balance reeducation. Turns out, practice does make perfect.
It’s not the hand you’re dealt, but how you play your cards. The most inspiring patients I’ve worked with have been those that remain positive and engaged in their lives despite facing the most challenging of circumstances. My years spent working neurorehab taught me that traumatic physical events don’t have end life as you know it, but it may be start of a new one. Yes, life will never be the same after such injury, but different can still be good. I love to be a part of that redirection - helping a patient start to look forward instead of back and focus on how their rehabilitation can help lay the groundwork for their new life.
Age means very little. I’ve met seventy year olds who look like they’re a hundred and centenarians who look (and act!) like they’re seventy. My favorite advice on living a long life came from one of my very oldest ladies: “Avoid men, and drink lots of white wine.” Another told me she has lived to be a hundred by reading the Smithsonian every day and highlighting the important facts. Then there are those who mistreat their bodies and are disabled by chronic illness quite young. Regardless, don’t judge a book by its cover - or a patient by their wrinkles. They may surprise you.
Educate. The average patient knows very little about the body they live in - from their ‘rotary cuff’ to their ‘prostrate’ gland. But knowledge is power. How can we expect them to take care of themselves without knowing why they need to in their first place. Being told to cut out salt to avoid CHF doesn’t mean much until you can understand why it causes volume overload. Who would work through the pain of ROM after a knee replacement if they don’t understand the process of healing and formation of scar tissue? Take the time to teach and it will pay off in dividends.
Ask the right questions. I can figure out what someone needs better through a carefully crafted subjective, than an hour of special tests. Asking if you’ve had any falls doesn’t tell you much. But asking where they happen, how they tend to land, how they were feeling before (and the 800 other questions I tend to ask) allows me to identify the patterns and then efficiently address the issue.
Learn everything you can from the people around you. Find a coworker, a mentor, or a PT community and suck all the knowledge you can out of them. Watch your colleagues work. Take note of their ideas and store them away in your toolbox. Read. Take classes. Never stop learning. I am sure I drove my professors and Clinical Instructors crazy with my non-stop questions, but I always got my money’s worth. If you find yourself in a rut, or using the same old exercise routine with patients, that’s the best time to take a class. Pre-kids, I took every class I could get the time off to take. My priorities changed for a while while they were little, but this forced Covid-sabbatical I’ve found myself on has given me the time and reason to start up again. I joined the APTA for the first time in years and signed up for my GCS exam. I’ve been ingesting Podcasts, online courses and journal articles nonstop. I haven’t been this excited to treat in years. If you every find yourself in a rut, make time to learn.
Go with your gut. Advocate for your patients. If something doesn’t seem right, chances are, it’s not. This can be anything from vital signs that make you nervous, a patient who ‘just seems off’ or a coworker who isn’t giving a patient what you think they need. Don’t just let it go, because it may be life or death for your patient. This is a competence I didn’t develop fully until I worked in home care. By nature, working in home care entails constantly triaging and independent decision-making. Sure, you can call a manager for advice, but at the end of the day, it’s your eyes, your hands and you have to make the call. Every time I send a patient out by ambulance, I apologize, but tell them I’d rather be safe than sorry, any day of the week, rehospitalization rate be damned. You may feel embarrassed the two of three times the patient ends up fine and gets sent home, but let me tell you, that third time it turns out to be a pulmonary embolism, you’ll never second guess yourself again.
Treat holistically. You’re treating a person, not an impairment or even a functional limitation. Their needs will always span past ROM, strength deficits or even pain. A lot of people just need to be heard. Many rarely find people who know how to listen without judging, or don’t want to burden their loved ones with their stress so they hold it all in. Others desperately need community referrals or education about their medical condition or any other list of non-PT activities you may find yourself doing. During home care visits, I’ve taken out trash, opened up stuck jars, looked up addresses on google - and more often than not, it’s these small things that are more helpful than even the most well planned session you can provide.
Talk to your patients. It’s the science that brings us here, but it’s the people who keep us around. You’ll learn amazing things from your patients. The oldest among them have seen things and experienced things that you can’t even fathom. They’ve bought houses for $5000 that are now worth half a million. They’ve met spouses at USO events and then went off to war. They’ve had babies at home. They’ve experienced unimaginable losses. They have stories that could be written into New York Bestsellers and they give amazing advice. One of my favorite questions to ask my older couples is what is their best advice for a successful marriage. My all-time favorite response came in very simple older gentleman who responded “just stay married.” Think on that one for a bit…
Don’t be afraid of change. I’ve always been the kind of person to keep a job forever - I literally held the same job from the age of eleven until I finished college. Straight out of graduate school, I took a job with the rehab hospital I had been interning for. Twelve years later, I’ve held six different positions between six different hospitals, skilled nursing facilities, outpatient centers, home health agencies and private practices. I would never have predicted this trajectory for myself, but between moves, and babies and life, this is where I’ve ended up. But the beauty with all of this change is that I’ve gained something special from each place I’ve worked. It is this mix of experiences that has made me the clinician I am today. I’ve gotten to see what life is like along the continuum for patients after they experience an illness or catastrophic event from the rehab to the discharge home to the transition back to community. I’ve learned from amazing mentors and colleagues and made friends and strong networks. I’ve developed a different set of skills to function in each setting, and had the ability to adapt these to benefit patients I treat in the next. I truly think the rich variety of experiences has made me a stronger therapist, a more mindful clinician and helped me be more empathetic to the patients with whom I work. The funny thing is, among all these travels, never once have I considered opening my own practice. I’ve been asked by friends and family if I’d ever considered it, and my answer has always been a staunch no (‘I want to work, come home and not deal with any extra stress I don’t have to.’) But, as we’re all too keenly aware, this year, the notorious 2020, has forced us all to take stock, assess our lives and make changes we never expected to have to make. Leaving my home health job of seven years was something I hadn’t even been considering. I love the work, I love the company, it worked well with my life and I honestly assumed I’d be there till I retired. But, with my needs at home taking priority, I found myself on extended leave, at home, ‘crisis schooling’ my kids. Ten weeks at home later, with nothing to do but think, sleep and watch Netflix, I found myself considering heading in a different direction. What if I could combine all the things I loved about treating in outpatient with all the things I loved about treating in home into one? What if I could do this on my own, fit the hours in around my family’s needs - and be able to work through the upcoming and very uncertain year? As you can imagine, the next thing I knew (and if you know me at all, I’m sure you can imagine because you know I’m a crazy person once I come up with an idea), I decided to launch HAE/PT and created a new plan for myself. So, long story short, without change, we can’t grow. Don’t be afraid of change - it’s a part of life, it’s definitely a part of being a PT and in closing, I’ll leave you with one of my favorite passages: “Will you be troubled by every passing wind, or will you be the calm in the storm?” By accepting change, you’ll not only be the calm, but you’ll be able to make it work to your advantage.