7 years if school to walk people? SNF died a little inside...

[Mason108]

I finished my last affiliation this past summer in an SNF every day I was baffled. How do these doctors of physical therapy live with the fact that they went through so much schooling to use maybe 5% of their skills?We go through all of this schooling to earn such a "prestigious degree" but when it comes down to it 90% of the clinicians time in this SNF was spent doing leg extensions, walking, stairs, seated marches, ball squeezes, band abductions and bed mobility...

I died a little inside everyday during this affiliation, almost made me not want to be a PT anymore!(had it not been for loans i would have dropped out) 7 years of schooling to do something a person with a certificate level education could potentially do. Considering this is what a good portion of what DPT's do in their jobs its no wonder we aren't actually treated as doctors with direct access that can treat/diagnose without the need for a physician to hold our hand. most of the patients just thought i had an associate degree or something similar.

did anyone else who was set on working in outpatient go through this during their SNF rotation?

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[Azimuthal]

What was the clinical reasoning behind the functional training and basic ther-ex, and what would your alternative have been? When I fill in at our SNF, my patients know I have graduate level education.

 

[Mason108]

heres the thing i understand there are very few alternatives to the simple therex I'm getting more at the thought that it really doesn't take 7 years of schooling to work in this sort of setting. The patients needed care, but i needed more clinical science, problem solving, i felt an urge to use skills and practice differential diagnosing ect.

 

[PennyP]

If it's not your cup of tea, that's fine, but your post came off condescending to those who do enjoy the setting. Don't worry, no one can force you to work in a SNF after graduation.

 

[redrose424]

I finished my last affiliation this past summer in an SNF every day I was baffled. How do these doctors of physical therapy live with the fact that they went through so much schooling to use maybe 5% of their skills?We go through all of this schooling to earn such a "prestigious degree" but when it comes down to it 90% of the clinicians time in this SNF was spent doing leg extensions, walking, stairs, seated marches, ball squeezes, band abductions and bed mobility...

I died a little inside everyday during this affiliation, almost made me not want to be a PT anymore!(had it not been for loans i would have dropped out) 7 years of schooling to do something a person with a certificate level education could potentially do. Considering this is what a good portion of what DPT's do in their jobs its no wonder we aren't actually treated as doctors with direct access that can treat/diagnose without the need for a physician to hold our hand. most of the patients just thought i had an associate degree or something similar.

did anyone else who was set on working in outpatient go through this during their SNF rotation?

Agreed with the other posters. You don't like SNF, thats fine, but why are you degrading the therapists who do? That's ridiculous, maybe you should have asked your CI and the other therapists working there why they chose SNF and what they enjoyed about it. Maybe they could have enlightened you.

 

[Mason108]

i can a see why my post came of negatively but nonetheless maybe you guys can enlighten me on why you chose SNF, Because I just don't see how anyone can... it seems like the perfect place to practice the absolute minimum skills, almost like the work of a technician rather than a skilled clinician, thinker ect... Also it seems like the necessary education for such a setting is set way to high.

 

[Azimuthal]

heres the thing i understand there are very few alternatives to the simple therex I'm getting more at the thought that it really doesn't take 7 years of schooling to work in this sort of setting. The patients needed care, but i needed more clinical science, problem solving, i felt an urge to use skills and practice differential diagnosing ect.

I'll have to disagree. Differential diagnosis is not the be all, end all to 'skilled' PT. When in a setting such as acute rehabilitation or SNF, every time you ask a patient to perform a task, you are observing quality of movement, cognitive ability, functional limitations and impairments. If you simply asked the patient to 'walk' or 'climb stairs', with out monitoring their movement patterns and thinking of the barriers and proper intervention to address their needs, you're doing it wrong.

I am confused as how the clinical science and critical thinking components were not more apparent and it may have to do with how your CI presented you with this information.

So, let me ask you. Did you assess any of your patients' movement patterns, i.e., observational gait analysis, etc? Perform a balance assessment, i.e., to identify deficits in steady state, reactive, or anticipatory? Assess cognitive retention for learning or command giving? Did you derive a POC backed with evidence and time duration of needed intervention? If not, you may feel the way you do because you were, essentially, not providing skilled care. In that case, you are absolutely correctly, you were performing at the level of a technician. Unfortunately, and perhaps unethically, you probably billed for skilled PT.

 

[redrose424]

i can a see why my post came of negatively but nonetheless maybe you guys can enlighten me on why you chose SNF, Because I just don't see how anyone can... it seems like the perfect place to practice the absolute minimum skills, almost like the work of a technician rather than a skilled clinician, thinker ect... Also it seems like the necessary education for such a setting is set way to high.

You should probably stop adding more derogatory comments to your questions. Maybe what was lacking was your ability to critically think about what the therapist was doing and what the patient needed.

 

[SnozzBerry]

Its better than 8 years to dish out hearing aids...amirite?!

 

[summerX]

I wrote a similar post to the original posters a few yrs ago. I think our scope of practice doesn't match our level of education. We can take relatively easy things and dissect them until they get extremely difficult and complex (I.e transfers, gait training) or we can hopefully eventually have an increased scope of practice. I also think one of the reasons our doctor degree is sometimes looked down upon is our scope of practice. Don't get me wrong, what we do is important... I just thought I'd be doing more.

 

[PennyP]

I'll have to disagree. Differential diagnosis is not the be all, end all to 'skilled' PT. When in a setting such as acute rehabilitation or SNF, every time you ask a patient to perform a task, you are observing quality of movement, cognitive ability, functional limitations and impairments. If you simply asked the patient to 'walk' or 'climb stairs', with out monitoring their movement patterns and thinking of the barriers and proper intervention to address their needs, you're doing it wrong.

I am confused as how the clinical science and critical thinking components were not more apparent and it may have to do with how your CI presented you with this information.

So, let me ask you. Did you assess any of your patients' movement patterns, i.e., observational gait analysis, etc? Perform a balance assessment, i.e., to identify deficits in steady state, reactive, or anticipatory? Assess cognitive retention for learning or command giving? Did you derive a POC backed with evidence and time duration of needed intervention? If not, you may feel the way you do because you were, essentially, not providing skilled care. In that case, you are absolutely correctly, you were performing at the level of a technician. Unfortunately, and perhaps unethically, you probably billed for skilled PT.

I think this is a huge issue, especially in SNF. Therapists, whether PT or PTA (both are trained to give SKILLED interventions) go into robot mode. "Do 15 kicks.... good.... *jot dot a note* ...good" Without giving actual feedback to the patients form or body mechanics. If you aren't paying attention to how that patient is actually going about their therex or ambulation, then yeah, you're basically being a tech. If you aren't constantly assessing progression, then you aren't doing your job.

 

[Mason108]

So would anyone agree that a new grad would be served well by by going into a subacute setting because they would practice a wide variety of skills and learn lots of new treatment methods?

 

[truthseeker]

I agree with Mason.
I've been reading this thread and have been hesitant to comment but it keeps hanging around so I will add to the fire. SNFs are not for everyone. They are certainly not for me. If someone is good at what they do, they will be good in any setting. That said, a PT with poor skills has the best chance of remaining employed in a SNF because the patient's are unable to go somewhere else and essentially vote with their feet. There are plenty of PTs who don't use evidence, use no critical thinking, and basically follow protocols or the latest woo woo every day and by the power of their personality they have jobs. IMO its easier to "phone it in" at a SNF than at a rural or subacute or OP ortho, or neuro rehab center but unfortunately it is done in all of those places.

Unfortunately, the way many SNFs are managed, (with a premium on contact minutes to get in the highest possible RUG category) lends itself toward treating way beyond where the therapy is actually skilled and a meaningful change in the patient's condition will occur BECAUSE of the PT. this is certainly not the case in all SNFs but it is in way too many.

 

[PennyP]

I agree with Mason.
I've been reading this thread and have been hesitant to comment but it keeps hanging around so I will add to the fire. SNFs are not for everyone. They are certainly not for me. If someone is good at what they do, they will be good in any setting. That said, a PT with poor skills has the best chance of remaining employed in a SNF because the patient's are unable to go somewhere else and essentially vote with their feet. There are plenty of PTs who don't use evidence, use no critical thinking, and basically follow protocols or the latest woo woo every day and by the power of their personality they have jobs. IMO its easier to "phone it in" at a SNF than at a rural or subacute or OP ortho, or neuro rehab center but unfortunately it is done in all of those places.

Unfortunately, the way many SNFs are managed, (with a premium on contact minutes to get in the highest possible RUG category) lends itself toward treating way beyond where the therapy is actually skilled and a meaningful change in the patient's condition will occur BECAUSE of the PT. this is certainly not the case in all SNFs but it is in way too many.

It is easier to phone it in in a SNF, but if you do that you aren't doing your job. The OP specifically bashed SNF, if it's not for him then that's fine but if you're actually assessing your patient's movements and how they are progressing, then you are using your education. In any aspect of healthcare, there are places where the clinicians are phoning it in, it's up to the clinician to decide what type of professional they want to be.

Another it's also wrong to look down your nose at those with "certification level education" (PTAs)

 

[truthseeker]

It is easier to phone it in in a SNF, but if you do that you aren't doing your job. The OP specifically bashed SNF, if it's not for him then that's fine but if you're actually assessing your patient's movements and how they are progressing, then you are using your education. In any aspect of healthcare, there are places where the clinicians are phoning it in, it's up to the clinician to decide what type of professional they want to be.

Another it's also wrong to look down your nose at those with "certification level education" (PTAs)

No doubt. I think maybe if it was the OPs first clinical experience AND he had one of those who phone it in, it was probably a very bad representation of what PT in a SNF should be.

 

[ptisfun2]

Unfortunately, the way many SNFs are managed, (with a premium on contact minutes to get in the highest possible RUG category) lends itself toward treating way beyond where the therapy is actually skilled and a meaningful change in the patient's condition will occur BECAUSE of the PT. this is certainly not the case in all SNFs but it is in way too many.

I agree this can be a problem. But...SNFs require a high degree of autonomy among PTs. With high patient: nurse ratios, and minimal requirements for MD visits, PT (and OT) are often spending more time and evaluating the patient very holistically. Additionally, because the main goal when a patient gets admitted to a SNF is to get them out and home (although sometimes the main goal seems to be above quoted statement), PT (and OTs) are required to have high degree of clinical decision making.

A colleague of mine, who has been a PT professor FOREVER often states, "For too long, PT has been focused on the neck down. We need to shift our focus to the neck up." Now students think he is talking about treating patients with concussions. But what he means is a PT's brain, not their strength, or their hands, or their 'manual skills' should be the most important tool for a PT. WHY we are doing something must be the focus. Students focus on WHAT we are doing... because that's easy and they are still learning.

Skill acquisition and application should NEVER be the sole goal of a PT. Clinical decision making for the use of said skill should be the goal.

 

[PennyP]

http://blog.todayinpt.com/lost-creativity-antidote-nelson/

 

[BiffTheFlashRogers]

http://blog.todayinpt.com/lost-creativity-antidote-nelson/

That is a disturbing read.

 

[truthseeker]

disturbing but sadly true

 

[SloanTriumph]

Be that change you want to see in SNF!

But seriously, not all PTs are created equal, not all PT facilities are created equal. This is one of the biggest issue the APTA is trying to combat. SNF can often seem elementary at times, but it doesn't have to be. There are definitely complex and technical aspects to be learned. Also you don't have to work in SNF, so there's the silver lining.

 

[NewTestament]

Unfortunately, the way many SNFs are managed, (with a premium on contact minutes to get in the highest possible RUG category) lends itself toward treating way beyond where the therapy is actually skilled and a meaningful change in the patient's condition will occur BECAUSE of the PT. this is certainly not the case in all SNFs but it is in way too many.

This has been my experience in SNF's and why I try to avoid them. Skilled therapy can be provided in these facilities but too often the patients are inappropriate for PT or are given too many minutes (5o minutes for a bed-bound patient is abuse IMO). As long as a patient is breathing, the SNF will prescribe PT. I've treated patients who died the next day due to multiple medical conditions. Did I benefit them? Probably not. I think there is overutilization of PT in SNF's but some patients actually can benefit from skilled physical therapy. SLRs, ball squeezes, etc. are usually a waste of time but an easy way to bill for more minutes.

And can someone tell me what it means to phone it in? Thanks.

 

[truthseeker]

phoning it in means to just do it without thinking.

 

[Mason108]

http://blog.todayinpt.com/lost-creativity-antidote-nelson/

This is spot on

Honestly it does seem incredibly elementary. The hardest part of most days was should we make this person a lift or a modx2. Should they they do steps with 2 rails of 1 rail & cane. Then theres your go to exercises leg extensions, leg curls, ball squeeze band abduction, SLR, arc quads, lying abductions ect....

Also another thought. There are hundreds of outpatient orthopedic physical therapy blogs, speakers, "Gurus" out there, lots of new innovating ideas, nothing revolutionary but my point is why isn't it the same for subacute/acute? I see people get fired up about joint mobs, and interesting new ways to perform exercises in OP ortho but in SubQ/Acute i rarely see anything close to this type of burning desire for innovation seen in many outpatient PT's

 

[Azimuthal]

This is spot on

Honestly it does seem incredibly elementary. The hardest part of most days was should we make this person a lift or a modx2. Should they they do steps with 2 rails of 1 rail & cane. Then theres your go to exercises leg extensions, leg curls, ball squeeze band abduction, SLR, arc quads, lying abductions ect....

Also another thought. There are hundreds of outpatient orthopedic physical therapy blogs, speakers, "Gurus" out there, lots of new innovating ideas, nothing revolutionary but my point is why isn't it the same for subacute/acute? I see people get fired up about joint mobs, and interesting new ways to perform exercises in OP ortho but in SubQ/Acute i rarely see anything close to this type of burning desire for innovation seen in many outpatient PT's

I find that things seem to be thrown in one side of the spectrum or the other. Those bland routines aren't doing patients any favors, however, I can say the same thing about those "innovative" therapists out there. A few I refer to as "try-hards". They get so engrossed in changing things up they lost sight of even the most basic of concepts, such as progressive overload for strength. When I was in OP, one of the clinic's go to for quad strength development was "lunges on 2 BOSU balls with water pipe" (can't remember what they called it). Yeah, it's as bad as it sounds, and looked like an ankle sprain or other injury waiting to happen. Biomechanically unsound for the focused organ. I didn't say anything because I was a student and that therapist was not my CI, but now I would call it what it is - silly.

Dr. Marquez and Mr. Mihaiu () are correct, PT can be boring. However, I believe that Dr. Marquez is alluding to efficacy over routines. It happens in all settings. Also, these "innovations" you refer to are usually not found in subacute/acute because common sense would point to their differences in mobility level, strength, etc. However, there has been advances in techniques used in wound care, C&P, etc. It just happens that your bias lead you to ther-ex and manual techniques. It is also a shame that you felt the need to belittle those who work in SNF because of your limited exposure.

 

[truthseeker]

When I was in OP, one of the clinic's go to for quad strength development was "lunges on 2 BOSU balls with water pipe" (can't remember what they called it). Yeah, it's as bad as it sounds, and looked like an ankle sprain or other injury waiting to happen. Biomechanically unsound for the focused organ. I didn't say anything because I was a student and that therapist was not my CI, but now I would call it what it is - silly.

Tell me how it is unsound. I don't really know what this looks like but anything with the feet on the ground, with proprioceptive challenges trains the system When to contract which, in my mind, reduces injury risk. No seated therabands for eversion, no short arc quads, no straight leg raises do that. I'm guessing that wasn't the first thing they did but be careful what you dismiss as "silly". I have seen plenty of "progressive sports medicine OP therapists" do things that I would consider silly.( like the things I listed) I think those things are much more silly than a lunge on a Bosu.

 

[Azimuthal]

Tell me how it is unsound. I don't really know what this looks like but anything with the feet on the ground, with proprioceptive challenges trains the system When to contract which, in my mind, reduces injury risk. No seated therabands for eversion, no short arc quads, no straight leg raises do that. I'm guessing that wasn't the first thing they did but be careful what you dismiss as "silly". I have seen plenty of "progressive sports medicine OP therapists" do things that I would consider silly.( like the things I listed) I think those things are much more silly than a lunge on a Bosu.

Well, I can think of more effective ways of quad strengthening (the intended organ) in the closed chain versus if the intended purpose was actually proprioceptive feedback and joint stabilization exercises. I believe this became more of a balance exercise than strengthening as intended. Mechanically, patients almost never hit 50% of their achieved ROM (unstable surface + decreased confidence), which IMO limits strengthening. I should have mentioned that most of the population were not athletes or youths, but post elective sx. I understand that there is merit to rapid firing of the quads for the purpose of decreasing muscle activation ramp up time, but its not like the clinic was short on equipment. I mean, it looks more creative than my step up/down with/without airex, with/without weights, but I guess I'm not at that point yet.

 

[truthseeker]

My point is that when a muscle contracts is vastly more important than how strong it is. bosu, baps, balance exercises, lunges, weight shifts with other challenges like unstable surfaces, eyes closed, etc . . . sharpen the map of the body in the brain and encourages more precise control. yes, strong and smart muscles are best, but smart trumps strong every time. You don't need much equipment for that.

 

[Azimuthal]

My point is that when a muscle contracts is vastly more important than how strong it is. bosu, baps, balance exercises, lunges, weight shifts with other challenges like unstable surfaces, eyes closed, etc . . . sharpen the map of the body in the brain and encourages more precise control. yes, strong and smart muscles are best, but smart trumps strong every time. You don't need much equipment for that.

We're in agreement, minus the method. I personally will not use that particular BOSU technique. Again, less glamorous.

 

[Fiveoboy11]

In the SNF setting I tend to keep things simple. My preference is to have people do a lot of functional mobility: walking, transfers, and bed mobility. Lots of reps/practice. Definitely NOT walking "to the gym" and sitting down wasting time with 1.5lb ankle weights or any other reindeer game nonsense. If you want to challenge someone closed chain in a SNF besides that then take them outside! Ramps, curbs, uneven terrain, etc. Go for maximum carryover (i.e. Improvements in walking in this population will come from walking as rx). Goofing around will balls makes you good at goofing around with balls.

 

[NewTestament]

In the SNF setting I tend to keep things simple. My preference is to have people do a lot of functional mobility: walking, transfers, and bed mobility. Lots of reps/practice. Definitely NOT walking "to the gym" and sitting down wasting time with 1.5lb ankle weights or any other reindeer game nonsense.

Unfortunately this is what you see in SNFs more often than not. I read treatment notes all the time and I see the same thing: 3x10 hip adduction/abduction, SLR, etc. I can't believe Medicare still pays for it. I really can't.

 

[Fiveoboy11]

Why patients do seated exercises so often in SNFs is explainable. It's obviously the result of how things work. Set everything up on another planet the exact same way and you'll get the exact same result. Change how things work for the better and you eliminate unneccessary seated exercises. Remove payment for seated exercises all you want, you didn't solve any problem or make things work better. It'll be substituted for something else that serves the same purpose (easy work, easy minutes).

 

[OHIO PT]

In the SNF setting I tend to keep things simple. My preference is to have people do a lot of functional mobility: walking, transfers, and bed mobility. Lots of reps/practice. Definitely NOT walking "to the gym" and sitting down wasting time with 1.5lb ankle weights or any other reindeer game nonsense. If you want to challenge someone closed chain in a SNF besides that then take them outside! Ramps, curbs, uneven terrain, etc. Go for maximum carryover (i.e. Improvements in walking in this population will come from walking as rx). Goofing around will balls makes you good at goofing around with balls.

Its going to be all about functional mobility and functional mobility only soon in SNF setting due to bundled payments. Its going to go from trying to lengthen LOS and get pt to PLOF to very short LOS and getting them home at the minimum level they can safely return. It will be all about ambulating, transfers, steps, bed mobility, there will be no time for anything non functional.

In SNFs, just like any other setting, you will see complacency. I have been in OP clinics where it was more monotonous and boring than anywhere else. Following post surgical protocols, PTs seeing 3 patients at once, assigning ther ex and setting up patients on modalities that do literally nothing. SNFs are the punching bags sometimes but I dont think there is anything worse than an OP PT seeing 3-4 patients at the same time and just hooking them up to an e-stim machine and not putting their hands on the patient. I cant believe people are dumb enough to keep going to places that do that.

I also wouldnt be so quick to dismiss seated or supine ther ex in the SNF. Obviously this is a must for joint replacements. And these ther ex can really benefit LTC patients who have been picked up due to a change in function and have LE weakness. It needs to be progressive and shouldnt be the only ther ex done or only tx done but it isnt useless.

Also using balls or balloons to challenge balance can be beneficial for this population too. Certain patients no, but some yes.