Monday Memo 2/24/20

The Monday Memo

February 24th, 2020                                                              PITT DPT STUDENTS

Where Research Can Make an Impact in Patient Care – A Case Study

            As we continue reviewing journal articles and learning about research methods through our Evidence Based Practice curriculum, I am sure plenty of my fellow students are left wondering, “What current research is being done, what are the implications, and is any of it more interesting than comparing the effect of receiving physical therapy vs. not?” I have been a research assistant in the Ferguson Laboratory through the department of Orthopedic Surgery for just over a year now and would like to share my insights from the Head and Neck Cancer project I have been working on.

            Over at the Otolaryngology clinic in the Eye and Ear Institute, every Thursday there is a survivorship clinic during which head and neck cancer survivors are seen for their annual visits (including physical therapy, swallowing, and dental screens) and can participate in research studies if they so choose. One of those being the project I am working on, which is a study that aims to understand the relationship between Neck Disability Index, patient reported scores related to beliefs about pain and pain recovery (FABQ and TSK), and objective measurements of function (ROM scores). At the end of the day we are observing and understanding neck function in this population, however, when these patients are seen by the physical therapist there are plenty more things to consider. Shoulder function is observed and tested (scored via PENN-ASES/DASH) as well as eating and swallowing (EAT-10); deconditioning, lymphedema, trismus, and radiation fibrosis are all considered.

            Cancer is a disease that affects the whole person, and frankly its quite silly that the NDI is the driving score to determine whether a patient needs physical therapy or not. As well, it does not make sense to use it as a measure of recovery since in my experience I have seen both very good and very bad ROM for a range of NDI scores from low to high. Ultimately, this is a very complex patient population with many factors that affect decision making, however, we as students and practicing physical therapists can do more to advance the profession through research. Some of my lessons and observations thus far: quality of life is as good a score as any other to understand patient outcomes, we can look at specific NDI items instead of using the survey in its whole, as well the NDI could just not be specific enough to capture the problem for this population, and that some patients tolerate losses of ROM in certain directions better than others.

Sebastian Murati, SPT

February 24, 2020 |

Monday Memo 02/17/20

The Monday Memo

February 17th, 2020                                                              PITT DPT STUDENTS

          Navigating the Clinic as a First-Year Student

One of the aspects of physical therapy school that I was most excited about was the clinical education experience. While the didactic curriculum is pertinent and provides a working framework, the clinical experience is where we get to implement what we are learning in class and practice honing the skills that we will be using for the rest of our career. One of the unique assets of the University of Pittsburgh’s Doctor of Physical Therapy Program, and one of the factors that helped me decide to attend the program, is that “the curriculum is designed to emphasize early and intensive integration of [our] students into the clinical environment throughout their educational program.” Unlike most programs, the University of Pittsburgh gets us in the clinic part-time starting in our second semester of the program after just a quick summer term covering three basic science classes and a week of preparatory “Boot Camp.”

            The first day of my first clinical experience was a whirlwind. My CI was the only therapist at the site and was running between patients, trying to keep up with documentation while also attempting to orient me to the clinic. Everything was new and intimidating, especially because I had no previous experience as a rehab aide. I figured I would spend most of that first day shadowing and observing my CI, trying to get a feel for how the clinic is run and what a typical treatment session would look like. However, as the weeks went on, I found myself struggling to find ways to integrate myself into the clinical experience. The inevitable consequence of early integration into a clinical setting led me to be plagued by thoughts such “I don’t know enough,” “I am incompetent,” “I don’t want to make a mistake,” and “I don’t want to be a burden.” I felt lost and was constantly looking for ways to be helpful despite what I felt was a lack of knowledge and adequacy. As we began covering more material in our classes, it became a bit easier to try and incorporate information from class into the clinical setting, but I still struggled to find the balance between wanting to practice my skills and not wanting to make a mistake or get in my CI’s way.

            Another aspect of clinical practice that our classes did not prepare us for was working with patients who presented with actual deficits and impairments; this is something that just could not be simulated in our lab time during class. There is no predicting who will walk through the doors of the clinic and what they will bring to the table. Trying to figure out how to interact and connect with the patients and do what is best for them given their presentation, symptoms, and therapeutic tolerance also proved to be a great challenge initially. I quickly realized that I had a lot of patient management skills to develop, such as learning how to communicate with patients in terms that they could understand and ensuring their safety while performing their exercises.

            Now that I am in my second clinical rotation, the feelings of uncertainty and helplessness have diminished. While there are still moments when I feel as though I lack the appropriate knowledge and skillset to be of any help, I remind myself that I am, after all, a first-year student, and that the expertise will come with experience, practice, and dedication.

I would like to leave the future first year students with a few pieces of advice for when they go out into their first clinical rotation. First, do not feel as though you are a burden. You are in the clinic to learn, grow, and hone your skills, so take control and maximize on the learning opportunity you have been given. Second, do not be afraid to make mistakes. Making mistakes is part of the process; just be sure to take the opportunity to reflect on them and use them as a learning experience. Third, do not underestimate the importance of building rapport and trust with patients. Even if you are unable to practice any physical skills with them or are not sure how to engage yourself with their treatment given their unfamiliar or complex condition, something as little as taking the time to get to know the patient is an important aspect of providing quality care. In addition, there is so much that a patient can teach you about what it is like living with their condition and how it impacts their day-to-day life; the opportunity to converse with patients about their experiences is eye-opening and a privilege that not every career affords. Lastly, be patient with yourself! Never forget that every expert was once a beginner. Fighting feelings of incompetence is not uncommon and representing one of the best programs in the country can feel overwhelming at times, but trust that with a little bit of hard work and practice, you too will become a competent clinician.

-Kimmie Berkovich, SPT

References: https://www.shrs.pitt.edu/dpt/curriculum

February 17, 2020 |

Monday Memo 01/27/2020

The Monday Memo

January 27, 2020                                                                       PITT DPT STUDENTS

Do We All Take Women’s Pain Seriously?

            On the first day of neuromuscular PT 3, we watched a video where Selma Blair told her story of being diagnosed with multiple sclerosis. She mentioned how she was having symptoms of MS for months – weakness, falls, pain. She brought this up to her physicians, even asking for MRIs to be taken, but time after time they dismissed her claims. At one of her appointments, Selma unfortunately fell in front of her physician, and this is what it took for them to take her complaints seriously

            Sadly, this is a story that many women know all too well, even me. Physicians often struggle to judge the seriousness of a woman’s pain, which can lead to fatal consequences. A study in The New England Journal of Medicine found that women are seven times more likely than men to be misdiagnosed and discharged from the emergency room while having a heart attack. Everyone is taught that left-sided chest and arm pain could mean a heart attack, however, women’s symptoms can differ vastly. Some women can experience an increase in fatigue, neck and jaw pain, and shortness of breath when having a heart attack. Many people do not immediately pick up on these female heart attack symptoms because our studies of medicine have predominately been based around male physiology. Research has recently become more diverse, including subjects of all races and genders, but for the majority of the past century that has not been the case.

            Chronic pain is another area where the current U.S. medical system is failing women. 70% of people with chronic pain are women. Musculoskeletal pathologies such as fibromyalgia and complex regional pain syndromes are often seen as “made up” diagnoses, likely because the people suffering from them are mostly women. Stereotypes surrounding chronic pain diagnoses often lead to women experiencing pain more often and longer than men. Physical therapists can directly intervene here by listening to and advocating for our patients with chronic pain.

            Women are not the only group who experiences disparities in pain management. According to the National Institute of Health, PCP’s are more likely to underestimate pain intensity in African American patients. African Americans are also less likely to receive pain medication than white people. The NIH reports that opioids are more often prescribed to those in a higher socioeconomic status, although low income patients are more likely to report having pain. Reasoning behind these statistics can be due to access to care (geographically and financially) as well as implicit biases.

            To progress ourselves as a profession, physical therapists must be aware of our own implicit biases and educate ourselves on how to eliminate them. We need to listen to our patients and take their complaints seriously. One of the books on my reading wish list is Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick by Maya Dusenbery. In this novel, Dusenbery talks to physicians, researchers, and women to provide an account of what it’s like to seek medical help as a woman. From the brief excerpt I read, I believe that this book would be a valuable read to every student and practitioner in the health professions. Women deserve to have their pain seen as a priority. I hope someday we will get to the point where we don’t have another Selma Blair story.

-Kara Kaniecki, SPT

References:

  1. https://www.ninds.nih.gov/sites/default/files/DisparitiesPainCare.pdf
  2. https://www.health.harvard.edu/blog/women-and-pain-disparities-in-experience-and-treatment-2017100912562
January 27, 2020 |

Monday Memo 01/20/2020

The Monday Memo

January 20, 2020                                                                       PITT DPT STUDENTS

The PT Diversity Gap

“Diversity and Inclusion, which are the real grounds for creativity, must remain at the center of what we do” – Marco Bizzarri

For this Monday Memo, I was inspired by Dr. Gregory Hicks, Chair of the University of Delaware Physical Therapy Department.  On October 15th, 2019, Dr. Hicks visited the University of Pittsburgh to give the 2019 Endowed Scully Lecture entitled “Who Do We Want to Be? Responsible Stewardship of our Profession”.  Dr. Hicks spoke of the diversity of the Physical Therapy profession… or should I begin by noting, a current and persistent lack-thereof diversity in both practicing physical therapists and the present student body.  To premise, I am writing this as a Caucasian Female, the most prevalent statistic according to the APTA member demographics profile.  To some readers, this may be viewed as a “taboo” subject but increasing the diversity of the PT student body and workforce plays an integral role in the future direction of our profession, and our patient outcomes alike.  The intention of this Memo is to educate about the underlying issues regarding a lack of diversity and pose suggestions for what we, as students, can do!

First, we’ll begin with some statistics.  According to the WebPT Industry Survey of 2019, 79.4% of PTs are White, 4% are Hispanic or Latino, 2.2% are Black or African American, 5.7% are Asian, 0.7% are American Indian or Native Alaskan, 0.4% are Native Hawaiian or Pacific Islander, 1.6% are “Other”, and the remaining 6% preferred not to report their race or ethnicity.  From this statistic alone, it is clear to see that there is an apparent lack of diversity across the Physical Therapy profession.  Based off of APTA Membership in 2015, only 15.5% of members reported being of a minority race or ethnicity, whereas at that time, the US population of minority races and ethnicities was 33%.  Regarding diversity in PT academics, the disparities are also clear.  According to the American Counsel of Academic Physical Therapy, the following populations are currently underrepresented in PT programs as compared to the US population: Hispanic/Latino, African American/Black, American Indian/Alaskan Native, and Hawaiian/Pacific Islander.  From this information, it is clear to see that there is an apparent lack of diversity in both the current PT workforce, and within the student-body.

So, why is diversifying the profession so important?  According to Cohen et al, it is argued that achieving greater diversity will lead to a more culturally competent workforce, improve access to high-quality care for the medically underserved/underrepresented, increase the scope and depth of the United States’ health-related research agenda, and diversify the population of medically trained executives and policymakers taking on leadership positions in the health care system in future years.  One frequently cited consequence of inadequate minority representation within the healthcare professions is reduced utilization of preventative care and increased utilization of emergency services.  Increasing utilization of preventative services is particularly important for our profession, as upwards of 90% of patients with musculoskeletal injuries choose NOT to seek formal care from a physical therapist.  It is important to note that it is widely accepted that health care outcomes are improved, especially for minority patients, when the healthcare providers and staff in a hospital or clinic resemble the patient populations they seek to serve. To add to this, in 2013, Yeowell conducted a qualitative research study investigating physical therapists’ perceptions, views, and experiences of ethnic diversity in relation to the profession. Yeowell, too, argues that it is important for the workforce to reflect the patient population it serves, so they are better equipped to understand and respond to individual patient’s needs.  This is NOT to say that a therapist with a differing background from a patient is incompetent and unable to treat them effectively.  According to Dave Kietrys, PT, PhD, “We live in a diverse world, and our clients and patients come from diverse communities.  We should be mirroring that. We also should be welcoming people from all backgrounds into our profession. The greater our diversity, the deeper and richer our understanding will be of the needs of a varied population. We’ll naturally be more sensitive to underrepresented communities—what they’re going through and how they might have been marginalized, stigmatized, or treated with bias.”

There are many speculations to why a lack-of diversity is persistent in the field of PT, such as the astronomical cost of higher education, implicit biases of interviewers/directors, lack-of exposure to the Physical Therapy profession, and several other potential reasons.  As a physical therapy student, it may seem like we do not have control over this aspect of our future profession at this point in our careers. Luckily, the APTA does have some suggestions of what can be done to aid this pertinent issue while we are still students!

  1. Talk to our chapter delegates! Discussing these pertinent issues while we are still students gives us an opportunity to become “responsible for the stewardship” of our future profession! 
  2. Talk to faculty and staff in the program that you are attending.  Determine if there are any programs/policies that are currently enacted, or work diligently to establish a program to support future students.  For example, at the University of Delaware, there is a mentorship program in place for minority undergraduate students interested in the field of Physical Therapy.  Qualifying students have the opportunity to take classes alongside of PT students, meet with advisors directly in the program, and receive access to study resources.  This assures that these students are receiving support to function academically at their highest potential and remain solid, competitive candidates for Physical Therapy school programs nation-wide.
  3. Educate children in underrepresented minority, gender, and socioeconomic groups about what physical therapy is and how they can be part of our profession. A program that was enacted once within Pitt Physical Therapy with this goal in mind was referred to as the “Homestead Community Sports Medicine Exposure”.  Pitt PT students met with athletes from the Homestead area of Pittsburgh and showed them various exercises, as well as educated them about the field of physical therapy!  These are the fun, rewarding experiences that students will remember when they are choosing a career path.  This shows that having physical therapy exposure is not limited to patients walking into your clinic alone.  Exposure to the profession was identified as a more influential factor in career choice among minority students compared to white non-Hispanic students. However, Caucasian students are five times more likely to have had direct (being a patient) or indirect (family member/friend being a PT or being seen by a PT) personal experience with a physical therapist than their minority counterparts. 

I am hopeful that, as time progresses, diversity in the field of Physical Therapy will increase.  The future of our profession, student-body, and patients are counting on us to do so.

A special Thank You to Dr. Gregory Hicks for bringing this pertinent information to the University of Pittsburgh.

-Mariah Callas, SPT

References:

  1. http://www.apta.org/Blogs/Pulse/2017/11/Diversity/
  2. https://www.acapt.org/docs/default-source/reports/diversity-task-force-final-report.pdf?sfvrsn=2&sfvrsn=2
  3. https://ptthinktank.com/2017/06/12/rc-11-17-diversity-in-physical-therapy/
  4. https://www.apta.org/PTinMotion/News/2018/06/06/PTiMMagazineJune2018/
  5. https://www.evidenceinmotion.com/blog/2019/08/29/bridging-the-pt-diversity-gap/
January 20, 2020 |

Monday Memo 01/13/2020

The Monday Memo

January 13, 2020                                                                       PITT DPT STUDENTS

Death, Taxes, and Distance Runners Training Through Injury

I’ll start with a simple question that most runners get on a daily basis: “why do you run so much?” A good question nonetheless, but one where the answer truly never satisfies, nor is it one size fits all. Understanding this point is the key to treating the stereotypical distance runner.

I played basketball, soccer, and swam competitively all throughout my childhood, but gave it all up to focus on running track and cross country to earn a college scholarship at Pitt. To me, it was a sport first and foremost, a means to an end that would hopefully evolve into a lifestyle or a hobby that would stick with me through my adult life. To others, running can be an escape, a way to de-stress and retain focus and clarity. It is a form of community; it encourages healthy social interaction for many, and welcomes any individual no matter the experience or ability level. Exercise, weight loss, and various other health benefits also draw people in, but to understand the athlete, you must first ask the question: “why do you run so much?” Without the answer to this question, without understanding the motivation behind the athlete, you cannot understand and appreciate the method to our madness.

Many of us have experienced this exact scenario: runner comes in after initiating a program, they express concern over something they clearly feel is important enough to dedicate their time to looking into, and when you provide your analysis and utter the words “I think you should think about taking some time off,” you’ve lost them. I’d like to play a little unpopular devil’s advocate, as someone who has been told to take time off, and as someone who tells others to take time off. After the dust settles, instead of placing the blame on the runner for not following our recommendation, what if it is our fault for having the conversation the wrong way?  Einstein said that insanity is doing the same thing over and over and expecting a different result, so knowing the chances of success with this particular conversation, why do we still try to shut a runner down six weeks before the marathon?

I don’t have an answer, because the approach will not be a “one size fits all.” When it is definitive that an injury is too severe to run on, and it is evident to the therapist but not the patient, it is our responsibility to not allow that patient to be put in a situation where they could do potentially irreparable damage. When on the fence about shutting them down completely, I firmly believe airing on the side of caution can be as detrimental as running on a muscle strain or tendonitis. Physically they may feel better in a week or so if they take the therapist’s advice, but does that athlete want to come back when they have another set back only weeks from competition? Learn about your athlete and what motivates them, determine how you can help them achieve their goal/motivation, and develop a plan that works for you and the patient.

Just like all your patients, start with the goal, “I want to run the marathon.” If they are running because this race is the opportunity to run with their family member or for a cause they are passionate about, asking them to stop running may be the worse news they have heard in months. If they are trying to qualify for a bigger race or meet a certain time, they have invested countless hours into training and will probably not allow knee pain to keep them from achieving their goal until they are literally unable to walk. In my experience, knowing that my PT wants me to run my race, and understanding they are tailoring our sessions with the goal of getting me to the race, opens doors that can get forever shut simply by immediately suggesting time off.

I am not saying we should allow all our injured runners to run, I simply wanted to provide some perspective as to what the conversation might be like from the other side of the table. Running is a sport that involves a lot of pain and sustained discomfort, so it should come as no surprise that running through injury is very much a part of the sport. In my time at Pitt, I have had two navicular stress fractures, one femoral neck stress fracture, two hamstring strains, a quad strain, a partially ruptured Achilles Tendon, a torn labrum and FAI that required surgery, a concussion, back spasms, and just about every lower extremity tendonitis under the sun. I plan on going out for a 6 mile run later this afternoon, and I fractured my twelfth rib only three weeks ago. Why do I run so much? I run so much, simply because the work isn’t finished yet. I have the same level of dedication as the runner on your treatment table later today. I may be one of the more extreme cases, but just like the majority of your patients who are runners, every running injury I have ever had has come with the goal of getting right back on the horse.

-Joshua Trzeciak, SPT

January 13, 2020 |