Monday Memo 04/27/2020

The Monday Memo

April 27th, 2020                                                                       PITT DPT STUDENTS

The Bioethics of a Pandemic: Navigating the Moral Challenges of a Global Health Crisis

This public health crisis we’re all facing right now has forced everyone to ask impossibly difficult questions of themselves and others. COVID-19 has impacted nearly life in our nation and worldwide. Undeniably, a lot has been lost: physical connection, employment, a shared sense of health security, and most devastatingly, human lives. In this time, I’ve learned (with help from others) that very few good things come from comparing someone else’s suffering to your own. Sharing the burden of suffering… now that’s a different story. We are ALL going through things that are incredibly taxing right now. Consider it like this: we are all in the same boat, but not in the same storm.

If you couldn’t already tell how much self-reflection this quarantine has sparked, it’s a new level over here – and I have been thinking a lot about ethics. To begin the conversation on bioethics, I want to make the distinction between the two terms, ethics and morality. Although exact definitions are disputed, ethics is generally thought to be the practical, guiding principles of “right and wrong” conduct that is distinguished by certain communities, while morality is the principles of “right and wrong” based on a more subjective, individual code of beliefs. That said, “bioethics” or “healthcare ethics” is a branch of applied ethics studying the implications of the philosophical, social and legal issues arising in medicine and life sciences.

             As if these concepts and practices weren’t difficult enough in “normal times”, add a pandemic to the mix?! I have been mulling over all the different topics of concern in bioethics right now, and I won’t lie, it is a bit overwhelming. Here are a few pressing ones on my mind (certainly not all-inclusive):

  • Allocation of scarce resources – most pressingly: ventilators/medical equipment, PPE, food, and monetary support.
  • End of life decisions, especially for those without a pre-determined preference. (shout out to Atul Gawande’s wonderful book, Being Mortal.)
  • Balancing individual (patient-centered care) and community health (patient care guided by public health emergencies). This includes clinicians following triage protocols that may cause them moral distress, since they have had to change their usual practice.
  • Ethical issues surrounding human vaccine trials and expedited research.
  • Wellness vulnerability of undocumented or low-wage immigrants, as well as people that are impoverished or homeless.
  • Damaging impact of spreading misinformation, which can lead some to respond in a way that puts themselves/others at an increased health risk.

I don’t mean for this to stir up fears (or even more anxiety) on top of what we are all already feeling. These conversations are difficult, but necessary. I often find myself exhausted from the 24/7 pandemic coverage and have to ration my intake of news. Taking inventory of my emotional capacity is one aspect of self-respect that I’ve engrained into my own moral code. Something I’m constantly struggling to follow. And not for everyone. But whether or not we watch ALL the news or only some, we should acknowledge that there is definitely an obligation to stay informed for the sake of our collective health. This leaves us with a tricky balancing act – watching for safety and not watching for sanity. Some tips: pick a few reputable sources, check in with them in a way that honors your emotional capacity, and then step back.

PT school has given me the tools to begin these conversations around bioethics, but I certainly can’t do it alone. By having these exchanges with others (as you’re able), we can build up our own moral toolkit. Taking a piece here and there from the people we admire. Take lessons now from the brave work of our PT colleagues in hospitals across the nation, who are acting out the highest form of APTA’s “altruism” value. Now it’s our turn to practice APTA’s “social responsibility” value by staying home! There is no easy answer for these modern bioethical questions, (a lot of them answered by the classic “it depends” PT school answer). But as I like to think…. In the words of Pittsburgh’s dear Mr. Rogers: “Anything that is human is mentionable, and anything that is mentionable can be more manageable.”

-Hannah Davis, SPT

Monday Memo 4/20/2020

The Monday Memo

April 20th, 2020                                                                       PITT DPT STUDENTS

Psychologically Informed Care

For many people across the globe, 2020 has been a particularly challenging year thus far.  With the COVID-19 Pandemic, a sequala of stressors are arising in conjunction with anxiety, depression, increased incidence of domestic violence, alcohol/substance abuse, PTSD, and other mental illnesses throughout the world.  With social distancing in effect in many areas of the United States, many people are feeling alone and fearful in the midst of uncertainty.  It is CRITICAL during this time to be aware of signs and symptoms consistent with mental illness when we are interacting with those around us.  Then, you must be aware of ways to support yourself, your loved-ones, and your patients through this challenging time. Although, as students, we are not seeing patients currently, these are key points to take with you as future clinicians.

Stress has many physical manifestations that mirror common impairments we see in the clinic such as muscle pain, fatigue, spasms, tightness, and high blood pressure.  It is important to be aware of psychological triggers for the pain the patient is feeling, as well as physical causes.  As physical therapists, we often see patients for longer durations over an extended period of time.  Due to this length of treatment, patients share information with us that they have not yet shared with other medical professionals.  Listen to each patient when they talk, because they could provide you with a wealth of knowledge regarding how to best support them.  For example, Mr. Covid is a 52-year-old man referred to you for chronic low back pain.  You evaluate him, and it appears that he has a standard flexion-preference.  You treat him for five visits, he misses a week of treatment, and when he returns for visit six, he states that his pain “just doesn’t seem to be getting any better.”  You start talking to him about his home exercise program, and he tells you:

“To be honest, I just have not found any time to do it.  I was laid off because of this pandemic and have been spending four hours a day sitting in front of my computer trying to find a new job.  My wife is an ER doctor who has been working 12 to 14-hour shifts, and we have four children that I am taking care of and homeschooling alone.  I just am not doing so well right now.  I’m stressed, I’m eating everything in my house, I miss my friends, family, and coworkers, I’m not sleeping enough; this back pain just makes it all so much worse!” 

This patient report, although fiction, doesn’t seem very unrealistic, right?  It could be easy to write “no progress noted.  Pt. non-compliant with HEP” on their chart and move on with your treatment plan as scheduled.  Using psychologically informed care, the information that Mr. Covid shared could be critical for his mental AND physical progress.  Being the skilled-PT you are, you say to Mr. Covid:

“I hear you are going through a lot right now between losing your job, caring for your children, and this back pain that just doesn’t seem to go away.  Unfortunately, the stress you are under could be contributing to your back pain.  I really would like you to start working on some mindfulness techniques at home to help you destress; I will show you them at the end of the session.  If your wife is feeling stressed as well, these could be great to teach her, and you could practice together!  Every thirty minutes that you are at the computer or homeschooling your children, I would love for you to integrate some sort of activity break in – such as dancing with your children, doing a lap around your house, or some other form of activity for 5-10 minutes to break up those long intervals of sitting.  Today in the clinic, let’s do some milder activities to calm your back down, and modify your home exercise program so they are activities that you will have time to complete throughout your day.  This pandemic is incredibly challenging for everyone, and I want you to know that you are not alone.  Do you think you want to talk to a mental health professional about your stress?  If so, I know someone great who I could refer you to!”

               As Pitt Physical Therapy students, we often discuss the term “psychologically informed care”, but what does that term mean to each of us future clinicians?  According to 2nd Year DPT student Paige Paulus, psychologically informed care means being aware of the patient’s perspective; “Sometimes it isn’t about pushing what you want to do on them, it is adapting their treatment so that they can heal to the best of their ability.”  Christina White, a 2nd Year DPT student stated that it means “being in tune with the psychological factors that could be a barrier to care, but also aware of aspects that could promote care.  For example, if someone is motivated and ready to go, that is psychologically informed, but so is the opposite side of that continuum where a patient is not motivated.”  To 1st Year DPT student Nikki Ray, it means “recognizing when a patient is struggling mentally and noticing when they have their guard up and not pushing them past their boundaries.  They could have their guard up because they don’t want to get reinjured, or something else may be going on.”  2nd Year DPT student Kalli Seibert stated that, “for me, the psychological piece of treating patients is one of the most important parts; if you aren’t listening to what the patient needs to be successful, your outcomes will not be as great.  You could heal their body, but you will not leave a lasting impact.  In Women’s Health, we get a lot of patients who have many factors affecting their physical and mental health.  In my experience in this area of PT, using psychologically informed care is a key part of every treatment.  Patients may not remember the exercises you gave them, but they will remember what you said to them and how you made them feel.  You are not just treating them so they get better musculoskeletal-wise, but that they are also getting better emotionally and have more confidence in themselves after each session.”  2nd Year DPT student Kara Kaniecki stated “to me, psychologically informed care means being an active listener. Listen to your patients when they talk and listen to the way they say things. Listen to your patient’s body language. Observing how they present themselves can be so important when trying to understand how your patient is truly doing. Psychologically informed care means that your patients may have so many things going on outside of your therapy session. Their spouse could have just passed away. They could have just been fired from their job. They might have just failed an important exam. We need to take into account how their mental health is affecting them and how our treatment sessions can improve their health both mentally and physically. We need to keep our patience and empathy at all times. We need to do what we can to make our patients feel comfortable with us. PT shouldn’t be another stressor in a patient’s life! We are trustworthy and great communicators. Let us show our patients that as well.”

The Pandemic will come to an end, and we as a society will move through this… but some of the psychological complications of COVID-19 could last a lifetime.  As future healthcare professionals, it is crucial to listen to our patients, support them, and make appropriate referrals as necessary.  Be open to talking to your patients about their mental health as well as physical health.  Use your motivational interviewing and listening skills early and often for each patient that you encounter.  Additionally, just as the SBIRT training suggests, screen each patient, provide a brief intervention, and refer to treatment (whether that be for alcohol/substance abuse or mental health resources) as necessary.

As far as what we can do RIGHT NOW to make a difference: reach out to those around you who may be feeling alone during this time, be kind to each other, and most importantly—take care of yourself and stay healthy.  Our future patients are counting on us.

Mental Health resources posted by the University of Pittsburgh Counseling Center:

-Mariah Callas, SPT

Special Thank you to Paige Paulus, Christina White, Nikki Ray, Kalli Seibert, and Kara Kaniecki for their valued input.

Monday Memo 04/13/2020

The Monday Memo

April 13th, 2020                                                                       PITT DPT STUDENTS

My Day In An Interprofessional Education Program

In the fall, I was lucky enough to be chosen to spend a day at UPMC Presbyterian engaged in an interprofessional educational program. Our own faculty member, Dr. Vicki Hornyak, is the director of this program. I have since reflected on this day and how I believe that it has helped me develop my professional skills in the clinic. I am truly so grateful for this experience and hope to relay some things I’ve learned to you all.

I was partnered up with a nurse on the 5G unit, which often has a lot of patients with neurological injuries. The patients were often medically complex, requiring a variety of specialty team members such as neurosurgery, orthopedic surgeons, physical therapists, and everything in between. We started off the day with introductions and learning about each other. We were around the same age – she was a younger nurse who had just started at Presby a few months prior and I was a second year DPT student who was just starting a clinical rotation at UPMC Mercy.

We chatted for a bit about her morning routines – checking in on the patients, giving out medications, talking to the physicians and giving updates on her patients. She gave me a quick run-down on what the drugs were as she administered them to patients and provided me her thought process for patient care every step along the way. I really appreciated how in-depth she explained everything to me. Not yet having pharmacology, I did not know a lot about medications. She was understanding of this and was excited to teach me. I was excited to teach her a little bit about physical therapy as well.

Throughout the day, we talked to occupational and physical therapists, speech therapists, neurosurgery physicians, medical students, medical residents, plastic surgeons, and so many others that I cannot even recall. Nurses are responsible for their patient’s entire plan of care and whoever may come along with that. I never realized how much of a nurse’s day is spent checking in with other professionals. I felt as though every few minutes she was answering her phone, whether it was patient call bells or physicians. Before I knew it, it was time for another round of medications. Even though we did not do physical work all day, we were constantly busy.

Something my nursing partner said to me that will always stick in my head is “I wish we could have done this when I was in school. I didn’t know half of the things you guys did in the hospital.” This is why interprofessional education while we are still in our schooling programs is so important. I was able to learn so much about what a nurse’s day looks like. I never even could have imagined half of it. Even though our day was pretty calm and uneventful (a good thing!), she was busy nonstop. I have come out of this experience with so much more admiration for our nursing coworkers.

Whenever I become a licensed therapist, I will now have a new perspective towards others in the inpatient environment. If I’m trying to clear the floor for PT and cannot get a hold of a nurse, I need to understand that they have so many other things on their plate and talking to me might be the last of their priorities at the current moment. Open communication and teamwork lead to better patient outcomes. We all want what is best for our patients, and together as a cohesive team, we can make that happen. I hope more people get the chance to have this opportunity, and if any of you reading this get the chance, please take it!

-Kara Kaniecki, SPT

Monday Memo 04/06/2020

The Monday Memo

April 6th, 2020                                                                           PITT DPT STUDENTS

Thoughts From an SPT Regarding COVID-19

As paranoid thoughts begin to fill barren grocery shelves, it is safe to say that 2020 has been off to a rough start. Sports seasons canceled, universities shutting down, countries closing their borders. But the ultimate stinger, in my opinion, was the death of Kobe Bryant. The coronavirus has spread like wildfire, quite literally. It has been a combination of unfortunate timing and lack of preparation. At the onset of COVID-19 in the United States, many people had spring break trips planned and refused to abandon them even when the severity of the pandemic started to break news. Many universities began to cancel study abroad trips at this time, but nothing was done at the federal or state level to restrict travel and large gatherings until a few days later. A recent video went viral showing college students refusing to cancel their trip to the beach in response to COVID-19, citing reasons such as “just trying to have a good time” and “whatever happens, happens”. These outliers are what I like to call “COVID-iots”. Statistically speaking, we are the age group that is least affected by this. But the majority of us millenials/Gen X’ers do not sympathize with them. We are not the problem, we are the solution. Now more than ever, there’s an astronomical need for healthcare professionals. Millennials are now just entering the workforce. That means we are the next generation of healthcare workers. From my PT class alone, I see 61 other individuals who are more motivated than ever to offer their contribution to the world. We all joke with each other about this grueling situation that we are facing together but when it comes down to it, we all handle it with the utmost seriousness. All of us are being vigilant about social distancing in an effort to flatten the curve, for the sake of our patients, our friends and our loved ones. 

I see light at the end of this tunnel. This extended period of social distancing can get boring, but also hosts the potential for individuals to pick up some healthy habits. As we shift into spring, take advantage on the rare occasions that the Pittsburgh sun uncovers underneath its infinite clouds. Vitamin D is essential if we want to stay sane. Personally, I have been trying to stay active by running or biking alone outside, catching up on much needed sleep, and taking care of myself (I’ve discovered a newfound passion for flossing). Use this free time for self care. Put your mask on first before helping others. Facetime with loved ones who you cannot visit. After all, social distancing does not equal solitary confinement. Partake in some social media challenges, make tik toks. No one will judge based on your screen time. 

Never in my lifetime did I expect to experience a pandemic. Hospitals are ground zero. Antarctica is now arguably the safest place in the world. Nearly every aspect of our lives has been altered because of a stupid microorganism. But I know all of these protocols are implemented for the greater good. As citizens of the world, we have a duty to our neighbors to be responsible in the coming weeks in who we interact with. Healthcare workers, thank you for your bravery. Sacrificing your health for the benefit of others is the ultimate display of altruism.

In conclusion, stay away from others. Wash your hands. Cover your mouth. Stop buying all that toilet paper. Don’t be a COVID-iot. Thanks for attending my TED talk.

P.S.: Please stop calling it the “Chinese virus”. Viruses do not have an ethnicity. 

P.S.S.: With spring comes seasonal allergies. Do not be alarmed just because someone sneezes.

-Sam Yip, SPT


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