Cultural Competency: A Therapist Trying to Understand America

This is a crash course in cultural competency from a wanna-be know-it-all trying-hard physical therapist trying to make his mark in the world.  Now, whatever I am gonna say would purely be based on my observation and may not entirely reflect the truth.  While it is impossible to paint a complete picture of what is America and what makes America America, especially one who is not really into the science of sociology and more into the informal art of people-watching, it does not hurt to at least try as seen through the eyes of a full-blooded Filipino. 

Let me give you a little background about myself then so you can pass judgment on my judgment.  I haven't been here very long in the US, and there are still a lot of things I am trying to get around to.  I am based in the State of Virginia, first from Chester, somewhere south of Richmond and then I moved up to the northern part of VA near Washington, D.C. when my former facility decided to go in-house.  My experience is limited to skilled nursing and long-term care rehabilitation, at least for now.  I am now working in a wonderful nursing home with a racially diverse staff and residents.  In the rehab department (speech, OT and PT), we have four Indians, two Filipinos, three Caucasians and one Hispanic. Interesting to note, too, that the four Indians have different religions: Islam, Hinduism, Sikhism and Roman Catholicism.  In the entire nursing home, we have a healthy mix of races from Asians to Africans to Latinos to Middle Easterns to Europeans for the staff.  The cultural diversity in this facility opens up your mind more to different cultures and beliefs that encourage acceptance and tolerance. I hope that what I will be sharing will give you a little bit of insight about the most culturally-diverse country in the world.  

Hablo español. Americans, of course, speak English but Spanish is gaining a strong ground all over the US as Hispanics are the fastest growing minority here.  At first, when I think of Hispanic, I only think of Mexicans.  I was wrong.  I found out that everything south of the US, from Mexico all the way down to the tip of South America, they all speak Spanish.  Except for Brazil, which speaks Portuguese.  So although, speaking Spanish is not a pre-requisite, it can give you an advantage in dealing with Spanish-speaking patients.  The good thing is, as some Filipino words are the same or close to Spanish, we can understand a little bit here and there about that particular language. Also, if you affectionately address your patient as dad/father in Spanish, don't use papa as it can be mistaken for potato (also patata in Spanish).  Use papi instead.

Weather.  I found it odd at first that people talk about the weather quite frequently around here.  Initially, I thought it was just some ploy for small talk.  But, no, people take the weather seriously around here.  In the Philippines, people don't talk about the weather very much, not unless a very dangerous storm is coming.  Back home, when you wake up in the morning and see that it's bright outside, chances are it will be sunny the whole day.  If it's gloomy, it will probably rain the whole day.  It's simple as that.  Maybe now with global warming, Mother Nature can't decide very well what to do with herself, the weather gets a little unpredictable back home but I would still bet on either a sunny day or a rainy day, period. Here, it is quite different.  It may be gloomy when you wake up, sunny at around 10 am, cloudy by 3pm and thunderstormy by 5pm and back to humid by 9pm.  It matters to know what the weather is because it affects safety on the road during commutes and rush hours.  However, you can lay off blaming Pag-asa all the time about inaccuracies in its reporting.  Even here in the US, they can't predict weather patterns perfectly all the time, so give the Pag-asa guys some slack.

Umbrellas.  Since I started talking about the weather first, let me go to the next topic at hand.  People here do NOT use umbrellas unless it rains.  We, Asians, are used to carrying our folding umbrellas to combat the scorching heat of the sun and avoid getting soaked in a down pour.  Here, umbrellas are only used during rainy days.  They do not use an umbrella for shade even during the summer when temperatures can reach a hundred degrees Fahrenheit (that's about 38 degrees C). The umbrella is solely for rain and sleet.

Rice.  Americans are actually in bewilderment in how Filipinos can consume so much rice everyday.  It is not that they do not eat rice, they do, but only once in a while.  Even my Indian co-workers, themselves having rice as a staple, are amazed by how much we actually consume.  Indians don't usually eat their rice plain, like us Pinoys.  They usually have something mixed in it like some curry dish.  So they are surprised that Filipinos actually eat rice for breakfast, lunch and dinner, plain rice at that, too.  I explain to them that Filipino dishes are designed to be very flavorful, hence bland plain rice is needed to temper the strong, delicious flavors.  

Traffic.  For us living in large Asian cities, we grew up in traffic and noise with senseless beeping and honking all around us.  Eventually, we have gotten immuned to it as it becomes part of our daily lives.  Here, traffic is the pet peeve of Americans even though I noticed that they almost never have bumper-to-bumper traffic like what we have back home.  If a regular ten-minute commute turns to a twenty-minute commute due to "traffic", they go ballistic.  Also, honking is considered rude around here.  You don't honk unless it is absolutely necessary.  You could trigger road rage by using your horns inappropriately.  Having said this, as the general population here drives, a big majority of them are pretty responsible drivers.  They really do follow the traffic signs and have a good grasp of road courtesy towards other drivers.  Not unlike back home when every driver feels like he is king of the road and you have to get through traffic with jeepneys, and pedicabs, and tricycles weaving in and out of traffic the whole time.

Handsoap.  Americans pour soap into their hands first before wetting them unlike us who wet our hands first before applying soap.  I found it odd at first not to wet your hands before applying soap but this is how they do it here.  Americans are also very particular with toilet hygiene.  That may be arguably limited to toilet hygiene, not hygiene in its entirety.  They want their toilets flushed after use and people to wash their hands after using the toilet to do number one or number two.  They would be repulsed if they found out we wash our bottoms with our hand and soap and water.  You could always argue that soap and water beats tissue paper for proper cleansing purposes but it just grosses them out.  They would also be grossed out if they found out our men pee anywhere, not wash their hands, sit back on the table to continue drinking with other men sharing a single shot glass for everyone.  Yes, I know you like to "strike anywhere" just like I do but hey, in here, you don't want to pee on that tree if you don't want to be called out for indecent exposure.  

Handshake.  The American handshake is firm and not too brief nor too long.  It is firm to signify truth and sincerity.  Not too brief because that would indicate disinterest and not too long because that is errr... creepy.  Now, we are accustomed to the Filipino handshake, which is relaxed and soft.  The Filipino handshake is soft for goodness sake!  I don't think it is because we are not sincere when we shake hands with other people but rather we associate soft hands with being elite.  Those who give firm handshakes are ruffians with rough dirty hands that are associated with having menial jobs.  Giving a soft handshake with soft hands indicate that you are educated and didn't really do a lot of housework for yourself.  Alas, not here though.  So when someone introduces their name to you and reaches out for a handshake, give him/her a firm and not too brief not too long grip.

Weekend activities.  Americans work the whole week.  Yes, you might say, well I work the whole week too.  Not really.  Filipinos work AND play the whole week.  It is not uncommon to grab a beer or two with friends after work, or maybe catch a movie with your girlfriend after work, or maybe go shopping with your friends after work, or maybe just hangout.  Bottomline is, a Filipino's workday doesn't end with you just going home, unless you are a really really busy mom or dad (which even then every once in a while you get a break).  In the US, they work M-F and seldom do stuff after that.  They work for the whole week and almost always have plans for the weekend.  They would ask one another about what are their plans for the weekend or what happened during the weekend.  I don't know about you guys but personally, I don't really like to plan weekends.  I'm good with having a very busy weekend or a very lazy one.  But as everyone here, again, wants to take the pressure off from working hard during the week, I understand why they want something less drab to do during the weekend.  Just a tip, you usually have to drive to get to bars and you gotta be careful if you drink or drive around here, you get yourself into some serious legal mess.  Also, you can't get too drunk and decide to go home by foot so as not to be caught drunk driving.  That would still land you in legal trouble for public intoxication.  So if you plan on getting buzzed and wasted during the weekend, your option is to have a non-drinking friend be the designated driver or to stay at home altogether and get wasted there instead. 

Eating shrimp.  Americans cannot eat anything that has a head and a face staring back at them.  They cannot eat shrimp or squid with their heads on.  Heck, some can't even eat anything with bones on them like chicken (boneless chicken like nuggets are okay for them).  Squid, if it's too small, is not food for them, it is bait. Shrimp, they can only eat if it's headless.  Few of them will try dinuguan unless they are ignorant of what it's really made of and fewer still will brave eating the notorious balut.  On the brighter side though,  almost all Americans I know who have tasted the world-famous Philippine Adobo  have all praises for the dish.  And they mention it just out of the blue.  Like I have a patient who when she found out I was from the Philippines said: "Well, my grandson just married a woman from Philippine and oooooh that woman from Philippine is so sweet and she makes this wonderful dish..what, it's called..what, it's called...oh! adobow!"  Sometimes, I think that adobo will bring the Philippines recognition faster than our now growing economy and our wonderful beaches.

Freedom.  Americans value freedom more than anything else and that is why the American president is considered the leader of the free world.  Having said that, respecting personal space is something they all exercise here to the limit.  That means my business ain't yours and your business ain't mine.  Unless I do something illegal, you have no right to interfere with my life, my home, my backyard or whatsoever. It is inappropriate for you to give me advice unless I ask for it, tell me how to do my job unless you are my superior, tell me how to raise my children etc. Back home,  if it's someone's birthday, you do your videoke, disturbing the peace of the neighborhood, until midnight or something like that, and the neighbors seldom complain or send the police over as long as it is not too much, knowing that you will give them the same consideration if they will celebrate their birthdays with a bang like you are doing now.  Here, you have to take that ruckus down or else the police will be knocking on your door.  Though it is true that you have the right to do what you want as long as it is not criminal, your neighbors also have a right to peace and not be disturbed by the uber-energetic party animal that you want to be.  

My friends, this is all that I have for now, I'm sure as I discover their culture more I can share more with you.  I am very open to corrections and if other people would like to share their experiences and observation, I would welcome it, too.  Again, my insight is far from perfect and I tried to generalize everything.  In the end, we are all unique and not one quality can define us all.  For those of you who are not here yet, I hope this helps you understand the country you want to work in even just for a little bit.  For now I bid you all, adieu!

Coping With Medicare Changes

Some of you may have read my previous blog post and worried yourself sick over the future of PTs in the US.  Some of you are students, some are professionals on the path to achieving their US license and some are already PTs in diaspora scattered throughout the US.  Now, after reading my last blog entry, a little hope might have died on you or you may have lost a little faith in yourself and in your future as a therapist in this country.  This blog entry I am now writing, is intended to restore whatever was lost in you and make you dream big again.  

Once more, I am no expert in Medicare as well as in the many different practices of healthcare in general and physical therapy in particular.  Therefore, I would very much welcome all statements and comments from other US PTs in our community to help clarify the real goings-on in our practice.  

The thing I want all of you to engrave in all of your being is that there is a need for PTs in the US.  There is a need because the baby boomer population is getting older and they would need therapy eventually.  There is a need because PT programs here reach a staggering seven-year curriculum to get a DPT.  Education is very expensive in the US.  Unlike in the Philippines where it is considered the parents' responsibility to send their kids through university, here people work to get themselves an education.  A whole seven years to spend schooling is seven years of maintaining high grade point averages while working at least one job on the side.  Most people would have a hard time coping with such a schedule.  Thus, fewer Americans are taking up physical therapy as a career and as older American PTs go to eventual retirement, they would need replacements and even more PTs to keep up with the demand from baby boomers.  Most likely, they would hire Indian and Filipino PTs because of our good command of English and very close resemblance of our PT school programs to theirs.  

Now I did mention of Medicare going bankrupt and the Manual Medicare Review being a pain in the ass in my last entry.  It is largely out of frustration that I blurted that one out.  Though the fact remains that Medicare may run out of money if drastic reform is not undertaken to curtail unnecessary expense and fraud, I am hopeful that the reforms they will apply are reasonable and can be worked with.  The Manual Medicare Review (MMR) will eventually become more organized and efficient and will be streamlined with private insurance company procedures.  Now, private insurance companies may be stingy with the amount of treatment they would be paying for the patient (like allowing only 10 treatment days instead of the fifteen days you would request to work with a patient) and are also very demanding with paperwork, private insurance companies are efficient in their delivery of benefits.  It is like you contact them regarding a patient under their insurance policy, send them the necessary paperworks including your prognosis and expected outcomes for the patient, you would usually receive a reply from them within the next two days.  MMR, on the other hand, would take a month to process everything and send out a reply to you.  However, once the MMR system becomes more organized, delivery of services and reimbursements will be faster and more efficient.  

I would also like to clarify that the mess that MMR has gotten us into, so far has no effect on Medicare A patients.  Medicare A covers hospital care and that means PTs working in acute care rehab (hospital in-patient) and skilled nursing facilities (sub-acute care) are not affected.  MMR affects outpatient services under Medicare B which includes homehealth therapy, outpatient rehab and long-term care such as nursing facilities.  (Take note that a skilled nursing facility is different from a nursing facility. A nursing facility is basically a nursing home, a retirement home for the elderly  where the patients are usually long-term whereas a skilled nursing facility is more of sub-acute care.  Patients in SNFs are usually short-term; they are those that don't really require very close medical monitoring but are not yet healthy enough to go back home.  It is not unusual that a nursing facility may have several skilled bed units or a skilled nursing facility have some long term care residents).  The new Medicare changes will have the MMR process continued for this year, so hopefully those running the system start getting the hang of it and get things done faster.  To cap it all, life goes on easy for PTs working in SNFs and hospitals but PTs working in nursing homes, home health and outpatient facilities will have to make necessary adjustments. 

Another point I would like to stress out is that the demand for PTs continue to be really high in many parts of the US.  We probably never hear of them because almost all of our peers are concentrated on the Eastern and Western seaboards.  Almost everyone is in NY, NJ, California, Florida, Illinois, Maryland, Washington and Texas.  These become supersaturated with PTs that it seems you won't be able to find another place to work at if you move.  However, if you think about many other mid-Western states and other states without the very large metropolises, this is where PTs are needed most.  Think New Mexico, Arizona, Alabama, North Dakota, Oklahoma, South Dakota, Ohio, Oregon, Missouri, Iowa, North Carolina, Tennessee, South Carolina, Louisiana and Mississippi.  In these places where it is less flashy and more quiet, you can get the most out of your money.  I live in Northern Virginia, about thirty minutes from Washington DC, and I pay fourteen hundred for a two-bedroom apartment.  My friend in New Mexico pays five hundred for a three bedroom house with a fenced yard.  I get paid slightly higher than her but with the cost of living here, she gets a whoooole lot more for her money.  Try living in New York and your wallet would hurt more. True, you probably would have to drive at least two hours (or maybe five) to get to something exciting over there in New Mexico.  And true, Washington DC is but a half-hour drive for me.  But the fact remains: How many times do you really need to see the White House and get your picture taken before you're satisfied?  Even in a big city like New York, you won't even be able to enjoy exploring it if you are working hard five times a week.  At the end of the day, it is best to pick a place where you have a good work-life balance.  And another tip, if it is possible, don't pick a state where there are a lot of Filipinos.  You'd be free from all the drama and pataasan-ng-ihi events.  It is best to pick a state where Filipinos are afew and therefore are a much tightly-knit and closer community.  You'd thank me later. 

Finally, my friends, our best defense against evolving Medicare regulations is to hone our ability to perform a very necessary but seldom emphasized skill in the clinic: documentation.  In the Philippines, we take for granted writing notes because 1.) we directly communicate with a patient's family and his doctor regarding his progress and 2.) we copy/paste our notes for almost all our patients involved (e.g. PT Note dated today:  Pt was seen with the same management as so-and-so date.  Pt tolerated tx without untoward incidents.)  We write this PT note for all our patients sa Pinas.  This is way different how we do things here.  Our notes  are more detailed and functional progress (or regress) should be stated clearly and in a meaningful, complete but concise detail.  In order for you to be able to do that, first of all you should be keen in your observation and evaluation of your patients.  I mean, how can you write a good, accurate and scientific PT document, if you don't even know what to observe in a patient in the first place, or what questions to ask the patient in an interview or if what a patient is explaining to you may even be relevant in your note-writing?

Your clinical decision-making skill will be called upon if you want to keep a steady caseload.  It is very important to know how to screen patients who are appropriate to be picked up by physical therapy.  Take note that I used the term "appropriate" instead of "need".  Not all patients who need therapy are appropriate to be picked up by physical therapy.  It is you who make a clinical determination of that.  Remember that the appropriateness of giving skilled physical therapy services is among the factors that will ultimately determine denial or approval  of MMR.  Modesty aside, since October to early December 2012, from among the fifteen or twenty patients that I have sent out for MMR, I only had one denial.  That denial was based on technicality (wrong Medicare number or something) so that isn't my fault.  The reason for my success with the MMR process is simple: proper and complete documentation.  I am not saying my notes are perfect, but they are definitely suffice to the standards set by Medicare.

As I conclude this blog entry,  let me leave you with some advice.  1.) Don't worry about the future of PTs in the US; we have a good future here.  We are skilled professionals.  People will get old, people will have fractures, people will get sick.  There will always be a need for us.  Worry ka ng worry sa future mo hindi mo nga mapasa-pasa yang lintek na TOEFL na yan.  Focus on the present first and later on decide to cross the bridge when you get there.  2.)  Despite the rumors (or urban legend :-D ) that documentation is really hard, the truth is, it is only hard in the beginning.  Once you get the hang of it, it will just flow more easily from you. 3.)  Learn to drive.  Unless you want to live in NYC where you can get anywhere with trains, anywhere else you would need to be able to drive around.  So before you leave the Philippines, take some driving lessons (with an automatic transmission car); it will make your life way easier and acculturation way faster. 4.)  If your main goal of going to the US is just to earn money, you will never be happy here.  Better stay in the Philippines with your loved ones than come here and hate your job and situation.  To be satisfied with your lot in life as an expat PT, come here to LEARN first, and to EARN second.  Money is not the end-all and be-all of your life as a PT.  Happy New Year to all and I hope nabuhayan ng kahit konti ang mga pangarap ninyo.

P.S.  I would very much appreciate comments and additional information that you guys would like to add to paint a more complete picture of our experiences here.  Let us work hand in hand to ensure that more PTs will discover their true calling as extensions of God's healing hands. 

P.P.S  For the grammar Nazis, my apologies.  Tao lang po. 

How Medicare Reform Can Affect Your Future as a Physical Therapist

I originally wrote this piece on the 31st of December 2012 but unfortunately was unable to finish it until now.   It is the fourth of January, and the both Houses of the US Congress has finally set a deal a couple days ago preventing the much feared US fiscal cliff from happening. 

The US fiscal cliff is an economic apocalyptic event of drastic spending cuts and dramatic tax hikes to reduce the US budget deficit.  With spending cuts, jobs will be lost resulting in decreased consumer spending.  Decreased consumer spending means companies, for example Walmart or McDonalds, will not be hiring more people when they don't have a lot of costumers to cater to.  Otherwise, they might also start laying people off.  Imposing tax hikes means less money for every family to spend and presents the same effects regarding decreased consumer spending.  This will send the fragile US economy back into recession and will pull the world down with it.  Which leads me to my next point, what does it have to do with healthcare workers, in particular physical therapists?  Let me explain.

Medicare alone accounts for almost $600 billion in 2010 and is expected to rise to more than a trillion bucks in 2022, when most of the baby boomer generation would require more health services.  All physical therapists based in the US, in one way or the other, are dependent on Medicare reimbursements for their services may it be in out-patient clinics, home health services, skilled nursing facilities, nursing facilities or acute care rehab.  If this fiscal cliff happened, and the s--t hit the fan, cuts to Medicare will seriously affect delivery of care to patients and may result in loss of employment or underemployment for therapists.  For foreign trained PTs, like us from the Philippines, it may be harder to get working visas when there are no jobs available to start with. There is always talk of increased demand for therapists as the baby boomer generation enters their twilight years and would need more help to increase mobility, improve function and quality of life but the lingering question is who is gonna pay for their therapy when Medicare cuts are implemented here and there? Most won't be able to pay out of pocket.  Our skilled services are expensive so to speak as new PTs here spend an average of seven years to be a DPT. However, I personally think it is justified how much we are compensated for our services. 

 I work in a nursing home with a few skilled beds so I cannot really speak in behalf of other PT specialties but let me explain this one too.  As a PT, my job is not only to evaluate and make a program for every patient I have, short-term care or long-term care patient it doesn't matter.  It is also part of my job to constantly assess the patient and be in constant communication with other therapists (OT and speech) as well as nursing (which basically encompasses a broad base of unit nurses, restorative nurses, Medicare nurses, unit managers and nursing assistants/aides) with regards to the overall health of the patient.  Everyday that I work with the patient, therefore, I am evaluating him if he is making progress, if this program is working for him, if he is at baseline and most especially, if something is off with him.  I don't have to diagnose what is wrong with him as that is not part of my job but it is my job to let everyone involved in his care know that something isn't right and has to be put into observation or noted.  There are times when a patient is making good progress and then gradually declines for no obvious reasons.  Having reported it to nursing, nursing may reveal that his medications may have been changed and when they found out that the patient is not doing so well with the new meds may contact the physician.  To make the long story short, a therapist is involved in a large part of patient care and as we play a central figure in restoring patient function and overall quality of life, it is only right that we are paid decently for our clinical judgment and responsibilities. 

With a deal reached in Congress, the 27% pay cut to doctors (and by extension to us, therapists) will not happen, or perhaps more accurately,  at least not now.   However, Medicare reform will soon be an area of great interests to the politicians as they try to rein in the cost of healthcare.  According to Wikipedia, only less than 5% of all Medicare claims are evaluated, which means that 95% or more of claims get refunded without adequate verification of appropriateness of reimbursement.  Having said this, many firms, both bogus and legal, have turned Medicare into their cashcow, essentially draining the system of much needed funds faster than these seniors can go into full retirement.

In New York alone, Medicare must be losing hundreds of millions on fly-by-night physical therapy clinics that are essentially hot-packs-TENS-factories that change names every two years to avoid detection from government agencies for fraud.  These clinics, employ unlicensed PTs to treat dozens of patients a day and are in cahoots with a licensed therapist who comes in only once a week to sign documents to make the operation appear legal. I know this for certain as I have a couple friends verify this.

Insurance fraud such as this adds up to the bankruptcy that is facing the Medicare system in the face.  Many reforms have been introduced and as recently as October of last year, they introduced Manual Medicare Review (MMR), towards which they hired (I assume) non-healthcare professionals to assess, evaluate and approve or disapprove request for more therapy for patients who have reached their caps for the year.  A cap is the maximum amount of money that Medicare can pay for each patient receiving skilled therapy for the year. If the patient goes beyond cap, theoretically he has to pay out of pocket. Before the MMR, even if the patient reaches the cap, a therapist can write justification explaining why the patient would need more therapy despite having used up his money for the year.  With MMR, you are only allowed an evaluation once the patient reaches cap.  Then all the necessary documents pertaining to the patient will be sent out to the agency performing the MMR, on which the agency will have ten business days to decide and approve or deny the evaluation and need for therapy.  Their response will be sent out via snail mail back to you. 

I will say it up front.  The whole MMR process is a mess!  A big, and utter mess!  For starters, ten business days is two weeks from evaluation.  Add the days for completion of documents and the days for snail mail and you are looking at at least three weeks (or in my experience even two months!) before you get to know if you can start treating a long term care patient.  How in the fucking world can you expect the patient to stay at the same level, set the same goals for the patient after evaluating him a month ago? How in the world do you expect the patient not to have declined in that span?  For example,  I have a patient evaluated for a fall and I sent the patient's paperwork out for MMR.  The evaluators took their damn sweet time processing the papers and I received a reply more than a month later approving twenty treatments for the patient.  By that time, the patient has had fallen two more times and has now progressively weakened from the pain and the fear of falling again.  How in the world do they expect me to fix him now?  I'm pretty sure I need to re-evaluate him as his needs, level of function have changed.  But I can't!  Because if I do, I would have to wait for God knows how long again before I get their reply.  By then I'm not even sure if the patient would still be alive.

The inefficiency of those doing the MMR was so blatantly upsetting, that by the end of the year, three months after the MMR was introduced, I was left with only two patients to see.  Two patients mean I can only stay for work for a very short time thus leaving me broke by the new year.  Many other therapists who work in nursing homes also reflect the same sentiments.  And all the papers I sent out are just there awaiting nothing, no response from MMR whatsoever.  I have sent out at least ten patient evaluations and no response from them.  It was very frustrating and my fear is that this Manual Medicare Review might go on as the future of Medicare reform.  This does not bode well for the future of the healthcare practice and professionals.  But most of all, it does not bode well for the quality of life of patients.

It becomes a big irony when they tell you the need for PTs will continue to rise in the future as more and more baby boomers get older and need therapy but at the same time the politicians are looking at choking the lifeline of these same health care professionals and eventually driving them off the workforce.  We can only pray that they would know better and make better recommendations at health care reform.  Before we all drive ourselves and jump over a real cliff.