Philippine Physical Therapy---In Crisis?

(Disclaimer: This blog entry is created solely for entertainment purposes.  The content of this entry is the sole expression and opinion of its author and does not necessarily reflect those of any other entity, organization, company and such.  The characters mentioned herein are, uhm, to cover my behind, entirely fictional.  Any likeness to actual persons, living or dead, are, yeah, strictly coincidental. True story, bruh.) 

The future of physical therapy in the Philippines is in crisis and you may not even be aware of it.

No, I am not just talking about the steady stream of therapists leaving the country in search of greener pastures in first-world countries with a rapidly aging population, most notably the United States. Or that because of the hiatus of hiring of PTs in the early turn of the millennium resulted to a drought of PT graduates to replace those who have already migrated.  Or that the recent batches of PT graduates opt to prepare for the NPTE as soon as they pass the local licensure exam instead of opting to get experience first in their community hospitals and health centers.  True, all of these contribute to the sustained decline in the quality of delivering physical therapy services in the Philippines.  But what could be the biggest factor in this continued deterioration is us--the physical therapists ourselves and the culture we have grown so accustomed to.  We are slowly asphyxiating our own profession, our calling, our service and our unique practice.

Most of us are probably unaware of it.  But throughout the years, we have developed a PT culture that is closed-minded and clannish.  Arguably, the best years of Philippine PT practice was in the late 80's to the mid-90's, when we were producing therapists who were top-notch and brimming with clinical competence.  After that, the slow and steady decline began, and we haven't even noticed it.

Are Physiatrists Over-reaching Into Our Practice?

One of the main reasons that our profession is as it is right now is that we have made the  practice of Physical Therapy so physiatrist-centered and thus, medical management has completely taken over the rehabilitation process, pushing nursing care and physical and occupational therapy to the sidelines.  The result is poor patient outcome once they are discharged from acute care.  Let me get this clear, though; I am not blaming the physiatrists for what our practice has become.  In fact, the person I most look up to as a physical therapist was my dean, friend and mentor who is a physiatrist. What I am saying though is that this captain of the ship principle has gone too far. Philippine PTs have vague recognition as to what a physiatrist really is; most of us know that they are the head of the rehab department.  In truth though, they are medical doctors trained in the medical aspect of physical rehabilitation.  Ergo, they are largely knowledgeable in medications and pharmacology affecting physical function and movement; they are experts in performing and interpreting medical and special tests to determine the source of pain and physical dysfunction; they are adept in providing treatment alternatives to surgery; and because of their diverse awareness in multi-system affection that impact physical function, they serve as the primary contact person or lead practitioner in a medical team that may include therapists, neurologists, orthopedic specialists, cardiologists, pain specialists and such.

So, being doctors of physical medicine and rehabilitation and head of the rehabilitation department, it is their responsibility to make the plan of care and for the therapist to follow that plan of care, right? Both yes and no. By law, yes; a therapist cannot evaluate and execute a plan of care without the signed approval of a physician.  Take note, people, a "physician", which means that other doctors can sign off on the order and the therapist plan of care.   It is not exclusively the physiatrist that can give physical therapy orders.  Therefore, as a PT, by law if, for example, an orthopedic surgeon has given PT orders and your resident physiatrist is out for a few days, you can evaluate the patient and establish a plan of care.  That plan of care can be executed immediately providing the surgeon agrees to it and signs off of it.  You do not have to wait for the physiatrist before you can implement a plan of care.  
And although the physiatrist is an expert in physical medicine, they are NOT trained in specific therapeutic exercises, modalities, manual therapy and such.  They are NOT experts in training a patient in the proper, safest and most efficient way to transition from supine to sitting at the edge of the bed. They are NOT trained in teaching a patient how to use a walker and how to walk with it safely with the correct hand and foot placement and even advocate for compensatory strategies when a physical limitation cannot be overcome.  They are NOT experts in fitting and measuring wheelchairs and assistive devices for patients with different disabilities and positioning needs.  Those things I just mentioned (and many more) is the job of (you guessed it right) the physical therapist.  It is our responsibility, our task, and our job description to the T!

Now let me be the one to call out that although I recognize the physiatrist as the head of the rehab department in the Philippines, I find it utterly ridiculous and reprehensible that he/she will limit my ability to exercise my clinical decision-making by boxing me in with orders for PT to execute a combo-meal style exercise prescription every single time! And the sad thing is, this combo-meal style exercise prescription is commonplace everywhere you go.  Example: Stroke with L sided weakness. Mx: AROM on R UE/LE, PROM on L UE/LE x 10 reps, 2 sets, AP.  E-stim L UE flexors, L LE extensors. Walking inside // bars.  This is just so common everywhere.  And some of these managements go on and on for years.  Hotpacks with TENS x 20 mins on the low back for low back pain. Motor point stimulation on facial muscles for Bell's palsy.  Lumbar traction x 20 mins for low back pain patients.  Sigh.

This. Is. Ridiculous.  And it has to stop.

Moving forward, what physiatrists should start doing is to give orders that are broad and non-specific but are generally encompassing, rather than orders that are restrictive and confining.  With "non-specific", I believe it would be better if physiatrists wrote orders for "therapeutic exercises" rather than specific orders for AROME R UE/LE and PROME L UE/LE x 10 reps x 2 sets, AP.  Or, for example, the physiatrist has interpreted the brain MRI or CT scan and determined that the patient has cerebellar degeneration, he should write an order for "balance training" or "fall prevention strategies" or "compensatory strategy training for balance dysfunction", statements that are generally encompassing.  This way, the therapist can make his own determination as to which exercises precisely fit the patient.  Therapy prescription should be individualized and although there are many gray areas in prescribing treatments, there should be no room for this combo-meal type treatments.  Not only do we subject ourselves to irrelevance by following orders for exercise that we have not ourselves evaluated for their appropriateness, we also are party to the crime if the patient fails to progress at a reasonable amount of time because we leave all the power to the physiatrist to evaluate and re-evaluate patient function and progress which, most of the time, does not include our thorough professional output.  

The therapist should be given utmost discretion to do their own evaluations and discuss them with the physiatrist and they should make the plan together.  This way, the physiatrist can focus more on really tackling the medical issues surrounding patient care.  Once as an intern and again once as a practicing PT in the Philippines, I have encountered cases of Stevens-Johnson Syndrome, which is actually extremely rare.  Both cases were pretty textbook manifestation of the disease and both would have been preventable.  Turns out, both cases are most likely caused by an allergic reaction to certain antibiotics (if memory serves me right, both cases involved pneumonia among their diagnoses) and would have been prevented if it was caught on earlier.  I am not putting the blame on the physiatrist for not catching this on as I believe the nurses and other medical staff involved in the care would have had more access to the patient, what I am saying is if we free the physiatrist from micromanaging even the exercises of the rehab patients, then they would have more time to deal with really important medical stuff.  Like minimizing chances of preventable medical complications such as this.

A Serious Lack of Medical Coordination

Another factor that gravely affects effective delivery of healthcare to the general population is the serious lack of medical coordination. This arguably stems from our especially vibrant but also greatly diverse cultures.  As a people, we are very clannish. The Ilocanos have more affinity to Ilocano-speaking people they meet in a new place, the Visayans do the same, and so on and so forth.  Therefore, if an Ilonggo, for example, is placed for the first time in Australia and he seeks out a FIlipino community, the first acquaintances he would get to know more would probably be another Ilonggo.  This does not mean he would not be friends with the other Pinoys, it just that our cultures make us lean towards those which are closest to ours.  

This mindset, unfortunately, has also been deeply ingrained in our hospitals and other healthcare venues, and this greatly affects patient care.  Ergo, the nurses take their own vital signs, the therapists take their own vital signs and the doctors also do a quick check of the vital signs for their own purposes.  Never did those three disciplines come together to discuss the significance of those data.  Why? The nurses and the therapists all rely entirely on the judgment of the doctor himself, never once considering that their input could actually be crucial to how the doctor makes his medical decision.  The nurses and the therapists hold an invisible grudge against one another stemming from their imagined rivalries in college and thus offer some sort of cold interaction with each other.  So in the corners of their spaces, the therapists refer to them as ass-wipers, while the nurses consider therapists as glorified masseuses. We should break this set-up and engage in better communication as a medical team, not a sectarian labor force without any form of synchonicity. 

How important is it that we coordinate what we find out, as physical therapists, to the nurses, the doctors and our own physiatrists then? Take for example a patient with an acute stroke.  He has been given pharmacological and medical management by the doctors and the nurses have been taking his vital signs (in the bed, supine, head slightly elevated), and he has been cleared for therapy.  Now, the therapist comes in there, takes the vitals, then sits the patient up and then, the BP drops and the patient starts complaining of lightheadedness. Therapist then moves to the feet and start the (ugh!) passive ankle pumping then rechecks the BP again, still low.  Repeats the process.  Still low, still lightheaded.  Therapist then puts him back to bed, reports this to the physiatrist, who promptly orders patient to be trialed with a tilt table. And so it goes.  Pt shows signs of orthostatic hypotension results to default management by MD as part of the combo-meal prescription: tilt table pronto!  Boom! We could have saved our energy and regained our self-worth if we have been in good coordination with the nurses and doctors in the first place.  The remedy would probably have just been a lower dosage or a different anti-hypertensive drug, rather than directly assume that the patient is appropriate for use of the tilt table.  (For the record, since I moved to the States a few years ago, I have not heard a patient or a therapist mention that they have ever used a tilt table. The only reference to tilt tables were those therapists who have been in the practice for 20 some years and mention that they have used them very long ago).  

Oh, and another thing, stop hyping up this PT vs Nursing rivalry in our schools and in the hospitals and clinics.  It is not helpful to both our practices and it is pointless to try to upstage one another because we are clearly separate entities of the medical practice who seriously need to get our acts together if we want to elevate the medical practice in the country. Oki? 

The Culture of Elitism in Healthcare

As a people, Filipinos are arguably very elitist. We give so much emphasis on titles, pedigree, skin color, affiliations, etc.  In essence, we put blind faith in certain politicians despite their lack of track record because they have a familiar sounding name. We silently admire the balikbayan who hails from the US without even knowing that this balikbayan works minimum wage as a grocer at Walmart and outright dismiss the OFW from Hongkong as a lowly household help.  We have a deep fascination about the the lives of the hacienderos, the glamor of the elites, the next door neighbor with a famous last name and is allegedly related to the town mayor.  We take the local bishop's interpretation of the Gospel as truth because as a bishop he must have a direct line to Jesus Himself and therefore, speaks the truth. Yes, we are an elitist society, and our healthcare system has been subjected to this too.

By many measures, the high regard that society places on doctors is well-deserved.  They spend years in medical school, learning, studying, preparing for the day ahead when they will be tasked to make a decisions that will dictate if another human being lives or dies.  They have to take many exams, trainings, internships and such to deem them competent to practice their professions and a new set of education, training and such to specialize.  They spend their productive years in medical school while their peers are raising a young family and are slowly creeping up the corporate ladder.  In many ways, the respect that the common folk gives them has been earned. The typical patient would believe what his doctor tells him because he is a "doctor", he knows what he is doing.

This sense of respect that doctors get, however, is also a double edged sword. This could lead to sense of entitlement, prejudice and condescension. Trust me, there are a whole lot of good doctors out there breaking back and sweating blood in service of others; but just like any other medical profession, you also see the bad ones in abundance, wherever you are, in the US, the Philippines, Saudi, wherever, just like you see excellent doctors everywhere.  And the problem is that like all people, I myself, after awhile forget those incredible moments when a brilliant doctor blew my mind away; but I can clearly remember those few times, when a bad doctor has a blunder and digs a deeper hole each time he does something in an attempt to cover it up.  These incompetent doctors in charge of other people's lives walk among us, and they are too arrogant or/and ignorant to ask for assistance and advice from colleagues and fellow medical professionals.  They look at themselves too highly to ask help from the therapist or from the staff nurse who has been there for two decades and serves as a treasure trove of knowledge because, hey, I'm the "doctor" here.  They fail to see that the best doctors in the world started out as novices with broad minds, learning from mentors and patients alike, a little bit over here, a little there until they have found their niche and became icons in their respective fields.  The key is to keep learning, from peers, patients, family members, caregivers and not sit on your medical high horse because you are a "doctor".

These are the very same doctors who prefer to write their diagnosis as a "mild stroke". A "mild stroke" even if the patient is completely flaccid on one side, is choking on his own spit and is completely belligerent. A "mild stroke", they diagnose, to calm families down and to avoid worried questions from spouses and adult children as to what will become of their sick loved one.  Their reason might even be the subconscious attempt to not offend because our culture also does not condone frankness and being straight forward.  The wordplay, though, of calling a stroke "mild", carries a lot of power when it comes from a person of authority, such as the MD.  Because the MD officially called the stroke "mild", people believe that they can be lackadaisical in their approach to it and God knows how much impact it has to compliance to taking medications and adopting a lifestyle change.  So next time, call a stroke a stroke, don't add colorful adjectives to make other people feel better.  They need to be educated and consoled up to a certain point, but they definitely do not need the sugar coating.

In the rehab setting, I have encountered physiatrists who are so high up on the pedestals they refuse to listen to reason.  I have encountered physiatrists who have questionable ethical practices but then again, as I mentioned earlier, we have an elitist society, and therefore, as an intern, I should know my place in the social order: physiatrist > head PT > staff PT > PT volunteers > PT interns > earthworms/vermin/pests. I have once been ordered to put Estim on B UE/LE flexors and extensors simultaneously, to save time. Omg. Another physiatrist, who was a geniunely good and likeable person but with very bad osteoarthritic knees, had a patient on the second floor ward without elevator access referred to her.  She, of course, could not manage stairs and without evaluating the patient told me: "Siguro pareho na rin yan sa ibang patient natin na stroke. So same management na lang ha", and proceeded to write the orders.  A female physiatrist from Bacolod allegedly prescribes glutathione pills, grapeseed and other supplements to the tune of thousands by misleading patients and their families that they help them.  Glutathione pills help cure stroke patients? Yeah right. Like its antioxidant properties will heal necrosed nervous tissue.  There is a physiatrist who comes in like a thief in the night into the patient's rooms for a few minutes to talk to them and then we would find out later from the patients that they got billed by the thousands for those unmerited visits. Another physiatrist refuses to order home health therapy to patients even if they live hours away and insists that family bring them in each time because "they can be closely monitored in the clinic", which I believe is really stupid.  It takes a lot of money and effort to transport a patient who lives an hour and a half away each way thru jeepney rentals and caregivers to the clinic for something that can be safely performed at home anyway in the presence of a licensed and perfectly abled therapist.  But then again, if he orders home health PT, the money goes to the PT and not to the clinic so, yep, no home health for you, sorry.  I didn't say anything, I was an intern, I had to know my place.  That place is a fixed, immovable position just above earthworms and vermin.  Thank you very much.

In my entire practice as a physical therapist in the Philippines, there were only several times when the physiatrist actually asked me to evaluate the patient myself; the physiatrist would then leave me alone with the patient and come again later to ask me questions about my evaluations.  Those "several times" were afforded to me ONLY by one physiatrist, my mentor and former dean, Dr Manuel Gayoles Jr.  He would actually take the time, if he can spare some, to do impromptu lectures and demos in front of interns and staff.  Most physiatrists don't think that way though; they reserve a certain aloofness towards volunteer staff and throw cold invisibility cloak over the ever-rotating faceless interns.  This detachment translates to the staff where the head therapist arguably looms over as lord of rehab when the physiatrist is away ordering staff therapists here and there according to his whim; the staff therapists in turn, project their hatred to their lead PT towards the volunteer PTs and, most especially, the lowly, scum of the earth, interns.  When the head of the department projects an aura of exclusivity, everyone else finds their own corners of solace and bubbles of discontent and ill-feelings brew, acidic and unhealthy.  Interns, (I guess rightfully so) speak in hushed whispers about their growing discontent and anger but in the breath in fearful overtones of just bearing it out so they can graduate.  And this is not an uncommon incident.  Clinical instructors everywhere either have an inkling to power trip on interns or intend to develop romantic relationships with them. Ugh. 

The most striking experience for me, though, that reveals this failure of leadership through condescension and elitism, is when I was relegated to treating a patient who was extremely difficult and bitched a lot, excuse my French there.  She was being very difficult because she was in so much pain.  I vaguely remember her face and I forgot her name.  I just remember she has thick, shoulder length hair, she was in her early to mid-40s, and an assistant manager at a bank.  Her treatment involved hotpacks across her entire back, soft-tissue massage and cervical traction.  She came every day at about 1 pm and everyday she harped about how bad her back pain was.  I asked my CI then why she was in so much pain and what her diagnosis was and the CI dismissed me offhandedly with "Oh, she just has neck and back pain".  Three weeks into treatment I finally stumbled into the patient's chart, and there as I thumbed thru her diagnosis page, clear as day, an XRAY report revealing a suspected lung mass.  The patient had a metastatic tumor from the lungs that has spread to her bones and the physiatrist madapacking missed it! The C.I. just followed orders from the physiatrist without doing thorough evaluation and chart review and missed it too.  And this lowly intern had to carry the burden of hastening her eventual demise.  I did not get to find out what happened to her next after that.  I remember she flew to Manila to get treatments but how truthful that was, I don't know.  I only heard it from the same CI who was still as clueless to her serious medical blunder as the physiatrist who ordered them.  That case happened almost ten years ago, but that experience truly opened my eyes to how F-ed up our system is.

Is the Education System Failing Us?

Our education system is probably one of the biggest contributors to our decline as a profession.  We are basically stuck in the 90s, 20 years behind where the rest of the physical therapy world is gearing towards. Whereas the APTA is fighting for DPT as an entry-level professional requirement I assume to further the cause for direct access care, the Philippines curriculum for PT has relatively remained the same in the past 20 years, except for a few subjects added here and there (like research and emergency procedures) to comply with education requirements in the States. [Sidebar: Direct Access care just means that patients can go directly for PT evaluation without MD orders; I know the State of Michigan has already approved their own Direct Access Law but I believe Medicare rules have not changed and if the patient has Medicare as their insurance, they need MD orders to eval.  Private insurance companies follow Medicare rules, so if they have private insurance, they still need MD orders.]  I find it sad that CHED requirements are changing inorder to comply with education requirements in the US and not because the therapists themselves find that our education is inadequate for our increasing responsibilities in the practice. But, then again, how do we know right? After all, we just follow orders, we don't know how to think for ourselves, it seems [insert sarcastic eye rolling here].

I, for one, am guilty of perpetuating a failing education system.  As a student, I was made to believe that PT is one of the hardest courses there are, figurative mortality is high and the board exams are one of the hardest with one of the lowest passing rates in the country.  I was in awe at the third and fourth year students carrying gigantic tomes of PT knowledge, stacks of photocopies on one hand, Braddom on the other, silently mumbling memorized codes of muscle origins and insertions.  And then I became them, reading chapter after chapter of Physio and Ana, praying to the high heavens that I will remember all of them tomorrow during the short quiz that Dr so and so is going to give, after the major practicals in assistive device training, and right before the long quiz for the anatomy of the UE.  I felt like I was gonna die.

And then I became an intern, where I was expected to be a well of knowledge by my CIs randomly telling me in the midst of treatment: Okay explain the Virchow's triad. Or, a random question such as: What is the hallmark of Rheumatoid Arthritis? Or something like: Please enumerate the different types of polysaccharidosis.  All the while the CIs would look at me expecting an answer. And, inside my brain, I am mumbling "Watdapak are you talking about?" while outwardly slumping my shoulder and letting out a nervous defeat giggle like "ah..eh...uhm... I forgot, sir, ahihi, sorry, sir".  I can almost feel their disgust from my utter cluelessness about all the questions they asked.  Haha. My worst exchange went like this. CI: Can you tell me the origins of the long head and the short head of the biceps? Me: What long head and short head? CI: Long head and short head of the biceps brachii!! Me: Oh, it has two heads? CI: (walkout).  Burn. Big burn right there.

And then I took the boards, passed it no sweat and eventually became an instructor at my university. I took that job seriously. I prepared for my classes very well. I taught multiple subjects and took pride that I read multiple books to compare data and share it with the students.  I taught them everything I can think of, anything that could be covered when the board exams came, anything that my former teachers missed to teach me, I taught them everything in the playbook. And I was damn good at what I did (with confidence talaga).

And then I went to the States.  And it is there I realized, I messed them up.  Or my education messed me up. Either way, I think we need to change it.

Our PT education in the Philippines is like a hyped up hamburger.  The toppings are all there, but the bread is way too thick and the meat is thin and tasteless. And I don't know if CHED is at fault for its inadequacy, or is it the board examiners fault for making the tests as it is (anatomy, med surg conditions, PT apps). It is like a which comes first, the chicken or the egg problem.  Is the board exam patterned that way because CHED requirements lean towards those subjects or are the CHED requirements changed to determine that the passers of the boards fit the standards that the examiners set? Whatever the reasons, it is not getting us anywhere. It just leaves us with too much information that are generally irrelevant to the practice of physical therapy.  For example, I understand our great need to master the musculoskeletal and neuromuscular systems because those are really our area of expertise.  But tell me this: How does knowledge of the different mucopolysaccharidosis impact my practice as a PT?  Is it in the off chance that sometime in the future I might encounter someone with the exact diagnosis? Tell me why was I asked in my board exams a question wherein the choices involved the types of the human teeth? Will that make me a better clinician if I can differentiate the purpose of the molars from the incisors? Why was I asked in my board exams in how much aqueous humor each eye holds?  Will mastery of the anatomy of the human eyeball make my manual therapy skills better? Tell me why in my board exams in a question where the choices involved the correct words for the acronym of LASER? Or how many METS are there in downhill skiing?  Or at what age is the chicken pox vaccine given? Ahhh the ridiculousness of it all! The examiners are making a living off of "good-to-know" information that have little to absolutely no bearing to the practice, in my opinion.  What is the Borg scale score if the patient describes the activity as "hard"? What is the wavelength of infrared light? Who developed the PNF techniques? Tell me how in the world will knowledge of this trivia is going to impact my clinical decision-making.  

When I was reviewing for the local boards almost a decade ago, I was in awe at the lecturer who listed down almost ten other names for Reflex Sympathetic Dystrophy (which is now more commonly referred to as CRPS).  I was in awe because I really believed deep in my heart and I know that he truly believed deep in his heart that knowledge of this "other" names, almost all of which are seriously outdated, might come useful in the off chance that the examiner "might"ask the question.  In hindsight, he, too, was messed up by the system.  There is too much focus on this "pageantry", to prove that we have to keep the mortality rate of PT board examiners high, because we are "one of the hardest" exams ever in the Philippines.  I'm willing to bet my neighbors' house and dog that if we hypothetically read through all the questions they give for the medical-surgical conditions portion of the board exams, at least half of those questions are NOT physical therapy related; they are too medical, more for our physiatrists than for us.  In my brash opinion, knowing the presentation, common functional deficits and bigger clinical picture of the patient is more important than knowing (in the off chance that the examiner will ask the question ugh!) and learning the specifics of an impaired anatomy.  For example, as a therapist, it is more important to me to discern, with very high probability, that a patient presenting with severe balance problems both in bright and dark environments, ambulates with a wide-base with poor foot clearance and tends to "miss" the edge of the bed when putting her hands back to sit down may have a cerebellar pathology.  And I would address those deficits if I can and develop compensatory or/and adaptive strategies if I truly cannot.  It is NOT significant for me to know that the damage is at the vermis, or paleocerebellum, or the flocculonodular lobe, or the middle cerebellar peduncle or wherever.  It is good to know, yes, but that should NEVER be the focus of our education.  We should take it as whole, it is of cerebellar pathology and we treat the subsequent deficits.  The specifics of the cerebellar pathology is for the physiatrist and the neurologist or the neurosurgeon to know because they will deal medically with the issue. Our job is deal with the physical manifestation of dysfunction, not fix the pathology if it is not musculoskeletal in nature because that is not our job.  Period.  

And so when I passed the boards and became a member of the faculty, I employed the same misguided delivery of lectures as the board review instructor did, full of good-to-know information and pageantry, lots of toppings, little meat.  So do I believe that my students learned from me.  The answer is a definite, yes.  It is just if I learned that the system is broken early on, I would've been able to streamline what I was teaching.  I was meant to teach them how to think like physical therapists but instead I leaned to having them think like doctors.  Yes, our education system is broken and something needs to be done, and done soon. 

Are We Failing Our Patients?

We all live for the hype and pseudo-prestige of being a Physical Therapist.  For all the overly medical and less practical education that we suffered through, we have remained an extraneous medical profession, forgettable, no pizzazz. We didn't study for five years to become massage therapists, we say, yet we seldom do anything distinct and significant to change people's mindset about us.  We follow physiatrist orders blindly. We don't question. We don't produce research. We don't research. We don't participate in research. We wallow in mediocrity.  But the worst offense we ever do to ourselves and our profession: we never, ever, ever provide consistent, thorough, and practical education to our patients and their families.

Maybe it is just because we were never trained to be educators.  Maybe that is never part of the specially worded order by the MD.  Maybe we don't know what we need to educate people on, where do we start, how much do we tell them? After you read and spent hours and hours of reading through all those books, PowerPoint presentations and photocopies, you were never able to apply that knowledge into practice.  Is the reason being that you don't really know what you are supposed to be doing? I will tell you right now even as a licensed PT in the Philippines I was clueless about my job description. I know better now as a practicing Physical Therapist (the real thing not the pretend PT who is not allowed to do evaluations, progress patients, set goals and work with patients and their families to reach those goals, prescribe physical therapy treatments, apply my clinical judgment, exercise my clinical eye, and really make a difference in patient lives).  If we want to be free from the stigma that demeans us, then we should learn to have better marketing for ourselves and for our profession.  If you think that people who think we are masseuses are ignoramuses, then we should cure them through education.

No, you don't have to explain to the patient's family about the Circle of Willis when the patient has a stroke.  Chances are, they won't understand and thus, won't care, and you'd probably get it mixed up anyway.  Don't be way too technical and speak medical jargon (unless necessary), nobody cares and you would end up repeating yourself anyway because nobody would understand it but you (pat yourself on the back, congratulations, you know a lot of good-to-know info from your board review, nobody cares).  Instead, we should start talking to family about plans and discharge.  Yes, at the beginning of treatment, at the start of evaluation, expected discharge should already be discussed.  Why? Because you tailor therapy goals towards eventual discharge of the patient. We are NOT meant to see patients forever! Sadly, in the Philippines, patients are on caseload forever, if they have money, forever, if they have no money, sorry (walang forever).  There is no line between skilled therapy and maintenance programs.  You don't write goals, you don't save enough time to train family members, who will most likely become the primary caregivers, and you don't train your patients to become functionally independent. If you are reading this right now, be honest, how many times have you trained a patient and his caregivers on how to transfer safely from his wheelchair to his car, a tricycle, a jeep or a pedicab (whichever is his mode of transport is to go to rehab)? You may have done hundreds of AROM on the R UE/LE and PROM on the L UE/LE but really, be honest, how many times have you trained your patient to get up from the bed, walk to the bathroom, open the door, walk to the toilet, turn around, pull his pants down and do his thing? Did you ever look at those free wheelchairs from city hall or somewhere (yes, the one with plastic Orocan chairs on them) and tell you patients and their families to return them if they could because they are not ergonomic and safe?  Have you ever trained families and caregivers, and I mean trained not just demonstrate, on how to turn patients in bed, get  them out of the bed, transferring them and have them walk? Have you given suggestions on how to improve patient safety inside the home, it doesn't matter if it is a mansion, a condo or a hut?  Have you ever trained patients to walk on the sidewalks and get up curbs?  My point in all of this is we should have been training our patients and their family to be able to return to their highest function and not to impress with their repetitive performance at the therapy gym.  Our constant education and training of patients and their caregivers will carve out a better understanding by the general population of how our practice really works.  We are doing a remarkable disservice to the patients when we leave out education because we are so focused on completing the AROME and PROME program that we were set up to do.  Sad thing is, the patients have very little choice but to only go with what we offer them. We compound the problem by doing the "I'm the therapist, let me do my job" thing instead of working together with the family to accomplish goals, their goals, not solely the clinic's financial target.  If you are able to significantly improve a patient's quality of life by simply putting up the extra time to train someone's husband how to transfer the sick wife into her wheelchair from their bed so he can take her to watch Miss Gay at the barangay fiesta, then you are A physical therapist.  If you are able to educate and train a patient's son, how to guard him and walk him safely with his cane down the steps of the house so the poor man won't be cooped up inside the house all the time, then you are A physical therapist. If you are able to educate the family that the fake Havaianas flip flops they have Lola wear is too big and is a safety hazard and you recommend a better alternative to decrease her risk for falls, then you are A physical therapist.  

Education and training goes a long way, folks.  Never, ever, ever underestimate its power. And never, ever, ever be remiss in it again. 

And so, my friends, yes, Philippine physical therapy is in crisis. We can always argue that you really cannot compare our PT practice from that in the US. We are a third world country, anyway.  But let me tell you this: It is true that we are a third world country and that our understanding and delivery of physical therapy services is still in its infancy, but that doesn't mean we cannot aspire to provide world-class and competitive physical rehabilitation.  We have a big-ass room to grow, but we are running out of time.  We have to make changes and do them now.  If we are still beholden to merely defending our practice to the premise that we are not "masahistas", then half the battle is already lost.  If we spend our energy merely maintaining the affluence of having the hardest board exam that does not translate to the workplace anyway, then our energy is seriously misplaced.  Our practice is dying a slow, painful and inevitable death, just like the small grocery stores at the wet market when an SM mall sprouts out of nowhere.  Where will you be when the sh*t hits the fan?

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Post-script:  

I re-read this entry before posting and it might seem very abrasive towards our physiatrists and the MDs, in general.  Do know that I am speaking out of frustration and genuine desire to make our concerns known. This is not to trash our medical professionals, but I would speak out strongly against the culture of medicine that I believe leads to mediocrity and poor service.  I would like to (though unsolicited) act as the mouth piece of physical therapists (licensed practitioners, students and interns alike) to mention things that they themselves would never say to their physiatrists, CIs, professors etc.  I never intend to hurt feelings or put down the medical profession by mentioning my negative experiences.  And I hope no one should use this blog entry as an excuse to start waving the I-know-crap-that-you-don't flag at the clinics because that is just downright distasteful.  

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For those reading the blog and feel that I am all mayabang because I moved stateside, it is actually quite the opposite.  I was humbled when I moved here.  At least back home, I was a respected educator.  When I moved here, I actually didn't know how to discharge a patient.  Like, really, I didn't know when and how to discharge a patient because in the Philippines, we see patients until they run out of funds to pay us or when they die.  The more I learn about how they practice therapy here in the States, the more I realize that my professional growth has been stunted even before I became one. It is as if I feel like I was robbed, my potential stayed that way--a potential--and nothing more.  I feel like I have to relearn how to be a therapist, or maybe I felt like I was never a PT back in the Philippines. Because really, what we do there in the Philippines, is what PT assistants do here in the States. Ask anyone you know who is here, and they will tell you the same thing.  

Yes, my potential was not realized when I was still practicing in the Philippines, but the future generation of PTs has a chance at something more, something we have not had before. But we have to grab the bull by the horns and act now.  

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This blog entry is not just to point out issues without offering solutions. My next entry will focus on possible solutions to the problems I presented, and then some.  They won't be perfect, they won't be based on facts merely opinion, and they might not even be something worth looking at twice.  But I will do it anyway.  I can't stand the status quo. I will not stand for the status quo. And I will strive for change. So should you.

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I would like anyone reading this blog entry to say something. Stop being so damn passive.  Speak up.  Spread the word. Share this blog entry.  Write a short comment.  Write a long comment. Say why you think I'm right.  Speak out louder if you think I'm wrong.  Let us debate point for point.  Let us have a discussion.  I don't care if you agree or disagree with me.  But this is an issue for all Filipino PTs.  We have an issue. We have many issues.  It is time to speak up.  It is time for us to talk about this. So spread the word everyone. Here is some fool who thinks he can change the world.  Here is a truly passionate clinician fighting for his practice.  Here is why he is wrong. Here is why he is right.  We need to have a serious conversation about our practice.  I started the talk.  It is up for the rest of you to keep the conversation alive.

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