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?

_______________________________________________________

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.  

--------------------

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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end

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10 Things Your PT Books Didn't Tell You (Part 1 of 2)

It's been quite awhile since I've written a PT blog entry.  I have received several messages through Facebook "encouraging" me to start another entry for PTs to read.  So to those who message me on FB, thank you so much for appreciating my write-ups and I will try to fill up the void.  I guess reading a PT blog entry is sometimes a welcome relief from the mundane exercise of going to your PT class, PT review and PT job.

Let me start off by saying that everything I am listing down here is completely unscientific.  There is no research to prove anything that I am about to say--- and I don't read researches anyway like duh!  Thus, you cannot quote anything here without justification.  And you cannot debate with the contents here in a well-Kisner-said-this-and-that manner.  All of what I have written here are purely based on observation and experience.  Now, all of us will have them differently but I'm sure at least one way or the other you can relate to the errrr "truths" (misinformed or otherwise) that I am going to share.

It is also very important to discern that if you are preparing for the US licensure exams and some of the contents confuse you, ALWAYS pick the other source, not this blog entry.  Remember, this is NOT scientific.  However, I would also like to point out that the things that I will discuss are completely relatable especially if you are or will be assigned in a skilled nursing facility or a nursing home.

Now as I went on writing this piece, I realized it was getting way too long so I decided to make it in two parts for easy reading and less information overload.

As always, reactions, corrections and intellectual discussion are highly encouraged.  Feel free, in any civil manner, to express your opinion on the subjects presented.  Now with everything in place, let us start the countdown.

1.)  Be wary of giving water to patients during exercise.

Yes, I know that the Bible tells us to give water to the thirsty.  And yes, all health magazines highly recommend drinking fluids before, during and after workouts to maintain steady electrolytes and prevent dehydration.  So why, you ask, should we be wary of giving water to patients during exercise?  Here's why:

Remember that the patients that we see in skilled nursing facilities and nursing homes are mostly elderly.  Many of these patients have many medical complexities including history of stroke, Parkinsonism, dementia or a combination of everything.  Many of these medical complexities have direct or indirect effects on swallowing muscle control.  Hence, the importance of you not giving water freely especially when you have no idea if the patient is at risk for aspiration pneumonia.  The best thing that you should do is, of course, consult your speech therapist.

Now, in the Philippines, I believe most PTs have not been exposed to speech therapists (ST), aka speech-language pathologists (SLP).  As their title implies, of course they are involved in evaluation and management of speech impediments arising from neuromuscular conditions.  Aside from that, they are also specialists in cognitive therapy such as memory enhancement, pill management and implementing safety strategies for patients.  The most important aspect of their job, for me, though, is their evaluation and management of the pt's ability to swallow bolus.  It is, therefore, the ST's job to determine if Lolo can still safely eat the steak he loves so much.  It is their job to assess if Lolo is at risk of having his half-chewed steak down into his lungs instead of his gut.  Well, you all know that if it goes to Lolo's gut then it turns into poop, normal, old boring poop.  However, if it goes to Lolo's lung, with his age, Lolo could easily succumb to aspiration pneumonia sending poor old Lolo into the great big steakhouse in the skies.

Question 1:  If we have no ST at the moment, how would you determine that Lolo is choking on his food or his water?  First of all, you look into the obvious signs: Upon drinking, Lolo starts coughing, or clearing his throat, or grunting, or a wet voice, or coughs again.  That is a very overt sign that Lolo is aspirating.  However, there is also such a thing as silent aspiration wherein Lolo doesn't show obvious signs of choking but food or water may still be going towards the lungs.  Some of the signs would be: watery eyes, runny nose, and change in voice quality after ingesting fluids.

Question 2: What happens then if you determine that Lolo possibly might be aspirating on food/fluids? You automatically refer the patient to your ST for evaluation if they are still not under caseload.  If the ST determines that the patient is indeed aspirating, he/she might be able to downgrade the patient's diet.  For food, if the patient is not aspirating then he is given "regular food", meaning he can eat anything he wants at any consistency.  The downgrade would be "mechanical soft" which has softer sides and chopped meats (also given to patients who lack dentures and can't chew meat very well).  The next downgrade is puree in which everything is put into a blender.  If the patient is still aspirating on pureed food then a gastric tube might be recommended.

The texture of the food though doesn't really affect us PTs because we are mostly uninvolved with feeding unlike STs and OTs.  However, we are very involved with the fluid intake of patients.  When we exercise patients, of course they would feel tired and thirsty and would sometimes ask for water.  When a patient is not aspirating, he is given "thin liquids" or basically just regular drinks.  A downgrade would be "nectar-thick consistency fluids" and further down is "honey-thick consistency fluids".  The further the downgrade the thicker the consistency is. Remember: Never ever give patients any water unless you know the consistency that the patient should be on less you risk the patient developing pneumonia.

Also, remember to check the chart or ask the nurse if the patient is on fluid restrictions.  This is usually the case with patients with CHF or/and using diuretics.  Ask the nurse how much water you can give the patient during exercise.  The patient is only sometimes allowed a certain amount of water throughout the day and thus, we cannot just freely give water to the patient even when the patient asks for it.

2.)  Watch out for skin tears in patients on blood thinners.

We learned from Goodman/Snyder that bruising if typically observed on patients on blood thinners.  What the book didn't inform you is that bruising is not the primary concern of PTs as the patient can bruise even without trauma.  Our primary concern is to decrease the patient's risk of having his skin torn.

Remember that as PTs we are involved in training patients in ambulation and transfers and unless the patient is high-level, we usually are in close contact with the patient during transfers and ambulation.  Our close contact relationship with the patient, plus equipments that we use (e.g. walkers, rolling walkers, gait belts, parallel bars) increase the chances that a patient may accidentally rub his skin on the area and tear it in the process.

A patient in chronic use of blood thinners literally give new meaning to the expression "balat-sibuyas".  Their skin is sometimes so thin that they tear even while asleep.  I can only assume that they probably rub it in the creases of the pillow or blanket.  

Question 1:  Your patient has a skin tear during exercise, what should you do first?  My first action is to make sure I am not in contact with the blood (don gloves whenever possible).  I will ask the patient if he is alright and then I will call the nurse.  I won't do first aid or put pressure on the artery above the tear (wow, manual arterial pressure ka pa ha? panalo) or attempt to stop the bleeding.  Remember, this is just a skin tear, this is not a medical emergency, so calm the f--- down.  The nurses will come in, assess, measure the size and clean the wound and they would usually tape the skin back into place so it doesn't flap around.  You would also probably be asked to write an incident report on the matter.

Do not be terrified of writing an incident report.  It will not ruin you or your career.  Just write everything in detail and that same incident report which you dread so much will protect you in the future.  If a patient has a skin tear, it is most likely not due to your negligence, it is just a side effect of prolonged blood thinner use.

3.)  A patient with chronic hepatitis may no longer manifest with jaundice

Jaundice as a review is caused by the inability of the body to complete the breakdown of old dead red blood cells in the body. The heme in hemoglobin will be turned into bilirubin which the liver will process to turn into bile which will assist in digestion of fats (note: it's been too long since I have read anything about hepatitis so this may not be accurate; correct me if I'm wrong).  With hepatitis, the liver becomes inflamed and swollen, it no longer is able to process bilirubin and bilirubin floods your bloodstream in a condition called hyperbilirubinemia (tama ba?).  The yellowish hyperpigmentation will manifest first in the sclerae and then the skin including other mucus membranes. 

Now the history of my patient who had chronic hepatitis was vague but basing it from what his mom said, it is alcohol related.  What was curious was that despite not turning SpongeBob-color, he did have manifestations of chronic liver disease.  Since his liver can no longer detoxify very well, the toxins in the body try to escape via his skin, so his skin appears to have many eruptions and vesicles.  It didn't appear flaky like dandruff but it was rough and his hands were always itchy.

 He also manifested with hepatic encepalopathy.  I reported this observation with his nurse who informed his doctor.  He was a high level patient but he needed O2 supplement prn.  The hepatic encepalopathy developed within three days wherein I noticed at first that his attention span became shorter.  That was followed by lethargy, then complete confusion and total decline in function.  He was one who was walking around the facility pushing his wheelchair and now he can barely stand up.  They did lab work and found out that his bilirubin was off the roof.  He got back to his old self after a few days of medical management.

I never got to find out what happened to him after that since I moved to a different facility.  Also, I never got to find out if he had clay-colored stool as what Goodman/Snyder said. Haha

4.)  You can survive without kidneys

One of the most interesting cases I've ever encountered is that of an extraordinary woman without kidneys.  She lost both kidneys, 10 years apart, from kidney cancer.  She is in dialysis three times a week where she stays for about 4-5 hours each time. 

I already know that a person can survive sans one kidney.  What happens is that the remaining kidney usually enlarges to almost twice its original size to compensate for the missing kidney.   Remember that the kidney is also an endocrine organ which produces the hormone erythropoeitin, which triggers the production of erythrocytes.  Without the kidneys, red blood cell production is severely limited and causes erythropoeitin-deficiency anemia.  So aside from the fact that the patient undergoes dialysis which makes him very tired already, he also suffers from anemia, the patient would most likely be able to participate in only very light activities.

Beware/ Warning:  During dialysis days, treatment time for a patient is usually reduced and the day after the dialysis, treatment time is increased mainly because of patient's activity tolerance.  A reasonable rehab director should be able to identify this.  However, there are facilities and companies which always put all patients in the ultra-high RUG level.  Ibig sabihin, the patient should and must be seen at the highest possible minutes that you can, irregardless kung me dialysis siya or what.  If you belong to a facility/company that forces you to treat a dialysis patient who appears very weak for 70-90 minutes for that day, or even forcing you to treat a patient for the entire assigned minutes who appears dying (dying na! malapit nang matigok!) make sure you develop an exit strategy from that company! When your gut feel tells you that the patient is not able to tolerate anything but you still force him to do stuff just because you are being told to do so and you know that what you are doing is unethical or simply alam mo na it's not right, you should be firm and stand your ground to justify why you are not getting his entire minutes.  Then, get out of that company as soon as you are able.  You are risking your hard earned license and your future!  That is borderline fraud, and believe me many companies do that.  I am just lucky that both my rehab directors are reasonable people.  Not all therapists are that lucky.  

On a lighter note, the patient I had (who also became a very dear friend) who lost both kidneys, is no longer able to PEE! Paano ka pa iihi eh wla ka nang kidney? Haha. She told me that the fluids get flushed through her bowels.  And we would always joke around that "she would laugh so hard she would pee herself".   And then we'd laugh again.  I just learned yesterday that that wonderful patient passed away just a month and a half ago.  I surely would miss her and her vibrant spirit. 

5.)   Depression largely goes undiagnosed with the elderly

A lot of elderly residents in my facility are diagnosed with depression.  However, I don't think that the extent of their depression are accurately determined by the psychologists and psychiatrists.  Based on my experience, depression is high among the elderly but even I cannot be certain and am certainly not the best professional to make a judgment if the resident is merely sad and homesick or has fallen into real clinical depression. 

Clinical depression is a persistent unhappiness and feeling of emptiness that affects activities of daily living for weeks or months.  Sometimes, I feel like it is so subtle you can barely notice it.  It is very important that we, as therapists, although we are not clinical specialists for depression, should be sensitive to this anyway as in the long run, we might just happen to save a life.

I personally think that undiagnosed or underdiagnosed depression may cause adult failure to thrive.  I don't perfectly comprehend what what they call "failure to thrive" is, I know that it is a reason for residents to be picked up by hospice.  But my understanding is that failure to thrive is that a person is showing signs of decline (e.g. losing weight, poor appetite, weakness etc) without apparent cause.  Lab results would be normal or very close to normal, no signs of infection whatsoever, but for no apparent reason the patient is just going downhill.  I still think that depression is closely linked with this phenomenon.  

I work in a wonderful nursing home with completely diverse staff from all over the world.  The facility is Medicaid-supported, shared by three counties and has two assisted-living buildings on its wings.  It has constantly ranked highly and has had a five-star rating for a long time.  It has consistently been included in the top 50 best nursing homes in the entire US.  There are more than 16000 nursing homes in the US and to be counted in the top 50 means that you are giving the best care there is that a nursing home can offer.  Now, if you ask if the nursing home is grand with exceptional amenities, the answer is no.  It is Medicaid-funded so you won't expect that it will have swimming pools or spas or bowling alleys.  But it does have a great kitchen staff, exceptional nursing care and all.  

Add to that, the activities department of this facility is wonderful.  They have a lot of programs and activities for the residents all the time to keep the residents entertained.  They have games, movies, pet therapy, parties, parades, trivia and many more that keeps the residents entertained and busy all day long.  Compared to my old facility whose only activity is bingo, everyday bingo, this new facility is actually way above its class.  

You would think that all of these parties, karaoke, therapy dogs that are too cute and sweet, musicians, art classes etc will keep the residents happy.  Sometimes, they do.  But there are times that these poor elderly just feel...sad.  These elderly people sometimes talk about suicide.  Suicide for God's sake! 

Question:  What do you do if a patient tells you he wants to kill himself?  First, try to empathize with the resident.  Ask him what is bothering him and how you can help.  Try to talk to the patient and comfort him.  Whether you think the patient is serious about his suicidal ideations or not, you have to let the nurse know.  Any desire of a patient to harm or kill himself is urgent, you have to let the nurse know.  Alarm the nurse.  They will assess the patient, and would do necessary measures to ensure that the patient does not harm himself.  I had one patient who told me he wanted to kill himself.  I knew he had a history of deep depression and I immediately reported it to the unit manager.  They took off everything that he might use to hang himself like belts, nurses bells and blankets and they set a 24 hour watch on him with a standby CNA.  

On one of the assisted living units though, during the early part of this year, a resident committed suicide.  She called a cab to pick her up (they are allowed in ALFs to use public transport), then she had herself dropped near a train station, walked towards the rails and leapt to her death towards an oncoming train.  If I were to guess how she felt before she decided to end her life, I would say she felt depressed.  Why else would you end your life?

Which leads me to a very important point.  You may not think of yourself as important.  But know that as a therapist, you have a close relationship with a patient.  And sometimes we take for granted that we might be the only person, the whole day, that the patient can really talk to.  Yes, nurses talk to patients and so do CNAs.  But casual talk is not real talk.  We therapists talk to our patients while we exercise them and it sometimes our silly conversations with our patients help them make it through another day in a nursing home, where they are resigned to live a mundane life until their Maker takes them.  

My friends, let me end the first part of this blog entry for now.  I hope you learned something that might be of use to you in the future.  Once again, commentaries are very appreciated.  God bless us all, God bless Filipinas!

side-by-side

side by side, we sat
    the tension there once was
        has faded like
            the sounds of our laughter

the look in our eyes is of
     nothingness

we are the strangers we
didn't know we could become

strangers, we have become
    and still we cannot tell
        the difference
          between holding hands
and
    hand-holding.

side by side, we sit

strangers
there is nothing here
      nothing
and the hand I am holding,
   the hand that remains,

is my own.

6/15/2013 3:03 pm

Visiting Lexington

It's been quite awhile from since I wrote my last entry for this blog.  Let's just say I've gotten preoccupied with pretty much a lot of useless stuff completely unrelated to fruitful living.  I've been hooked on the same computer game with a few new serious player friends I met online.  Also,  I've been trying to work out.  Yes, me, the botod, is trying to get fit.  Nope, I am not giving up pork or beer or smoking completely.  But I have started running on the treadmill and lifting weights.  So far so good.  I haven't bulked up yet and I see no guns on my arms but I noted that they are not as flabby or as lard-soft as they were before.  I have also noticed that my endurance for running on the treadmill has improved.  Whereas when I started I can only manage probably a maximum of five minutes before my thighs start burning prompting me to slow down and catch my breath, I ran for forty straight minutes without slowing down just yesterday.  That is a feat for super sedentary me.  I have lost several pounds and gained a couple back during the past weekend when I went over to Teffy's place for another whine and wine experience.

Now, Teffy is my former colleague and boss at the College of PT at St Paul University where we also both went to PT school at before becoming instructors there.  She lives about a three hour drive away from me at Lexington, VA.  Lexington is a quaint picturesque historical small town famous for its significance in the American Civil War.  This is also the burial site of the famous Civil War general Stonewall Jackson and the location of his house now turned into a museum.  I just love how this small town thrives and bustles with life, a strange blending of the old and the new, literally and figuratively speaking.  

Lexington houses two well-known universities: the VMI, Virginia Military Institute and W&L, Washington and Lee, which is a very reputable law school.  Lexington, however, is also considered a retirement community where mostly middle-aged to senior couples find solace in the peace, beauty and laid-back atmosphere of this town. I find it refreshing how the burning red energy of youth can blend in well together with the calming blue aura of wisdom in this lovely town.  True, occasionally, they would clash with mostly the elderly complaining about the college people's noise but generally, the town is peaceful as it's meant to be.  

One thing that draws me towards this town is that the school system here is doing really well and is highly ranked within the state.  If you would want to raise a family, you would want to have your kids go to a decent school and Lexington offers them such.  Teffy was trying to sell me the idea of moving over the area once my wife comes over.  I still have my reservations but yes, that place looks promising for me.  

However, unlike where I am now, that small town is less diverse than what I am used to.  I have seen only a handful of Asians there, a few Blacks and almost no Hispanics which is weird as Hispanics can be found almost everywhere.  I don't know if discrimination exists there but it would be hard to expound and build other friendships when the town is overwhelmingly white.  I don't know though, because to be honest  so far I have not experienced discrimination in the strict sense of the word, maybe because I am quite lucky to be more educated than most.  

Anyway,  I am just letting you into what I have been up to for the past couple months: starting a book I never got to finish, starting my exercise regime (holding up for almost a month now), and driving up and down Lexington twice.  I already have an idea of what my next entry would be for this blog.  The only problem is when will I ever get to writing it.  Till then, stay tuned. 

TOEFL-ibt and You... A Love Story

The bane of many therapists since its conception, this dreaded exam has broken many hearts comparable only to its equally, if not more, challenging big brother we shall nickname NPTE.  This exam is a lingering wraith on your back, a heavy shadow on your future, a dragon you need to kill to get through the first phase of your American dream.  Yes, I am talking about the TOEFL-ibt, frequently mentioned with colorful adjectives preceding it such as: P. I.ng TOEFL yan! or lintek na TOEFL yan!  The popularity, or lack thereof, of this particular exam continues to grow. More often than not, it invokes a strong sense of dread and hatred but at the same time of intimidation and respect.  For some, it has grown into a sort of urban legend, fed by the many stories of failures, to which quite a few have balked to take it.

A lot therapists do complain that the requirements for TOEFL is quite steep, most of them up in arms with the speaking cut off score of 26/30.  It doesn't matter if your other scores are good, a failing score in speaking is a failing score overall and a headache for the examinee.  Now he has to take the exam again or to risk having it rescored which can go either way.  The more painful part is that most therapists who fail TOEFL fail the speaking part by a mere point or two.  So, if you ask me, would it be better if the speaking requirement of  TOEFL be decreased to 24/30? That way everyone is happy. My answer might surprise you.  I will say no. 

Now before you bitterly spew out the words: Wow pare ang yabang naman! Feeling! Let me explain why I don't think they should lower the requirement. First of all, you want to come here to the US to work.  You do understand, though, that for every PT job given to a foreigner, like you and me, it is one less potential job for a US citizen, irregardless if they can fill that position or not.  Therefore, that foreigner has to prove that he deserves the job.  One way to prove it is having a good command of their native tongue.  Being able to communicate well in English is a must in our profession.  We will be interacting with many patients, nurses, doctors, social workers, nursing aides, etc.  Sometimes, it just isn't enough that you understand English.  It is necessary that you KNOW how to communicate in English and communicate well at that.  

As a therapist, you will have to go to care plan meetings every now and then.  A care plan meeting is a convention of the patient/family of the patient and everyone else involved in the patient's care: therapy, nursing (floor nurse, nursing aides, Medicare nurse, wound care nurse etc), dietary, activities and social workers.  At care plan meetings, the team will be discussing the patient's current status, the family's concerns if there are any, the goals, the outcomes, the discharge plans and a lot more.  It may take a long time especially if the patient has a lot of medical complexities.  However, as a therapist, you would only be able to attend for a short period of time.  During that short period of time, you have to discuss the patient's functional progress with the family and with the rest of the medical team.  The family might ask you questions and you have to be prepared to answer them.  Will my mom be able to walk again?  My dad is speaking, why does he still have speech therapy?  Would my mom always need a walker?  Will Dad be able to climb up steps to get into the house? A lot of different questions can arise during care plans and your main goal there is to get in and out as fast possible while giving clear and satisfactory answers to the family's queries.  Why the hurry?  Well you have other patients to see and care plans (if the patient is not present) is considered non-billable time which means that therapy is losing money the longer you stay there and not treat patients.  Therefore, your responses have to be straight to the point and yet should not lead to confusion.  Ergo,  you need to speak fluent English and not waste time with your "uhms" at every word.  "Uhm... Mrs Smith, uhm... would probably use the, uhm, walker to, uhm, get around the house to uhm, go to the bathroom, but, uhm... she would need somebody to...uhm...assist her".  This just doesn't cut it.  It will make you sound like you don't know what you're doing.  And yes, those who are generous with their "uhms" usually fail the speaking part of TOEFL.  Or am I wrong in that assumption?

Also, the subjective parts of TOEFL include the dreaded speaking part and the writing part.  The writing part of TOEFL can be trained for, mostly in review centers.  The speaking part errr... not so much.  They can give you all the advice in the world but at the test center, you're on your own.  Now, in review centers they would probably advice you to write in a basic format: a heading (the intro), a body and a tail, which would be a brief summary of the intro and the body.  It would really help if you train yourself to think in English rather than think in Filipino first and translate it to English.

 The need for you to think in English and transform your thoughts into sensible sentences would eventually benefit you when you are working in the rehab setting in the US.  Tandaan: Each workplace have their own productivity expectations for their therapists.  What is productivity?  Productivity is the amount of time you spend treating a patient over the total time you spend at the facility.  My company has 82% productivity expectation per therapist.  This means that at least 82% of the time you are treating patients and making money for the facility.  You have 18% of your 8 hours (if your patient load allows you) to do everything: write notes, print papers, send emails, write orders in the chart, fetch patients, take patients back etc.  That is about an hour and a half each day to do stuff not directly related to billable patient care.  Lahat yan, technically, is counted against that hour and a half: washing hands, going to the toilet, asking aides to get patients up or cleaned up, chatting with co-workers etc.  It is hard to keep up with productivity expectations especially if you have a ton of notes to write.  It certainly wouldn't help you if you would spend (read:waste) time translating your thoughts into English when writing your notes.  It is important that you know how to express your observations in a clear and concise manner when writing your notes.  You won't be able to do that when you don't have good command of English.  Hence, the need NOT to lower TOEFL requirements but rather, us, Pinoy PTs, should step up to the challenge of this test which has delayed many a therapist's American dream.  Some even gave up totally dahil hindi mapasapasa ang lintek na TOEFL na yan. So pano nga ba ipasa ang TOEFL?

How to pass TOEFL ibt:

I'm sure you all have received a lot of advice from fellow PTs and from review centers on how to pass the exam.  Probably, the few tips that I might share may not even influence your opinion on how to approach the test.  But I'll try anyway, who knows I might be able to help someone out here.  

I took my TOEFL-ibt test five years ago and passed it on my first try.  I hope I don't sound like a douchebag but I got a really high score.  I don't mean to brag but I got a score of 117/120.  I got 30 for reading, 29 for listening, 28 for speaking and 30 for writing.  Now, before you make the assumption na ako'y nagmamayabang, let me explain this first.  All of us were given extraordinary gifts by the Lord, some are talented musicians, others mathematicians, others are gifted athletes, others are gifted with charisma, others with beauty etc.  I was gifted with the gift of linguistics, I have a knack for language, meaning I always have excelled in English class, literature class, Pilipino class, anything that has anything to do with words, writing, vocabulary, pronunciation and language itself.  Although I believe in humility as a virtue, I also strongly believe that failure to acknowledge the Lord's gift by shying away from compliments like saying "Hindi, chamba lang yan" or "Sinuwerte lang" is in a way a form of rejection of His love.  But that's just me, I don't want to impose my beliefs on anyone at all.  

Anyway, let me give you some unsolicited advice on how to improve your TOEFL scores.  First, start reading real reading materials in English.  This does not include beauty magazines, Harry Potter books or Shades of Grey.  Instead read opinion sections of newspapers, essays by Patricia Evangelista, Fr Joaquin Bernas or Conrado de Quiros, books by Jessica Zafra or National Artist Nick Joaquin.  Read something that will enrich you while improving your vocabulary.  Your vocabulary will grow without you having to try very hard when you constantly bombard yourself with these kinds of reading materials.  Difficult words, when encountered in sentences often, will eventually reveal their meaning to you.  You don't have to look  up  the dictionary all the time, sometimes just by how they are used in sentences you get their meanings.  By following this advice, you have hit two birds with one stone: you'll have better reading comprehension while improving your vocabulary to use in your writing.  

Second, with listening, there is nothing much really I can do to help you with this part.  No one can train you in how to understand what you hear.  So probably the best thing to do is to take down important notes while listening to the conversation.  Remember: I said take down important notes not everything they said.  Some people rush to scribble everything said that they eventually don't understand what the conversation was all about.  By doing that, they won't be able to answer the questions for the speaking part of TOEFL.

Finally, the speaking part.  Here is the advice no one has told you before:  SPEAK YOUR LOUDEST during the speaking part.  Speak loud short of screaming.  I did that when I took my test.  I didn't care that there were other people beside me taking the test.  I didn't care that they can hear my answer.  I didn't care if I intimidated them or I sounded stupid to them.  I didn't care if I am distracting them.  All I know is that I just wanted that even if the Internet connection is not perfect or the recording machine is f*ked up, the person on the other end will still HEAR me.  So I spoke as loud as I could without shouting.  That way my answers were clear.  Of course, I had my uhms and of course, I was nervous, but the hell with all of that.  I need to pass this exam and I don't care what the other test takers would think of me afterwards.  So there you go: this is one good secret for the speaking part.  

As I conclude this rather lengthy blog entry, let me remind you that the TOEFL exam, does not and will never define you as a therapist.  Just because I passed my test on the first try and you passed yours on your seventh, doesn't mean I am a better therapist than you.  Physical therapy is a profession, a culture, a passion, a devotion and a calling.  It rises waaay above an objectified and potentially flawed language test called TOEFL.  So treat TOEFL like it should always have been, a worthy opponent but a roadblock not worthy enough to stop you from success and your American dream. 

Dyud and the Zombie Apocalypse

Just when the world has gotten pretty much over with the 80's and 90's alien invasion as the would be cause of humanity's demise, the new millennium ushered in speculations that zombies would eventually overtake the world.  The new zombies are still flesh-eaters and are seen overrunning cities and metropolises in their slow never ending limp to eat human flesh, blood trickling down their half-opened mouths, uttering guttural sounds. Blockbuster movies like Zombieland and I Am Legend, and widely popular series The Walking Dead and even social activities like Zombie Runs have highlighted the world's fascination for the dead who don't want to stay dead.

In deep thought, yours truly had an epiphany.  If, God forbid, we indeed would have a zombie apocalypse in the future, distant or near, yours truly would not be the crusading hero, (in ascending volume) blowing zombie heads off, scouring and eventually finding the remaining survivors of the human race ready to make one last stand for the sake of the future of the human race and of the world. Whew! Like, yeah right, like that is soooo gonna happen.

The epiphany I had was the complete opposite.  I realized I will not be able to survive the zombie apocalypse.  In fact, knowing me, I would be the first to be converted to a zombie.  Now how did I reach that conclusion?  Here, let me show you a picture:

 

That is me, about three weeks ago, in Pennsylvania.  That is me, posing, like the poser that I am, pretending that I know how to ski.  I sucked at it.  I even took group classes for beginners so that I could at least get to learn how to do basic skiing.  And yes, I sucked so bad at it, the instructor eventually gave up on me. (For the record, though, the instructor wasn't even remotely good. He just showed us once and expected us to do it right the first time and moved on to the next task).  Anyhow, my balance was bad and I spent all the precious little energy that my poor deconditioned body can muster getting up from the snow cause I fell...again...and again. What broke my heart though, was not merely that I was falling every time, unable to  maintain even just a little bit of stability, and ski peacefully in the soft almost flat out horizontal beginner's slope.  It was the fact that each time I struggle to get up, there are a couple three or four year old kids running circles around me in the skis or snowboards, making it look so easy for them but not for me.  You have to fight the urge to whisper: Your parents don't love you, you are adopted just so they feel as bad as you do.  It shakes your belief that all men were truly created equal.  And yes, there goes your dignity.  So there I was, defeated and cold, waiting for my friends to finish up so we can go home.  

During the summer, we went to my roommate's friends lake house in North Carolina.  The owners of the lake house are the the most humble secret millionaires I have known (errr well I don't really know a whole lot to begin with).  Anyhow, they own a speed boat, a couple jet-skies, a couple kayaks for water sports.  Of course, the amazing muah decided to try wakeboarding for a change.  My roommate went first and did it seemingly without any difficulty.  I tried it next and viola! Before I knew it I was struggling with life and death, gurgling lake water and using up whatever questionable amount of energy I had splashing around to get back into the boat.  That, despite having a life vest on me.  In fact, I was so weak, the boat had to circle down several times so they can get me from the water.  Ah, the shame.  

My weak body and my weak spirit, ultimately, will be my undoing.  I can never be a soldier or a warrior.  I can barely do ten decent push ups, can barely run a mile without stopping to breathe and walk.  And I am not even fat fat. I can't tie ropes very well, can't fix a car, know nothing about electronics, know nothing about computers except the addresses of free porn sites.  I can never survive on my own, in the wild.  I can never be a warrior, a fighter, a soldier.  Hell, I don't think I can defend myself if my life defended on it. 

What I do think though is I would have made a good propagandist in wartime.  I would be one of those instigators, rallying the crowd to the cause and slipping back into the shadows as chaos ensues.  I have always known how to inspire and to provoke.  I would never, ever want to be in the frontline.  I revel in shrewd, calculated cowardice.  For me that is an art form.  I learned in psychiatry class that I am passive-aggressive and I will probably play that part come the zombie apocalypse.  

I won't be able to run far, so chances are 1.) I would be eaten first or 2.) I will hide.  I would probably be the last to pack up provisions and when people would start the exodus to go away and hide, my dissenting opinion would be to hide where I am, praying desperately that the zombies don't get me.  Hide in the shadows and wait for the opportune time to escape or the perfect time to be eaten and converted.  

If I turn zombie, I would probably be a picky eater.  Like I won't eat the hairy ones, the fat ones and definitely not the ugly ones, especially the fugly ones.  And I would probably prefer to eat a vital organ, heart, liver or brain.  Intestines would be out of the menu, same for hair and sex organs, ewww.  Oh and if I turn zombie, I probably won't do the zombie walk: slow, lumbering eternal steps.  Lazy as I would ever be,  I would be one to drag my leg on the floor, or hide in fresh loam and stick my hand up like this: 

That is probably how I would get my prey assuming anyone even dares to come near it.  At the end of the day, it doesn't matter if I survive the zombie apocalypse or not.  I found a wonderful meme to summarize everything I have bitterly typed here today:  

 

Have a great zombielific day ahead!