Top 7 Lessons From My First Year in Practice

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Before I left for physical therapy school, I had one great fear: no matter how hard I tried, I was going to be a bad PT. I confided this fear to a mentor of mine, a well-respected PT himself. His response is one I’ve thought about regularly since that day- that with a solid foundation in school and good mentorship afterwards, there was no doubt I would be a great PT.

 Having now completed my education and practiced for a year, I realized that my mentor’s comments ring true for not just me, but for anyone entering the profession.With a new cohort of freshly licensed PT’s and PTA’s coming in to the profession, I took some time to reflect upon the major lessons I have learned over my first year in practice. The below points have resonated with me most, but please feel free to add your own in the comments section below!

 1. Mentorship is made by you, not provided by someone else. When interviewing for jobs, we all hear promises of weekly mentorship time and guided learning. Yet, if you do not prioritize this time, it’s likely to get lost in the pressures of the day. It’s our responsibility to make sure our mentorship time actually happens and is effectively used. Here are a few practices I have found helpful: a) block off your mentor time on your schedule- it’s simple, but makes the time more official; b) make sure your mentor is someone who you want to learn from; c) plan it out- set individual goals for yourself each time you meet with your mentor.

 2. Don’t compromise your values. Coming out of school, the lines between right and wrong seem pretty clear. However, those lines may quickly blur by pressures to bill more units, see more patients, or take on a practice outside of your ethical comfort zone. Remember that these decisions are ultimately in your hands- it’s your license and happiness that’
s on the line by being in a job that challenges your morals, ethics, and ability to take quality care of your patients.

 3.   Develop self-management strategies and remember your role. Patient care is hard. And a lot of responsibility. While we may see 60 patients per week, our patients only see us once or twice. Many times, we are the only health professional caring for their well-being. Because of the time we spend with our patients and trusting relationships we develop, many patients often end up airing all of their concerns to us. We may not be trained as social workers or psychologists, but the nature of our job demands we play a role as a quasi director of their care. There’s no doubt about it- doing this for patient after patient is mentally, physically, and emotionally draining. In response to this fatigue, I’ve developed a couple strategies to make my day more manageable. First and foremost, I always try to remember my role- we don’t have the time or training to be everything to everyone, so I make sure to refer to other professionals when appropriate, even when it means embarking on a difficult conversation. Second, I try to take 2-3 minutes between patients to decompress. Just a few minutes allows me to refresh, knock out a bit of documentation, and ensure I approach the next patient as a clean slate. I find I can bring more to the treatment session with those couple minutes to myself, even if it means I’m slightly late to the next treatment session.

 12080051_m4. Attitude is truly infectious. It’s easy to fall down the wormhole of complaining about patients or co-workers, but finding ways to stay positive, smile, and bring joy to the clinic is much more rewarding. We all have difficult days, but bringing a positive attitude to work can change the entire culture within a clinic. I challenge you to be that compassionate and empathetic person that brings positivity to a clinic. Once you do, your colleagues will start to look at you as a leader and your patients will notice.

5. Recognize your needs. Then verbalize and fight for them. Everyone has an idea of what it means to be successful, but only you know what you need to be successful. Too often, I see new employees try to conform to a system and environment that does not work for them. Whether you feel you need more mentorship, want to attend a continuing education course, or even would like something as simple as a slightly longer lunch, do not let a resentful feeling brew- approach your employer in a respectful fashion. Chances are that your employer is looking to support you, but does not see your needs. If your employer is not willing to acknowledge or support your needs, it might be time to consider a change.

 6. Reflection really is important. Be a conscious practitioner. In PT school, our class reflected on everything. In fact, I’m pretty sure we reflected on our reflections. We reflected so much that reflection became a dirty word. However, I have come to find great power held within reflection. Make sure to periodically ask yourself, “what could I have done better during my last treatment session,” or “what could I improve upon from last week?” It’s easy to go through the motions, but approaching your treatment session consciously, by analyzing what you are doing, why you are doing it, and how you can improve will lead to greater growth and fulfillment.

 7. It’s worth it. Patient care is challenging. Most days are exhausting. Yet, if you give it your all and fully engage with your patients, it can be extremely rewarding. The feeing you get when someone looks you in the eye, shakes your hand, and says a genuine ‘thank you for your help,’ is a feeling I have never reproduced elsewhere in the world. We play a special role in our patients’ lives, giving them our time, touch, and knowledge. Cherish your relationships with your patients and never forget what it feels like to help someone achieve their goals.

 Any big lessons I missed? Please consider adding your own lessons to the list in the comments section below!

About the Guest Blogger: Josh D’Angelo, PT, DPT served as APTA Student Assembly President in 2013 and is now active with APTA’s DC Chapter and Private Practice Section. He graduated from George Washington University’s Doctorate of Physical Therapy program in 2013, where he was the University’s sole student to win the George Washington Award. Josh is also a former APTA Mary McMillan Scholarship awardee and is currently practicing in the outpatient orthopedic setting in Washington, D.C.  He is a regular contributor at PTHaven.

What is Quality in Physical Therapy?

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I have had some interesting interactions in social media over the past few weeks that have had me thinking about the definition of quality in physical therapy. Therapists are paid for our time and the procedures we perform. Because of this (or at least I blame this system) we tend to define quality around ‘actions taken’ and method of work. For example:

  • Quality providers are able to manipulate an acute low back
  • Quality providers avoid modalities
  • Quality providers provide good home exercise programs
  • Quality providers set and track goals
  • Quality providers use evidence based interventions
  • Quality providers spend (however long) with each patient
  • Quality providers do not use PT Assistants or Aides
  • Quality providers have this or that certification
  • Quality providers have/avoid the latest gadgets
  • Quality providers use/have/do whatever is important to you…

We do this in large part because these are the most visible parts of a practice we might judge it by. However, I would argue that while there are a host of factors that the best practices have in common, quality is not defined by actions or our broken reimbursement system. Quality is defined by patient outcome and by patient experience. In this post, I’d like to provide a window into how we measure quality at Texas Physical Therapy Specialists.

In our practice, we measure outcome using a national database called Focus on Therapeutic Outcomes (FOTO). This system uses adaptive surveys to determine a risk adjusted baseline when a patient starts physical therapy, and then tracks their progress. The results can then be used to provide feedback to individual therapists (i.e.”Dr.____, your outcomes with ankle patients aren’t as good as Dr.___’s, lets see what they are doing that you are not) and more importantly can be used to compare outcomes with other participating practices across the nation.

The other component of quality in physical therapy practice is patient experience. We break this into two components: customer service (all staff interactions) and providing quality connection between the therapist and the patient.

We measure customer service with a survey that has multiple components but centers around the ‘net promoter score‘. Often called ‘the most important question in business’ it is simple and captures the desired customer service outcome for most practices.11268773_m

“How likely is it that you would recommend us to a friend or colleague?”

Much harder to measure but equally important to patient experience is the quality of connection between patient and therapist. This is how well a therapist listens and how much empathy they show. These things have a powerful impact on clinical outcome so we measure them separately using a survey specifically for these items (Consultation and Relational Empathy instrument or CARE) at the completion of the first visit. Interestingly, our therapists scored significantly better in this area after receiving training specific to compassion and empathy.

The confluence of these three things is the product our practice produces.

The amount we charge a cash-paying patient, the contract we sign with an insurer or the assignment we accept from the federal government is simply how we receive payment for that product.  Our current payment system bases this on time spent and a host of other items that have no direct relationship to quality.  Paying for time without accounting for outcome is like paying a mechanic for the time spent on your car without accounting for whether the problem is solved.  Regulating work methods is like mandating that a mechanic can’t use helpers and again not accounting for whether the problem is solved.  We have to comply with these external definitions (which vary wildly by state and payer) but we do not have to let them define what Quality is.  In my opinion, quality in physical therapy is a simple equation:

Quality = Outcome + Patient Experience.

There are many ways to get there, and undoubtedly some are better than others.  Having the ability to measure quality gives us the opportunity to find bright spots and emulate best practices.  How do you measure the quality of your service?

Never Give Up

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Last weekend, I had the pleasure of listening to Diana Nyad speak at the 2014 TeamBeachBody Coach Summit.  This amazing lady shared the story of her lifelong goal of swimming from Cuba to Florida, which she achieved at age 64.  I vaguely remembered seeing this on the news last year, but I failed to realize just how impossible this swim is.

103 miles in the open ocean, through waters teeming with sharks and jellyfish.  In the 30 years since she failed the first time (still setting a world record by swimming to the Bahamas instead) nobody had broken her record.  To be honest, part of me thought that wanting to do this in the first place must be a special kind of insanity.  Then she said this:

It’s not about what you get, it’s about who you become

This really struck me.  What if I could apply the mindset of arguably the world’s toughest athlete to my own life and endeavors?

Its easy for me to stay in my comfort zone and to complete my daily work without ever really stretching myself.  I’ve always wanted to write a book.  Its a scary proposition, though… what if nobody wanted to read it?  What if I put all that work into it and then it didn’t go anywhere?  Its always seemed like an impossible goal.

Diana told us that achieving her goal wasn’t what made the difference… striving for the goal defined her, fulfilled her and allowed her to build a tremendous resilience.  She failed and failed and failed until she finally succeeded.  The most important thing she did was to try.

I think I’ll take that little quote, put it in my journal and try to be a person that fails at massive goals.  After all, that’s exactly who Diana was when she started her fifth and final try at that impossible swim.

Do you have an impossible goal?

…and fire quickly.

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I have never met a leader or a practice owner that regretted firing somebody that was a poor fit for their team. While I have not had to let many of my teammates ‘find other, more suitable employment’ one example comes to mind.

DOFIStacy (not her real name) was a pretty good DOFI. DOFI stands for ‘Director of First Impressions’, a title shared by all of our front desk personnel. All the patients loved her and she took care of the data entry and scheduling portion of her job well enough. The downside was that she was often late and her ‘sick days’ tended to fall on the Friday before a 3-day weekend. I must have put up with a half-dozen ‘throat hurting’ and family emergencies (I think her grandmother died twice) and way too much aggravation before she finally pushed me over the edge. After a very dramatic sick call, she posted some great pics from the lake on Facebook! We let her go the next day, only to find out that she had been stealing co-pays from patients for on and off for over a year.

Lesson learned! I should have let her go as soon as I figured out that she had an integrity problem. Here are a couple of relevant quotes to help us remember to make the decision to remove people from our team more quickly.  I find that it helps to think of ‘firing’ as rectifying my own mistake in hiring the wrong person.

“The moment you feel the need to tightly manage someone, you’ve made a hiring mistake” (Jim Collins)

“Don’t beat yourself up if you get hiring wrong some of the time. Just remember, the mistake is yours to fix.” (Jack Welch)

So if you find yourself tightly managing someone or smelling a culture mismatch, move into addressing the problem without delaying to see if it will rectify itself. If its a problem with competence, you should be able to address it and see improvement. Chris McChesney of Franklin Covey said it best:

“If they can’t do it, they are in the wrong seat. If they won’t do it, they are in the wrong organization”.

Hire slowly…

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One of the most important decisions in building a great practice comes whenever we are hiring people. Likewise, one of the surest ways to destroy a great culture and derail growth is to pick the wrong people for your team.

“The old adage people are your most important asset turns out to be wrong. People are NOT your most important asset. The right people are.” – Jim Collins, Good to Great.

This principle from ‘Good to Great’ has been useful lately as we go through a round of hires at Texas Physical Therapy Specialists. Whenever we find ourselves in a position of needing to hire, inevitably the growth or circumstances that necessitates the hire pushes on us to accomplish it quickly to remove the pressure. The challenge is that this is the best time to slow down and be disciplined and rigorous.  Its painful (just ask my directors waiting for help!) but it pays to put in the energy up front and hire the right person.26325920_s

Here are 4 of my favorite rules to help us make this important decision:

  1. Cast a broad net. You want to make sure that you capture a large pool of applicants, rather than a sample of convenience. Sometimes a ‘good’ applicant appears fortuitously – making the path of least resistance a quick hire without much need for rigor. What if the 5th or 10th applicant would have been somebody great?
  2. Don’t compromise. The surest way to build a mediocre team is to hire mediocre people. Deal with the short term pain of the search and hire the very best you can find. The long term pain of a mediocre hire is worth avoiding.
  3. Hire for attitude, over aptitude. Unfortunately, we don’t always have the luxury of waiting for that perfect candidate to come along or we have to choose between two great people. When we do have to choose, we should give attitude and fit within our culture greater weight than competence and skill set.
  4. Do more than an old school interview. There are alot of tools out there to help you dig into who a person is. Consider using tools like the Omnia profile, Emotional IQ, Strengthsfinder or the VIA character strengths profile to give you a window into your candidate. Using this type of tool (don’t try to use them all) will make you slow down and think deeply about who you are hiring and their fit within your team.

party-busPackard’s Law captures why getting the right people on the bus is so important:

“No company can grow revenues consistently faster than its ability to get enough of the right people to implement that growth and still become a great company”. – Jim Collins, How the Mighty Fall.

Take the time to hire slowly…. and the second half of that adage is … fire quickly. We’ll talk about kicking people off the bus next time.

What does the Hedgehog say?

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One of the most elegant and useful concepts from Jim Collins’ Good to Great study is the Hedgehog Concept.

The Fox knows many things, but the hedgehog knows one big thing – Archilochus

In his famous essay “The Hedgehog and the Fox“, Isaiah Berlin divides people into two groups: foxes that see the world in all its complexity and pursue many ends at the same time vs. hedgehogs that condense concepts and reduce challenges into simpler ideas.  The parable would have the crafty fox attack the hedgehog with a variety of clever strategies, to be repeatedly beaten by the hedgehog’s simple, but powerful strategy – roll into a ball so the pointy parts are facing out.   While the fox is crafty and nimble, the hedgehog is focused, determined and stays the course.

The companies that went from good to great discovered and then had the discipline to stay within a foundational hedgehog concept that kept them from being distracted from their core business.  In contrast, the comparison companies that never made the leap to greatness often lost focus and took opportunities that were outside of their strengths.

A hedgehog concept is found at the intersection of three dimensions:

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  • What you can be the best in the world at.
  • What drives your economic engine.
  • What you are deeply passionate about.

The good to great companies (compared to comparison companies) were disciplined enough to understand and stick to their Hedgehog concept despite the temptation to chase after increased profits or ‘once in a lifetime opportunities’.

In the medical field we see some great examples of finding and sticking to a hedgehog concept.  One local example is a practice called Sullivan Physical Therapy.  This practice has a niche – women’s health – that they are great at.  Another is Balance 360 that focuses on balance and vestibular disorders.  In these cases, these practices don’t try to be all things to all people – they have a concept that they can be the best at, that drives their economic engine and that they are passionate about.

I don’t think that the hedgehog concept applies only to practice niches, though.  At Texas Physical Therapy Specialists, we can be the best in the world at developing clinical specialists and team leaders.  This is where our passion lies and the team it produces drives our economic engine.  By understanding and sticking to our hedgehog concept, we have the potential to be the best in the world.  We have to have the discipline to avoid ‘once in a lifetime opportunities’ that don’t fit within our concept and we have to have the discipline to stay the course when it seems like jumping to a different strategy might be more effective.

What’s yours?