FUBAR

FUBAR.

A military acronym that stands for ( lets use the sanitized version ) [Fouled] Up Beyond All Recognition. Apparently Fubar originated back in WW2 and is slang (mangled German) for the word "Furchtbar" which means terrible or horrible. When it comes to the current state of the healthcare system, terrible or horrible just don’t do it justice. The healthcare system is, in my opinion, FUBAR.

As a physio for almost 24 years I have been through the healthcare trenches, and seen many changes. I mean, when I started EMR wasn’t even thought of! We were scribbling notes out and writing out charges. In PT school I may have touched a computer once. I literally had to photocopy ( 10 cents a page) every article I wanted to read! In short, … I’m old!

We have made incredible progress over the years in our profession with some amazing clinicians developing and progressing the profession. However at the same time we, collectively (PTs, MDs, admins, politicians, insurance companies – the medical industry)  have completely failed our patients. Sure , there are amazing stories of innovation, we are saving more people from maladies that would have killed them years ago, we are transplanting organs, performing surgeries only once dreamed of, and many people are living healthy lives in the western world. Yet at the same time, when we look in at the experience of the patient, our client, the person right in front of us that has come to us for help it is a frightening tale of failure.

This really rang true to me this week with a couple of patient encounters. The saddest part is that these two stories are not rare in today’s system. I guess I should have written this earlier. I don’t know why it has struck me now to speak out… maybe I’m just getting into my grumpy old PT mode as I age…. Or maybe healthcare is getting worse.

Patient 1:  A middle aged gentleman. Referred by an orthopedic doctor with the diagnosis of “tennis elbow.” He tells me his pain started a month ago when he was turning a stuck valve and felt a pop. He has had increased pain since. He tried OTC meds without relief and it got to the point that picking up objects was painful and really affecting his work and home life. He saw an MD and, of course with NO alternate options on their mind for musculoskeletal pain, went through a month of NSAIDS, then injections- all with no relief.  After a follow up visit in a month it (for some reason) occurred to the MD that a referral to physiotherapy may be appropriate. If it persisted, imaging was the next stop (MRI).

On a brief evaluation he had pain and tenderness at the radio humeral joint and pain with resisted supination. No real pain with any resisted wrist motion, no radial nerve signs and an otherwise clean exam. After a manipulation of the radial head and soft tissue work and dry needling to the supinator he reported instant relief.   

   

Lets look at a few of the multiple problems here:

1) The same insurance paid the physician 4x as much as they paid for my service – TWICE. Then paid for medications, and steroid injections, and almost an MRI.

2) This man spent a month in pain affecting his work and family life all based on a diagnosis that really appears to be wrong.

3) Taking NSAIDS (which did not help) can have significant effects on the GI system and as was recently highlighted by the FDA heart attack and stroke risk increase even with short-term use, and the risk may begin within a few weeks of starting to take an NSAID. Furthermore, steroid injections are also not without risks and side effects.

Patient 2:  An 81 year old gentleman who comes for evaluation for chronic back pain. He has had pain on and off since his twenties which has become constant and severe. Reviewing the history I see that he has had an implanted spinal stimulator, injections, has been on opioids and has been followed by “pain management” for years. He recently had his opioids cut back. Sixty years of pain (30 of them bad by patient report), this wasn’t exactly an eval I was excited to be a part of. Yet when I went in the room I was met by a pleasant and kind man who explained that he was primarily frustrated because his pain is limiting him from caring for his wife who is suffering from dementia and needs almost around the clock care and supervision.

He had placed her in an assisted living center but when he went to visit found she was not receiving good care and he wanted better for her – thus bringing her back home. He is doing everything at home and even obtained a bed alarm that alerts him when she gets up at night and wanders. She had once wandered out of the house alone in a confused state. He also reports that he is no longer able to sleep well.

I went through my eval and did discover some issues I felt we could address physically - significant loss of hip and knee mobility, hypomobility through the lumbar spine and significant trunk and hip weakness to highlight a few. Along with the obvious need for pain neuroscience education I felt that we could definitely help this man, at least to some degree. The most shocking part of my evaluation is when he told me he had not seen PT before. He stated that he was “tired of going from medication to medication and having injections” and continuous procedures. He literally said, “I feel like exercise and moving is what I need.”

This gentleman had been stuck for decades in the medical industrial complex being pushed from one med to another, one intervention to another, and obtaining no relief. He underwent procedures that had risks and side effects and was taking numerous meds and opioids with all of their risks. At no point did anyone actually place their damn hands on the man and assess his movement. At no point in all these years was therapy suggested. At no point was he provided education on pain to decrease catastrophizing and fear avoidance behavior.

I was dumbfounded. We, collectively as a medical system and as a society, have failed this man. I believe that even after all these years he can improve. However, think of the possibilities if he had been managed differently all these years. How would that affect his life now? How would that affect his wife’s life now? We will never know what could have been but I do know it could have been better.

I want to be clear that I do not write this so as to place blame on other providers and elevate my abilities. I mess up on a daily basis. I don’t make the right decisions on treatment every time I see a patient. I don’t always address psychosocial issues as much as I should. I don’t always progress and develop my treatments as well as I should. We are all human. Almost all medical providers have nothing but the best of intentions. However they are often stuck in a system that is FUBAR.

I know I can do better. I know we can all do better. We need to do all we can to get our voices out there and let everyone know that we are the alternative to meds, imaging and surgery. I am so grateful for so many voices in our profession that have begun to speak over the noise and bring forward thinking solutions and promoted the profession like never before. @timothywflynn , @jeffmooredpt, @theaphpt, @dr.mitch.dpt, @ryansmith.dpt, @updocmedia, @theducklegs, and of course @physio.praxis  (Just to name a few)

Physical Therapists are the answer to so many of our systems issues. We owe it to our patients to work on being a solution and not another cog in an out of control system.                                           

These are My Reflections: [D]Pt. I & II

Part I:

A systematic theme over the outcomes of my life has always been one that leaves me feeling as though I could have done much more. Today, as I reflect upon the goals I set for myself at the beginning of this course, I do not necessarily have this feeling. My initial goal was to render “the ability to look deeper into a matter immediately after the matter has occurred,” in an effort to solve the problem as quickly as possible.

All professionals have metaphorical or tangible tool belts. Physical therapists have goniometers and manipulations, Popeye has spinach, and Batman has batarangs and a zipline. What builds the efficacy of a professional is their ability to call upon these skills in a matter of seconds in their individual lines of work, but it all starts with how they think.

I comfortably reside in the fact that I acquired the skill I initially set out to ascertain at the beginning of this course. Through conversations with peers, reading and writing on numerous topics, and developing relationships with faculty who know much more about these skills than I do. I believe this cornerstone of knowledge is one that will withstand future winds of uncomfortable learning, and will not wash away like biased thought built on a house of sand.

The goal was to acquire the axe, and though it may be dull, I have the wet stone to sharpen it. I believe I have found a mentor like Liam Neeson in Taken. He “[has] a very particular set of skills, skills acquired over a very long career.” This is a grand happenstance, as it is my hope to saturate every gyri of my cerebral cortex; well, more specifically my hippocampus, as I move forward in this crazy whirlwind known as Physical Therapy School.

Part II:

Dear Self,

I hope this letter finds you well. It has been an arduous and downright difficult journey.

But alas, as sure and true as Chris D’elia’s impression of drunk girls: 

WE DID IT. We actually did it. You are graduating this week. All of the cadaveric blood, lab partner sweat, and learning-the-gait-cycle-tears have paid off. You are about to become a Doctor of Physical Therapy. We are at the event horizon now, so let’s take a look back shall we? 

We have learned a lot over these years. So much about anatomy and biomechanics, pain science, and biopsychosocial models of medicine. From school and internships, we’ve had a very real and visceral look into what is to be expected in our next 40 years in the field. From the internet, we’ve learned that a lot of our colleagues have varying, and sometimes vehement, opinions on the path that should be trodden with patients to arrive at the same conclusion – return to what they love to do.

Furthermore – stretching is usually not warranted, foam rollers just kinda suck, and saying adhesions on the Internet is a sure-fire way to get a lot of people #triggered,

so avoid that all costs. But always continue to promote loading it over stretching it, that just always seems to get the job done.

You’ve surrounded yourself with a group of individuals whose hope is to change the game of Physical Therapy – stay close with them. Ya’ll have a lot of work to do, so stay diligent once you walk out of that venue with your cap and gown. These are my reflections.

Your benediction is as follows:

Continue to ask questions, always ascertain the why, show others the why, learn something new daily, problem solve, know why you do things before you do them, remember why you went into this field, help people, empower people, love people.