It can save your practice—and at the very least, your sanity.
By Mike Cibulka, PT, DPT, MHS, FAPTA, OCS
My first job was at a geriatric hospital. I quickly realized that the physical therapy department had a few professional problems. The first one I noted was the poor caregiving by one particular therapist who had been practicing for about 10 years. Regardless of the patient’s diagnosis, she always had the exact same treatment plan. Patients would sit in a wheelchair “lineup” against the hallway and our physical therapy technician would have them do two sets of 10 military presses with either a one- or two-pound dumbbell. Then after that the physical therapist would put a gait belt on them and have them walk down the hall 10 feet not once but twice, never more, never less. This was the extent of the physical therapy program, every day the same program.
When I first came on board I did not really think anything of this, I just figured that was all of the therapy these people needed given their impairments. But it became “like déjà vu all over again” (borrowing a famous Yogi Berra quote) for each patient. Over time I realized that this was neither appropriate nor ethical, and in fact it was fraud. I discussed my concerns with the physical therapy director who told me that it was none of my business since I was not the director. I soon grew tired of watching this pretense; before long I got out of there and moved on to a new job.
I was hired by a local hospital that was supposed to be one of the most progressive orthopedic physical therapy programs in the area. I had worked there for about 10 months when one day I was given a challenging new patient. The patient was a 48-year-old female who was referred to me for low back pain and sciatica. The “prescription” called for moist heat, ultrasound, and pelvic traction, the usual standing orders for this particular orthopedic surgeon. The patient gave a history citing a laminectomy six months prior, as well as a recent onset of pain down the right leg, from her thigh to foot. On examination she could forward bend, backward bend, and side bend fully without complaint of any back or leg pain. Both the straight leg raise test and crossed straight leg raising test were negative for reproduction of any kind of back or leg pain. Neurologically she had no weakness in either lower extremity, no sign of sacroiliac joint dysfunction, or pain with lumbar spring testing. In fact there was really nothing that should have warranted a diagnosis of sciatica.
The physician’s orders sounded both safe and explicit: The patient just had an aggravation of her sciatic nerve, I should treat it as such. I found this odd because this did not appear consistent with her pain-free and full trunk range of motion (ROM), a negative neurological exam, and unremarkable special test findings. As I hooked her up to traction one day, I again asked about the nature of her pain and was told the pain mainly came on after walking a specific distance. This was starting to sound less and less like sciatica. I checked her lower extremity pulses and noted with surprise that both the right posterior tibialis pulse and right dorsalis pedis pulse were nearly absent when compared to the opposite side. Something was seriously wrong here and a strong surge of adrenaline kept pushing me to think “I may have found her problem.”
I found the referring surgeon and told him about my promising discovery. What I got back was even more astonishing: “When did you get your medical degree?” I was taken aback at first; I told him that I did not have a medical degree but was well trained as a musculoskeletal physical therapist. I was berated with expletives and was told to “back off” (in so many words). My only thought was how could defensiveness play such a strong role in allowing a health care professional to interfere with the clinical decision making for a patient.
I did not lose hope, however. I went to my physical therapy director and told my patient’s story, and the response was eerily similar: “He is the doctor, do what he says to do.” So now I felt stuck between a rock and a hard place. I went back to treating her, without success, and unsurprisingly by the sixth visit her leg pain worsened. I knew I had to do something for this patient. I did what made the most sense; I approached the patient’s family physician and told him what I found. He listened and he followed up with her. Later that day I found out she had received an arteriogram followed by emergency surgery for a condition called “Leriche’s” syndrome, a stenosis of the right internal iliac artery (I had to look that up.) Once again, I felt like I was making a difference in this world. Little did I know what was to come! The next day, I was brought into the physical therapy director’s office and blindsided by the guest appearance of the orthopedic surgeon. In short, I was subsequently fired for insubordination of this particular case. How could that happen? I thought that I helped save this patient from a potential life-threatening condition.
This was one of the most difficult times in my professional career, but it made me a much stronger physical therapist; it gave me the desire to persevere and to believe in myself. It is important to be persistent when your heart tells you that you are right. A few years later while working on my master’s degree at Washington University in St. Louis, I was in Dr. Steven Rose’s office. He was a great mentor, friend, and legend in my eyes. On his wall was a quote written by U.S. President Calvin Coolidge that I will never forget. It read:“Nothing in the world can take the place of persistence. Talent will not; nothing is more common than unsuccessful men with talent. Genius will not; unrewarded genius is almost a proverb. Education will not; the world is full of educated derelicts. Persistence and determination alone are omnipotent.”
As a practice owner for the past 35 years and manager of several employees, I still occasionally recall this story. I look at the current trends in interprofessional collaboration and how far we have come, not only in our profession but also within the health care community as a whole. If you are in a situation like the one I was in, do not let it get you down, and more importantly, do not go along with the masses. Trust your instincts, trust your heart, and provide quality care for your patients because they have placed their trust in you.
Mike Cibulka, PT, DPT, MHS, FAPTA, OCS, is an associate professor in the physical therapy program at Maryville University in St. Louis, Missouri. Mike also is the founder and owner of Jefferson County Rehabilitation and Sports Clinic. He can be reached at firstname.lastname@example.org.