It looks like we’ve had our second contributor, Dr. James Bailey, DPT, PT, come through to offer his transition into the tribal system. As I’ve mentioned before, the tribal sector is not a road well travelled and making the transition from an outpatient facility to a tribal facility isn’t an easy task. Thanks for taking the time to post, James.
My name is James Bailey and I obtained my doctorate in physical therapy from the University of Oklahoma in 2011. I was excited to graduate and start my career in an outpatient facility where I believed I was ready to take on any and all patients. Just like any new grad I was excited but also a little petrified about taking on a patient-load while knowing I was solely responsible for patient outcomes. This unease melted away quickly as I became more efficient with my techniques and my ability to communicate to address patient questions. My rotations while in school helped tremendously with these skills, but it is not the same when you are set loose with a clinical license and become the one making the ultimate decisions with patient care.
I fully appreciated my first job and all that I learned. When I started I was the third therapist and we were expected to see approximately 15 patients a day. I thought this was perfect and I felt like I spent adequate time with each patient explaining why we were doing certain exercises or what I believed my manual therapy techniques were achieving and how their home exercise program would help to keep the gains we made in the clinic. I became really good at post-op surgical protocols and could tweak them as needed to be more functional per patient. Unfortunately, most of my patient load was post-op and I attributed most of the pain or nagging discomfort as just that, post op pain, and it typically decreased as the tissues healed and we progressed to more functional movements. For the most part, patients got better and they were discharged on their way to achieving their set functional goals. For those patients that were not post-op, I had a bit more difficulty due to the chronicity of pain. Still, more often than not the patients had good outcomes and if not they were usually progressed to pain management and/or surgery per physician-decisions as was standard in our clinic with our specific referral sources.
Unfortunately after about a year of work, one of our therapists took a management position and our supervisor thought we could absorb the patient-load. Our 15 patients per day soon turned into 20-25. I started to lose time with each patient and found myself staying at one table performing some manual therapy, wiping it down, bringing another patient over performing more manual therapy, rinse and repeat for the entire day. I caught myself frequently performing manual techniques on one patient while watching 2-3 other patients perform exercises from a distance and trying to correct if needed through verbal cueing. I pride myself on having good time management and ability to multi-task but I know my manual techniques, the exercise quality/progression, and the ultimate outcomes started to decline. My post-op patients still got better overall but I noticed my patients with insidious onset and/or chronic pain tended to have more issues. I did not have enough time with them to address their many concerns and to really hone in on exercises/techniques they could use at home to continue progression and pain management. I brought up these concerns with my supervisor but he was quite content with how the clinic was performing from an outcome perspective and very happy with profit.
After six months, I became very frustrated and felt like a factory worker performing manual techniques on patient after patient and getting less results but making good profit for the clinic. I felt profit was being enforced more than patient-care and this did not settle well with my moral compass. This began my journey to search out a new job. I did a quick stint in home health just to get away from the monotony of the outpatient setting and I enjoyed the freedom of scheduling but did not enjoy home health. I then realized the outpatient setting was where I belonged. I truly enjoyed the first year of my job and searched for a clinic that was more focused on patient-care and less on their bottom-line. My mother-in-law mentioned her tribal employer was searching for a physical therapist to open a clinic. I will admit I was not familiar with the tribal setting and was intrigued by the opportunities of opening a clinic. I went to the interview with an open mind and many questions to be answered. Some of the many selling points included: I could see as many patients as I felt necessary in a day but that patient-care was the most important aspect, the patients would never feel a financial burden to attend physical therapy, and the clinic was attached to a wellness center with a heated pool, personal trainers, dietitians, and a healthy heart/diabetic program which was all at no cost to the tribal members. This was such a different setting than I was used to and I was easily sold on the prospect of caring for tribal members for the sole purpose of getting the members better and back to a higher quality of life.
The one main transition I did not fully appreciate was the patient population. Aforementioned above, in the normal outpatient setting I was seeing probably 75% post-op with pretty straight forward protocols. The patient population of the tribal facility was around 10% post-op and 90% insidious onset/chronic pain. Needless to say, a quick learning curve was needed and I started to do my research on better techniques to help my patients self-manage and to improve their quality of life. This was a steep learning curve and one that would be taken without a mentor. I was more than ready to accept the challenge and I am grateful for the opportunity. Some of the main changes I have instated are: the way I talk to patients and help decrease perceived threats from anatomical/biomechanical deficits, adding therapeutic neuroscience pain education, simplifying my evaluation/exercises to allow for patient adherence to HEP, and including more functional movements to address motor control deficits.
I am very thankful to work in a tribal setting where patient care is the number one priority. I still have plenty to learn and to improve to better myself and improve my patient outcomes but I feel I am on the right track. I will be posting much more on the changes, improvements, lessons learned (the good and the bad), and complications I have experienced in the last year as well as the ongoing evolution of patient care in the tribal setting. My next few posts will be about some of the main influences I utilized to help improve my clinical mindset and techniques after facing the new challenges of the tribal population.