Everything's going to be alright

[Barrett Dorko]

It’s been a quiet week in Cuyahoga Falls…

Today I picked up three books from atop a shelf in the waiting room, tucked them beneath my arm and took them out to the car.

They were two volumes of poetry by James Whitcomb Riley, 1902 and 1908, both illustrated by Howard Chandler Christy, and a 1946 copy of Marjorie Rawlings’ The Yearling, this one illustrated by N. C. Wyeth. I imagine they’re all worth something.

My plan is to carry a few more books out each day, spreading this task out over the next few weeks. Strong as I am, my body wouldn’t take all of this moving at once. I have a lot of books.

I came home early and searched through the stations, landing eventually on the movie “Broadcast News.” Ten minutes after settling into my recliner I heard Albert Brooks say to Holly Hunter the very line I needed to write today. Brooks’ character had just quit his job at the news bureau and Hunter was angry with him, feeling he’d abandoned her, but he interrupts her complaining, citing something he’d heard from an old-timer:

Bernie said, “You’re lucky if you get out when you can still cry.” Which means I shoulda quit this place three years ago.”

The fact is, my clinical practice used to lead me and now I drag it along behind me like some kind of irrelevant, leaden and expensive weight. When I let it go entirely in February a few patients may complain but I don’t know a single physician or therapist around here that will notice. Many things contribute to endings like this, but the words in my head today are apathy and indifference – and they don’t describe me.

I want to finish with this; an essay I wrote in December six years ago after having arranged for my father’s admission to a skilled nursing facility:

Everything’s going to be alright

It’s funny the things you notice…Trying to remember the room number they gave me at the reception desk, I walked down the broad hallway and stepped passed a housekeeping cart. An older woman wielded a mop over a floor that, to me, already looked clean. She paused, peered through wire-rimmed glasses at a shining tile of linoleum, frowned, and then removed a small putty knife from her back pocket. She bent further forward and started to scrape, her whole body reflecting efficiency, strength and singleness of purpose.

I felt my throat and shoulders relax, and continued to look for my father.

There’s a poem by Derek Mahon running through my head today:

Why should I not be glad
To contemplate the clouds clearing
Beyond the dormer window?
There will be dieing
But there is no need to go into that
The poems flow from the hand unbidden
And the hidden source is the watchful heart
The sun will rise in spite of everything
And the far cities are bright and beautiful
I lie here in a riot of sunlight
Watching the daybreak and the clouds flying
Everything is going to be alright.

My father responded to his life by writing a thousand poems but today just speaking requires all the strength he can gather. He’ll need all the help they know how to provide in this place, and I’m going to talk to the PT about how things might go with her department. I hope not to scare her.

Meanwhile, if I know my father, he’ll look toward the window from his bed and contemplate the clouds and the sunlight. He’ll think of poems he might write and, as always, the source will be his heart.

He’ll look at me and say, “It’s okay Barry. Everything is going to be alright.”

Maybe the care and efficiency of the housekeeper says something about this place. I hope so.


Today I remember seeing his wounded foot for the first time that day and knowing deep down that he would never leave that place.

I didn’t have the courage to write it at the time, but I do today.

[Randy Dixon]

So how do you like sappy country songs that bring tears to your eyes?

UpperCut » Artists S » SAWYER BROWN » The Walk
Down our long dusty driveway
I didn't want to go
But I set out with tears in my eyes wondering
Daddy took me by the hand
Looked out at the school bus and his little man and said
"Don't worry boy it will be all right"

CHORUS

Cause I took this walk you're walking now
Boy, I've been in your shoes
You can't hold back the hands of time
It's just something you've got to do
So dry your eyes I understand just what you're going through
Cause I took this same walk with my old man
Boy, I've been in your shoes

Down our long dusty driveway
I set my mind to go
I was eighteen and wild and free and wondering
Daddy took me by the hand
Looked at the world and at his grown man and said,
"Don't worry boy it will be all right"

Down our long dusty driveway
This time we both would go
He had grown old and gray
And his mind was wandering
Daddy took me by the hand
Said, "I know where we're going and I understand
Don't worry boy it will be all right"

CHORUS

[EricM]

Now to me that sounds like a great waiting room, one where I’d try to arrive early just to spend some time.

A practice devoted to doing nothing ends up with nothing to do. Not that I’d ever say that to your face, but it’s ironic, don’t you think? If this was a roast, that would be funny.

Unless I’m completely misinterpreting your meaning, you do not seem overly bothered by this turn of events. I don’t detect defeat or surrender in your tone rather a sense change, where to stay put could be, well, painful, even if closing the doors of your practice is in itself a final act. You’re creative instincts, if left unchecked, will carry you onwards. You’re nothing if not consistent.
This isn’t defeat or surrender is it??

As one who is just now planning to embark on my own doomed path to personal integrity I hope you’ll be so kind as to post a few pictures of your treatment space; a way to remember the place where nothing was ever done.

Eric

[BB]

I've been thinking about how to respond to this post all day. Not in choosing the words but in its impact on me.

I start by thinking that the health care community of Cuyahoga Falls doesn't deserve to have you around anyway by the sounds of it.

It makes me sad to see a clinic, run by someone who seems to me to be uncompromising of his principles which are very solid, who is truly one of only a handful who understands patients in pain to this level, not live on.

It makes me nervous as well. I've always been told "do a good job with your patients and they will find their way to you." The fact that this is not happening in a sustainable way for someone who handles patients in pain with a respect that is rare, is a dis-heartening state of affairs. As a fellow ectodermalist, this shows blatantly what we are up against. As an ectodermalist who is in the process of starting a clinic, this is especially nerve rattling.

It is a bit exciting that now all of your energy (I'm assuming) will be devoted to teaching and changing this state of affairs. Now if we can just get more people to listen.

I'm sorry that this is what it has come to Barrett, but I'm excited to see where and how you land.

[nari]

I've been wondering about my response to Barrett's post as well....

I don't see it as a negative sort of move, rather a positive move on towards a different environment, and perhaps a different focus. Same but different. ;)

When I left the hospital after 23 years, it was pretty neutral; neither one way or the other. Dealing with the frustrations of my thinking outside the PT boundary, was something I was tired of. But I did write some poems and make a list of about ten people out of hundreds who were/are important to me. The rest were forgettable.

Barrett, you will thrive. You can't help but thrive, it's integral in you.

Eric, you have some youthfulness on your side. That always helps. There will always be the folk who want to go to places where everything is done bar the kitchen sink, but there are those who don't. Zap 'em with nothing.

In a way, you will both have more freedom. Have a squizz at the Daption Capense on the left. (Cape Petrel)

Nari

[vajranata]

Barrett,

Thanks for sharing this incredibly personal snapshot of your life.

I "lost" my father in 2003. It was unexpected and maybe even unnecessary. I don't want to explain it. My greatest regret in my life so far is not having known him as an adult. He died at age 64. I think of him almost every day. In some subtle way, my life is a tribute to him.

Don't worry about your practice. Others will pick up where you leave off. I will try, for my own very small part. We do what we can for each other...those off us that care more for our species than our cultures.

I salute you Barrett. Cheers.

[Diane]

I can get why you want to do this Barrett.
my clinical practice used to lead me and now I drag it along behind me like some kind of irrelevant, leaden and expensive weight.
An anchor is good when you're in harbour or when there are storms, but it's the last thing you need when it's time to move and enjoy some time in full sail.

I'm enjoying my last week of a three week holiday, the first three week holiday in ... at least a dozen years. I didn't go anywhere except further within, but it sure feels good to be off clock.

I imagine you'll teach still, and have more time to think, read, write.

[Barrett Dorko]

These thoughts were wonderful to waken to this morning, thank you.

It is not currently my intention to see patients any longer and no one I know will take up where I've left off. I recently wrote a letter to a colleague newly assigned a management position at a large local hospital. He professes a great respect for me but always tells others that "nobody knows what he does." He's never read any of my writing or seen me speak nor has his staff. I suggested he consider my doing something for their new, gigantic "wellness" clinic. "It's time that my work stop being such a mystery to you," I said. He said he'd look into it, but that was weeks ago and I expect nothing at this point. I guess giving nothing also results in getting nothing. (Eric, please save that for the roast)

Sticking with the father theme, in my considerable reading about men's issues it's clear that sons commonly "leave" their fathers for prolonged periods during early midlife and then return. I certainly did that. It is the father's job to prepare a place for the meeting, and mine did.

Similarly, patients "land" in my hands after some circuitous route through the healthcare system and I never figured out how to make that easy for them. In fact, physicians are now increasingly able to and willing to let them enter my door only after they have left their wallets behind (with the doctor). When my colleagues indicated that they would be glad to share their profits my practice was doomed. Competence is not a relevant issue to any physician I know.

For the past three years I kept my place prepared for the patient's return but I can no longer do that.

All I have left to offer are what I know and can do with that knowledge when a patient lands in my hands.

It will have to be enough, because soon a place to "do nothing" will close entirely.

[Jon Newman]

The Snow Man

One must have a mind of winter
To regard the frost and the boughs
Of the pine-trees crusted with snow;

And have been cold a long time
To behold the junipers shagged with ice,
The spruces rough in the distant glitter

Of the January sun; and not to think
Of any misery in the sound of the wind,
In the sound of a few leaves,

Which is the sound of the land
Full of the same wind
That is blowing in the same bare place

For the listener, who listens in the snow,
And, nothing himself, beholds
Nothing that is not there and the nothing that is.

--Walllace Stevens

I imagine a snowman might melt here (waiting room at Barrett's clinic)

[Jon Newman]

Wounded Foot--Joaquin Sorolla y Bastida (http://www.saint-andre.com/thoughts/sorolla.html)

[Diane]

It took awhile to find, because the title of the song isn't "Everything's gonna be all right".. the title is "Light of a Clear Blue Morning." Dolly Parton wrote it, and I even found a u-tube video of her singing it. (Which I will spare everyone.)

The lyrics are as follows:
It's been a long dark night
And I've been a waitin' for the morning
It's been a long hard fight
But I see a brand new day a dawning
I've been looking for the sunshine
'Cause I ain't seen it in so long
But everything's gonna work out just fine
Everything's gonna be all right
That's been all wrong

'Cause I can see the light of a clear blue morning
I can see the light of a brand new day
I can see the light of a clear blue morning
And everything's gonna be all right
It's gonna be okay

It's been a long long time
Since I've known the taste of freedom
And those clinging vines
That had me bound, well I don't need 'em

'Cause I am strong and I can prove it
And I got my dreams to see me through
It's just a mountain, I can move it
And with faith enough there's nothing I can't do

And I can see the light of a clear blue morning
And I can see the light of brand new day
I can see the light of a clear blue morning
And everything's gonna be all right
It's gonna be okay

I can see the light of a clear blue morning
I can see the light of a brand new day
Yes I can see the light of a clear blue morning
And everything's gonna be all right
Everything's gonna be all right
Everything's gonna be all right


It's gonna be okay

The mountain would refer to the mountain of books, I guess.. and it probably doesn't require faith to move so much as it requires a plan. Maybe some friends and a u-haul. :)

[Randy Dixon]

I was going to post something and didn't know where to post it, maybe here is a good place for it.

My wife is a Director of Rehab. for a large hospital, actually two hospitals right now (yeah, she is stressed out). A couple of weeks ago she got in her cline an Accu-spina traction machine. This is one of the newfangled traction machines that you see advertised in your local paper that is "the new solution to back pain" that prevents surgery and has an 86% success rate. It cost $150,000. My wife never asked for it or requested it, it just showed up. She has asked many times for another PT but that isn't affordable. I found out today the recommended treatment protocol and fees. 20 visits a month at a cost of $250 a visit. It has neat blue lights that bathe you in a relaxing glow and personal headphones that plays relaxing music while you are gently inclined and pulled on. What a deal!

In the meantime, Barrett is closing his practice due to a lack of interest and probably a reluctance on some to pay his fees. I guess he should have come with a soothing blue light and nice relaxing music.

My wife meantime has been informed that the contract company she works for has lost the contract with the hospitals she works at. Apparently being replaced by automation and a better deal. She is not allowed to tell her staff this. She looks like someone snuck up on her and shoved ice cubes down the back of her shirt but she doesn't get over it, she just keeps walking around like that. Tomorrow we are going to her clinic and using that machine. Lights, music, stretching. We can use it.

[Barrett Dorko]

Randy,

I've got the music already, and my fee was never the problem. I don't suck up to anybody, and sharing my fee with a referring physician isn't just unethical, it's illegal. I also have a reputation for being crazy because I practice as dictated by science, not by Florence Kendall. No one questions my results, and studies completed by Luke in Australia and Jason in Germany demonstrate quite clearly the construct validity of my theory and the effectiveness of ideomotion. They will be published soon.

What happened to your wife isn't all that uncommon and many therapists are walking around in a daze the past decade. I met a few in San Antonio while there a few weeks ago. Maybe some were from her staff.

[EricM]

I'm pretty sure it was Jon who originally posted this, but it bears repeating and certainly seems timely for anyone closing one chapter and opening another.

January First


The year's doors open
like those of language
toward the unknown.
Last night you told me:
tomorrow we shall have to think up signs,
sketch a landscape,
fabricate a plan
on the double page
of day and paper.
Tomorrow, we shall have to invent,
once more,
the reality of this world.


I opened my eyes late
For a second of a second
I felt what the Aztec felt,
on the crest of the promontory,
lying in wait
for time's uncertain return
through cracks in the horizon.


But no, the year had returned.
It filled all the room
and my look almost touched it.
Time, with no help from us,
had placed
in exactly the same order as yesterday
houses in the empty street,
snow on the houses,
silence on the snow.



You were beside me,
still asleep.
The day had invented you
but you hadn't yet accepted
being invented by the day.
—Nor possibly my being invented, either.
You were in another day.


You were beside me
and I saw you, like the snow,
asleep among the appearances.
Time, with no help from us,
invents houses, streets, trees,
and sleeping women.


When you open your eyes
we'll walk, once more,
among the hours and their inventions.
We'll walk among appearances
and bear witness to time and its conjugations.
Perhaps we'll open the day's doors.
And then we shall enter the unknown.


Octavio Paz,

translated by Elizabeth Bishop Cambridge, Mass,. 1 January 1975.

[Bas]

Wow. I take a week off work and internet - and bam. Barrett - all the best with this shift of things. Though it will be a change to help you move, I can't help but think that it is not that easy to let go of the original attraction of our profession: treating patients. A connection to your start as a PT?
Anyway - fair winds to your sails!

[Jason Silvernail]

If this change involves more teaching and writing for Barrett, then I'm all for it.
I think we might be looking at the calm before the storm - when some recent projects get published, I would imagine that it would generate a spike of interest in Barrett's course...

[Bas]

And one set of lyrics in one of my favourite versions (by a favourite "old " band Hothouse Flowers): "I can see clearly now..."

All the best Barrett.

[Randy Dixon]

Jason,

If you are talking about the research you are doing why don't you preview it here before submitting it?

[Jason Silvernail]

Hi Randy- I have already shown what I've got to a few folks for some feedback. I'll keep everyone posted.

[Barrett Dorko]

Bas wondered if treating patients is what drew me to the profession originally and so I was inspired to write the following:

Friday of last week I saw for the first time a woman in her sixtys. She was sent my way because she lives in Cuyahoga Falls and her Akron orthopedist’s primary concern was for her driving convenience. He didn’t care who did what to her.

She walked slowly through the waiting room leaning heavily on a cane, her torso twisted forward and a grimace on her face. She was pleasant enough but distracted by her pain. This situation was several years old. To put it kindly, she was deconditioned. We talked for a few moments and then I asked her to lie down on the table.

For the next ten minutes I handled her and simultaneously explained what I thought was wrong and what I knew to be right. All I needed to know in order to begin care had been revealed in her painful gait and the few answers she’d given in her sparse and breathless way. As she responded to self-correction with warming and softening and a dramatic movement toward abduction in the painful hip I felt as I always do at these moments; useful, not empathetic so much as compassionate, in the moment, personally fulfilled. All of this grows for a while and then diminishes as the patient’s understanding and awareness grows in its stead. She’s done wonderfully, and at her second visit – caneless and without significant pain – I was happy to see the response.

But it is those few minutes when my understanding is transferred somehow to the patient; what I feel as I pass on the memes I’ve so carefully constructed, well, I’ll miss that. After that, it’s all down hill, even though relief and improved function is evident. It’s those few minutes of intense teaching I’ll miss, not the patient’s appreciation and recovery.

That’s it for me anyway.

[krystos]

Barrett,
You have made a couple of references in this thread to your PT neighbors fee-splitting with the referring physicians. I am sorry to hear that this practice is going on elsewhere in the country as it is here in Texas. When I was consulting with a large pain practice in Houston prior to moving back to San Antonio to open my practice, I heard again and again from the non-therapist owners how this practice was such a great business model. This issue was just one of many that finally made me give up completely on corporate medical practice completely. The very idea that we as professionals should share the revenue that we generate by virtue of our education, skill, knowledge, and passion just because a physician who controls the referral stream is feeling the bite of modern "mangled" care makes me want to grab a pair of tweezers and pull out the last bit of hair that I have left on my shiny pate! All the rest of us, clinicians/business owners, have to tighten our belts or find more efficient means to complete the job at a lower cost. Instead, physicians panic and pay exorbidant fees (that they should use to improve efficiency instead) to medical consultants who tell them that they are needlessly giving out revenue that should be rightfully their's. While these physicians construct "integrated service practices" and eke out every last cent from the patient that they can, small independent practices wither on the vine.

One egregious example exists here in San Antonio, where the largest group of orthopedic surgeons in town have built an empire of five clinical sites. Each site includes the physician's offices/exam areas as they traditionally should. Unfortunately they have added an ambulatory surgical center, an imaging center, a pharmacy, a durable medical goods store, and a rehabilitation clinic at each site as well. Think of it! 64% of the city's orthopedic surgery business goes through their door each year and every step of the way, every dollar of profit generated feeds into these surgeon's pockets. Meanwhile, right down the street, I sit in my clinic seeing 30-45 patient visits per week and basically paying my bills and supporting my family of four in a rental house.

To top it off, one year into my practice, one of my two primary referral sources, a pain management anesthesiologist whom I like and respect, invites me over to his office to discuss "a matter that could be beneficial to both of us." I brace myself, already knowing what is coming, and drive over to see him. We sit down, and after some small talk, he says, I send you a lot of patients, don't I?" I agree, and express my gratitude for his faith in my practice and my sincere enjoyment in collaborating with him in caring for these unfortunate individuals who need our help. He responds with, "My only incentive to refer to you is that you do such a great job with my patients." As he leads off into the typical presentation about my no longer needing to spend money on marketing, no longer having to worry about paying my bills, etc, I am left thinking, "What other (expletive deleted) incentive do you need?" So, after a little time, I asked him where his patients came from. He said that they were typically referred by other physicians, usually neurologists and surgeons. I then asked if he would find it reasonable if they asked to share in the revenue of his practice based on these referrals. He stopped, thought for a second and tried to tell me that it wasn't the same thing. As kindly as possible, I told him that it was exactly the same thing. I explained my views on appropriate relationships, and I pointed out the 2-3 patients per month that I refer to him as well. I told him that I enjoyed working with him, his staff, and his patients, but that I could not in good conscience enter into a financial relationship with one of my group of referring physicians.

So, back to the office with all the fear and anxiety associated with the potential of losing nearly half of my patient volume. I called my wife, explained the meeting to her, and told her that we might have to liquidate some more assets if the worst happened. Over the next few weeks we exchanged several phone calls and emails as we usually would in the course of patient care, I saw a 5% drop in his referrals, and then things normalized again. We had dinner two weeks ago, and he told me that he had reconsidered the idea of creating a MD-PT relationship and that he respected my views and responses. We discussed the APTA Vision statement, including my reservations, fears, and hopes regarding autonomous practice. In the end, he has come to support the idea of a collegial rather than a subservient relationship.

While this is a very happy story, it is I am sure the minority outcome of such an encounter. Too often PT's become embroiled in the business of medicine and give in to such demands out of fear. I respect your integrity and courage in choosing to walk away rather than to give in to such a morally bankrupt, ethically vacuous medical community. I wish you all the best in your future endeavors!

Chris Goodwin

[Barrett Dorko]

Chris,

"Minority outcome"? Are you kidding? You performed a miracle, and if it weren't you writing the story I simply wouldn't believe it.

Yesterday in Dallas a woman wanted me to tell her if what I was suggesting she do (or "not do" in my case) would help her post spinal fusion cases. This isn't the sort of question I simply answer with a yes or no. I asked her what she thought was happening with all the difficult cases she saw from the group of neurosurgeons that (apparently) send her loads of patients to treat after their surgeries have failed to help as much as they had hoped.

She answered by repeating her story of a busy practice innundated with patients. She didn't want to talk about what she thought. It became clear that thinking wasn't a part of her practice - she just acted without any evidence of any theory to guide her. Now she wanted me to tell her what the future would hold for her patients - patients she was unable to describe in any meaningful way.

I could feel myself reacting to all of this. The death of my practice has everything in the world to do with my thoughtfulness and ethics. Her practice thrives precisely because she's willing to throw treatment of every sort at a problem she doesn't understand any better than the patients she treats, and in doing so she fills the referral's coffers. I'm fairly certain she saw no problem with that, but I don't know for sure.

I had to walk away.

[Randy Dixon]

An update on the Accuspina machine. It is pretty much booked. This despite no advertising, no marketing, not even mentioning it to anyone. The clientele is mostly local doctors and hospital executives.

I don't think things are going to change anytime soon.

We're off on vacation this afternoon which will also be a job hunt.

[Jon Newman]

This thread is reminding me of this acerbic quote

It is difficult to get a man to understand something when his salary depends upon his not understanding it.--Upton Sinclair

[Barrett Dorko]

Great quote Jon.

I know that my classes wonder at my unbridled enthusiasm for this site. They need to see a discussion like this from my solitary and, I'll admit, slightly trembling perspective, and they need to read this sent me by our friend Ian Stevens in Scotland a few minutes ago:

Uncertainty


The beauty of uncertainty is that it is motivates us to seek certainty. We are compelled to replace doubt with conviction, to replace confusion with clarity, to be more fearful of old ideas instead of new ones. Nothing is more disparaged than the person who is lost, hesitant, and anxious. Yet the true path to fulfilment comes from these conditions. Uncertainty becomes truly beautiful when connected with the certainty of that there is a better life beyond the life that is known. The artist, scientist, athlete and traveller: all embrace uncertainty as their muse. What is going to happen next is more enticing than what is happening now .The thrill of anticipation, the mystery of the unknown, the open road, mistakes as portals of discovery, the inevitability of change, purpose from chaos, questions leading to answers failure as the threshold of knowledge. All of these conditions inform the life of the adventurer, the human being who is engaged in becoming. The beauty of uncertainty is that it prepares us to embrace life in the face of death. Allows us the strength to deal with the freedom to choose .To willingly exchange the fear of uncertainty for the security of certainty is to admit defeat. To surrender to the fear of actually living your life. Nothing moves forward except by the craving to seek certainty from uncertainty.

Brian Hencricks Hobo Magazine from KT Tunstall Acoustica Extravaganza 2007

[Jon Newman]

I especially enjoyed this line

To surrender to the fear of actually living your life.

That Ian is always getting me to tweak my perceptions. I'm thinking that the Sinclair quote could be amended to

It is difficult to get a man to understand something when his salary depends upon his not trying to understand.--Jon Newman