Concussion

The Future of Concussion

and Medical Education

Original artwork by Jessica Schwartz Rendered by Chris Freeman

Original artwork by Jessica Schwartz Rendered by Chris Freeman

Jessica B. Schwartz PT, DPT, CSCS

There is a paucity of quality concussion education in entry level, residency, and post-professional medical education.

Why?

Because there is no evidence based medicine for concussion.

A bold statement as I introduce what I believe to be the worlds first yearlong, multidisciplinary, and post-professional concussion education program for clinicians.

Let me start with a story:

It was the week I got promoted to junior partner of my company.

The week I took a deep breath for the first time in my life and said “OK Schwartz…You’ve arrived.”

I was surrounded by people whom I genuinely cared about, professionally and personally, and I felt like my nose to the grindstone personality the last 13 years of formal didactic education, business mentorship, and the chase to this finish line had come to fruition.

That was the week I was hit by a car.

That was the week my life changed forever.

On October 3, 2013, I went from being Dr. Schwartz to patient 237427 in a NYC Emergency Department getting rolled through a CT Scan.

It’s a difficult journey being on “the other side of healthcare.”

I was that patient rolling to CT with my MD Calculator in hand who was able to recite the Canadian CT Head Rules like a proud elementary school student who had just learned her speaking part for the school play.

Physical therapy was my craft. I was mastering the craft of treating the patient as person, developing my patient rapport tools, building a wonderful international referral network, and understanding the nuances of running multiple successful businesses.

I loved every minute of it. The more I learned the more I wanted to learn.

A one week medical leave of absence turned into 10+ hours of rehabilitation a week for a year.

How could an injury so seemingly benign change my life forever?

What We Know:

In 1997, the CDC reported 300,000 concussions in the United States. In 2016, the CDC estimates are 1.6-3.8 million sports related concussions based off of the most recent 2006-2010 data.

I strongly believe that these numbers continue to be greatly underestimated based off of the heterogenous nature of this injury, underreporting[1-4], ~25% of people not seeking emergency department or other medical care[5], and lack of an agreed upon definition and consensus on what the injury is in the literature[6-8].

We know that approximately 20-30% of patients develop persistent symptoms crossing over into the post concussion syndrome threshold each year with ranges from 5-58% in the literature[9-11].

If we look at ~30% of all concussions crossing over into the persistent symptom category, that is 1.14 million people in the United States based off of the current data alone.

Remember, I continue to believe that this data continues to be grossly underestimated.

The Gaps:

We know that TBI is grossly underfunded yet it is a major cause of death and disability in the United States, contributing to about 30% of all injury deaths[12].

NIH TBI v Cancer Funding

According to the National Institutes of Health (NIH), Cancer research received $5.6 Billion in 2015. Comparatively and up from $88 million in 2015, TBI is estimated to receive just $91 million in 2016[13]. Approximately 5.6 million people are living with the long terms effects of TBI and 138 deaths occur per day[12] amounting to ~50,000 deaths per year in the US. In 2015, there were 1,658,370 new cancer cases diagnosed and 589,430 cancer deaths in the US[14].

Why compare cancer and TBI? Because cancer has made huge gains by breaking down cancer. We don’t treat cancer. We treat large cell non-Hodgkin lymphoma. We need to do the same in the concussion community.

Scientifically, we must start with agreeing upon a universal definition of concussion, mTBI, and TBI. From there we need to be able to break down the injury appropriately based off of neurophysiological changes and injury to specific areas of the brain. While these are lofty goals, I also don’t see this being tangible in the near future nor is it clinically and functionally relevant to the patient seeking care in front of us today.

The above statistics indicate that we are doing much better at saving patients lives from severe cases of TBI vs cancer; however, the true burden exists with TBI survivors suffering from the lasting effects of what a TBI does to a person as a whole being.

We know that 100% of all neuroprotection phase III studies are negative, less than 5% of New Medical Entities (NME) in clinical assessment make it to FDA approval, and 100% of all Phase III trials in TBI are negative.

This means that there have been zero phase three clinical trials in TBI that have moved on to completion, there are zero drugs for TBI, and that TBI and concussion are strictly a clinical diagnosis.

We have to do better. And we can.

Medical Education and Healthcare:

Daniel Goleman discusses the key concept of “iatrogenic suffering” in medicine. This is an added anguish by medical personnel delivering insensitive messages that can often engender more emotional suffering than the actual illness itself[15].

Historically in medicine if we do not understand an injury or disease pathway, we prescribe rest or send the patient to a psychologist e.g. syphillis, low back pain, B12 deficiency, cardiac issues in women, etc.

We’ve missed the mark in the concussion community as medical providers. Over the last few decades, we’ve allowed the medico-legal literature to get ahead of us in the medical community.

It wasn’t until 1989, a neuropsychologist by the name of Jeffrey Barth, was part of the first group to suggest that cognitive testing in preseason athletes may have some value due to concussive injuries presenting lasting effects.

We’ve enabled a culture of “I got my bell rung” to prevail and have not addressed concussion from a systems level until recently.

I’ve heard time and time again that “We can’t teach it because there’s no empirical evidence”.

Nonsense.

As I was being well-cared for by my team of physicians and clinicians, I continued to do my best to take a step back and look at the inner workings of the healthcare team, system and educational offerings that are made available to all clinicians from physician to PT et al.

When I learned that 2015 was the first year that neurology residencies were receiving formal didactic education in concussion within the ‘Behavioral Neurology’ section springing from the work and advocacy of the Sports Neurology Section of the American Academy of Neurology, I knew there had to be something done.

A change.

A change in the global architecture of medicine with respect to the concussion patient of today.

A concussive injury is an all hands on deck injury. It can often require a team of clinicians to identify, treat, and manage this patient population.

Leading Causes of TBI

Concussion patients port of access to the clinician of today is infinite. It can range from the athletic trainer, the emergency department physician, the primary care physician, the pediatrician, the nurse practitioner, the physician assistant, the school nurse, psychologist, physical therapist, occupational therapist, speech therapist, and anyone who has direct access to the patient of today.

I emphatically deliver this message when I speak publicly: it is not a matter of if you treat concussion patients. It is a matter of when you will encounter, treat, and/or refer a concussion patient.

A concussion is not a broken bone. That’s easy. We know normal tissue healing parameters in healthy populations.

A concussion is a neurophysiologic injury that can affect all domains of a person’s life from somatic, cognitive, emotional, vestibular, sleep, and behavior often with non-specific answers to the all important patient question of “when will I get better?”

It is gut-wrenching as a clinician to have the self awareness to look into a patient’s eyes and say “I don’t know.” It is even more painful as a patient to be completely unaware of if you will ever get better when you are being cared for by one of the best clinicians in the world.

We can do better. And we will. Here’s how.

Healthcare Teams:

Long gone are the days of the one physician model, yet we seem to be in a conundrum when it comes to communication and teamwork in medicine.

The Doctor Sir Luke_Fildes_(1891)

The Doctor Sir Luke Fildes (1891) https://commons.wikimedia.org/wiki/File:The_Doctor_Luke_Fildes_crop.jpg

In the fall of 2014, I had the privilege to virtually attend the International College of Residency Education’s (ICRE) opening plenary delivered by rhetorician scientist Dr. Lorelei Lingard on Collective Competence: Adapting our concept of competence to healthcare teams[16].

During this time, I was finalizing my concussion rehabilitation and Dr. Lingard’s words helped facilitate my eureka moment of how I can aide in providing a solution to this medical world of specialists all attempting to treat the same poorly defined and heterogenous injury.

Summatively, she states that individual competence does not equal good healthcare.

She elaborates reviewing a case scenario describing the maze of disconnected care episodes that the patient of today is experiencing.

Dr. Lingard states that we need to “evaluate in situ, broaden focus beyond individual actions to include inter-actions among individuals, capture the ‘cracks’ between the care episodes, and consider interactions among elements of the system, not just among people…Competence is a way of ‘seeing’ that both directs and deflects our attention. The cracks between care episodes, experts cultivating collective competence ‘know how the system usually fails in this situation, and plans accordingly.’ Our attention is directed towards individual competence and deflected from collective competence. We need both[16].”

My role is to facilitate collective competence in the concussion community.

Let’s think about the concussion patient of today.

A concussed individual can experience any one of the following myriad of symptoms all at once or over a period of time [See Chart].

Concussion Signs and Symptoms

Each of these symptoms can be managed by individual specialists that may or may not cohesively integrate their treatment models with a co-treating clinician.

Concussion identification, treatment, management, and having the self awareness to know when and whom to refer appropriately can be a complex team model and clinical algorithm.

Each concussion case is unique and treatment models are 100% situationally dependent.

Kenneth Burke, an American literary theorist, once said that “every way of seeing is a way of not seeing.”

We can’t simply “treat the headache” or “treat the balance issue.” Treating the concussion patient of today involves a complex series of evaluations across all domains in order to systematically identify injury deficits in order to appropriately make the decision of what to treat, when to treat it, and when to refer appropriately.

If you treat together, you must learn together.

Here’s how.

Rapport and Clinician Synchronicity:

“To feel with, stirs us to act for[15].”

Get in-synch with your concussion patients.

These patients often feel very disconnected to the medical community. Patient stories of seeking care from 5+ medical providers until they “find their person” in healthcare is not uncommon.

Rapport is key to successful patient, provider and caregiver interactions. When people are in rapport, their physiology actually attunes. Robert Rosenthal published a landmark article revealing the central tenets of “relationship magic,” the recipe for rapport. This only exists when three elements are present: mutual attention, shared positive feeling, and a well-coordinated nonverbal duet. As these three emerge cohesively, we spark rapport[15].

This is how lifelong patient-provider and provider-provider relationships are formed.

Nature is based upon energy and timing. Basic science has identified symbiosis throughout the natural world ranging from the firing of an action potential to the marvelous making of what happens between winter and spring.

Concussion is an injury of asynchronous firings at a cellular level which accumulate amounting to a functional dysfunction with ones self and environment.

Original Concept by Jessica Schwartz; Rendered by Chris Freeman

Original Concept by Jessica Schwartz; Rendered by Chris Freeman

We need to learn how to adapt to the needs of our patients who carry a host of pre and post morbid medical conditions and circumstances presenting with the complexities that the heterogenous nature of a concussive injury presents.

The Program:

The Evidence In Motion Concussion Certificate Program is committed to educating the post-professional multidisciplinary clinician of today in concussion identification, treatment, and management by fostering a rehabilitative team approach.

This 12-month program provides the latest clinical conversations, evidence-based guidelines, and consensus statements while integrating real world experiences from patients, providers, and caregivers who have navigated the complex healthcare network of today.

Content delivery is both interactive and dynamic, exposing the student to some of the most influential clinicians in the concussion community coupled with the unique learning experience of provider to provider, patient to provider, and caregiver to provider storytelling.

By fostering a rehabilitative team approach, the EIM Concussion Certification hopes to facilitate collective competence across the healthcare continuum in order to better triage, treat, and appropriately refer the concussion patient of any age from acute to chronic stages.

This year long multidisciplinary concussion certificate sets the learner up for success utilizing an asynchronous and synchronous online learning environment for the busy post professional of today.

The in-person weekend intensive reviews the psychomotor properties of the concussion evaluation, treatment, management, and referral options based off of the providers scope of practice during the 12 month didactic education experience.

As a pre-requisite to the program, each post-professional student will undergo a therapeutic neuroscience education course. As we embark on a multidisciplinary educational journey together, I sincerely believe that we all speak the same language of medicine; however, we bring many different dialects to the clinical table.

Current best-evidence shows that therapeutic neuroscience education improves pain ratings, function, pain catastrophization, physical movement and cost of healthcare utilization.

I will utilize the TNE course to cohesively meld the post-professional multidisciplinary EIM Concussion students in language, compassion, and competency of the therapeutic neuroscience evaluation in order to jumpstart their experience of learning together in a new environment. 

A few months before physician Kenneth Schwartz died, he stated that “Quiet acts of humanity have felt more healing than the high dose of radiation and chemotherapy that hold the hope of a cure. While I do not believe that hope and comfort alone can overcome cancer, it certainly made a huge difference to me[15].”

I hope to create kind, compassionate, and clinically efficient clinicians who foster rapport with patients, interdisciplinary colleagues, and across disciplines.

Care for the concussion patient. Care for him/her together. And care for him/her well.

The Faculty:

I’ve been fortunate enough to have returned back to patient care and have surrounded myself with some of the brightest and most dedicated faculty in the world in their respected specialties.

Over the last year, the energy that I’ve felt from this group of men and women has been palpable. I am honored everyday to have worked with and continue to collaborate with each and everyone of these passionate clinicians.

What do they all have in common? I systematically screened all interviewees for passion, high IQ, high EQ, and low ego who have the self awareness to take a step back from themselves and look at the big picture of clinical care.

We have a tall order in front of us and I know we’re here to do our best to help clinicians of today put our best foot forward to educate each other and our communities of coaches, parents, spouses, teachers, caregivers, and loved ones on the multifaceted injury that concussion can present itself as to the provider and patient of today.

Why Story?:

Paul Zak, a neuroeconomist, eloquently stated “Stories are powerful because they transport us into other people’s worlds but, in doing that, they change the way our brains work and potentially change our brain chemistry — and that’s what it means to be a social creature[17].”

Storytelling allows us to step back, view, and listen from an aerial and reflective standpoint while creating the neural groundwork of patient exposure by connecting to the story, the provider, the caregiver, and the patient.

Schwartz Rounds were invented by an ill physician who also experienced the dichotomy of both doctor and patient. His purpose was to facilitate understanding of how the patient perceives their own illness and treatment by deploying empathy and building rapport[15].

If we have no empirical data, then we need to learn from each other. I believe by deeply listening to each other, patients, and caregivers fosters an excellent way to change the way in which we begin to shift the global architecture of medicine with respect to the concussion patient of today.

How can we help and treat a mutual patient if we don’t sincerely understand what each of us can collectively do for one another in the best interest of the patient.

Story allows us to experience the injury through the eyes of experienced providers, patients, and caregivers who have navigated the complex healthcare system of today.

We need to learn from each other.

When we learn together we can treat together.

Welcome to the beginning of the Evidence in Motion Concussion Certificate Program.

“I did then what I knew how to do. Now that I know better, I do better.” ~Maya Angelou

#Concussion.

Bibliography

1. Register-Mihalik, J.K., et al., Using theory to understand high school aged athletes’ intentions to report sport-related concussion: implications for concussion education initiatives. Brain Inj, 2013. 27(7-8): p. 878-86.

2. Llewellyn, T., et al., Concussion Reporting Rates at the Conclusion of an Intercollegiate Athletic Career. Clin J Sport Med, 2014. 24: p. 76-79.

3. Kroshus, E., et al., Concussion reporting intention: a valuable metric for predicting reporting behavior and evaluating concussion education. Clin J Sport Med, 2015. 25(3): p. 243-7.

4. Kroshus, E., et al., Norms, athletic identity, and concussion symptom under-reporting among male collegiate ice hockey players: a prospective cohort study. Ann Behav Med, 2015. 49(1): p. 95-103.

5. Sosin, D.M., J.E. Sniezek, and D.J. Thurman, Incidence of mild and moderate brain injury in the United States, 1991. Brain Inj, 1996. 10(1): p. 47-54.

6. Menon, D.K., et al., Position statement: definition of traumatic brain injury. Arch Phys Med Rehabil, 2010. 91(11): p. 1637-40.

7. Quarrie, K.L. and I.R. Murphy, Towards an operational definition of sports concussion: identifying a limitation in the 2012 Zurich consensus statement and suggesting solutions. Br J Sports Med, 2014. 48(22): p. 1589-91.

8. Rose, S.C., A.N. Fischer, and G.L. Heyer, How long is too long? The lack of consensus regarding the post-concussion syndrome diagnosis. Brain Inj, 2015: p. 1-6.

9. JJ, B., et al., Epidemiology and predictors of post-concussive syndrome after minor head injury in an emergency population. Brain Inj, 1999. 13(3): p. 173-189.

10. Iverson, G., Outcome from mild traumatic brain injury. Curr Opin Psychiatry, 2005. 18(3): p. 301-317.

11. Babcock, L., et al., Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department. JAMA Pediatr, 2013. 167(2): p. 156-61.

12. CDC. Traumatic Brain Injury in the United States: Fact Sheet. 2016  January 11, 2016].

13. NIH. Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC). 2015  [cited 2016; Available from: https://report.nih.gov/categorical_spending.aspx.

14. ACA. Cancer Facts & Figures 2015. 2016  [cited 2016 January 11, 2016].

15. Goleman, D., Social Intelligence: The New Science of Human Relationships. Kindle ed. 2006: Random House.

16. Lingard, L., Collective Competence: Adapting Our Concept of Competence to Healthcare Teams. 2014.

17. Zak, P. The Neurochemistry of Empathy, Storytelling, and the Dramatic Arc, Animated. 2012  [cited 2016; Available from: https://www.brainpickings.org/2012/10/03/paul-zak-kirby-ferguson-storytelling/.

Metabolism of Sugar

Nutrition 101 Series for Healthcare Providers:

Keeping Healthy Eating Simple for You and Your Patients Part II

Metabolism of Sugar: How Added Sugars Lead to Weight Gain

a spoonful of sugar cubes.isolated on white

By Jenna Larsen, MS

“Food was just as abundant before obesity’s ascendance. The problem is the increase in sugar consumption. Sugar both drives fat storage and makes the brain think it is hungry, setting up a vicious cycle”- Robert Lustig, MD, University of California San Francisco [1]

A calorie is a calorie is a calorie.

This is a notion that America has been taught to believe, allowing consumers the freedom to trust that any food from the supermarket or restaurant has a place in our diet- as long as we manage to balance calories in with calories out.

And yes- it’s true. If we can balance calories, weight will not increase. So why has it become so difficult to maintain a healthy weight? Consider that 1) a significant increase in added sugars has seeped into the U.S. food supply since the 1970s; and 2) the way that sugar affects our brain and eating behaviors is unlike any other food particle we consume.

The onset of the obesity epidemic directly correlates with the advent of the U.S. dietary guidelines in 1977 [2]. As a result of the recommendation to decrease fat consumption, food companies dialed down the fat in their products while substituting sugar to maintain palatability [3]. The result…Screen Shot 2015-09-21 at 11.25.02 AM

Americans doubled their intake of sugar by 2000 and 80% of products available in the supermarket now contain added sugar [4]. What we lacked was an understanding of how sugar hijacks the brain’s ability to recognize satiety leading to an overall increase in total calorie consumption. 

Comprehending how added sugars are processed for energy helps explain why calories from different foods have varying impacts on fat storage and appetite. Consider 150 calories from an apple versus 150 calories from apple juice.

When you eat an apple, the fiber allows the sugar to gradually absorb into the bloodstream. Insulin is steadily released and glucose is taken into cells where it is used for energy. However, unlike an apple, apple juice lacks fiber. So instead of a gradual release, the bloodstream is bombarded with sugar. Insulin rises quickly, telling the liver to convert the sugar into fat for storage [5,6]. That newly formed fat is released into the bloodstream, blocking the effect of the satiety hormone, leptin [7]. The result? The brain tells you to eat more.

Furthermore, insulin spikes lead to blood sugar crashes, advancing the signal to the brain that you need to more food. These processes combine to induce lethargy and hunger that contributes to more eating, less physical activity, more fat formation, and overall weight gain [4].

In short- the calories in the apple lead to satiety and energy while the calories from the apple juice lead to hunger and lethargy- all due to the way sugar is metabolized.

The American Heart Association recommends just 6 grams of added sugar per day for women and 9 grams for men [8]. The average American consumes 80 grams of sugar per day [9] while a 12 ounce can of regular soda contains 32 grams of sugar [10]. Offering perspective as to how much added sugar we consume can help patients gain awareness and motivate them to make a change.

Supplement your discussion with these points:

  • For an effective visual, fill empty bottles of soda, juice and a sports drink with the number of teaspoons of sugar they contain (1 gram= 4 teaspoons). Patients will be surprised at how much sugar they are drinking when they see it presented in this way.
  • All sugars are processed the same way. White bread, white rice, and potatoes are no different than other types of sugar. Purchasing whole grain products keep the fiber intact so that the sugar is absorbed more gradually.
  • Food consumed closest to its natural form will have fewer added sugars and more fiber. Preparing fruits and vegetables is the best way to ensure that metabolism is functioning properly (Nutrition 101: Whole Foods)
  • Added sugars go by many different names, yet they are all a source of extra calories. Click here for a list of added sugars that doubles as a handout for patients.
  • Just as our palates have been conditioned to crave sugar, they can be conditioned to crave it less [4]. Coffee drinkers can train their palate by gradually decreasing the number of sugars while soda drinkers can start by diluting them with water.

The link between sugar consumption and chronic disease is not a new concept. In fact, more than 8,000 scientific papers have been published on the health effects of added sugars [11]. By investing a few minutes to discuss their importance, you play a key role in drastically improving patients’ overall health and well-being.

References:

  1. https://www.ucsf.edu/news/2009/06/8187/obesity-and-metabolic-syndrome-driven-fructose-sugar-diet
  2. Source: National Center for Health Statistics (US). Health, United States, 2008: With Special Feature on the Health of Young Adults. Hyattsville (MD): National Center for Health Statistics (US); 2009 Mar. Chartbook.
  3. http://www.npr.org/blogs/thesalt/2014/03/28/295332576/why-we-got-fatter-during-the-fat-free-food-boom
  4. Fed Up Movie
  5. Newman, Cathy. “Why are we so fat.” National Geographic 206.2 (2004): 46-62.
  6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC380258/
  7. http://diabetes.diabetesjournals.org/content/53/5/1253.full.pdf
  8. http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyEating/Added-Sugars_UCM_305858_Article.jsp
  9. http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyEating/Added-Sugars_UCM_305858_Article.jsp
  10. http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyDietGoals/Frequently-Asked-Questions-About-Sugar_UCM_306725_Article.jsp
  11. https://www.ucsf.edu/news/2014/11/120751/ucsf-launches-sugar-science-initiative

 

 

Concussed: Collective Competence & the Patient Experience

Concussed: Collective Competence in Healthcare

and the Patient Experience

Silos Concussion Bridge final rev2 (1)

Jessica B. Schwartz PT, DPT, CSCS

On May 16, 2015, I had the privilege to speak in front of 200 of my colleagues at Evidence in Motion’s 3 day hands-on and didactic learning festival, Manipalooza, at the University of Colorado’s Anshutz Medical Campus in Denver, Colorado.

If I had to sum the entire weekend up in one word it would be:

Inspired.

Topics of discussion and practical application included concussion, neuroscience, biases in healthcare, manipulation, pelvic health, workplace safety, advanced soft-tissue mobilization, and an epidemiological review of low back pain: where it’s been, where we are going, and how the physical therapist is leading the way.

I was inspired by the impressive cohort of speakers (Timothy Flynn, John Childs, Larry Benz, Adrian Louw, Jennifer Stone, John Groves, Julie Whitman, Teresa Shuemann, Tim Fearon, and humbly- myself) and that of the volunteer Fellows, past and present, to assist with knowledge dissemination and translation throughout the entire weekend.

I have learned that when you are surrounded by some of the top minds in the world who collectively come together with two interests in mind: 1. How to immediately make the clinician better for next day patient care and 2: the importance of being connected to oneself, as provider, including self-awareness of biases and our past patient/life experiences which in turn correlate to increased self-management increasing efficacy in and out of the clinic…it’s well, inspiring.

This low-ego, incredibly fun, and contagiously charismatic group of doctors, clinicians, and scientists was truly an impressive group to be a part of in all domains to engage with, learn from, and disseminate knowledge to a hungry audience of motivated professionals.

May 16, 2015 was particularly profound for me because I essentially got to go public with my story for the first time…and who better to present to than “my own people”, Physical Therapists.

The Schwartz adaptation of the David Sackett’s, MD Evidence Based Medicine (EBM) triangle including patient experience. I encourage all clinicians to listen to and learn from our patients stories. We can learn so much by deeply listening to our patients as people first.

I was in a motor vehicle accident October 3, 2013 and my life changed forever. I underwent a year of rehabilitation living with post-concussive syndrome. I had the good fortune to be cared for by the incredible team of physicians, non-physician doctors, and clinicians at the New York University Concussion Center for 10+ hours a week for about a year of rehabilitation and guidance so I could successfully Return to Life with my new abilities.

I said it time and time again during my physical, orthopedic, neurologic, and cognitive rehabilitation throughout the year… “if I don’t share this story with the medical community it’s essentially malpractice in my eyes”. I continue to hold strong to these goals and values of transparency, story-telling, and sharing of my own personal journey with the goal of increasing concussion patient-provider connectedness in the medical community.

I have one goal: facilitate collective competence amongst the healthcare community in order to better identify, treat, and manage the concussion patient along the entire continuum of recovery from acute to chronic.

I was able to update the audience on some of the latest happenings in concussion research and development, review some stigmas associated with post-concussive syndrome, present my case revealing the patient was myself about half way through the presentation, share some poignant moments of what it was like to live through post-concussive syndrome, and announce the Evidence in Motion Concussion Certificate Program for the post-professional medical provider.

I am absolutely thrilled to be leading this program with the key concept of instilling collective competence across the healthcare continuum so we as clinicians can 1. better understand the scope of everyones interdisciplinary practice, 2. increase abilities to identify commonly missed post-concussive symptoms (cognition, vision, vestibulo-ocular, persistent pain, etc), 3. empower the provider to feel confident in his/her abilities when evaluating, treating, and appropriately referring the concussion patient to a colleague as needed, and 4. empower the provider to educate the community from sports leagues, coaches, parents, school districts, fellow medical professionals, care-takers, employers, and patients.

A key theme of my professional being and future lecture series as it pertains to the concussion patient is built around the concept that there is no one provider who can comprehensively treat this population of patient. My core clinical values foster interdisciplinary knowledge translation. How can we refer to one another if we sincerely don’t have a grasp of what each of us across the healthcare continuum can do for one another as provider and for our mutual patient? I would like to facilitate this forward and collective thinking necessary to provide the concussion patient the best possible care. 

Faculty will include some of the top minds, researchers, and clinicians in the world collectively coming together to educate the post-professional academic learner. Faculty will include the neurologist (adult and pediatric), emergency medicine physician, vestibular physical therapist, traumatic head and neck disorder scientists, occupational therapist/vision therapy, neurogenic speech language pathologist, board certified sports clinical specialist physical therapist, certified athletic trainer, neuroscientist, and the neuropsychologist.

Specialty topic areas will include: Pediatrics, Geriatrics, Sports, Trauma, and the Service Member/Veteran.

Collectively, these incredibly bright and motivated minds will come together and I, as program director, will bridge the gaps empowering the clinician along the course of one year to become comfortable with their clinical abilities, their interdisciplinary colleagues, and most importantly- this cohort of concussion patient who is so often mismanaged in this maze of disconnected care episodes that healthcare system of today has unfortunately bred.

Future information will be launched soon on the Evidence in Motion’s website for a Summer 2015 launch date.

I look forward to being a part of an incredible movement to educate the healthcare practitioner in an online and in-person synchronous and asynchronous learning environment.

Cheers to a tremendous year to come for both the patient and provider with respect to the identification, treatment, and management of the concussion patient!

Thank you for time, attention, and coming along this exciting journey of advocacy as post-concussive survivor, story-teller, and educator.

*Please excuse the cough. The Colorado altitude got the best of me

Kind Regards,

Jessica B. Schwartz PT, DPT, CSCS

*Special thank you’s to Tim and John for the invite to Colorado!

Tim Flynn and Jess Schwartz

Timothy Flynn PT, PhD, FAAOMPT and Jessica B. Schwartz PT, DPT, CSCS at Manipalooza 2015 at the University of Colorado Anshutz Medical Campus May 16, 2015

John Childs, Jess Schwartz, and Tim Flynn #Manipalooza

John Childs PT, PhD, MBA , Timothy Flynn PT, PhD, FAAOMPT and Jessica B. Schwartz PT, DPT, CSCS at Manipalooza 2015 at the University of Colorado Anshutz Medical Campus May 16, 2015

Infant Swimming Resource (ISR)

Infant and Toddler Rescue Floating and Swimming:

What the Medical Community Needs to Know about Safety and Prevention

Today Show HD Video and Article:  www.today.com/video/today/55513113

Dr. Kristine McCarren PT, DPT

Editors note: I initially learned about ISR when I saw a piece on NBC’s Today Show. I’m thrilled to have Dr. McCarren educate the medical community about the benefits of infant and child rescue swimming via her guest blog post on PT2Go. Here, she will touch upon pediatric emergency department drowning epidemiology, the American Academy of Pediatrics stance on swim lessons, and differentiate between the Infant Swimming Resource and traditional swim lesson model.

“All children should learn to swim before they learn to walk…”

I hope the above quote challenges your thought process. It certainly did mine. Allow me to introduce Dr. Kristine McCarren, PT DPT. ~JS


 

The American Academy of Pediatrics (AAP) recently changed its position statement on drowning prevention based on the study concluding “participation in formal swimming lessons was associated with an 88% reduction in the risk of drowning in 1 to 4 year old children…”.[1]

Other than congenital anomalies, drowning is the number one cause of accidental death in children 1-4 years old. [2] 

As clinicians who work directly with pediatric patients or treat an adult patient population, we all have contact with parents of young children professionally and familially.

As spring months turn into hot summer days and nights, what is the solution to assist our communities in keeping our children safe from the number one cause of pediatric accidental death?

The answer: Infant Swimming Resource (ISR).

What is Infant Swimming Resource (ISR)?:

Infant Swimming Resource (ISR) is a program that teaches infants as young as 6 months how to save themselves in the event they make it into the water alone.

ISR is recognized internationally as the safest provider of survival swimming lessons for children 6 months to 6 years.

With nearly 50 years of research and development, Dr Harvey Barnett adapted his theoretical knowledge as a behavioral scientist in order to pioneer ISR’s Self-Rescue® method after witnessing the drowning of his neighbors infant son.

How Does ISR Work?:

Infants 6-12 months learn survival floating. Lessons focus on teaching the child to roll onto their back to float, rest, and breathe maintaining this life-saving position until help arrives.

Children 1-6 years old learn to swim until they need air, roll back to float, and then resume swimming until they reach the side of the pool.

As of April 2015, there have been more than 800 documented cases where former ISR students have used their Self-Rescue® skills to independently save their own lives.

Since 1966, ISR has taught more than 260,000 children internationally.

Is an ISR Instructor More Specialized Than a “Typical Lifeguard”?:

ISR Instructors are infant aquatic specialists who have been trained to teach water survival skills to infants and children 6 months to 6 years.

Instructors undergo an intensive 8-week program.

There is a minimum of 60 hours in-water training and 40 hours academic preparation and testing.  

Similar to many medical models, continuing education is required coupled with yearly re-certification to ensure maintenance of teaching skills.

Many ISR instructors come from medical backgrounds (physical therapy, occupational therapy, nursing, et al) and use evidence based knowledge regarding sensorimotor learning to teach these Self-Rescue® skills.

The ISR instructor monitors the child’s temperature through vasoconstriction checks throughout the lesson, and if the child is too cold, the lesson is over.

ISR instructors check for temperature fatigue and abdominal distention throughout lessons.  

Temperature fatigue precedes muscle fatigue, which leads to inefficient learning. Abdominal distention makes it hard to breathe, and if left untreated, can be dangerous.

ISR instructors rely on sensorimotor principles and positive reinforcement to teach each infant and child during their personalized lesson.

Based off of these sole principles alone, this is why the allied healthcare professional is the perfect fit to undergo this highly specialized training.

Tactile guidance and prompt reinforcement is the primary means of instruction.

ISR teaches infants as young as 6 months old; therefore, verbal instruction cannot be relied on to teach survival swimming skills which primarily involve instinct, cognitive and motor planning tasks.

The ‘Anatomy’ of an ISR Lesson:

ISR lessons are always one-on-one with the same instructor.

A child learning ISR receives 100% of the instructor’s attention 100% of the time.

Each child attends lessons for 5 days per week for 10 minutes each session.

The 10 minute lesson structure has been scientifically proven to optimize learning and increase retention for this pediatric age population.

A child learns survival skills by actively engaging in his/her environment. Instructors use the ambient air as a teaching tool coupled with the instructor’s touch. This facilitates creating an independent infant and/or child if they are ever faced with a dangerous water scenario.

How are Lessons Different than a Traditional Lifeguard Lesson?:

ISR pools are maintained at 78 to 88 degrees Fahrenheit.

Prolonged exposure to environments that are lower than a child’s body temperature are inefficient for motor learning.  ISR lessons are limited to a maximum of 10 minutes to prevent temperature fatigue and optimize efficiency. Children are monitored for temperature fatigue frequently throughout each lesson via vasoconstriction checks.  

Up to 86% of children who drown are fully clothed at the time of drowning [3]. ISR makes sure to build in real world scenarios with respect to having the infant and toddler fully clothed in the water upon graduation. 

ISR 16 Month Old Infant Survival Floating in Full Winter Gear

ISR Infant Survival Floating in Full Winter Gear

Training begins in summer clothes, sandals and sneakers. After this initial level of mastery, winter clothes including a coat, boots, hat, and gloves are added into the lesson. Swimming and floating in clothes is a completely different experience than in a bathing suit. The extra weight of the clothes and fully saturated diaper make moving in the water more difficult.

ISR lessons ensure that a child is competent and confident swimming and floating fully clothed.  

ISR Infant Sweater and Hat

ISR 6 Month Old Infant Survival Floating in Full Winter Outfit with Dr. McCarren

 

Infant Swim Resource

Traditional Swim Lesson

Registration

Family medical history, developmental milestones , current health conditions, developmental issues and medications. Specific conditions are reviewed by MDs and nurses, and instructors are notified of any specific safety measures to be applied during lessons

Child’s name and age is recorded and a parent signs a waiver to acknowledge risk of lessons.  

Specific health information is usually not recorded or taken into account

Documentation

Daily bowel, urine, diet and sleep patterns are documented in order to assess changes that may compromise the safety of lessons.  

If warranted, lessons will be shortened or cancelled

Do not assess the infant/child’s daily habits, and health concerns that may affect or compromise lesson safety

Lesson Duration& Frequency

10 Minutes

5 Days/Week

6 Weeks

30-45 Minutes

1 Day/Week

Instructor Training

CPR/First Aid Certified

Trained in:

Behavioral Psychology,

Sensorimotor Learning,

Shaping Behaviors,

Physiological conditions as they relate to exercise in the water, Emotional learning,

80+ hours of practical experience & studying/analyzing video.

Yearly recertification & continuing education required

Often medical professionals such as PT’s, OT’s, RN’s

CPR Certification not required

No formal training required

 

Critical Numbers:

For every pediatric fatal drowning, there are an additional 5 pediatric patients who visit the emergency department (ED) for nonfatal submersion injuries.

Within 2 minutes of submersion, a child loses consciousness. When a child is submerged underwater for 4-6 minutes, they can be left with irreversible brain damage.  

More than 50% of drowning victims treated in ED’s require long term hospitalization or transfer for further care. This potential irreversible brain damage may result in long term deficits, such as memory problems, learning disabilities, and permanent loss of basic functioning.[2]

Healthcare Community Challenge:

As an ISR instructor, it’s imperative to educate the community that water isn’t recreational until a child can survival float and swim. Accidents happen when children explore their environment by crawling, cruising or walking. Ensuring that infants and toddlers can survival float and swim before they walk is critical to prevent drowning.

If you are interested in holding a pediatric Grand Round for more in depth information, Harvey Barnett PhD provides in depth information to the healthcare community on the behavioral approach to pediatric drowning prevention.

I challenge you to educate five other healthcare professionals, friends, or family after reading this article. Not only will you be educating the medical community, you could directly be a part of saving a child’s life.

Kristine McCarren, PT DPT

Email: k.mccarren@infantswim.com

Facebook: ISR Seal Team Survival Swimming, Inc.

New York Contact: www.ISRNewYork.com

International Inquiries: www.infantswim.com

Twitter: @InfantSwimKris

Bibliography:

1. Brenner, R.A . et al., Association between swimming lessons and drowning in childhood: a case-control study. Arch Pediatr Adolesc Med, 2009. 163(3): p. 203-10. 

2. CDC: Centers for Disease Control and Prevention. [Accessed April 18, 2014]; Available from: www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet.html

3. ISR: Infant Swimming Resource. [Accessed April 19, 2015]; Available from: www.infantswim.com/blog/2012/01/86-of-children-who-drown-are-fully-clothed.html

 


Kristine McCarren ISRKristine McCarren is a Doctor of Physical Therapy (DPT) and Certified Infant Swimming Resource (ISR) Instructor residing in Mt. Sinai, NY.

Dr. McCarren received her B.S. in Exercise Science from Ithaca College and went onto receive her Doctoral degree in Physical Therapy at the University of Stony Brook. She underwent her Infant Swim Resource certification in Casselberry, Florida where she became a Certified ISR Instructor.

Dr. McCarren is experienced in the pediatric setting and dually practices physical therapy in the outpatient orthopedic and homecare settings. She is most passionate about preventing childhood drowning through parent education and instruction of ISR techniques. Her dream is to ultimately open an aquatic facility to teach infants and children ISR Self-Rescue® skills and practice aquatic physical therapy with the pediatric population. 

 

post

Choosing Wisely

Simplicity and Elegance of Positive Language Communication: Recommendations for How to Mentally Prime Our Patients for Success with the Choosing Wisely Campaign

Executive points out a spinning manager

Dr. Jessica B. Schwartz PT, DPT, CSCS

The impetus behind this article is to address the language behind the Choosing Wisely campaign. I hope by providing feedback and subtle paradigm shifts in language, I can aide in increasing communication success between both doctor and patient. 

Join me as I take you through the Choosing Wisely campaign background, my reflections on the American Physical Therapy Association’s (APTA) campaign, and action steps on how we can achieve optimal communication between clinicians and patients. 

Choosing Wisely

The Choosing Wisely campaign is a patient centered educational campaign based in the United States that seeks to improve doctor-patient communication and relationships about overutilization of medically prescribed resources[1].

I came across the APTA’s Choosing Wisely Campaign and the Consumer Reports article reviewing the campaign as I was sifting through my Twitter feed one morning. Not only was I excited to find out that we were the first non-physician organization to take part in this campaign[2], I felt proud that my organization was leading the way in advocating for patients to take control of their health and well-being.

The APTA campaign, entitled “Five Things Physical Therapists and Patients Should Question”, was my first exposure to the Choosing Wisely campaign. As I continued to read through other Choosing Wisely sections in Nursing, Orthopedic Surgery, Emergency Medicine and Neurology, I realized this whole campaign was speaking to patients using a structure based solely on negative language. Each sentence began with the words “don’t” or “avoid”.

Choosing Wisely Slide Images.001

Choosing Wisely Slide Images.003

Choosing Wisely Slide Images.002

Screenshots Accessed October 19, 2014 via www.choosingwisely.org/doctor-patient-lists/

As soon as I read these articles, I knew there was a better approach when it comes to speaking with our patients.

As I transitioned over to the Consumer Reports review of the APTA Choosing Wisely campaign, I was somewhat biased reading an article about my own profession written by a freelance writer who authored “Still Hot Your Uncensored Guide to Divorce, Dating, Sex, Spite and Happily Ever After”.

I would be remiss if I didn’t say I felt frustrated with the Consumer Reports article educating the masses using phrases like “wimpy exercise programs” to describe a doctoral level education plan of care with regards to exercise prescription for the elderly.

My discontentment with the Choosing Wisely campaign is not with the information being delivered, but how it is being delivered to the consumer.

I’d like to take a moment to address how I believe the Choosing Wisely campaign could be shifted to improve communication between the medical community and our patients.

Reflections:

It was during my undergraduate career when I took a sports psychology class in the hills of Ithaca, NY, I realized the importance of positive psychology and its role in achieving peak performance for all individuals.

Clinically, I have had the opportunity to work with patients who have felt absolutely helpless and hopeless about their present health situation to elite athletes who would like to conquer a new athletic endeavor.

As a novice or a master clinician I ask you, what do these completely different patients’ treatment paradigms have in common?

One central tenet: I treat them exactly the same. I cater to their individual needs, goals and desires while addressing their fears and uncertainties with confidence, realistic, and positive outcomes and goals.

Richard Boyatzis, a psychologist from Weatherhead School of Management at Case Western Reserve University, advocates that when we focus on strengths, there is a tendency to move toward a desired future which internally stimulates openness to new ideas, people, and plans. Talking about positive goals activates brain centers that opens you up to new possibilities. Reciprocally, focusing on the alternative, or negatives, evokes a defensive mechanism and leads us to close down[3].

A positive language and motivational model is often used when speaking with professional athletes and elite executives in corporate America. Rick Aberman, peak performance director for the Minnesota Twins, states that “when the coach reviews plays from a game and only focuses on what not to do next time, it’s a recipe for players to choke.”[4]

During my days coaching basketball, I remember watching every inspirational sports movie I could get my hands on from Hoosiers to The Mighty Ducks, speaking to other coaches about their best practices, referring back to coaching lectures, and reading coaching books by Pat Summit from the University of Tennessee for guidance.

I remember coaching a close game one winter in upstate New York. The score was tied and I called a time out. Tapping into all of my coaching research, I looked each and everyone of my players in the eye and initiated my plan of action to my point guard, “Alicia, you’re going to pass the ball to Katy and she’s going to roll off of the screen that Meg is going to set. She’s going to bank the shot in and all of you are going to full court press until the clock runs out to win the game so we can go home and celebrate”.

Why aren’t we speaking to our patients like this?

We can mentally prime our patients for success with the simplicity and elegance of positive language communication.

Master clinicians discuss this in academic medicine all the time: language and delivery matter.

Recommendations:

I challenge you to think about how you speak with your patients and colleagues on an interdisciplinary level. Every interaction doesn’t need to be a critical life changing beat the buzzer intense moment; however, words and language matter.

Moving forward as a cohort of passionate, capable and autonomous Doctors of Physical Therapy in the United States, it is imperative that we adopt this positive language delivery system ranging from our everyday practice in patient care to an elevator pitch when fellow doctors and clinicians ask us how Physical Therapy can benefit their patients.

This is my challenge to the healthcare community: Choose Your Language Wisely.

My name is Dr. Jessica Schwartz. I am a residency trained Doctor of Physical Therapy in Orthopedics and here is how I can help you Choose Wisely.

1. Do use passive physical agents as an adjunct to skilled manual therapy and supervised therapeutic exercise in order to aide in inflammatory pain management. If time is an issue or compliance is not an issue, do educate patients that they can ice, heat or use a TENs unit at home.  

-Our job is to make people feel better. The number one reason patients come to Physical Therapy is because they are in pain. The 21st century patient is busy and often stressed. In order for me to provide skilled one on one orthopedic manual Physical Therapy, I need my patient to be calm, mentally primed to disassociate themselves from life’s stressors i.e. to be as relaxed as possible so they are present and active in their treatment session, and for the area to be ready to receive treatment. Moist heat, cold and/or electric stimulation are all non invasive and safe alternatives to an anti-inflammatory or other oral medications. Patients are consumers and should be educated that it is not ok to receive passive physical agents as a sole form of treatment.

2. Do make your Physical Therapist fully aware of your activities of daily living, familial responsibilities, work requirements, athletic abilities and desires. All of the above are independent of your chronological age. Chronological and biological age of our patients vary greatly. It is our job to dose the exercise prescription intensity, duration, and frequency not to your chronological age, but to your biological age and abilities. We work with 80 year old triathletes and 20 year olds living in hospice facilities. Our job is to individually tailor realistic, functional, safe, and achievable short term and long term goals for our patients. 

 -Physical Therapists are educated so that we fully comprehend the physiological demands of the musculoskeletal, neurological, cardiovascular, pulmonary, and integumentary systems, how these systems interact with each other in order to differentially diagnose different pathologies appropriately for referral as needed, and how to get all of these systems working as efficiently as possible with a patient spectrum ranging from the frail elderly to the elite athlete. In other words, our job is to make the patient function to the best of their ability in a pain-free and energy efficient way. 

3. Do move with the skilled supervision of a Physical Therapist after an acute deep vein thrombosis (DVT) and initiation of anticoagulant therapy, unless significant medical concerns are present.  

-Patients lose 0.5–0.6% of total muscle mass per day on bed rest. Bed rest was the appropriate prescription for low back pain and DVT 20 years ago. Evidenced based practice has led us to present day conclusions that bed rest causes more harm than good (muscle atrophy, strength decrease, onset of insulin resistance, decline in basal metabolic rate, and other negative pathophysiological breakdowns). [5-6]

4. Do use continuous passive motion (CPM) machines in the complicated total knee replacement. Active prescribed therapeutic exercise for range of motion (ROM) and weight bearing (WB) status should be achieved multiple times per day after total joint replacement. If the patient is not compliant or not able to achieve post-operative requirements of prescribed movement, the CPM is a good adjunct with skilled physical therapy. 

5. Do use directed wound irrigation or a pulsed lavage with suction for wound management. Be wary of whirlpools due to bacterial cross contamination concerns. 

Choosing Wisely is an excellent campaign to involve multidisciplinary levels of communication to patients, consumers, and other healthcare professionals; however, I believe a subtle shift in the delivery can make all the difference in how patients perceive and receive the information geared towards them.

Physical Therapy as a profession is in a transitional time doing our very best to educate the masses about all the various therapies we can provide independently and complementarily to aide in optimal functioning across the lifespan. 

It is important to be comfortable with your doctor. If your Doctor of Physical Therapy is comfortable with his/her clinical abilities, he/she should welcome patient questions or concerns after a thorough review of their plan of care. Remind patients that it is okay to ask questions. If rapport is not established, more often than not patients are intimidated by asking questions due to fear, intimidation, risking feeling silly, etc.

I encourage questioning during the course of a plan of care because this way I know the patient is comprehending the value of their treatment session, are engaged, and are invested in advocating for themselves.

A master clinician is able to field all of the intangibles that the day to day environment brings in healthcare. Some clinics are busier than others. If a patient does not feel comfortable with their provider, remember to educate them that they have a choice to seek out a new provider to achieve their functional desires and goals. 

Finally, when a patient finds their ideal Physical Therapist remind them to stick with them! Having a healthcare professional who is easily accessible and who is knowledgeable in treating all of their musculoskeletal concerns throughout the lifespan is a wonderful relationship to cultivate in order to achieve optimal health and well-being.

We all have different strengths, specialties, and abilities, so make sure patients are educated to seek out a Physical Therapist that melds well with their personality, goals, and geographical location.

Good luck in finding the Physical Therapist right for you and here’s to Choosing Wisely! 

Bibliography

1.Cassel, C.K. and J.A. Guest, Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA, 2012. 307(17): p. 1801-2.

2.APTA releases its Choosing Wisely list of what to question. 2014  [cited 2014 October 28, 2014]; Tuesday September 16, 2014:[Available from: http://news.todayinpt.com/article/20140916/TODAYINPT04/140915009/0/TODAYINPT0%20105.

3.Goleman, D. (2013b). Focus (Kindle ed., pp. 320): Harper Collins.

4.Goleman, D. (2013b). Focus (Kindle ed., pp. 30): Harper Collins.

5. Brocca, L., et al., The time course of the adaptations of human muscle proteome to bed rest and the underlying mechanisms. J Physiol, 2012. 590(Pt 20): p. 5211-30.

6. Wall, B. T., Dirks, M. L., & van Loon, L. J. (2013). Skeletal muscle atrophy during short-term disuse: implications for age-related sarcopenia. Ageing Res Rev, 12(4), 898-906. doi: 10.1016/j.arr.2013.07.003

 

post

#SoMe

Social Media and Medicine (#SoMe): How to Use Technology to Increase Knowledge Translation and Self-Directed Learning Processes

PT2Go SoMe Cartoon

History Behind Article:

We’re clinicians that live and practice in exponentially different ways with one seemingly universal commonality: We’re busy. 

Factually, we lose attention and retention with initial memory formation between 20-40 minutes via axonal projections from the hippocampus to the cerebral neo-cortex [1]. Learning requires modification from some of the most basic synaptic interfaces at the dendritic level. The dynamic nature of these dendritic spines are important for neuro plasticity and our ability to take on new information [2].

After formal education and residency, we are expected to remain clinically competent and synaptically sharp in a world inundated with information, tasks, and projects. I have earned the title of Doctor- now how do I maintain this perceived clinical acuity and sharpness that my peers and patients expect of me independently? 

In graduate school and residency we’re handed information. It is easy to take for granted the work and effort it takes to be caught up on the latest research and trends in medicine. More importantly, how to stay passionate while minimizing frustration levels with streamlining and accessing seemingly endless amounts of information. What’s relevant? Did I just waste 20 minutes reading an article that was pointless?

As stated in my original blog post, I hope to share my passion and authentic curiosity for medicine as well as facilitate passionate conversation with the intention of creating better clinicians and self-directed learners.

In an effort to guide you through my process, I will share the educational, social media and research pearls that have set me up for success and kept my synapses firing in 2014.


What To Expect:

At any given time we have an abundance of external distractions inundating us with pings, alerts, scrolls, vibrations, etc. I’m fairly certain in grad-school, I answered my remote control working on my thesis, quieting my puppy, avoiding Facebook notifications…

Sound familiar???

This leads us to the key question of this article: How do I quiet the external noise and organize myself professionally in order to become a better clinician? (And still lead a socially productive life!)

Below you will find my organizational process incorporating my present (and ever-changing) incorporation of using Social Media and Medicine to increase knowledge translation and self-directed learning processes with the intent of becoming a better doctor.

Apps and Programs I Use:

1. Feedly
2. Twitter
3. EndNote
4. Pomodoro Technique® Timer


 

Feedly

History: 

During the 10 years of my formal pedagogical career I  asked one question throughout every single college or university I attended: How do you receive new information and organize your research/medical content? 

After years of disorganized manilla folders, lost papers, and bookmarks strewn across various web browsers, I learned about Feedly. 

Feedly Pearls: 

Feedly is a news aggregator with a beautiful User-Interface (UI) for iOS, Android, and your computer that allows you to process, receive, and sift through information in a very intuitive and minimalistic way.

Feedly allows you to organize nearly everything on the internet from peer reviewed journals, podcasts, blogs, news sites, and YouTube Channels in a list, card, or magazine view.  

Feedly organizes topics with Categories. Categories are essentially folders if you would like to think about Feedly as a desk with drawers. Take the time to organize your Categories and then add your favorite journals, podcasts, etc. 

The beauty of the product is that everything gets delivered to you instead of you having to seek out the information in piece meal. I equate it to going to Blockbuster or the Movie Theater back in the 1990’s and now everything is streamed and filtered to you via NetFlix, Amazon Prime, Hulu, etc via the cloud. I personally take 30-60 minutes on the weekend and sit with a cup of tea on my balcony and sift through incoming information and news streams. 

I can sift from 20 to 100’s of different titles scrolling through ~5-10 pieces at a time on my iPhone or iPad (my preferential viewing style). My goals are to move through all of the content that I have in my Categories and get to Zero. Anything I see along the way that interests me, I hit Save For Later. When I get down to Zero, I then go back into my Saved For Later Category and then take the time to meaningfully go through the content that I have found interesting.

Any journal articles, podcasts, or blog posts that I deem worth keeping, I immediately store them in EndNote (see below), my Web-Browser folders or Evernote. If something is too long, I have a “Read Later” folder in both my EndNote and Web-Browser that I sit down with at a later time before I decide if I want to keep said article of interest. 

[For cohesive integration of Feedly, Twitter, and Endnote see below]

Feedly Screenshot Category in BJSM Mac View
Screenshot of Feedly on MacBook Air


picstitchScreenshots of Feedly on iPhone

Summative Feedly Pearls: 

1. Set up your Feedly on your computer

2. Find what you know

3. When you are comfortable, branch out and search broader topics of interest

4. Read and sift through articles on your iPhone/iPad or Android device taking advantage of the excellent UI

5. Work in 20 minute goal oriented time frames 

Twitter 

History:

There are endless possibilities for how to use Twitter. 

My friends in media have used Twitter for years to promote themselves and their brands. It wasn’t until recently that I became aware of a select few of my friends and colleagues using it for medicine. I started noticing that most professional organizations, hospitals, journals and conferences were also on Twitter. 

If you don’t enter the space of Twitter cautiously and well planned, it can feel like you are standing on one leg, in New York City traffic, juggling ultrasound heads while trying to catch clinical and educational pearls thrown at you by the medical community…that are lit on fire (i.e.-It can be very intimidating). 

The key question is: how can we streamline this and make it efficient so it’s not overwhelming?

The answer is to integrate yourself into Twitter in bite-sized digestible pieces.

Twitter Pearls: 

My #1 Twitter Pearl = Create Lists. 

Lists allow you to organize people, organizations and topics into smaller cohorts. 

For example:

By clicking on my Twitter handle @DPT2Go and clicking on my Lists page you can subscribe to anything that I’ve made public (Medical Organizations, PT’s, Rehab Medicine, Medicine, Medical Organizations, Journals, etc). As you create more connections with people whom you follow, you essentially create this entangled web of people, places and organizations that provide you with seemingly unlimited access to experiential or voyeuristic learning opportunities.

It’s O.K. to sit back and not tweet/participate. Saving informational pieces in your Favorites is completely fine. In fact, it took me a few years to start Tweeting!

In an effort to save time searching, you can subscribe to other peoples lists as well.

If you aren’t sure where to start or where to look, I recommend the Symplur Hashtag Project specifically relating to healthcare.

Hashtags group tweets into topics so they can easily be searched later on. Popular hashtags include #PT, #DPT, #MedEd, #FOAMed, #SoMe, #Healthcare, #DPTStudent, #Hospital, etc. Conferences also create hashtags for themselves and change yearly. 

Getting overwhelmed with Twitter/Feedly: 

Because there are seemingly endless amounts of things on Twitter and Feedly, here are a few suggestions to get you set up efficiently:

1. Set specific goals for yourself when you signup. 

2. Begin with searching and following organizations and journals that you know. e.g.: JAMA, Journal of Orthopedic and Sports Physical Therapy (JOSPT), American Physical Therapy Association (APTA), Academic Medicine, JNNT, Cochrane Reviews, PeDro etc

3. Search more global things like “Medicine” “Rehab Medicine” “Sports Medicine”, “Insert Specialty Here”, etc

4. Work in 20 min increments (See Pomodoro Technique below). It’s easy to get lost for hours syphoning through endless possibilities and connections. And remember, that’s all we really have meaningful attention for anyway…

The more gradual you enter this space of Twitter the higher likelihood of retention, maintaining interest, and knowledge transfer will occur for long term and meaningful use. Process the information at your own pace. Review it. Review it again. And find a process that works specifically for YOU. 

An example of how I’ve organized some of my lists below:

Twitter Home Screen Shot Skitch

Twitter Skitch Screenshot Lists

Summative Twitter Pearls: 

1. Twitter is essentially a microblog that allows you to communicate in 140 character bits of information

2. Create your Twitter Handle keeping the above in mind so people can reply to or include you in Tweets without compromising the 140 character limit

3. Create lists + Organize yourself early

4. Start your search with what you know

5. Branch out and search broader topics when you are comfortable

6. Remember to always be respectful and mindful of your professional presence. Seriously, the Library of Congress archives every single tweet. Read more here if you’re interested

7. Choose to be an educational voyeur or interact and engage with the Twitter community. Either way-Have fun and learn!


EndNote:

History:

Every institution I have been a part of during my educational journey has literally handed out EndNote for free. It is supposed to be the platinum package of commercial reference management software. I literally had hundreds of dollars of software handed over to me during a decade and didn’t use it.

I equate it to being handed a piece of Grade-A organic grass fed steak sans utensils or a means of cooking it. I had NO idea how to use it and the bigger issue early on in education…I didn’t really care to.

As a novice learner, I was literally inundated with so much data that I really only cared to learn to differentially diagnose X and treat Z.

The UI is not the most intuitive and past versions, to be blunt, could’ve been designed by a novice coder. However, they have spruced a few things up at Thomson Reuters to make things more intuitive and useful for the clinician on-the-go. 

I am going to discuss EndNote; however, there are a few other notable players in the reference storage, PDF annotation, and citation management game (See Table 1 for comparison).

I continue to stick with EndNote because it’s what I have always used; however, I think Papers 3.0 has some serious potential with respect to cost, UI, and cross-platform access; however, until they can improve on their cloud storage and glitchy updates I’ll continue to use EndNote.

Ref Management Table

(Table 1: Reference Management Software Comparison)

EndNote Pearls:

Organize EARLY.

I have thousands of articles that I’ve accumulated over the years. I recently started from scratch and began organizing things I need and want in my present library.

Arrange your “My Groups” (similar to Categories in Feedly and Lists in Twitter) on the left part of the screen under My Library

EndNote Screenshot

EndNote Screenshot Skitch

For the most part, EndNote is very intuitive. If importing PDF’s from PubMed, WorldCat, a specific journal you have access, etc- it will migrate most data over for you. There are some instances where it won’t do that.

My advice is manually import the relevant data right away. Bare necessities: Title, Journal, Year, Author(s), Pages, Volume and PubMed ID. The PubMed ID is preferential; however, I would much rather copy and paste “24658701” than a full title, author(s), journal, etc. 

EndNote Web Screenshot

The beauty of EndNote X7 is My EndNote Web which allows you to access your files on-the-go complete with annotations, highlights, etc. There are very few times I am without my laptop, however, it does make file access and citation management very easy especially during travel. 

Summative EndNote Pearls:

1. Organize and setup groups right away

2. Make sure important data is migrated in with article. If not, do it manually ASAP

3. Annotate and highlight directly in EndNote allowing you to search via My EndNote Web and iPad later


Pomodoro®Timer:

The Pomodoro Technique is a time management method developed in the late 80’s by Francesco Cirillo. Essentially the technique breaks things down in to 25 minute intervals assigned to a task list that you create implementing short breaks in between each ‘Pomodori’. 

I use a Pomodoro Timer on my phone. Essentially it is just a fancy timer, but it has helped me immensely with regard to breaking up larger tasks into smaller ones and decreasing distractibility. In other words, I don’t get distracted by email pings, Facebook notifications, Twitter alerts, my dogs, etc while I am working on the task at hand. I simply wait until the 5 minute break allotted to me.

So simple and highly necessary when I am in the middle of a project!

Pomodoro


 

Putting It All Together:

Twitter Feedly EndNote Cartoon Slide

Initially, this can all seem quite daunting; however, I can’t imagine practicing without having  integrated social media and technology into my educational process. The initial time and energy spent to organize, integrate and utilize these multiple services early-on will reap tremendous rewards for the you as a self-directed-forever learner.

Good luck in your educational journey  and continue to stay hungry, engaged and passionate!

Cheers,

Jessica

Twitter Handle: @DPT2Go

Email: Jessica at PT2Go dot Co

Disclosures: None

References:

1. Squire LR, Zola-Morgan S. The medial temporal lobe memory system. Science. 1991;253(5026):1380-1386.

2. Bhatt DH, Zhang S, Gan WB. Dendritic spine dynamics. Annu Rev Physiol. 2009;71:261-82. 

 3. http://library.med.utah.edu/WebPath/TUTORIAL/LEARN/LEARN16.html (Accessed May 24, 2014).

post

Welcome To PT2Go!

cropped-WEB_BANNER_1250x250v5_TAGLINE_02.png

Greetings Folks! 

My name is Jessica Schwartz and I’d like to take a moment to introduce you to PT2Go!

You can find the mission statement here; but first, I’d like to share how PT2Go has organically developed over the last several years. 

Conceptually, I thought of this intellectual space of PT2Go as I entered Orthopaedic Residency in 2010. During residency, I learned to truly appreciate the multidisciplinary communication, candor and enthusiasm across all aspects of medicine. After 10 years of formal education and 3 degrees later, I can honestly say that I was never a great self-directed learner.

During residency, I learned how to reason and think differently. In my first 3 months of intensive learning and direct supervised practice, I had become a completely different clinician than I was the day I walked across the stage at graduation and donned that famous doctoral hood. Despite the lack of sleep, buckets of coffee, and stress of having one too many things on my plate at any given time it was an honor and a joy to have learned and grown clinically with my class of residents. 

After graduation from residency, I had a dilemma. I didn’t have someone telling me what to learn, how to learn, and there was no standing on the firing block for weekly peer review and feedback.

I had become incredibly efficient at work and I had rejuvenated my long lost social life with family and friends, but there was something missing. The work, life…learning balance. Where would I fit the time in for learning? How would I do it on my own? How would I do it efficiently?

THIS is where PT2Go comes in. 

My goal is to promote the field of Physical Therapy in a collaborative and multidisciplinary way. I hope that by sharing some of my own self-directed learning experiences: the good, the bad, and the ugly (and believe you me I’m talking ugly!) I can assist in fostering interdisciplinary connections and conversations similar to the connections I made during my time as a resident. 

Here is what you can expect*:

    • • High Yield Evidenced Based information that you can attain on-the-go
    • • International and domestic contributors providing thought provoking and energetic guest pieces 
    • • Opinion (Op-Ed) articles that may push the envelope, foster passionate conversation, and encourage thinking outside of the box
    • • Tips on how to use and integrate Social Media and Medicine (#SoMe) for the Millennial and Generation X Learner
    • • A series on my own Post-Concussive-Syndrome experience. The Dichotomy of The Doctor Becoming The Patient: A Shared Experience of Personal Moments with an Evidenced Based Twist
    • • Concussion Story: A collaborative space for survivors and health care professionals to gain insight into the lives of their patients
    • • Links to Clinical Prediction Guidelines and tips on how to access the information we need in the clinic in real time
    • • A holistic approach to food and nutrition in medicine: taking care of ourselves, food and environmental responsibility, and how it relates to our patients 
    • • Collaborative Case Studies

And much, much, more… 

So cheers to you for coming on this self-directed learning experience with me. I hope to share my passion and authentic curiosity for medicine as well as facilitate passionate conversation with the intention of creating better clinicians and self-directed learners all around the world. 

Enthusiastically,

Jess

Note*: Initial 3-5 blog postings will be primarily related to Concussion

PS-  As promised, I did say Evidenced Based right? My first blog post is written is in a story based format. Here are some links establishing the power of storytelling in medicine and business:

    1. Calman, K. (2001). “A study of storytelling, humour  and learning in medicine.” Clin Med 1: 227-229.
    2. Becker, K. A. and K. Freberg (2014). “Medical student storytelling on an institutional blog: A case study analysis.” Med Teach 36(5): 415-421.
    3. Schwartz, M. R. (2012). “Storytelling in the digital world: achieving higher-level learning objectives.” Nurse Educ 37(6): 248-251.
    4. Stephens, G., et al. (2010). “Speaker–listener neural coupling underlies successful communication.” Proc Natl Acad Sci U S A. 107(32): 14425-14430.
    5. Scott, S., et al. (2013). “Protocol for a systematic review of the use of narrative storytelling and visual-arts-based approaches as knowledge translation tools in healthcare.” Syst Rev 2: 1-7.
    6. Hensel, W. and T. Rasco (1992). “Storytelling as a method for teaching values and attitudes.” Acad Med 67(8): 500-504.
    7. Diagnosis Goes Low Tech By Dinitia Smith Published October 11, 2003. Accessed May 8, 2014.  http://www.nytimes.com/2003/10/11/arts/diagnosis-goes-low-tech.html
    8. Lead with a Story: A Guide to Crafting Business Narratives That Captivate, Convince, and Inspire Truth by Paul Smith. Accessed May 8, 2014.  http://www.leadwithastory.com/
    9. The Power of Story Telling as seen in PT In Motion Published July 7, 2011. Accessed May 8, 2014. http://stephaniestephens.com/wp-content/uploads/2011/07/0312_PTM_Storytelling_MedRes4.pdf
    10. George, D. R., et al. (2014). “How a creative storytelling intervention can improve medical student attitude towards persons with dementia: A mixed methods study.” Dementia (London) 13(3): 318-329.
    11. Cavazza, M. and F. Charles (2013). “Towards Interactive Narrative Medicine.” Stud Health Technol Inform 184: 59-65.