My Craft As A PT: The Patient Who Shaped It And My Career

Anthony Buccafurni, PT, DPT:

Hello my name is Dr. Anthony Buccafurni. I’ve been a physical therapist with FOX Rehabilitation since 2003.

Anybody who knew me in physical therapy school knew that I was an outpatient orthopedic physical therapist. I was focused on sports medicine, orthopedics. Any chance I could get to further my craft in that space, that’s what I was focused on.

And so when I started my career, I started in an outpatient private practice in southern New Jersey doing exactly what I’d set out to do: I was seeing patients from average ages of high school, high school athletes, through some college athletes, workman’s comp clients, and some weekend warriors.

A PHYSICAL THERAPIST’S PIVOTAL CAREER MOMENT

And I was practicing for about two years, just as I had anticipated I would, when I had a pivotal moment in what I would consider my craft when I met a patient named Mary. So Mary was essentially your prototypical 84-year-old female with spinal stenosis or narrowing of her some arthritic changes in her spine, resulting in central low back pain. It was kind of a straightforward diagnosis for an outpatient orthopedic therapist – I mean, outpatient clinic. She was sweet as can be. She came in for her evaluation and was a little scared about the whole situation. She had probably had never seen a physical therapist before. But we did her full exam, all the tests and measures for standard, low back client, built a plan of care that was pretty consistent with where her deficits and impairments were.

And one of the things that she said really on her exam was, “I’m struggling with two things. I’m struggling with making my bed without really bad low back pain and removing the dishes from the sink and putting them up to the cupboard.” And so with that in mind, we did the evaluation, worked with my team, and built a plan of care.

I had a physical therapy assistant who was working with her as well. And for the next four weeks, I took her through a typical course of management and the environment was your typical outpatient gym. It was fun: lots of different patients, the all-around the camaraderie of the clinical setting. And Mary came in and came out and did her thing three days a week for several weeks.

Four weeks later, I did her re-evaluation. It appeared to me she’d been doing well over the last few weeks, so I didn’t expect much of this re-eval. I took the same tests and measures that I did the first time around and went through it very systematically with Mary. I said, “Mary, I tested your lumbar spine mobility and it was this and now it’s that. Your abdominal strength was so poor. And look what we’ve done with your core, so your spine is much more stable. Your hamstring flexibility is better,” yada yada yada.

And I was pretty proud of myself and what we had accomplished. Mary said to me and I will never forget this. It’s like it was yesterday. She said to me, “Honey, I know you said I’m better. You think I’m better. But I’m really not. I still can’t make my bed without really bad pain and I still can’t take the dishes out of the dishwasher and put them up to the cupboard without significant low back pain.”

RE-EVALUATING MY PHYSICAL THERAPY PLAN OF CARE

And I was really floored. I mean this was a pivotal moment in my career and my craft as an outpatient orthopedic therapist I missed something with Mary, right, and the plan of care that I established. I subsequently met with my team and we kind of re-engineered her plan to care for the next four weeks to incorporate much more functional simulation of activities. We tried to simulate her very high bed that her daughter had just recently got for her to try to teach compensatory strategies on how to make the bed. We did the same with trying to simulate removing dishes and placing them up into a cupboard. And we kept a little better pulse on her own feeling of how she felt she was doing and was she using these strategies at home.

And so four weeks later I felt like I had a better handle when we met and she felt better. She, you know, Mary expressed to me, you know: thanks for listening to her, intervening, trying to really identify where her problems were, and building strategies to try to solve them.

But I still to this day feel really bad about the way that I approached Mary’s case in the beginning. It changed the way I took care of older adult clients for the rest of my career.

THE POSSIBILITY OF LIFE-CHANGING PHYSICAL THERAPY IN THE HOME

I was introduced to Tim Fox. He was a physical therapist who had this idea in his head that people were uneasy about because it was so new and it hadn’t been done: that you could provide outpatient orthopedic therapy to older adults in their home.

And I sort of pushed back on it for a period of time until finally agreeing to a meeting with Tim. I really wasn’t looking for anything at the moment, but I met with Tim. And the first thing he did was put three articles out in front of me. And in essence what the articles spoke about were older adult clients’ reports of subjective limitations are more significant than any physical test or measure that you might you might find or measure. And it floored me because this is the exact example that I had just lived with Mary, right?

And so I’m talking to Tim further, he said, you know, “It’s orthopedic clinicians like yourself. It’s people with your skill in your craft who can take care of this population in their home, who right now today are being underserved. They don’t have the opportunity to receive the same services that the rest of society was receiving in an outpatient orthopedic clinic. And to take it a step further, it’s outpatient orthopedic therapists like yourself who aren’t able to take those skills and see a client in their home where they’re really able to look at the full impact of functional limitations within the environment that those clients live, resulting in the best outcome that you can possibly obtain for these clients and patients.”

So it was at this moment where I had this sort of collaboration of this experience with Mary and my patient care and meeting Tim and really kind of coming to terms with the fact that there is this group of clients that deserve the outpatient orthopedic skills and craft that we have all honed over so many years. And for our ability to take that into the home environment and maximize function of older adults in their homes to keep them there safely.

They’re the most thankful and probably those patients in the most need of our services who frankly were being missed you know in the health care continuum. So the opportunity that I had to take my craft outpatient orthopedics and bring it in the home setting with not just the lens I had isn’t worth outpatient orthopedic therapies but also through the lens of being able to see the patient and functionally mobile in their own environment.

It was a really powerful opportunity for me. And it really changed the delivery of my craft and the future of my professional career.