Thoughts on the Hospital Stewardship 5 Years Later

1375275_530604127019053_1098772742_nWhen I signed up for the 10 day Healwell course I intended to become a massage therapist working in a hospital. It was my dream, or so I thought. Nearly five years later, I have not worked in a hospital as a massage therapist, nor volunteered at a hospital as a massage therapist, yet I am still profoundly grateful I attended the stewardship program. Here’s why…

Healwell is an incredible experience of being in a supportive environment of classmates and instructors in a hospital setting. The lessons and insights learned in working in the ICU, oncology and rehab floors and the dynamics of each patient, and sometimes their family members in the room are invaluable to any massage therapist. Learning skills such as charting as part of electronic medical records (EMR), positioning in hospital beds, using hospital beds, working around oxygen and IV lines, and interacting with hospital staff etc. are incredibly valuable skills. And also understanding the unpredictability and assortment of challenges that arise when working in a hospital setting.

I have numerous examples from my stewardship experience, however one patient encounter still resonates with me today. I was assigned a room where the patient was actively dying from leukemia, his family was also present. As my classmate and I walked toward his room my own nerves and self-doubt kicked in as I was a rather new massage therapist. My classmate, with more years of experience than I, put her hands on my shoulders and said ‘trust yourself’. Because we walked through that hospital room door we touched a family. I watched vital signs stabilized on a monitor. I held shoulders as family members cried. Through that experience I was profoundly touched and reassured of what massage therapists can offer to the world.

All of these skills were 100% transferable to my own office in working with persons in cancer treatment or a cancer history, and also in my work for 3.5 years as a traveling massage therapist with hospice going into patient homes and nursing facilities. I learned necessary skills throughout the stewardship program and also learned to be adaptable, to trust my training as a massage therapist and mostly to be fully present with a patient when so many other things were going on around them. Being present with a patient is a skill which transfers anywhere, and was reiterated numerous times during the course, through patient interactions and also class activities.

best-silly-group-healwell-150x150Being part of the Stewardship Program and having a small glimpse of working in a hospital profoundly helped me to shape my private massage practice. I realized that working in my office is a better arrangement for me and that many times I have repeat clients after they are discharged from the hospital, or after their weekly chemo infusion. My office can be a place of calm for those going through or recovering from medical treatment who want a break from their medical journey and that my skills as a massage therapist can allow a client to be supported and to be exactly where they are in their process.

Stacey Schultz
Oncology Massage Therapist
Malaika Massage Therapy
Rochester, MN

 

Traumatic Scar Management: An Interview with Nancy Keeney Smith

Nancy-Keeney-SmithHealwell is honored to be presenting Traumatic Scar Management with Nancy Keeney Smith at the Teal Center, January 8-10, 2016. She was gracious enough to spend some time talking with us about her work, the class, and her soon-to-be-released textbook.

Healwell: How did you get involved in this kind of work? What drew you to it?

Nancy Keeney Smith: I was looking for an alternative to surgery and medication for my own issues with scarring and lymphatic issues. A friend was a student at the Florida School of Massage and needed a journal entry. The impact on my scarring and health was immediate. Several years later I decided to go to massage school to help those like myself with traumatic scarring.

Healwell: Talk a little about why you use the term “traumatic scar tissue.” Isn’t all scar tissue evidence of trauma?

NKS: It’s true trauma is in the eye of the one with scar tissue. Scars are not obligated to be problematic – where would we be without our body’s natural ability to heal itself following a wound? However, normal physiological processes can be altered in a variety of ways and, when altered, this constitutes what is termed pathophysiology.

Abnormal or pathophysiological scars can impact function within and beyond their physical borders and present considerations outside of the physical/physiological aspect of the scar.

Problematic scarring following planned and unplanned trauma can be accompanied by serious physiological and psychological considerations and, as such, led me to co-author a book with Cathy Ryan, RMT entitled TRAUMATIC SCAR TISSUE MANAGEMENT.

Traumatic scars can occur as a result of accidents, acts of violence and other catastrophic events (e.g. disease, burn accident and surgery).

 Healwell:What motivated you to offer this class with Healwell? How does Healwell’s mission connect to the work you do?

NKS: Healwell is an industry leader in presenting cutting edge therapies that are relevant to today’s professional body worker. I am honored to present the class to the Healwell community.

I offer my services to the burn survivor and cancer communities in my area. I offer a sliding scale and pro bono work for those that can’t afford a session. Healwell’s mission statement of demonstrating the ability of hands-on integrative therapies to measurably improve outcomes for patients through clinically sound, replicable methods is what I strive for in my teaching.

Healwell: What’s your favorite thing about teaching this work?

NKS: The “ah-ha” moments in a student during lecture and hands-on demonstrations; assisting students to recognize they can do this type of work with the skill set they have; and to hear from former students about how the information and work has enhanced their practice.

Healwell: Do you have a teaching moment of which you are particularly proud?

NKS: Just one? I have several students that have started their own journey with teaching and opening clinics for traumatic scar clients that include burns, cancer survivors, and returning veterans. I’m so proud of them and how they are opening doors for others to experience the work.

Healwell: You mentioned that you have a book coming out soon (January 2016). Tell us a little about that.SMITH-Front-cover-website-1-Sep-15

NKS: I was honored to be a presenter at the International Massage Therapy Foundation research conference in Boston, Massachusetts in April of 2013. After my presentation, I was introduced to Mary Law of Handspring Publications (Check out their stable of authors! Very humbling.) and Cathy Ryan, the chair of the College of Massage Therapists in British Columbia.

Cathy and I found a common bond in our approach to traumatic scar tissue and noticed a lack of published information for body workers. We recognized the management of scar tissue is a growing problem for massage and manual therapists. In our teachings, we have found many are afraid to deal with it in their practice. This book shares research that shows appropriate massage treatment can have significant results both physically and psychologically. Existing books may dedicate one chapter on the problem but there is no practical manual available on the subject which instructs the therapist what to do and how to do it. TRAUMATIC SCAR TISSUE MANAGEMENT fills the gap, explaining the physiological and pathophysiological background and provides practical guidance on how to help our clients and patients.

Healwell: What makes Traumatic Scar Management different from other scar tissue massage courses?

NKS: Traumatic Scar Tissue Management builds a foundation of knowledge from the anatomy and physiology of scar tissue and research on scar tissue and manual therapy. This course includes exploring the important role the lymphatic and nervous system plays in scar healing, interviewing techniques and clinical decision-making for working with all types of traumatic scarring including cancer, surgery, and burns. Therapists will put their knowledge to use during a hands-on clinic with volunteer traumatic scar clients.

Therapists are encouraged to bring their own experiences and questions to the classroom. I make no claim on having the only way or the best way-just presenting data and clinical observations to assist the therapist in working safely and confidently with all types of traumatic scarring.

Whether the client’s scar tissue was brought on by a burn, surgery, auto accident, injury or cancer recovery, scar management treatment can help with range of motion and improve their quality of life. I enjoy combining years of research with my clinical experience of scar clients to develop a protocol that combines gentle hands-on techniques to facilitate the best healing environment.

Healwell: What’s a common mistake/misconception that you encounter when teaching massage therapists about working with scar tissue?

NKS: That you will cause the client pain when you are doing the work. This is where the knowledge acquired in class eases the fear and instills confidence in the therapist.

Another is the need to go deep and hard on the scar tissue. We learn why this is not the best idea for lasting effects.

Healwell: Is there anything else you’d like to share with our community?

In the developed world alone, a total of 100 million people develop scars each year as a result of 55 million elective operations and 25 million operations after trauma. Current statistics estimate that over 50% of postsurgical patients will experience scar-related complications.

Millions of people, world-wide, are inflicted with non-fatal burn injuries. Although mortality and morbidity from burns have diminished significantly over the past several decades, these statistics do not reflect the overall impact on the burn survivor and how well they carry on with life and manage post-burn deformities, contractures and other disabilities that collectively present with aesthetic and functional considerations.

The prevalence of occurrence, complications and sequelae associated with problematic scars, of varying etiology, present important clinical, economic and social considerations.

My hope is the therapists that sign up for the class will be ready to open their clinic doors and help the traumatic scar population regain their quality of life.

Healwell: Thank you so much for sharing your time and knowledge, Nancy. We are so grateful and excited to bring your class to the Healwell community.

There is still time to enroll in Nancy’s Traumatic Scar Management class at the Teal Center in Arlington, January 8-10, 2016. Register today!

Nancy Keeney Smith is a Board Certified Licensed Massage Therapist, Certified Lymph Drainage Therapist, and a Florida and NCTMB Provider of Scar Management Workshops.  Nancy’s Scar Management Workshops have been taught internationally to students, LMT’s, PT’s and OT’s.  Nancy is a member of the Associate Research Team at the Florida School of Massage in Gainesville, Florida, former 1st VP of the AMTA Florida Chapter, member of the American Burn Association, the National Lymphedema Network, and the Phoenix Society for Burn Survivors. She has a private practice in Gainesville, Florida. You can learn more about Nancy at www.ntouchtherapy.com. You can order a copy of her text book from Handspring Publishing.

Frankly Speaking

me n Frank II

Learn more and register today for Mindful and Compassionate Service with Frank Ostaseski at Friends Meeting of Washington on Saturday, May 17th.

Confidence.  Confidence is something we often equate with expertise. The more you know, the more confident you feel.  Information, mastery, knowing…these are the things that give us power, make us feel safe and provide ground under our feet. (more…)

Doctor’s Orders

doctors ordersHow many times have you heard another massage therapist say something like, “Well, I got the doctor’s permission, so I…” after which she launches into a story about choosing to ignore this issue or that contraindication or choosing not to ask that question or make this adjustment, all because they had a doctor’s note?

Too many massage therapists assume that a doctor’s note or an official prescription for massage means that they don’t have to consult their training, conduct a thorough intake or, in extreme cases, take responsibility for what happens in their treatment room.  Still others proudly announce, “I won’t work with an oncology client without a doctor’s note.”

The concept of physician endorsement in our work is complicated.  There is an unexamined assumption around the perceived need to have “a doctor’s note”, whether in the hospital setting or in private practice.  We take a doctor’s note or order or prescription as a green light to forget what we have learned about how to work safely or we decide that our training alone is not enough to qualify us to work with such a person.

Don’t get me wrong.  Endorsement of our work by physicians is a good thing.  Each time it happens, the door to a larger conversation opens.  When we and our patients and clients ask for written “permission” from a physician, however, it is important to recognize it more as a tool of relationship cultivation than of clinical significance.  It’s an opportunity for education and dialogue.  It puts massage therapy top of mind, if only for a split second. It says to clients, patients and therapists, “Massage is good.”

What it doesn’t say is “Massage is safe. Full speed ahead.”

When a doctor provides a patient with written “permission” to receive massage, it is just that; permission to receive massage.  Any massage.  In most cases, it is not a bulleted list of the myriad concerns that our training and experience as massage therapists tell us we need to take into consideration.  It is not permission for us to check our brains and accountability at the door.

As healthcare continues to distill itself into increasingly smaller bits of specialization, massage therapy is following suit. There are fewer and fewer massage therapists who simply do “massage” anymore.  We do CST, AIS, SCS, MLD or OrthoBionomy…or we are “oncology massage therapists”.  The list goes on.  This trend will not make it any easier for doctors to understand how we are working with their patients.  I am not advocating that we abandon the trend for specialization (that’s another topic altogether).  I’m suggesting that it places a larger burden on us to educate other health professionals about exactly what we do.

It is no more fair for us to expect a physician to understand the specifics of massage therapy than it is for a physician to assume that a massage therapist understands how to do open heart surgery.  The truth is that most physicians, when they sign or write an order for massage therapy, are saying, “It can’t hurt.”

You and I know differently.

The next time you receive a note from a physician giving your client or patient permission for massage, remember that we owe it to the people we touch to work as safely and responsibly as we know how…no matter who gives us the “all clear”.

**Please keep in mind that some facilities require a physicians order or prescription.  This post is not intended to suggest that you stop adhering to that requirement; simply think about what it does and doesnt mean to have a doctors endorsement.

Practice building tip:

Doctors and massage therapists have the same goal:  to make people feel better.  We can highlight this commonality while also raising massage therapy to a new level.  Start putting those doctors’ notes, prescriptions and orders to good use.  Ask your client if he/she minds if you send the doctor a write-up about the session, explaining the adjustments you made to ensure safety.  Or simply call the physician or send a note of appreciation with a business card and a brochure about what you do and how you do it.  Keep it short, simple and consistent.  You can (and should!) send the same note and information to the same physician or practice each time you work with one of his/her patients…and don’t be attached to results.  You’ll make a big impression on some physicians and none at all on others, but if we all start doing this, the momentum will build and the way will open for us to serve more people in a bigger way and to participate in healthcare.

(Originally published at www.lighthold.org)

Stop Whining and Start Reading

keep-calm-and-own-it-19Massage therapists have historically lamented the lack of respect paid our profession by the medical community, insurance companies and even the public.  We roll our eyes and throw up our hands, mystified and defeated by our perennial subjugation. Woe are we!

I have good news, friends.  The mystery is over.  We can stop demonizing doctors, “big medicine” and territorial physical therapists.  We can draw a straight line to a prime factor within our control that has perpetuated our situation.  You and me.

As massage therapists, we are taught to extol the circulatory, toxin-flushing, muscle tone-improving, cortisol-reducing, immune system-boosting benefits of massage therapy.  These claims have been the holy grail of massage marketing.  The problem is that there is little or no evidence to support these claims.  In fact, in some cases (namely, “increased circulation”), the small number of studies conflict (see Chapter 6 of Tracy Walton’s new book Medical Conditions and Massage Therapy).  In the case of cortisol, the body of evidence clearly states massage does not lower ithttp://www.uwstout.edu/faculty/moyerc/upload/MT-meta-analysis-PB2004.pdf.  Period.  Although these claims are still taught in massage schools, propagated in the literature, and carried across legions of massage promotional materials, they reflect only theories, opinions, lore, and wishful thinking.  In oncology massage, at the forefront of the medicine-massage interface, we must be scrupulously honest, and well-supported in our claims.

No matter what we are taught in school, or read in the massage literature, it’s our professional responsibility to question what is claimed about massage, think them through, and look for consensus on each point.  It’s our responsibility to continue to learn and grow, and become as research literate (or at least “conversant”) as possible.  When we do this, we find that many of the “massage benefits” we have learned along the way are unproven, disproven, or are still theories with no research effort at all behind them.

In this regard, the reform of the massage therapy profession is certainly a monumental undertaking and not one that this wee newsletter and we can tackle alone, but we can each do our own small part to create momentum.  We can start by bringing greater mindfulness and accountability to the way we promote massage therapy.  We must commit to stricter standards and to model legitimacy before we can put our hands out to be pulled up to what we think is our rightful place at the mainstream healthcare table.

First and foremost, bear in mind:  one single research study does not establish a truth.  No matter what the title of the article says (“Massage improves X and Y in cancer patients!”), even a well-designed study only suggests a relationship and invites more research.  By themselves, a handful of studies do not tell us anything conclusive.  Instead, there needs to be a body of work, enough strong studies from enough different places to say for sure what massage does and doesn’t do.  And the body of work needs to be formally evaluated statistically to determine what it tells us about massage, then published as a meta-analysis or quantitative review.

When we really look at the body of work, rather than a single study, the science tells us that, for people with cancer, massage therapy decreases perception of pain and anxiety.  That’s about it, at this point.  This is what we can truthfully claim that massage “does”, according to replicated, well-designed, credible studies.  As far as other claims, we can say that it “may” increase energy, may boost mood and some of the other things we are currently claiming.  BUT we need to stop just tossing these benefits around willy nilly as though they are proven facts.

It’s a simple matter of answerability in our choice of words. Be clear about what’s possible…and what’s not.  Take it upon yourself to learn (or review and refresh) your massage claims and physiology, then familiarize yourself with the research that is out there.

There are so many resources in the massage research realm.  Follow the free open-source international journal http://www.ijtmb.org/index.php/ijtmb  at the Massage Therapy Foundation website.  Read the summary in Gayle MacDonald’s book, Medicine Hands.  View Tracy Walton’s webinarhttp://s4om.org/div0/walton_webinar.htm on massage and cancer research for a summary of what the evidence says (and doesn’t say), and how we evaluate the evidence.   Check in at the National Library of Medicine (www.pubmed.gov) regularly and use the search terms, “massage” and “cancer” or “massage” and the factor about which you are interested in knowing more.  And remember that any one study you pull up will probably not tell the whole story.

I know, I know.  Maybe you’re saying, “But science isn’t everything.  Have you no soul?!”  As with most things, it’s all about balance.  While you’re being all professional and responsible don’t throw the lotion out with the holster.  There is probably a lot that massage does that we can’t quite put our fingers on.  Personally, I “know” that my clients feel loved and heard and more hopeful and a host of other positive things that science will likely never get around to measuring.  How do I know this?  Because they tell me.  These “benefits”, in my humble opinion, are why clients really come back week after week and year after year. Sure, I make their shoulders feel better and I ease their headaches, but the expansive beauty of what we’re each offering in our treatment spaces defies explanation…and that’s just as well if you ask me.  That daily sip of the mystery is how we can do this work for years and years without burning out.

So then how do we do this dance of professional due diligence and not lose the heart of it?  I think of myself as a sort of double agent.  In my treatment suite I am making a living simply by loving my clients through clinically safe, physiologically sound massage therapy, curious and caring listening and good old fashioned presence.  Meanwhile, outside my treatment suite my job (and yours!) is to be a responsible, committed, well-educated healthcare professional.

Each doctor, each nurse, each physical therapist and insurance company who is convinced of the value of massage therapy by my professionalism, demeanor and adherence to the standards of respectable, legitimate, safe, effective healthcare opens the door for me to use massage therapy as a means to love, to hear and to foster hope in one more person who may never have considered massage therapy before.

You and me?…we are that powerful. Let’s use that power to its most beautiful, empowering and legitimate potential.

(orginially published at www.lighthold.org)

The Scientist and God

Belief-Restructuring“And God came to me.”, he half-whispered, the fading sun glinting in his eyes.  He leaned up a little in his bed to share this secret with me.   This “secret” he had shared with each member of the care team who had worked with him in the preceding days.   Everyone told me their version and everyone was completely enthralled with this scientist.  This adorable, likeable, tough, old, dying man who couldn’t be cured and who would die in this hospital sometime very soon.  His pain was well-managed, so he was low on my long list, but one of my colleagues shot me a puckish smile as she leaned over, circled his name on my paper and drew an arrow up to the top of my list.

He was androgynous like I’ve seen people get as they get close to death.  Upright, in a suit or in a labcoat, it was clear he would appear quite manly and even unfriendly and serious.  Today, his small face was etched with life, but soft and childlike.  His eyes danced as words fell from his lips in a mottled east European accent that forced me to lean in and focus all sensory attention on my eyes and ears.  Notes from pastoral care and social works visits had painted a vivid picture of a life without a single dusty corner.  Cutting edge science, Cold War imprisonment, 70+ years of marriage to a woman who was still living and, doubtless, just as alive as he.  Walking many miles a day, every day near his suburban home until this hospitalization, but he was ready to go.  He didn’t want to go, but he was ready.

He believed, his whole life, only in things he could touch, explain or examine between the stage clips of a microscope, but he saw God and didn’t doubt it for a second.

“He appeared to me”, he said, as surprised now as he must have been in sleep, “and he was real.”  He held one hand up, circling the pad of his thumb on the pads of his first two fingers like he was feeling God between his fingertips.  The amusement, the joy, the sheer revelation of it found him chuckling as he spoke, his head nodding as if to convince me.

“He put his arm around me and we walked.  He smiled with love and said, ‘I know you don’t believe in me.  It’s okay.  I can’t be understood with your mind.’ and then he made me this offer.”  He held up his manicured hands, a lone saline line hanging from his arm, to show that the offer would have a “this or that” option to it and he nodded his head once quickly as if to say, “Yes?  You see?”   By now though he wasn’t even telling me the story, he was there with God.  His eyes closed, I could see him walking with my own image of God as God would appear in a dream like this.

“God told me that I could go with him just then and I would save myself ‘a lot of trouble’, but it was my choice.”  He paused, reviewing the decision again without regret. His lower lip subtly jutted out as the corners of his mouth turned down.   “But I didn’t want to die.  I wanted to go back to my wife and to living.  To the adventure.”  His face crinkled.  He wondered how it was possible that God wouldn’t know that living this life was so good;  that God would think he would be even vaguely tempted by an early, trouble-free exit from the rich, textured path he had walked for the last 92 years.

His eyes opened slowly and God faded from both of our minds as he lamented, “The next day?…I got a speeding ticket.  And then?…a few months later, I got cancer and now here I am…for a few more days, maybe.”  He shrugged as if to say, “This isn’t such bad trouble.”

Healwell has arrived!

open door blue wallThank you for your interest in Healwell and our musings about the experience of caring for patients in the hospital setting, running a non-profit, the state of healthcare and all of the intersecting pieces of illness, culture, economy and education that go into making Healwell happen.

Healwell’s Program Director, Lauren Cates is the primary author of Healwell’s blog, so much of what you’ll find here will be from the practitioner’s point of view, but you may be surprised to find that the practitioner’s point of view is a lot like the human’s point of view.  In our work with patients living with serious and life-limiting illness we are brought face-to-face with issues of real life and the places where systems of care meet the actual people who move within them as patients, as doctors, as nurses and as families.  Some posts will be like glimpses into our work at the bedside.  Others will take on bigger issues of healthcare and access or current trends in care.

Sometimes we’ll have guest bloggers or members of our board of directors or our advisory board will contribute here.

We hope you’ll enjoy what you find…and that you’ll keep coming back!