S1E4: Get Comfortable with Ambiguity

Cathy and guest host, Rebecca Sturgeon, have an interdisciplinary talk fest with Sam Cotton, of the Trager Institute in Louisville, Kentucky. Hear how one institution is training the next generation of professionals to work as a team to provide the best care to older adults.

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Check out the great work of the Trager Institute here: https://www.tragerinstitute.org/

About Our Guest:

Samantha (Sam) Cotton, PhD, is a program manager at the UofL Trager Institute and the 2019 Geriatrics Academic Career Award recipient.

About Interdisciplinary:

In this podcast, massage therapy educators, practitioners and positive deviants Cathy Ryan, RMT and Cal Cates, LMT will use research, science, experience and humor to explore the broad landscape of health care through a truly interdisciplinary lens. We will be joined by compassionate, self-aware humans who are actively participating or are interested in participating in interdisciplinary care to have honest, uncomfortable conversations about topics like access, racism, death, ageism, ableism, and equity that address the intersection of being a human being and providing quality care, so that we can expand our impact, confidently navigate new challenges, and together create lasting, sustainable changes in health care. You’ll always learn something. You’ll always laugh and you’ll come away better informed and with real things you can do in your own community and practice to create a more compassionate and collaborative system of care for all humans.

Transcript

Rebecca Sturgeon: Hello everyone and welcome to Interdisciplinary, the podcast where massage therapy educators, practitioners, and positive deviants Cathy Ryan and Cal Cates use research, science, experience, and humor to explore the broad landscape of healthcare through a truly interdisciplinary lens. I am not Cal Cates, I'm filling in for Cal Cates. My name is Rebecca Sturgeon. I am the Education Director for Healwell. And today, as in all of our episodes, Cathy Ryan and our guest and I will have an honest, sometimes uncomfortable conversation about topics like access, racism, death, ageism, ableism, and equity that addresses the intersection of being a human being and providing quality care so that we can expand our impact, confidently navigate new challenges, and together create lasting sustainable changes in healthcare. As always, you'll always learn something, you'll always laugh, and you'll come away better informed and with real things you can do in your own community and practice to create a more compassionate and collaborative system of care for all humans. So, welcome. (Cathy Ryan: Yay, Rebecca!) Thank you Cathy Ryan. (Cathy Ryan: Yay!) So, Cal is not here and they're usually the keeper of the puns, but to keep that tradition going, I brought one. But you know, Cal's jokes are usually dad jokes. And I wondered if it was appropriate for me to tell a dad joke. Because I thought it might be a faux pas. (Ba-dum tss.)

Cathy Ryan: Just a second. That was a thinker, that one. Good job, friend.

Rebecca Sturgeon: So Cathy Ryan, how are you today?

Cathy Ryan: Oh, well, you know, I'm doing all right. The sun is shining, which is nice. And it's still winter, and COVID is still a real thing. And, just continuing to do my part as best I can to keep myself and everybody around me safe and healthy. How are things in Louisville?

Rebecca Sturgeon: Oh, well, we had some snow yesterday. And it was very exciting driving in the snow in a place that doesn't often get snow. But yeah, things are good here. I just got my first dose of the COVID vaccine last week. So, yay for that. The rollout seems to be going pretty well in town. And I'm really excited today to be joined by a guest who is also in Louisville, Kentucky. And I will let our guest introduce herself. So welcome, welcome guest.

Sam Cotton: Hi, hi everybody. My name is Sam Cotton. And yes, I am also in Louisville, Kentucky. Get excited about that and the snow. Let's see, I'm a horrible academic, because I always forget all the things that I do that I'm supposed to add after my name, but I am a social worker by profession. I have a PhD and a Master's degree in Social Work. I work at the University of Louisville Trager Institute, and I wear a lot of different hats there, both literally and figuratively. I like hats. I'm not wearing one today, unfortunately. But that would have been a good joke if I were. Like missed opportunity for a joke. I screwed up there. Y'all are gonna kick me off the show, never invited back. I'm a geriatric academic career awardee. So, a lot of my time is spent doing interdisciplinary, interprofessional training and education opportunities for learners from social work, nursing, medical school learners, pharmacy, just to name a few. And then I also work a lot on our geriatric workforce enhancement program grant where I help in terms of coordinating our Alzheimer's disease and dementia-friendly communities initiatives. So, I do a lot of community-based work and a lot of work with in terms of the workforce development. So, thinking through what are the evidence-based practices that we can help in terms of teaching, whether you're just starting out in your profession, and you're going to work in healthcare all the way through that; maybe you're a seasoned vet in the healthcare world. But what are some things that we can do to help in terms of you understanding what it means as you get older or some of the holistic integrative healthcare pieces. So, that's what I do in a nutshell. I'm sure I'm forgetting things.

Cathy Ryan: That's our job to ask questions and see if we can draw that out.

Sam Cotton: My boss is going to listen to this. She'll be like you forgot to talk about this!

Rebecca Sturgeon: Well, then your boss will have to come on the podcast later. 

Sam Cotton: I know! You should invite her on. She's very interesting.

Rebecca Sturgeon: Alright, we'll talk about that. So, first of all, tell us more about the Traeger Institute, what it is, and what y'all do there. 

Sam Cotton: Yeah. So, we do a lot of different things. We, in terms of our work, are very focused on, again, workforce development. So I mentioned some of the things that I do. We also are the base for the Republic Bank Optimal Aging Clinic as well. And so, we actually have a clinic on site where we provide primary care services to individuals. And we also have specialized care for the 65 and older population. We really are moving towards trying to build out like a one-stop shop in terms of healthcare. So, thinking through what are those things that help individuals as they age and helping them age optimally. So, at our clinic, in addition to the primary care services, we have what we call more of our lifestyle, medicine, or wellness services that we have as well. So, we have acupuncture, massage therapy on site. We also offer a number of different exercise classes like Tai Chi, functional movement, yoga. Right now, a lot of those classes are happening in the online environment because of COVID. But the idea is that one day, we'll have that all in one space, so that when patients come, we're not just referring them out to other things. They can come back to a place where they're comfortable and receive these different services. So the idea is if you walk through the journey especially with an older adult, them having to go to all these different places for coordinated care can really be a barrier for them. So, we want them to have that comfort place that they can come to. The other thing that we really have focused in on, and this predates us being part of the clinic, before we even had a brick and mortar clinic, we have our Flourish care model of healthcare that we implement with patients, typically 65 and older. But we do have some patients who are much younger than that who are enrolled in our programs, because we don't really think that chronological age sometimes is really that person's true age. So, maybe that individual has dealt with structural inequalities that have prevented them from having access to adequate healthcare. And so, that really plays into a person's true age. And so, what we typically do is we try to go ahead and help the individual in terms of connecting to different resources. And, we have students who are part of our program who act as Flourish care navigators. And so, they help in terms of coordinating services. So, let's say a patient has a specialty appointment with somebody who's outside of our clinic. So, maybe this patient sees us for primary care, but they go to cardiology through our healthcare system. The student then goes and helps coordinate that appointment. They go to the appointment with the patient. They make sure that they can have that conversation with the provider when possible about what's going on in terms of managing care. We also do things like help them connect in terms of different social services that they might need as well. So, we do home visits with most of our patients when we can to check in and see how things are going. Because a patient on the telephone or in the office can tell you all day long "things are going fine," and then you get in the home and there's no food. Or, you're working with somebody who has mobility issues, and you get in the home and they have wood floors with rugs on top of them and slippery--that's the potential for falls risk. There's also, we get into the home and sometimes there's things that are difficult in terms of that person's everyday life like showering; having grab bars and things like that can be very helpful. So, our intern tour, learning and developing those skill sets do a lot in terms of the care coordination piece. And then a lot of that too is also education for our patients as well. So, yeah. I mean, I could talk all day long about some of the different things.

Rebecca Sturgeon: And this is, there's so much there. Like it's so rich what you all are doing, and I'll go ahead and give my disclaimer now that I am the massage therapist at the Optimal Aging Clinic. So, just started, so I'm just learning about it myself. But I mean, there's so many different places to--(Cathy Ryan: I have a thousand questions. I'm not sure where to start). Go ahead, Cathy. Cathy pick one.

Cathy Ryan: Okay, I mean, you talked about how the coordination of care, so when patients are seeing a specialist outside of your clinic that you having like a patient advocate go with them to help them coordinate that care, which, from my perspective, I think is one of those huge gaps in healthcare in general. Because not everybody knows what kind of questions to ask. Or sometimes if you're being given difficult information, it's challenging to take it in. So then you get home. I think in terms of my parents as they were aging and how difficult it was for me to get accurate information from them about what happened at their doctor visit. So, I mean, I ultimately got permission, so that I could speak directly to their physician, because my parents didn't live near me. So, that is fantastic. My other question around interprofessional dialogue within the clinic itself: are there like group meetings where practitioners get together and talk about particular patient care and how that is coordinated?

Sam Cotton: So, we actually have a couple of different ways in which that happens. Providers are often very busy, because they have a lot of the healthcare system. I mean, we could talk all day about how it creates inequalities for most patients, but part of it is also how providers are expected to have back-to-back 20-minute appointments. So there's a lot in terms of that they cannot address in those appointments. That's just, especially for older adults, that's not a reasonable amount of time for them to get all of their needs addressed. So, you have providers who are burdened by the system in and of itself. So, we have a number of different ways where our interprofessional team works together. Some of it's asynchronous, and some of it's us coming together and really dialoguing about patient care. So, we've put in a lot of measures for our providers to get feedback. So, our students actually tack the provider's information in our electronic medical record system to keep them in the loop on what's going on with patients that we're actively working with on an ongoing basis. So, that's more of the asynchronous way that we try to communicate in real time. Also, when we do assessments with patients, we try and upload the PDF of that information for the provider to review when they have a chance to do so. The other thing that we do, and this is, from a patient care standpoint it's important but also from a learning standpoint for our learner. So, I don't know if I mentioned this. I said we had interns from a number of different disciplines but predominantly are individuals doing practicums or interns with us are with us for about 20 hours a week. Right now we have about 63 learners from social work, counseling, psych, and then we have Doctorate in Nursing Practice psych students as well. We also have one exercise physiology student as well who's doing an internship with us. So, those students are expected every week to come to our interprofessional workshops that we offer weekly from 8 AM to 1 PM on Wednesdays. But part of that is our case conceptualization meetings. And that's really the core of getting organized and figuring out what's going on with a patient and coming up with a very solid plan of care for that patient. And so, case conceptualization is a time where students are able to present cases of patients that they're working with. And then, we also have in addition to the students there, we have faculty members from our different disciplines who attend that and provide recommendations, supervision, feedback. We also have community organizations like our Area Agencies on Aging who come to those meetings as well. And then other community organizations as we need them. So, a student might say, "Oh, I could really benefit from some advice related to someone in the housing sphere." They are more than welcome to get in contact with somebody there and invite them to case conceptualization. So sometimes our meetings are rather large for that. We sometimes have anywhere from--we have 63 students who are expected to attend. So, we usually have about five or so pharmacy students in addition to that, and then by the time you get all of the other people involved, it's about 70 to 80 people, depending on the week. So, that's our time to really have conversations about that piece. Each student has about 20 minutes to present the case that they're working on and then about 10 minutes for recommendations from the team. So, we usually get about two patients that we talk about per hour. Now, you might be thinking, "Oh, that seems inefficient because you probably have so many patients." But the idea is that this is a very excellent way for students, even if they're not presenting that week, to learn something that they can then implement with their patients. So, it really does have that dual purpose. So even if you're not the person presenting, the idea is that you're sitting there and absorbing all of that information that your colleague is getting in terms of their patients. And odds are something's going to overlap there in terms of your patient caseload and some of the things that are going on with their patients.

Rebecca Sturgeon: Yeah. So I'm wondering, I'm wondering lots of things. But I'm wondering also, since you mentioned like, they might want some help from housing assistance, or maybe somebody is food-insecure or something like that that can come up in the case meetings. Is this something, like this kind of awareness of the social determinants of health, something that is built into your education program? Or is it something that kind of students arrive with? Because you're also associated with the university as well, yeah?

Sam Cotton: Yes. So, it depends on the discipline that students come from, whether or not they've touched on this at all. I would say that in terms of our nursing students and our social work students, it depends on what classes they're in at the point of which we get them, because we have all students of all different levels from Bachelor's all the way to Doctorate, so it just depends, again, on where they're at in their curriculum. But, some students come in with more of an awareness than others. Sometimes students come in with life experiences too that have really opened the doors for them in terms of thinking about this. But, we really teach them right off the bat about our holistic care model. And I don't think I've mentioned this before. So, sorry if I repeat myself. I was actually teaching some of this content this morning. So I'm gonig to have to remember what I told my students versus talking about right now, because a lot of overlap here. But, we do health risk assessments with all of our patients so that we can right off the bat think through, "Okay, what are the risks for these patients that we're working with? And what are the strengths? What are some things that we can tap into into their life?" And in terms of our health risk assessments, we really look at six determinants of health. We look at biological. We look at psychological, individual health behaviors. We look at access to health services and affordability. We look at environment. And then we also look at social determinants. So, for most individuals, what we have found in our work is that you have individuals who come from diverse backgrounds. And a lot of times, all that happens in the healthcare system is the biological pieces getting addressed. But we know that there's so many factors that play into what's going on in terms of the biological piece. So, we really try to teach our students that in terms of all of these different areas, they're all interwoven, interconnected. We also have our counseling psychology students. In terms of their training, they do a lot more focus on the clinical therapy practice piece. But, our goal is to really help them outside of the training that they get in the classroom. We want them in their field experience with us to really start thinking through, "Okay, psychological health is connected to the rest of one's health. So how do we really work in terms of looking at those and the connection between those things." So, anywhere from thinking about if a person has depression, they see a flag for depression, and we're going to start working with them in terms of doing therapy with them. What are they eating? So, thinking about those foods that can help them address some of their psychological needs. So, really teaching them that it's all interconnected and that it's really important for us to focus in on the determinants of health.

Rebecca Sturgeon: Yeah, yeah. There's like these holistic, interconnected circles that I'm kind of seeing in my mind. You have this whole, all of the different determinants of health, plus a whole bunch of different disciplines who are coming into this place and learning how to work together, hopefully, which is of course what this entire podcast is about. So I wonder what you are finding with students in terms of their understanding of or their approach to really working in an interdisciplinary, interprofessional kind of way.

Sam Cotton: I think a lot of students, when they first come to us, if they've never had any experience working in interdisciplinary teams before, interprofessional teams, they think it's the same thing as multidisciplinary. So, they don't really understand the differentiation between those two terms. Because in healthcare, we use multidisciplinary a lot. And honestly, we want to move away from that, because what that means is that the people who are working, maybe they're all working with the same patient, but they're all doing their own thing. Like so, in social work, I stay in my lane, and I'm only addressing those resource-related or access-related issues for the patient. I'm not addressing any of these other areas of somebody else's job. So I'm going to stay out of their way. With interdisciplinary, we're really more focused on working together towards a joint plan of care. I'll give you a good example of this in terms of our training and how we approach this in interdisciplinary ways. We have a project right now that we're doing with patients who are, maybe they're not diagnosed yet with diabetes or hypertension, so they're pre-diabetic or pre-hypertensive. And we're concerned based on all of the metrics we're seeing right now with them. So, we're trying to engage them in this program where we provide them with a kit. It's a remote patient monitoring kit where they can take their blood pressure. They can take their glucose blood sugar levels. They can check their weight. They can, I don't know if I said this, there's a blood pressure cuff and a pulse oximeter as well. So, they can manage all of these things remotely. And then they have an app on their phone that we can also see what's going on with them from that end. So, we have nursing students and social work students who are working together on this. And something from the beginning that we've really tried to help them understand is that they're teaching each other things as well along the way. And so, sometimes they come in at the beginning when we first start talking to them about the project, and they think, "Oh, I'm nursing, I'm only going to be looking at the person's vitals. That's all I'm going to be doing." And maybe providing them some education about what those numbers mean. And then the social worker thinks, "Oh, I'm just going to go do the home assessment while this person does this." And, we're kind of doing our own thing. That's very multidisciplinary. So, a lot of students come in with that mindset, just because they think that's what we do. But then they start really understanding, "Oh, we should really have this conversation. We're working together, we're on the home visit together with the patient. Let's look at the numbers together. Let's really educate the patient on all these different aspects of their life." So I would say that a lot of students really come in with a skewed view of what interdisciplinary is, and then they leave really understanding what it means to work on the team and the value of it and that sometimes it's not about staying in your lane. It's about understanding what your colleague knows and contributing to that, because all of that is involved in patient care.

Cathy Ryan: I mean for me, as a massage therapist, we're quite used to the hierarchy and not really having our voice really being honored and considered, so a model like this for me really sounds like it's created in a way that there's true collaboration and that every member on the team is valued, and their input is valued. So for me, that is very exciting to hear that something like that is truly happening in the way that it is out there.

Sam Cotton: And, that's a struggle too. You mentioned the word hierarchy. And that comes up a lot because you're working with students. And so, you have these Bachelor's level of social work students, and they're like, "I don't want to go talk to the provider about this. I'm just a student." They get really nervous and uncomfortable. And so part of it is really helping them learn the common language that we all have in the healthcare world and the medical world and being able to be comfortable by the time that they're finished with their internship with us going to the doctor or the nurse practitioner and saying, "Hey, this patient's really struggling in this particular area. Let me show you some solutions that I'm working on with them." And to have that common language that we use. But yeah, it's a struggle, because students feel it a lot when they first start.

Cathy Ryan: Well, and again, this comes from a massage therapy lens, but I think that even though we are not coming from a university setting, the potential that your organization might consider internship for massage therapists down the road, I think would be so much value for this profession.

Sam Cotton: Yeah, I think that would be really neat.

Rebecca Sturgeon: Yeah, yeah. Well, just that there are complementary services like massage and acupuncture and yoga and other wellness services available. I love that that kind of puts it in front of the students. And what I've been seeing, and I think, Sam, you can speak more to this, is it seems like there's kind of an interest in pooling those "complementary" disciplines into that circle and into that conversation even more. And I wonder what your thoughts are on that and how that can best be achieved.

Sam Cotton: I think that exposure to different ways that individuals can engage in other healthcare is really important from a learner's perspective, right? Because you cannot as a student or going into the healthcare professions that we have here be able to speak to and recommend these different types of services to patients if you yourself don't understand what they are. I think we see that a lot more. Well, I will say, I think with massage therapy a lot of people don't necessarily see it as healthcare. And so, when students come in, it's a really great learning experience for them to see that as part of our clinic services, because they have like this one very narrow vision of what it can be and what that should look like, because of the way that I guess maybe the larger society talks about massage therapy. Same goes for acupuncture. We have a lot of people who have hesitation in terms of coming for that service. And so, we've really been trying to work with our team to figure out "Okay, how can we really promote this?", because we know the benefits. And so, how do we get everybody who's in our circle already to understand that so that it really benefits the patients too?

Rebecca Sturgeon: Yeah, can we talk about the patients some more? (Sam Cotton: Yeah.) Because a large part of the population you serve are older adults. And I'm curious about what your thoughts are on this interdisciplinary approach. What are some of the unique challenges and benefits of that for older adults in particular?

Sam Cotton: I would say that for a lot of our older adults that we work with, there's sometimes some hesitation. And you might be thinking, "What? There's all these great services! Why would they be hesitating to engage in this?" Well, one, I think a lot of it has to do with the fact that our healthcare system as a whole--now I'm not talking about us at Trager, but I'm talking about our healthcare system as a whole--it's very illness focused. We don't spend a lot of time talking about prevention. So, an older adult comes in, and maybe they don't have that in the grand scheme of things, they're not dealing with a lot as it relates to chronic conditions. But here we are recommending all of these other services they can engage in. Or, let's pair you with a health navigator to help coordinate some of your care. And, from their perspective, they're like "Oh, I'm fine! I'm not sick, I don't need that." Because, again, we train ourselves to talk about health as the same as sickness. We don't think about the prevention piece. So one, now there's hesitation on that end. Two, I think that sometimes, patients are a little bit skeptical about the services that they're receiving through us, because maybe they've had bad experiences from the healthcare system too. So, there's some challenges from that end. But I would say that for the patients that we have worked with for a long duration, and I mentioned that some of the services that we offer predate us being part of a brick and mortar clinic, we didn't have all that. We were just operating in terms of doing home visits mainly with patients, had some sites out in the community that we worked with and partnered with and saw patients there. So, I would say that the patients that have been with us the longest and our students have been able to build rapport with and then every year they get a new Health Navigator that they work with. For them, I think they see a lot of the value in it, because they are able to look back and say, "I was not in a very good place when I started working with this team. And here I am now, and I'm able to better manage my chronic conditions." Now, I would say too for a lot of our oldest older adults, sometimes we're not expecting to see a trajectory up in terms of some changes related to their different determinants of health. However, a lot of them are seeing that they're not seeing a lot of change. So there's not decline, which is really what we want. We want to see that. So, sometimes even just the simple things that we're able to do with our patients to build that rapport and that trust with them, I think means all the difference in terms of them accessing the services. And then again, I would also add that we as part of our different programs do an annual wellness visit. So, a Medicare annual wellness visit, if anybody's familiar with that. And sometimes when we call, they get patients set up for those, they're in disbelief that it's a free appointment and that it's going to be an hour long, because that's not part of what we talk about a lot of times in the healthcare world. So, I would say that once patients understand what we're trying to do, they're really excited about it and very interested. But, sometimes there's hesitation. I totally get it. Because of the way the healthcare system is structured as a whole, so.

Cathy Ryan: And that was going to be one of the things that I wanted to touch on is accessibility. So, for individuals out there who do not have extended medical insurance, can they still access care?

Sam Cotton: So, what we typically try to do too is one of our missions from the very beginning was to work with medically underserved and rural patients, especially because we receive funding through different various grants that are focused in those areas or those spaces of that conversation. And so, we do have some patients who we're working with and doing some of the chronic care management-like work. And so, they receive that for free as part of that program that we have our Flourish program. For the patients that we are able to bill for, and they can pay for services, they do that as well. So, we have kind of a mixture in terms of our service base. I would say in terms of access to this, something that can be very frustrating, from the patient standpoint can be very frustrating: behavioral health. And, I think we don't put enough emphasis on that when we talk about the healthcare system. And there's a lot of barriers and challenges for people to access behavioral health. If you need services, and you have insurance, and you have to pay a copay every time, sometimes it could be like $60-90 or even more than that for you to receive therapy. That is really bad, because we have a lot of patients who could really benefit from services who aren't necessarily getting it, and maybe they're not connected. Because we use a lot of students for the work that we're doing as part of their training, we're able to provide some services for free that way. That's what makes it sustainable from our end. But if people don't have that connection, I'm thinking about especially in our very rural parts of Kentucky, for example, access to something like that, that makes it very difficult for them. So, those are things that we have to think about. I think we're always having those discussions about how do you keep the lights on versus how do you serve patients. And so, I think there's always going to be that tension because of the way our healthcare system is set up.

Cathy Ryan: Well, and I mean you touched on, we're so focused on illness care, and there's been very little attention given to prevention. And I think COVID has exposed a lot of areas of deficit in society and certainly in health care. And I know here in BC, the Ministry of Health, one of their priorities is keeping people in their communities, trying to keep them out of long care facilities. And now we're seeing some of the horrific issues with some of the long care facilities. Certainly here in Canada, we've seen some of the information coming out of there even before COVID, what the issues were. So, having programs like this that are starting to help push that culture shift around thinking, around encouraging all of us as a population to start thinking more about wellness and prevention really supports that initiative going forward to try and keep people in their communities for as long as possible. An independent with some assistance can stay in their home, as long as they've got good health.

Sam Cotton: Yeah. And I would say too, you have to think about a number of different factors, and something that we really try to do here at Trager, and we also train our students in is this "4Ms" model of Age-Friendly healthcare systems. And so, the first "M" is what matters most to the patient. And so, for those patients who want to stay in their own home for as long as possible, we want to try and help them actualize that, whatever that looks like for them. What matters most can sometimes be very simple things. But, a lot of times I do think it goes back to that feeling of being independent and want that home to the best of, with assistance if needed, but in their home, because that's their safe space, that's where they want to be. So, looking at how do we help individuals actualize that is a large part of our conversation. Now, we do do a lot of work with long term care facilities as well. And, a lot of that really centers around addressing some of those things that I think you're probably talking about that have been coming out of some facilities and focusing on that compassionate care piece, especially for those patients who are residents of those facilities who have Alzheimer's disease and related dementias. So, really thinking through, "Okay, looking at the behavior that might be causing the situation, what's causing the behavior? Let's start there." For some individuals with dementia, even taking a shower can be very overwhelming. So, having them get into a shower, it's to them loud, especially if they have any kind of audio issues. Sometimes the water pelting them can be very disturbing to them, because it hurts, it's painful. It does not feel good like it would for any of us. So, thinking through those things, because if a patient or a resident of that facility is getting agitated or aggressive every time they go to help them take a shower, we need to figure out how to address this. It's not worth it to cause that type of distress for the person every time. So, how do we implement these compassionate care models? Thinking about how--that's all basic care. We focus a lot on basic care. How do we do that? And I'm not saying you don't need that in nursing facilities. You clearly, obviously need to help people with those basic activities of daily living, that basic nursing care, but how do we elevate that and add in the compassion piece and really spend that time? And so, I think sometimes we don't really spend that much time talking about that. It's more focused on that basic nursing care piece. So, I would say that in the work that we do in long term care facilities, it's really honoring that for the person, honoring the rights of the patient, and how do we figure out ways to do that?

Cathy Ryan: Well, and that's such an important piece. And certainly one of my rants as a massage therapist, one of the areas that I often talk about in our professional world where there's a real deficit, is we do not have a pathway for advanced clinical practice kind of training, particularly for specialized populations. So, it's kind of like, we had a guest on talking about infant and child massage, and it's not just your same massage, you're just working on a smaller body. No, you only use your finger. Same thing, I'm working with elders. It's not just a body with a few more years on it. That's not the case. There are some special sort of situations that we need to be mindful of. And I think that the shower piece is a classic example of a piece that most people probably wouldn't even be aware of and just get agitated with that person to get the heck in the shower kind of thing. So, that is for me one of those things, that compassionate level of care. I might have to move to Louisville.

Rebecca Sturgeon: We don't have the same kind of furry animals that you have.

Cathy Ryan: No, but I am getting older, and knowing that there is a facility, an organization out there that is putting together what you're doing is really exciting to me. And hopefully it starts to become the norm rather than the exception.

Sam Cotton: Yeah, and I would say too, it's really interesting, because we have all of these great grand ideas about implementation of our different programs. And sometimes they don't end up getting executed the same way in which we had envisioned them. And part of that is because of the whole system at large. We have to really kind of figure out how do we make this fit into these little boxes. And so, I wish that we let my dream for the healthcare world would be that we were able to pilot more projects and to really be able to, without all of these different parameters, figure out some of these different best practices for individuals. Because I think a lot of times our programs can get stifled by some of those challenges just that are inherent in the system at this point. So, I dream of a world where we don't have to have these discussions. Like you're being concerned about as you get older, I wish that that wasn't a fear that people had to have about what their care is going to look like. I wish it was just part of what we did in our system. And so, yeah, that really resonates with me what you just said, because I think about all of my loved ones that I've worked with in terms of the care. You don't have that somebody advocating for you, sometimes you don't have that persona, when your team helping to fight for you. It's problematic, right, you can get lost in the shuffle. And I just wish that our system, if we were to completely dismantle it and start fresh, I wish we could do that, because I think there's a lot to be said for just some of the structural things that we have in place with our system that we could do better.

Cathy Ryan: Well, with COVID, this might be a perfect opportunity to start to deconstruct some of what has not worked very well and start to look for better ways moving forward. So, you have my vote, Sam, to help sort out the problems and figure out better solutions moving forward.

Rebecca Sturgeon: Right. Well, I'm wondering about too going back to the shower example that made me think about compassion and kindness training. And how does that figure into particularly working with older adults. Like I started my career working in a nursing home. So that's kind of always been where I've been oriented. But I've seen people who work in nursing homes who are maybe not oriented that way get frustrated in ways that affect the care and kind of need, I think we all need, a little bit of humanity training for lack of a better term. And I wonder how that figures into the work that you do with this?

Sam Cotton: Yeah, so we talk about that a lot. Well, I've done a lot of work with CNAs and training them in terms of compassionate caregiving. But I also try to encourage the students who are going through our programs to think this way too. I think sometimes students come in and they encounter their first difficult or challenging patient, and they think that person is just being stubborn, they don't want to be a part of this program. They're just, they are who they are. And I really encourage them to critically step back and think about, "Okay, there's a reason why this person is upset about this whole system." You don't know what they've encountered in terms of the healthcare system. And it is fraught with trauma for a lot of individuals. The first time they ever went to a doctor's office and maybe their BMI was high. And the doctor just said, "You need to lose weight. Fresh fruits and vegetables." Well, they can't afford that. So, that just immediately turned them off, because they were like, I can't afford what this person is telling me. They don't even care. So thinking through, how do you step back and say, "Okay, this person has a lifetime of things that have happened to them. They've gotten to this point." So really think about that. They also think about the fact that for some individuals, especially as it relates to helping find those anchors that will motivate them to make those changes as it relates to their health behaviors, they have a lifetime of doing things a certain way or being taught a certain way that are now ingrained into it, how they approach their health. And again, I think some of this comes back to that societal focus on illness instead of prevention or from that standpoint and the way in which we talk about stuff. So, really teaching the students that you're not going to help them change their behaviors today. That's not what you're here for. That's not the goal. Your goal is to really help them find their motivation for making those changes. And so, really trying to instill that in them. Because it can be frustrating from the student standpoint, because we teach them all these wonderful things that they can do with patients, and then, they get stuck sometimes when they encounter individuals who have just really struggled with the whole system from the beginning.

Rebecca Sturgeon: Yeah, and I wonder if sometimes for providers, I know I've come across this sometimes with clients, that sometimes the hardest thing is to just kind of accept not defeat, but accept that this person's approach to their life is different than what you might think it should be.

Sam Cotton: Yeah. And so, that's where we talk about what matters most to the patient. What you as a practitioner think should matter to the patient is probably going to be different than what matters to them. So, you always need to go with, they are the expert of their own life. You are not. So, it's really trying to meet the patient where they are and figure out what matters most to them. And I think that there's something to really be said for that and we don't address it enough across the board. (Right. Yeah.)

Cathy Ryan: I believe that's called patient-centered care.

Sam Cotton: That's compassion or love of a long duration. (Yeah.) And so sometimes with patients, I was telling some of the nursing students we were working with this morning about a patient that has been engaged in our program for a long time. And I was trying to explain that concept of this person's been with us for this many years. And I explained all the different things that I won't get into here but what was going on with this person. And, you can just see them being like, "Oh, wow. It takes a really long time sometimes to get from point A to point B." You don't make changes overnight. And sometimes, we also have to explain to students. And this also extends from thinking about health, physical health, and all of that to mental health services as well. Sometimes the things that you work on with a patient, you're never as the practitioner going to get to see those actualized, because one day, six years from now, a light bulb's going to go off, and they're going to tap into some of those things that you taught them, but you're never going to see it. Same goes for therapy. You might work with somebody for several years, and they can move on. And three therapists later, they have this epiphany as it relates to what's going on with them. So, it's more about their journey, not about yours as the practitioner. And so sometimes you have to think about it from that standpoint too. And that's a difficult concept from the beginning for students, but we get there.

Cathy Ryan: As a massage therapy educator, that's something that I've spoken to too is that we as a professional cannot be attached to an outcome. We show up and do the very best job that we can. And don't get attached to a particular outcome, because...

Rebecca Sturgeon: Well, we as humans...

Cathy Ryan: It's not about us. Yeah, it's not about us, it's about the patient.

Sam Cotton: Yes. Or isn't it? It's always very interesting when I have to have this conversation, because I feel like across the board, we must be just as humans very us-centered or narcissistic. The health profession field, all of us, like massage therapy, social work nursing, we are having these conversations about like, "It's not about you." It's just very interesting how we're very individualistic and sometimes in a way where even those of us who are in these caring professions, we have to separate, detach from those sorts of ideals or biases. Maybe it's a bias, I'm not sure.

Rebecca Sturgeon: I think it relates to how our brains work. This is how our brains process information. We take shortcuts, because if you had to notice everything all the time (yep), that's a little much. Yeah, yeah. And finding out how to notice the shortcut and go the long way around instead sounds like it's kind of what you're doing with the students in the program. Yeah, yeah.

Cathy Ryan: I want be an intern. (Sam Cotton: Come on down!) I want to be one of those 31-years-in-practice and become an intern.

Rebecca Sturgeon: (Sam Cotton: Let's do it.) Absolutely. (Sam Cotton: We welcome you.) Yeah. Do we have an international student program?

Cathy Ryan: I can kind of slip in once the border opens.

Rebecca Sturgeon: Yeah.

Sam Cotton: I feel my philosophy is always like, let's just say yes and figure it out as we go along. That's my philosophy. It's not going so well for me, but usually I figure most things out. 50/50. So I like your odds here. Pretty good.

Rebecca Sturgeon: That seems like kind of how Traeger works, like yeah, we can do that. Let's figure out how.

Sam Cotton: I have found in my experience, and you all really need to have Dr. Faul on, Anna Faul, because she could really speak to this too, but sometimes it's just about leaning into those opportunities and saying yes in that moment and figuring it out. Because it's so unexpected, like what will happen. Like a good example of this is this remote patient monitoring project we're working on. It amazes me, especially our social work students have been with us longer at this point. And so, they just jump in and take ownership and learn by doing and getting comfortable with ambiguity in practice. Because when you do a home visit, you don't know what you're going to expect. And I can't teach you that. I can't teach you every little thing that could show up when you go do a home visit. I mean, I've done home visits where the patient has had no flooring. Like, we walked in and the person had mobility concerns right off the bat. Had no flooring. They only had like the plywood almost, what normally goes underneath flooring. We went into homes with no food. We went into homes where it was really situations that needed to be addressed urgently. And you cannot prepare somebody for that. You kind of have to go and learn as you do. And so really encouraging students to be comfortable with ambiguity. So, I think that's one of the first things we always ask students when we interview with them is how for practicum we always say, "Do you understand what ambiguity is? Do you tolerate ambiguity in practice?" Because that's what a lot of social work is. Yeah, you can't. Nothing fits in a box.

Rebecca Sturgeon: Yeah, that's a lot with what every profession is. Yeah. I think that's a great exposure for a human who's going to work with other humans. Because these brains are big and unpredictable.

Sam Cotton: Yes. Yeah. And I'm sure like from a massage therapy standpoint, I mean, you all probably get people who in the moment disclose things to you that you would not have thought that that would have happened in that session. So, yeah. I'm sure. (Yeah.) (Oh, yeah.) Yeah, it's always like, what is my keep calm face, you know? That's something all humans I think have to practice from time to time is when somebody says something to you that you're like, "Oh, I gotta address this now." But looking calm while doing it.

Rebecca Sturgeon: Yeah, that learning how to, I mean, whatever you call it, keeping calm, holding space, keeping the environment--absolutely vital. Well, thank you, Sam, for being here for this discussion and for all of the information.

Sam Cotton: This has been too much fun. The rest of my day is not going to be fun after this.

Rebecca Sturgeon: What, we're more fun than the students? Yay.

Sam Cotton: Yeah, I think so. I mean, it was like more of a conversation. Sometimes when I teach, I feel like I'm a talking head, just especially the first few weeks because there's a lot of information to disseminate. So, I'm just a talking head at the front of the table or on the computer. So, all good. Real conversation.

Rebecca Sturgeon: Yeah. Well, we're delighted. Thank you so much again for being here with us. And thank you everyone who is listening. There will be a link to the Traeger Institute in the show notes so you can check out a little bit more about it. And sitting in for Cal Cates, I am Rebecca Sturgeon.

Cathy Ryan: And I am still Cathy Ryan. And yes, Sam, thank you so much. And thank you for being a great example for all of us to follow with regard to how we should be approaching healthcare. So thank you so much for that.

Sam Cotton: Thank you all for having me. I really appreciated it.

Rebecca Sturgeon: You are welcome. So, this has been another episode of Interdisciplinary, the healthcare podcast from Healwell. You can subscribe, give us all your likes and all of your pets' likes and all of your stuffed animals likes' and reviews. It really helps us out. We have a Patreon, which the link will be in the show notes. So, if you love Cathy Ryan and Cal Cates and good conversation, check out our Patreon. You can get episodes early and some special goodies there. And you can find us on all of the podcasting outlets and on our social medias, and we'll look forward to hearing you next week.

Interdisciplinary is produced by Healwell. Our theme music is by Harry Pickens. You can send us feedback at info@healwell.org. That's info@healwell.org. New episodes will be posted weekly via Apple Podcasts, Spotify, and our Facebook page. Thank you.