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There is extensive evidence for how movement and lifestyle changes are beneficial for improving a person’s experience of pain, and the same is also true for using these tools to help people manage diabetes through physical therapy. Irregardless of age, the lifestyle choices we make today can dramatically impact our health now and moving forward in our lives.
Inevitably, the reason for improving a person’s health is about enhancing their life, not just getting their weight down or the blood glucose to appropriate levels. Similarly, all of the tools available through Integrative and Lifestyle Medicine are there to enhance a person’s quality of life.
At this time in our country, people are diagnosed diabetes, obesity, and cardiometabolic disease at astonising rates. Unfortunately, these diseases contribute to significant healthcare costs (both nationally and individually), progressive health challenges, and just generally impair personal well-being and life satisfaction.
There are a variety of factors that may contribute to these diseases including (but not limited to): genetic predisposition, increased production of appetite stimulating hormones, adipose induced inflammatory pathways, environmental factors, poor nutrition, poor stress management, sleep issues, and physical inactivity.
But the really amazing thing is that you can treat these factors. If you are a physical therapist, you can address all of them with your patients. Yes, every single one, really.
Physical therapists are ideally positioned to help people make significant lifestyle changes that can both improve their quality of life while improving their health too. In a US Diabetes Prevention Program (DPP) trial, adults with pre-diabetes (A1C 5.7-6.4%), who exercised at a moderate intensity for 30 minutes 5 days per week had better blood glucose levels (measured 10 years later) than adults with pre-diabetes who took the drug, Metformin [1]. They also experienced a modest weight loss of 5 to 7% of their total body weight.
As physical therapists, we are the movement specialists of healthcare. We understand and can guide people through proper movement and exercise prescriptions better than anyone else. But, we also (with the proper skills and education) can teach people how to improve their sleep, change their diet, and even manage their stress better. All of these changes can impact a person’s weight and cardiometabolic health.
Dr. Ginger Garner recently sat down to interview Dr. Rupal Patel. She co-wrote the chapter, “Obesity, Diabetes, and Cardiometabolic Health,” in Integrative and Lifestyle Medicine in Physical Therapy, with Dr. Nola Peacock and Dr. Ericka Merriwether. She also has performed her own research in a community setting guiding groups through lifestyle changes to effectively reduce their risk for developing Type II Diabetes.
Dr. Rupal knew that people needed her help. She knew that the people in her community who were struggling and suffering and needed support and guidance to feel better and get healthier. Additionally, she wanted to help create a format for the next generation of physical therapists to put this into practice in their own communities.
Our communities need us.
They need help addressing their obesity and managing diabetes through physical therapy, because no one else in the healthcare world is giving them the time or resources they need.
Interesting in learning more? You can listen to the podcast or watch the interview on Youtube, using the link below.
For those of you that prefer video, watch this discussion around how to manage diabetes through physical therapy with Dr. Ginger Garner and Dr. Rupal Patel.
You can also check out the chapter she co-wroten, “Obesity, Diabetes, and Cardiometabolic Health” in the book, Integrative and Lifestyle Medicine in Physical Therapy.
Texas Woman’s physical therapy professor and alumna Rupal M. Patel, PT, PhD, attributes her servant’s heart with growing up in India and the values she inherited from her parents when immigrating to the United States. These values now drive Patel to give back to the physical therapy profession and her doctor of physical therapy (DPT) students on TWU’s Houston campus.
Patel has 30 years of involvement with the American Physical Therapy Association (APTA). She first joined APTA as a student and has stayed involved in some capacity over the years, including leadership positions at the local, state, academy and national levels. Patel is currently serving a three-year term as an elected member of the APTA Nominating Committee and an elected delegate-at-large from Texas to the APTA House of Delegates.
Patel also holds leadership positions within other components of the APTA, including:
Through APTA, Patel advocates for health policies at the federal level and direct access to physical therapy services in Texas. Patel states that a lack of access to physical therapists leads to poor health outcomes and higher healthcare costs for all, especially for people with musculoskeletal problems such as lower back or chronic pain. These conditions are highly common and manageable with physical therapy services.
00:00 Dr. Ginger Garner Hello, everyone. We’re back again. And today I have a wonderful guest with us, Dr. Rupa Patel. And thank you for being here today. Before we jump into our conversation, which I’m very excited about, let me tell you a little bit about Dr. Patel.
She is Texas Women’s Physical Therapy Professor and alumni. She attributes her servant’s heart to growing up in India and the values she inherited from her parents when immigrating to the United States. These values drive her to give back to the physical therapy profession and her doctor of physical therapy students at TWU’s Houston campus. She has 30 years, pause for that 30 years of involvement with APTA, American Physical Therapy Association. She first joined as a student. I remember those days joining as a student and stayed involved in some capacity over the years, including leadership positions at the local state academy and national levels.
She says, I believe it’s my responsibility and duty to serve and give back to the profession that has given me so much. I had tremendous role models who were servant leaders who inspired and encouraged me to get involved back then. So welcome.
01:26 Dr. Rupal Patel Thank you. That was very nice introduction.
01:30 Dr. Ginger Garner: I love your story. And so that is the very first question I want to ask you is what made you choose physical therapy?
Dr. Rupal Patel: Yeah. So, you know, I identify as an immigrant Asian Indian American woman. And that’s what you said in my intro is the immigrant part. And, you know, I think of myself as a health promoter first and as a physical therapist second and working in academia now full time for a long time. And I think that I chose physical therapy as a career after I walked into a physical therapy department in high school when I was actually doing preceptorships in different departments.
And I thought I wanted to be a cardiac surgeon. And I remember going into the cardiac surgeons day and it was this dark gloomy room with a monitor and the body looked like it was dead because it was all covered. And then there was a scope and it was cold in there. And literally just that’s what he did. And then I asked him, I said, Oh, when do you get to interact with patients? And he goes, I just did. And I was like, Oh, my God, like, this is not what I want to do. You know?
And so I was so bummed because I was like, Oh, my God, what I’m going to do, what I’m going to tell my parents, they expect me to, like, be someone who is going to have a good career, good education, and everybody that we knew either was a doctor, nurse, engineer, maybe a few lawyers, you know, in the Indian community back then. And so I was really I didn’t even tell my parents that I didn’t want to be a cardiothoracic surgeon, because it was just looking miserable. And so then as I continued my perceptors ships, and I walked into a PT department, and it was, you know, like any inpatient department, a big gym, and you just see all the energy and all the engagement and that relationshipness or relatedness, the connectedness, and that vibe really spoke to me. And you know, between the patient and the provider, and in this case, the physical therapist, and at that moment, I knew nothing about physical therapy, I’ve never had it. And never knew anybody that was a physical therapist that looked like me in the profession. Certainly, my parents didn’t know anyone.
And so, but I’m like, you know what, this is what I want to do. Like, literally, it was a feeling, it was like intuition, the gut feeling. And then at that time, the director of that department was just the most wonderful person. And I sat down with her, and she told me kind of, you know, what it takes to be a PT and education and all that. And so she was my first kind of guiding light in terms of that.
And then I had to convince my parents that it was a good thing. And they knew nothing about physical therapy, they never had it, they had no friends whose kids had become physical therapists. And they were immigrants coming to America to make sure that my brother and I have a better life through education, and through a career that’s going to provide for us, you know, and so I literally I remember having to go to the library back then, and get the job outlook book, you know, it used to be a big binder, and then like finding physical therapy and looking at the projections, right, in terms of like, the career and like, hey, look, this is a good job, it’s going to provide and like, having to show that to my dad and say, look, dad, here’s the facts, like, this is a good career, you know.
And so, needless to say I convinced him and, and then, you know, of course, he’s proud as ever, you know, since then, after he’s, you know, experienced me going through a PT school and becoming a physical therapist and what I do. So that’s how I got into PT.
05:09 Dr. Ginger Garner: Oh, wow. Wow. So what has been over the decades? What’s been one of your favorite things about being a PT?
05:17 Dr. Rupal Patel: Yeah, you know, I think that I didn’t really think about that until in one of my roles at the APTA House of Delegates, when we were talking about our professional vision, which we have now of transforming society to improve that by optimizing movement to improve the human experience. And one of our wonderful colleagues in the profession, Dr. Terry Nordstrom out of California, he got up there on the house floor. And if you ever just even Google Terry Nordstrom House of Delegates, you know, PT vision, you’ll see the video snippet that I think has been viewed a lot. And he described what it meant to him to be a physical therapist and how he how we as physical therapists can impact the human experience. Because a lot of us sitting in that room, we’re like, what do you mean human experience, we move people’s bodies and like, what is this human experience thing, you know, and so what he said really resonated with a lot of us in that room at that time.
But that’s what I mean, I’m like, you know, what is my favorite thing about being a PT? It is that I’m able to impact the human experience, you know, being part that human experience being that of either my patient or client that’s sitting in front of me, the caregiver that I’m training, who has to take care of their loved one with a spinal cord injury now, or of the community when I do community based stuff in the community and seeing the community make changes, you know, collectively, and as a whole. And then my students, you know, like when I see a lot of those aha moments where they they’re able to then connect what I potentially present to them in a lecture or lab to like the real world in the clinic, or when they’re out doing community based service learning, and you see the connections and, and that’s when I know that impact on human experience, you know, and so that’s, that’s kind of my favorite thing is to be able to do that.
07:06 Dr. Ginger Garner: Yeah, I love being around students and their energy, when I adjunct or when I do lectures. Last week, I was at a local university lecturing in their musical theater department on pelvic health. Wow. And the core and the voice connection. I just walked out and they’re so enthusiastic and ready to learn and learn something very different than they’re learning, you know, day to day, which was exciting. So I love that.
07:38 Dr. Rupal Patel: And what a neat experience to be able to connect with students from another discipline and helping them see the connection between what they do and what we do.
07:47 Dr. Ginger Garner: Yeah, yeah, yeah, it is. I had posted a picture of it on Instagram and most people were like, oh, those are DPT students. I’m like, definitely not. Usually I could say yes, that’s a, you know, it’s a lecture to DPT students, but not last week, but the energy of students are just amazing. Yeah. So that brings me to the question that I often ask when I hear, I’ve got, got the book here in front of me. So for those of you who haven’t seen the book, Integrative and Lifestyle Medicine and Physical Therapy, and here is the chapter, is a wonderful chapter: Obesity, Diabetes and Cardiometabolic Health, which you contributed and wrote with Erica Merriwether and Nola Peacock.
08:40 Dr. Rupal Patel: Yes, I did.
08:42 Dr. Ginger Garner: So, um, I know a little bit of their origin stories about integrative life and lifestyle medicine and how they got into it and how they evolved, but tell me about yours. How did integrative and lifestyle medicine merge with physical therapy for you?
08:55 Dr. Rupal Patel: Yeah, well, it didn’t for a long time, for about 20 years of my career. And then, about 20 years into my career, I started a PhD program, because in academics, as we moved to DPT, we either had to get our transitional DPTs or get a PhD. And I decided to get a PhD and really kind of sink my teeth into an area that was always of interest, but not, um, I didn’t have enough knowledge and skills. And, uh, and my interest in health promotion actually started when I was a new graduate physical therapist working in inpatient rehab with brain injury patients.
And I remember the catastrophic injury and seeing the downstream impact, right? And a lot of it was lifestyle choices. A lot of my patients were young, between 16 and 25 years old, drunk driving, high speed, you know, not good health behaviors, including bicycle safety and helmets for some of them. And so I always thought like, oh my God, look at this life now, completely changed. And what if we did things to mitigate this, you know, upstream?
And so that was always thing, bike safety rodeos. And, um, you know, there were programs from the spinal cord injury association of like, um, diving feet first. So I was always involved in like prevention, that kind of thing, going out there in the community, telling people, don’t do this, do this, you know, but obviously that still wasn’t making much impact, right? We’re still seeing the injuries and stuff. And so that’s why, when I decided to do a PhD, I said, okay, I’m going to dive into this aspect of it.
So it was through my PhD in health promotion and wellness, um, through Rocky Mountain University of health profession professions that I started learning about the field. And around the same time, my father-in-law who had lifelong diabetes was starting to have a lot of the complications that come with diabetes. So, you know, I started to wonder, what determinants were at play in his manifestation of these complications. He was 60 years old at that time. And why was this happening? Like, what was missing? He’s educated, he speaks English, he’s literate, he has a engineering job, you know, so like all those determinants of health that would make him healthy were not the protective factors. And so what was missing? What did he not get throughout his life in terms of either care, advice, training, skills to help him lead a healthier lifestyle?
And so those questions, you know, like just watching a loved one go through that at that stage in their life, and then studying about all this stuff really led me to my dissertation, which was creating a culturally tailored community-based lifestyle modification program to reduce risk factors for diabetes among Asian Indian Americans.
And I wanted to be community-based because, you know, the national diabetes prevention program trials, which occurred in the mid nineties showed how effective lifestyle modification is. But in order to really make a dent in our population’s health, we needed to kind of take it a step further from the one-on-one model to a community-based model and tailor it to the culture and offer it in a place where people live, play, pray, and do all those things. Like one of, and so I offered it at a Hindu temple on Sundays before weekly services, so people are already there and they can participate.
And we did a 12-week program and it was a randomized control trial, so I had a group that participated in the 12-week program. And then another group that was just, you know, we did their pre-testing with A1C and their lifestyle habits, their waist circumference, their BMI, weight, all that stuff, and then just told them, okay, for the next 12 weeks, eat right, exercise, sleep more, stress less, you know, basically all the regular things we tell patients, come back in 12 weeks and let’s see what your A1C and all these things are.
And, you know, there were significant, you know, statistically significant changes in the intervention group versus the control group, and those changes were sustained when I asked, measured them again and asked them the questions again six months later. And so, and then to this day, like I go to that particular temple a few times a year and I run into my participants and I still hear from them.
And it’s heartening, like that’s what research is about, is like changing people’s lives. And they’ll tell me like, oh, my family’s doing this now. My husband who never would now is doing this. My, you know, in-laws that live with me or my mother who lives with me, she’s better and managing better. And then just as a community as a whole, they’ve changed some practices at that temple in terms of what they do. So that to me is just like the reason why, you know, and that, with that research.
And so, you know, I really feel like we need to do more community-based screening and education that really targets specific populations because risk factors can vary among ethnicities. And so, another study I did was compared three screening tools and the American Diabetes Association has a diabetes risk test and so there’s an Indian version. And then we looked at that and we found that the Indian version was a better predictor of diabetes among Asian Indians than the American Diabetes Association one. And so, again, it’s tailored, the risk factors are tailored to what’s more prevalent in terms of risk in Asians and so, like, waist circumference. So, you know, it’s just those kind of things that I think really made me interested in kind of using this concept and then in research and then in practice, the community-based practice, you know, that I did as part of my study.
14:51 Dr. Ginger Garner: Your story is really incredible and I think it’s really moving to me because when I started out in PT, there was no health promotion, prevention, there were no classes on it, we weren’t talking about it. I had to argue to get experience in another department just to have that, you know, under my belt. And so, to hear your story and to hear what a profound impact it had on your community because things are culturally sensitive and relevant, because you have established relationship and trust, because it’s convenient for people.
So, the evidence is overwhelming. What’s sad to me is that we don’t have a system that takes your work and so many other people’s work and says, look at this, it is lower cost, it is more effective, it has long-ranging, sustainable change to it that would improve everything. Because if we don’t have our health, it doesn’t matter how wealthy our country is or how much money we have in our pocket or what our job is, we don’t have anything without health. So, I’m just very moved by your story.
16:07 Dr. Rupal Patel: Well, thank you. And you know, like I said, my father-in-law was my inspiration and it was unfortunate because my last time that I had to actually be on campus for my PhD studies before I entered dissertation was literally right before he passed away from all this. And so then the research became personal because it was like, I want to do this in his memory and in his honor. And so developing that research took several years to develop the program and then to actually execute it and then follow through and all that stuff. So, probably took a lot longer to do the dissertation phase than a lot of people take. And a lot of people told me like, oh my God, Rupul, just pick something a little easier to do, like doing a randomized community, a controlled trial in a community setting. Like it’s just hard and it’s going to take you a long time. And there’s just going to be a lot of stuff and you’re going to need a lot of help. And I’m like, yeah, but this is important. Like we need to do this kind of work in research and to have, like you said, there’s nothing out there that, you know, proven programs led by physical therapists, you know, in the research. And so I just felt like I needed to do it, even though it was hard, even though it took a lot longer, took a lot of blood, sweat, tears, whatever, you know, but I felt like it contributed hopefully to the body of knowledge and that it’ll help future generations.
17:36 Dr. Ginger Garner: Absolutely. It will. I, and so many people listening to this, I’m inspired, we’re going to be inspired in the same way. And if you’re a student or you’re thinking about physical therapy, think about the impact that you can have in your communities, right where you are and making it personal. Thank you for sharing that. That makes me think about students. It makes me think about PTs earlier, you know, in their career and some of the challenges they may face. I’m sure you can talk about some of these challenges. I mean, you talked a little bit about colleagues and friends telling you pick something easier, right? But that’s not where your passion is. And so what would you say to the students out there or the people considering physical therapy based on what some of the challenges are that you see? You know, what would you, what would you, what do you see as some of those biggest challenges?
18:35 Dr. Rupal Patel: Yeah, well, I’m biased in this answer in terms of what I think is a challenge is that our lack of emphasis on primordial and primary prevention and also health protection and health promotion in our DPT curriculum and our practice and in our research. You know, and very specific in me saying primordial primary prevention and health protection and promotion. I think we do a decent job now. You see the literature in PT on prevention and some of the, especially like sports and injury risk prevention, you know, but that’s still or secondary prevention when an athlete or someone is, you know, already have some risk factors and whatnot, but it’s that primordial primary prevention and health protection and promotion of the big killers. And the big killers in our world are heart disease, diabetes, cancer, you know, and so that’s like this chapter in this textbook. I was so excited that you invited me to take part in it because that literally, no bias, right? Is the most important chapter in the book because those are the big killers and we need to know about primordial and primary prevention and how do we go about health protection.
So, you know, right now, most of our practice is really tied to third party reimbursement versus alternative payment models such as cash-based, community-based, employer-based. And, you know, if I think about just my curricula in my program at Texas Women’s, we don’t teach this stuff at a level where my students actually build their skills, like similar to building their manual therapy skills, right? We have hours and hours and courses content on that. So they don’t have that confidence. They lack self-efficacy and kind of developing their own, what I know and you know, to be a health-facing practice like the one you have, right?
And so, you know, like moving beyond third party reimbursement, like we don’t touch upon those topics as much because we focus our curriculum on CAPTE criteria, CAPTE being the Commission on Accreditation for Physical Therapist Education, and, you know, the essential skills of a DPT that is, you know, in the criteria, which are, by the way, changing. I think there was a comment period open until the end of March for practitioners and anyone to comment on like the new criteria. And so we emphasize that and the stuff like building our self-efficacy and confidence in primary and primordial prevention, health protection is looked at as fluff. And, but yet you and I know it’s not fluff. Like this is what really matters when it comes to improving a population’s health.
And so, you know, I think curricula need to change, but a lot of that is driven by, you know, what CAPTE says and we can do more than what CAPTE says, but then by the time we finish doing what CAPTE says we have to do to stay accredited, where’s the room? And if we add extra courses, then who’s going to come actually take that DPT program? Who’s going to enroll in that program versus another program that only takes two years or less, three, you know, three, because there’s a lot of cost associated with that. So it’s not an easy challenge to overcome, but that is definitely a challenge.
And I think in research funding doesn’t go to PT researchers that are doing lifestyle medicine research, at least not when I was doing it. I applied for grants when I was doing my dissertation, because it was going to take a lot of resources. And the work was, my grant was rejected multiple times. And the feedback that I usually got was really nice study, good design, but not really a PT study. And we focus our funding, we’re so limited in our funding, we, you know, we focus on PT. So that was like, oh my God, if you don’t as a physical therapist, focus on changing lifestyles…
22:41 Dr. Ginger Garner: Then what are we doing?
22:43 Dr. Rupal Patel: Yeah, so I think that, you know, in itself is, you know, some things that I feel like are, are challenging, you know, that are facing us today, you know, in all areas and in curricula and practice and research.
22:50 Dr. Ginger Garner: Yeah. Oh, my gosh, you just, you just said so many important things. You talked about moving past the third party reimbursement model versus other payment models. So if we talk about that one first, where do you see, you know, how can we overcome? How do we navigate that particular challenge? What are some of the things that go through your head with respect to that? I know I have a few thoughts on it.
23:19 Dr. Rupal Patel: Well, of course, you have a health facing practice where you do so much of that. I think the biggest is like changing perceptions of like, this is not viable, this is not something you can actually make a living doing. And then like, well, I don’t want to be the provider that just does cash-base to people who can afford it and not provide services because a lot of these health disparities in terms of heart disease, diabetes, obesity, you see the disparity in populations that are minority, that are lower socioeconomic. And so just doing cash-based doesn’t always work. But then again, I know cash based practitioners that, you know, devote a part of their profit towards building like a community based program where they’re doing pro bono or partnering with community centers that are offering things and aligning and assisting with training lay people in certain things.
So there’s, you know, there’s a lot there that I think if we open our minds to kind of like, how do we do this? And how do we collaborate and align with others? And not thinking about this is just like me as a PT doing it. But how do I bring others along? Because this is a societal issue, and it’s going to take societal effort. And how do I connect with others? So I think that’s important is to be able to, you know, kind of think about different models and cash based.
And then my friend Mike Eisenhart, who owns Proactivity PT, he’s been in this space doing employer based direct to employer model for like 20 plus years, you know, and, and like, how do we market and show the return on investment to lifestyle medicine to employers that a physical therapist, a company owned by physical therapists can do this, you know, and so there’s models, you know, out there that are that are like that. So I think exposing students, new professionals to things like that, I know, in that particular practice, it does have like a residency internship program where new graduates can come learn how to do it. And then they can go set up their own, you know, practice. And he’s done that successfully with several, I think, folks.
So those kind of things, I think, are innovative that have been around, and then insurers, like literally, like taking some of their return on investment, and like, hey, look, if you allow for a physical therapist to come and do that primordial primary prevention, health protection, all that, then, you know, three to five years ROI is going to be significant in terms of them not needing the one on one physical therapy, which is much more expensive, you know, and so it’s that whole, you know, flipping the switch, you know, which I think where we need to be, and it’ll take practitioners like you ginger, who are full time practitioner, doing it showing how it’s done, and convincing others, say, Hey, look, this is doable. And that, you know, it’s different, but it’s what we need.
26:27 Dr. Ginger Garner: It absolutely is. And we needed it decades ago. So it’s very exciting to me now to see this beginning to happen and more people actually showing alternative models and succeeding in those and making it affordable at the same time, because that was my when I went first went cash based, it was in 2004. And it that’s when you had to write letters to terminate your insurance contracts. And so I did that in order to because my hands were tied by the insurance company, and I was seeing all chronic pain, and they weren’t paying for it. But if they weren’t paying for me to see them in the insurance model, I couldn’t actually see them outside the insurance model either. So I couldn’t see them. And so that made me go cash based. And I opened a physical therapy/yoga studio, where for a low membership cost, which is another alternative model for a low monthly cost, they could come to as many classes and see me directly. Or, you know, if I taught 17 classes a week in conjunction with some other therapists that I had there, they technically wouldn’t need to come to physical therapy, because they had access to us all week long.
27:45 Dr. Rupal Patel: Yep. Yeah. I mean, that’s that’s the kind of thing. That’s the kind of innovation that needs to be diffused, you know, because people don’t think outside the box like you did, and knowing that, hey, that’s physical therapy, and I’m doing it at a different level. And, you know, I think there are a few other models like that out there. But even like I said, teaching, like you mentioned, new professionals and students, you know, so I try to like have a panel and maybe this next year, I’ll invite you to be on the panel, but of people that have these health facing practices, just to give students an idea of like, this is doable, you know, it is not something. But then the hard part is their rotations, you know, like our students do three full time rotations, and then an internship, those are all in the traditional models. So they’re in, you know, acute care in outpatient in neuro rehab, you know, in pediatric, and so they see the traditional reimbursement models, and then they it’s hard for them to kind of visualize outside of that, you know, and so I think, you know, any kind of exposure to models such as yours and others is good, because it exposes them to those possibilities.
So I try to do that. But again, it’s surface level, I try to connect them with practitioners, but they don’t get immersed in anything like that as in a clinical or, you know, beyond that. And so I think they’re again, their self efficacy to then go out there and do that as a new graduate with the loan debt and everything else going on, they feel like they need like that job where there’s a steady paycheck, versus I, you know, I can go out and start doing this even at a smaller scale, and then build that, you know, so that’s the kind of stuff that I try to expose them to.
29:35 Dr. Ginger Garner: Right, which is wonderful. To be able to see someone who is doing what you want to do that looks like you, that’s a powerful thing, because it’s very scary when you don’t have that in front of you. And you feel like you’re, you know, cutting a path alone, instead of having a community. And so the lovely thing about this is, you know, inside the book, inside these, you know, different practice models, is a community waiting to support you as a student or a new PT, or really, honestly, any kind of therapist and occupational therapist who’s looking to incorporate this as well.
30:15 Dr. Rupal Patel: Yep. That’s so true. And that’s a great point that, you know, in the book on in the back, there’s actually like, little bios about all of the authors. And when I looked at that, I’m like, wow, look, look at this resource, you know, and, and that’s exactly right. And I think as physical therapists and others, we are, we’re everybody that contributed to this book is very passionate about this. And we want to see the needle move. And we want to see change. And so I think, you know, if you’re a student or professional in any of the fields, looking at the book, and you’re, you have more questions, or you have like, Oh, well, how do I do that lifestyle program that you did in that research?
You know, in my community, I mean, you can email me, you can call me, you know, with the information in the book, and I would love to set up a time and talk to you and say, Okay, here’s what I learned. And here’s where you go for the information, and go do it, you know, and so because that’s, again, my goal is to be able to promote this so that more communities, you know, can have better lifestyles. And so, and I think in any of the chapters, we would be more than willing to do that. And so, yeah, you know, another advantage of getting the book as a resource, because you get like, a live team of people that come with it.
31:34 Dr. Ginger Garner: Yeah, definitely. Which is fantastic. Oh, I had several thoughts that kind of converged all at once. I thank you for that generosity and openness, because that’s one of the chief reasons that I emailed Joe, my co-editor, this crazy little idea about the book is because I wanted pts to believe that they could, and to know that it’s within their scope of practice to do this, and to feel comfortable with it. Not feeling like they had to go out and chase, you know, a bunch of certifications or whatever, because they are able to, it’s within our scope.
And that last point that you made too on, you know, shifting our curricula in DPT education, and having more classes available, and also funding, you know, research, and, you know, in a better way. Do you have anything else to add to that or to build on it? You’re sharing a little bit of information with me about exciting new class that you’re going to be teaching, right?
32:49 Dr. Rupal Patel: Yeah, I know. I think the underlying everything, you know, is advocacy, and changing systems and policies. And if we look at kind of the population health model, you know, that’s the basis, policies and programs are the basis of what changes determinants, what changes outcome, right? And so I think that’s very powerful. And again, we don’t give advocacy its weight as a profession.
And so, you know, but yet, when you look at the socio ecological model, and especially in health promotion, you know, the individual level stuff we do is important. But it’s as you go on the outer layers, and that outermost layer is society and looking at societal change through policy changes. That’s where we need advocacy. And that’s what we need on all fronts to really change our education, our practice and our research. And so advocacy with CAPTE, with PT programs and administrators. From community members from physical therapists in the community who are doing health promotion, you know, talking to their academic administrators and PT programs and kind of showing like this is what’s impacting health of this community. And these are the kind of things that need to be in the curriculum. And you know, if you’re willing to offer your time, treasure and talent to initially volunteer, then to adjunct, like you’ve done, or, you know, come on board in some realm as a faculty member, to then have real life experience brought into the classroom about that, or to offer internships or concentrated studies as preceptors in your practice. So in academic, I think we can do things like that to really educate the community about that.
And then, you know, expanding kind of funding scope, right, that takes advocacy on the regulatory front with everything from Medicare to all the way to private party and third party reimbursement to Medicaid. In terms of why lifestyle medicine, why these community based and group based models, and, you know, and showing that return on investment, allowing for maybe some pilot or demonstration programs, you know, to happen so that we can have a proven model that then can be reimbursed on a bigger level.
So I think advocacy on all those fronts, and then advocacy for research dollars, you know, to really encourage more academics to conduct research in lifestyle medicine, because, you know, the thing is, like, as a researcher, you look at where the funding lines are, and then you kind of build your research agenda around that. I mean, that’s, that’s what you’re supposed to do. That’s why I said, you know, people are like, why do you want to do that? Like, that’s not the funding we get.
And then, and so it is changing. There is a little bit more of that. And certainly in injury prevention and surveillance research, there’s been great PT researchers that have been doing that with sports and other things. But I think you’re seeing more now researchers that are PTs that are getting degrees in epidemiology and public health and, you know, in health promotion and like doing more health services research, population based research, so that we can show the PTs role in that. And hopefully the dollars in terms of funding will come.
So to me, advocacy is the biggest thing. And that, you know, I try to, again, impart that to my students. I teach health policy, where, you know, have them do advocacy work. Take them to Austin for our Hill Day for state, you know, the years we just did that in February of this year. And, you know, because before they go, they’re like, Oh, where are we going? All day, we have to get up so early to get to Austin, or, you know, all this stuff then, you know, and they hate the answer, the paternalistic answer, like, just trust me, guys, after you do it, you’ll love it. You know, they hate that, right? Like, no, I mean, they’re all adults. So, but then, sure enough, you know, after they go, and I’m like, now, and they’re like, you were right. So, you know, and at least if they’re never going to do it, at least they know how and they feel empowered. And that empowerment, that self-efficacy in doing advocacy work is so important, you know, and like you mentioned, in your practice that you had to write letters to insurers when you switch the model, like that’s advocacy. Like, you know, it doesn’t have to be like going and talking to Congress and picketing, or it’s doing the things like that, you know, but we don’t, again, give credit to that in our curricula, or in like, that’s a huge part of practice, like you were able to switch your model, I bet, because of that advocacy effort you put in early on, or whenever you did, you know. So that has helped you thrive, is that advocacy, you know. So I think that the biggest thing we need to do to overcome or navigate challenges is advocate on all fronts.
37:37 Dr. Ginger Garner: Yeah, absolutely. There’s so much great information in what you just said. If you’re a PT or a PT student, or you’re thinking about being interested in PT, you should rewind the last few minutes. Now I’m showing my age, right? Rewind, right? Press rewind. And listen to that again, because I 150% agree about the advocacy piece. It seems like a big scary thing, but advocacy could be joining APTA. Advocacy can be, yes, attending your capital day, your advocacy day. Advocacy can mean volunteering. Advocacy could just be speaking up to every single patient and person and letting them know that integrative and lifestyle medicine is an integrated part of physical therapy and we can’t really leave it out. That’s also advocacy. So, you know, if you’re listening, don’t be afraid to say that, you know, you’re an advocate or don’t be afraid to advocate because it can start very small, but snowball into something that’s much bigger. That does change the trajectory of your life and of our profession.
39:00 Dr. Rupal Patel: Yeah, well put. And I think, you know, a lot of people equate advocacy to politics, and it can be, but it doesn’t have to be. Like you’re advocating for the betterment of your society, of your population, of your community, of your patients. And so that’s not left or right. It’s just what it is. And so I think that is important, you know, and like one of the things I tell my students is that I have gone in and advocated for like forever when we had the Medicare therapy cap.
I mean, during those 20 years, the people that represented me in Congress were of both parties and I had no issue going into the office, even if I didn’t vote for that person, because they are now my Congress, a member of Congress, and, you know, and I need to advocate with them of how this thing was affecting my Medicare patients. It doesn’t matter. You know, it’s the right thing to do. It’s for my patient’s health. So I think if you kind of think of it that way and not think of it as like, well, I can only do this if I voted for that person or that, and that’s not true, you know, when we’re talking about advocacy at the legislative level.
40:09 Dr. Ginger Garner: Absolutely. I often tell people that the problems that we face in healthcare are much bigger than politics. It goes far beyond that. This is not a political issue. It’s basically a human rights issue and having access to care that works and that gives you long lasting effect. So I have one more question for you because let me go back to the chapter because for those of you who don’t have the book or you haven’t read the chapter yet, I would say yes, because the, you know, the top three factors that take people that we love out of our lives too soon are in this chapter that it is a very important chapter to read. What would you say is one of the most important things, you know, tidbits out of that chapter that you would say that you want people to know about?
41:05 Dr. Rupal Patel: Yeah. So, you know, my portion was on diabetes. And so I think knowing the risk factors for diabetes as a professional is really important because what we know is that almost every adult in America, not almost, but at least more than half, and the statistics are in the chapter, already have pre-diabetes. So like, what is that? There’s a screening that you can do, paper and pen questionnaire from the National Diabetes Education Program, and see like every patient in your practice you should ask those questions of, and if they’re pre-diabetic or already at a high risk for diabetes, then you’ve got to kind of do something about that, right?
And so I think that’s one thing, knowing the risk factors, conducting a screening, and then making your patient client aware about their risk. Most people don’t even know they’re at risk, okay? And then ask them if they want to change any of their risk factors. And then if they say yes, they’re interested, or tell me more, then work with them, coach them, right, through health coaching, motivational interviewing, to help them reduce their risk factors.
And there’s tons of, in the book I mentioned publicly available evidence-based resources that are available to us as physical therapists to help create these lifestyle modification programs. And that’s what I did. I looked at what was available through the diabetes prevention program trials, and then I took that evidence-based stuff, and then I went into literature and culturally tailored it to my population. And so that was a big lift as I developed that, but as a PT, you don’t even have to do that. Now the diabetes prevention program materials are publicly and freely available. And yes, you can still adapt them to whatever community, but those are the kind of things that are written about in that chapter that I think everyone needs to know. And thanks to you and Joe, you’ve done a good job of editing and helping us edit to make it an easy read. So it’s not this long drawn out thing you have to read, but in a few short pages, you can kind of get the gist of it. And if you want to know more, you can certainly go and find that other information in the references we have.
43:18 Dr. Ginger Garner: Yeah, absolutely. One of the things that you said really sticks out in my head, because so many people are at risk for diabetes, and that was knowing what your risk factors are. For example, this is why I ask for lab values. Do you know what your hemoglobin A1C is? Do you know what your fasting glucose level is? Because maybe their primary care physician or PA or nurse practitioner was busy. Maybe they weren’t looking carefully, but oftentimes when people come in, they’ll say, my labs are fine.
But if you look at their labs, they’re already pre-diabetic, but they weren’t told that they were pre-diabetic. Because they’re not diabetic. So the labs were interpreted as fine. And so the impetus is on us, ask for those lab values, because if they are in that pre-diabetic range, then that’s where our work begins.
I mean, it should start before that, but it really is important to do it then. So that really stuck out to me because I’ve had a few people lately where I asked for their lab values and they came in and said, oh yeah, they’re fine, but they weren’t fine.
44:30 Dr. Rupal Patel: Well, I love that you do that as a practitioner, because that’s literally what I try to teach. And then the students are probably like, well, nobody really does that out there when we go out there. So I love that, that you do that, because that is exactly what we need to be doing. And it’s the yellow category people, because the green are the ones that are healthy and don’t have any risk factors.
Then the yellow are the pre-diabetics, the pre-hypertensives, the pre-obesity, all the pres. And that, again, if we don’t address that, they’re going to go into the red bin when they already then have the disease process or condition. And now management of that is, we can still do lifestyle management, but they’re going to need that plus intensive therapy plus medication, plus maybe surgical. So again, the cost becomes greater.
Whereas every PT, if we looked at hypertension, we measured weight, waist, and did the pre-screening questionnaires for diabetes, boom, we can catch them. And we see them over several visits, over several weeks or months. And so when we talk about health coaching, we’re in the perfect place to do it. Whereas again, the physician or the primary care provider that’s not a PT, they’re just circling what’s out of range and out of range just being the disease, not what’s in the yellow range.
But it would be wonderful to see lab reports that literally were color coded, green, yellow, red. And if you’re in green and yellow, you still need intervention. You need lifestyle intervention. If you’re red, then you need medical care and intervention.
And literally, that’s where all the guidelines say. When you look at the American Heart Association guidelines, you look at diabetes, literally everything in their algorithm say for the red zone, medicine, surgery, lifestyle modification, for risk factors, lifestyle modification.
If you’re healthy, keep doing. So as physical therapists, we need to own those spaces and not just think of ourselves in the red bin, meaning that we deal with people in that red bin after the condition has happened. And then now they need our one-on-one care. Yes, we still need to do that, but that’s not where we should focus. I feel like we need to really shift our focus as a profession to more the green and yellow bins, as I call them.
46:51 Dr. Ginger Garner: Right. Because we will get better outcomes from what we’re working on because if they have systemic inflammation, if they have autoimmune issues, if they have pain problems and mental health issues, all of that gets wrapped up in these comorbidities of metabolic syndrome, of diabetes, of heart disease, because we’re not going to get the outcomes we want unless we’re actually screening for these things that you’re talking about. If we leave that out, their back pain may not ever change. If we think it’s just mechanical, if we’re not considering these important systemic factors, including asking them about their lab values.
Dr. Rupal Patel: Yeah, that’s definitely true.
Dr. Ginger Garner: Well, thank you so much for spending this time with me today. I’m so inspired by your story and so many other people are going to be too.
47:51 Dr. Rupal Patel: Likewise, Ginger. I’ve always been a fan of yours, seriously, and all the stuff you have done in your career and then now coming full circle with this textbook, and especially you and Joe as clinicians spearheading this effort. To me, that’s the biggest thing because so many times textbooks are written by academicians in our ivory towers. Certainly, you have academicians like me that are contributing to this, but it’s you and Joe who are clinicians at heart that see the value in it, that have been doing this for as long as you have, and now you have brought all of us under this one umbrella with this fabulous textbook. So, hats off to you.
48:30 Dr. Ginger Garner: Well, thank you. I appreciate it. It’s been a labor of love and to be able to come full circle after being on the front lines like that and realizing that this integrative and lifestyle medicine is also about improving our own health to help take care of ourselves so that I can work another however many years in PT and not be burned out and not give up and not be frustrated to realize that the root cause of many of the reasons people come in with musculoskeletal pain, in my case, and pelvic pain, is not because of that pelvic pain. That’s not primary. It’s secondary or tertiary or further down the list that it’s these underlying lifestyle habits and their ability to manage stress, which are really the root cause. Well, thank you so much. And until next time, guys, keep living well.
Dr. Rupal Patel: Great. Thank you.
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