I Think That Managing Type 1 Diabetes Should Involve More Than Just Insulin. Here's Why I'm an Advocate of Symlin.

It took me a while to realize that I don't remember having the kind of pressing hunger that I've lived with for the past 12 years before I was diagnosed with Type 1 Diabetes. I ate meals whenever I got around to it, occasionally but rarely needed to snack in between them, and felt full after what I felt like was a normal portion size. 

My hunger crept up on me somewhat gradually, and has waxed and waned throughout my years with Diabetes. In undergrad, I was able to eat massive portions (for me) in the meal hall - a huge plate of salad piled up, chicken, vegetables, and then two or three servings of diet soda just to make my stomach feel more full from the fizz. I had a fridge in my room for snacks after dinner. Thankfully, with access to large portion sizes of relatively healthy dining options, I was able to manage my hunger quite well in college.

In grad school, I would anxiously wait in between classes to eat my between-meal snacks twice a day, barely able to think about anything else until I did. I would eat and then two hours later, feel absolutely ravenous after. I would eat a large lunch, and always try to go straight home to eat. Afternoons have progressively become the worst. 

When I lived alone, I could compensate more easily for it. I'd leave work around 5, and then eat my pre packed dinner before 6:15 yoga class. Then I'd go home and have a huge snack, usually a giant bowl of popcorn (about what you'd get in a big bag at the movies, I always made it myself) and a drink or two until I finally felt full. Life with another human was harder, because I'd have to eat two or three snacks after work just to tide myself over until dinner around 7, or I'd skip my workout all together because I was so hungry, and just choose to make dinner earlier. Having to run an errand before dinner felt nearly impossible, because all I could think about was how hungry I was, and I would feel irritated and have trouble concentrating until I could get home to make dinner, snacking the whole way through cooking until dinner was ready. I'd go back for 2, sometimes 3 portions, and still go to bed feeling hungry from eating early. 

I had read about Amylin back in undergraduate school, raising my eyebrows as I sat at my work study desk in the admissions office, wondering if this was why it felt like I was hungry all of the time. I would rush to the dining hall right at noon for lunch, and then right back at 5, like clockwork, barely able to wait for mealtimes to begin, and it felt like no matter how much I ate, I could always eat more, if I let myself. Funny enough, I actually learned about amylin in an animal physiology class as I was pursuing my Biology major, where I learned that pancreatic beta cells secreted more than just insulin. 

What I learned in a college level science course was something that no medical professional had ever mentioned to me. No one had ever told me about Amylin, or the fact that insulin was not even the only thing that my body was incapable of now producing. Amylin is a second beta-cell hormone. In case you're not familiar with the physiology of Diabetes, Type 1 Diabetics have an autoimmune disease that develops when our T-cells (immune system) attack our own pancreatic beta cells, rendering them unable to produce insulin. However, it also renders our cells unable to produce amylin, too. Amylin is co secreted with insulin, and whereas insulin allows our cells to absorb sugar and carbohydrates, amylin helps to keep glucose from entering our blood stream by suppressing insulin's counterpart, Glucagon. While insulin lowers blood glucose, glucagon raises it, and in a normal person, your body controls these two hormones in sync, allowing for perfectly controlled blood sugar levels. (Note, Amylin is different from Amyloids). 

Our Beta cells also create something called C-peptide, but I won't get into that here.

Amylin does a couple of important things. Firstly, it slows the rate of stomach emptying, meaning that food leaves the stomach slower. This is important for 1.) post meal fullness, but also 2.) Slowing the rate of rising blood sugar after a meal. It's worth noting that blood sugar rises in Diabetics post-meal or drink far faster than in our non-diabetic counterparts (in about 10-15 minutes), simply because food leaves our stomach so much faster. And as such, that means we are also hungrier quicker after meals, so not only is our appetite not well suppressed, but it's also not suppressed for as long... hence my feeling hungry 2 hours after a meal.

Amylin also helps us to feel full during meals. Amylin helps to reduce the amount of glucagon secreted by the liver when we eat. Glucagon is essentially sugar that the liver produces. Glucagon is also one of the reasons diabetics cannot survive without insulin, because your liver will keep releasing glucagon naturally into the bloodstream without insulin to suppress it. (This is why in a Type 1, mealtime insulin isn't enough. We need a "basal", or 24 hour, insulin to help suppress that glucose that enters our bloodstream from the liver. Glucagon also stimulates the appetite. So, as we eat, Amylin suppresses glucagon release, and as such, we are also signaled that we are full. Without Amylin, our brain isn't properly signaled that we are full, and as such, it oftentimes takes the actual feeling of pressure from our stomach to indicate we are full, oftentimes many large helpings and portions later, at least in my case.

Amylin is secreted in equal amounts to insulin in a normal body, and truly, our body cannot properly regulate blood sugar without it. It's a little wild to think that insulin is the sole treatment used to treat Type 1 Diabetics, and that perfect nondiabetic blood sugar is expected when we're only using a third of our beta cell hormones to manage our blood sugar.

It's worth noting that actual Amylin isn't stable enough to be used in drug form, and thus an analog version, Pramlintide, aka Symlin, was created in 2005.

It's also worth noting that lack of Amylin has been attributed to cognitive decline and low bone density in later age in some high quality studies.

Unfortunately, at the time that I learned about Symlin and started to realize that my excessive hunger wasn't normal, was also a time when I had out of state Medicaid that didn't cover anything except the bare minimum - certainly not Symlin. In fact, most insurances to this day either are reluctant to cover Symlin, or don't cover it at all. 

As I went on through graduate school and had no insurance, no access to a medical professional, and no access to consistent insulin supplies, Symlin was out of the question - I just needed to survive. But it always stayed in the back of my mind, and I managed my hunger as best I could, with snacks always packed and eaten frequently. Even when I did have insurance, it was always a struggle to afford copays for my insulin pump, my CGM, and even my insulin - so I didn't even bother to press the topic. 

It wasn't until I switched to my husband's insurance this year that I even considered having the conversation, because finally, I had access to insurance to cover things more affordably than I'd ever had before. Even my last employer's insurance indicated that my close looped insulin pump that I'd fought for 1.5 years to get was going to be a $350 copay per month, and I was so grateful to end up leaving jobs and choosing to switch over to my husband's insurance just for the peace of mind of a reasonable copay for my pump.

My fasting blood and between meal blood sugar has always been good, but I'll be the first to admit that I developed some bad habits as a diabetic who couldn't afford good care, and I struggle with injecting insulin 15 minutes prior to every meal (that's how long it takes to start working), and then continuing to monitor and adjust my insulin levels after. We don't really give enough credit to how hard it is to estimate how many carbs we're eating, consistently give it before meals (especially when you are starving because your body doesn't make amylin), and then to continue to monitor after, especially with the rigors of work and life. It's a huge mental drain. And it's for every meal you'll ever eat for the rest of your life, so hug a Type 1 Diabetic next time you see them. It’s tough out there. Thus, my post meal blood sugar control leaves work to be desired, and after 2 years of going back and forth with my doctor, with little improvement, I think we were both feeling frustrated. My doctor basically told me "I don't know what else to tell you." I had tried a faster acting insulin once, Fiasp, but I just couldn't afford the copay at the time of $190 a month for a single vial, and thus I left that experience feeling a little burned out and sticking with my $35 humalog. 

At my February appointment, I finally mentioned to my doctor that I had been struggling with somewhat insatiable hunger issues for years, and that is was causing me to often overeat, skip exercise so that I could prepare meals sooner, and I believe made it at times harder to control my blood sugar. "I can try to prescribe Ozempic," she stated, "But it's going to get denied, you're not obese or Type 2." I had read recently that GLP-1's like Ozempic could help Type 1 Diabetics, because they helped replace those hormones we don't make, but sure enough, 2 weeks later I got my denial letter. (Note: GLP-1’s differently than Symlin). I was annoyed, but in retrospect rather happy, as the lack of long term use studies of Ozempic concern me, and the side effects are difficult to manage. Symlin is a far safer fit for my body. My endocrinologist went on maternity leave, and then cancelled my August appt, so the next time I could see her was October. In October, I once again mentioned my hunger issues, and this time I pressed for her to try Symlin for me. She was somewhat resistant. "We can try," she said. "If insurance will cover. And do you really want to give a shot at every meal?"
"I want to try," I told her. Besides, what was more needles to a Diabetic, anyways?

It took a frustrating 3 weeks of back and forth to get my doctor's office to even file the prior auth, and even then, once it was approved, I was informed that my copay for a month would be a whopping $289 dollars. I spent 3 combined hours on the phone with insurance begging them to do something. Symlin is off formulary, and as such, I pay tier 4 pricing, meaning I shouldn't pay more than $250, but since a month's supply "is technically 41 days", I pay $289. After being informed that I should either "make more sacrifices to afford it if I want it" and "just ask your doctor to put you on a cheaper alternative" (which there is none, there's literally no other version on the market), and a good cry later, I found a coupon to bring the price down $100. I almost decided against it. It felt exorbitant, and once again I found myself at the pharmacy being asked "Are you aware of the price?". At least this time, I could at least pay my large copay. I told myself I'd try it for a month, and if I didn't notice any improvements, I would stop.

Despite Symlin being around since 2005, only 5% of Type 1's are on Symlin. Even my pharmacist at a busy metro Atlantra grocery store pharmacy in the Southeast told me that she had never had anyone order Symlin before, and they had to special order it. There are several reasons for this, some of which I've addressed.

1. Many insurances don't cover or it's off formulary. My insurance is some of the best there is, and even with that, it's classified as tier 4 off formulary.

2. As such, even if insurances do cover, it's oftentimes very expensive

3. It's needed for proper blood glucose control in combination with insulin, but since we can live without it, unlike insulin, it is rarely discussed

4. It involves administering a shot with every meal, which is yet another cumbersome medication to keep up with for already needle fatigued and generally fatigued diabetics 

5. It doesn't save our lives, so again, maybe it's easy not to care about it

6. It's not taught to Diabetics

7. (Opinion) Health care providers are uncomfortable prescribing it. Even my pharmacist did not know how to administer it without reading the instructions in front of me, and told me the wrong info. I had to look it up later. My doctor didn't tell me how to prescribe it at all. I just had to sort of figure it out. I was also the one who had to research Symlin, advocate for myself to be put on it, and fight every step of the way for it. And even then, my insurance makes it difficult for me, despite it being a hormone my body doesn't make. 

Symlin unfortunately also is more acidic than insulin, therefore it cannot be mixed with insulin at this time. I do honestly believe that if Symlin's importance were to be better promoted, that more studies could focus on combining the two. A few studies have tried, but unsuccessfully so far, but studies do indicate that this should be a focus for the future. 

Despite it being somewhat of a nuisance with an extra three shots every day, and despite the price, I have noticed such a drastic improvement in my hunger levels, as well as improving glucose levels in just two weeks, that I am motivated to be an advocate for Symlin. I want to raise awareness for this hormone so that other Type 1 Diabetics realize that just prescribing insulin should not be the only focus in our care. We deserve better. And for the first time in years, I finally have normal hunger levels. I wake up, have my coffee, can leisurely enjoy a light breakfast, and I don't count down the clock until lunch. I have a normal portion, feel full after, and don't have to rely on constant snacks to get through the day. I may have a light snack here or there, but I generally feel pleasantly full. My portion sizes have shrunk to normal helpings, and I feel satisfied and full while I eat, which is something I haven't experienced in years. I don't have to arrange my day around wanting to be home right at 5 to cook dinner, that extra errand before meals doesn't leave me hangry and reeling, and I actually feel in control of my meals, instead of them controlling me. It has really so drastically improved my life, and I'm hoping more discussion around it can help make it more affordable and more accessible for Type 1 Diabetics.

Many people have said that insulin makes you gain weight, but I actually think it may be more attributable to the lack of amylin. (It's natural to gain weight when starting insulin, as your body has effectively been starving without it. Insulin in studies hasn't directly been linked to weight gain).

Side effects are minimal - some light nausea in the beginning (I did have one wave of nausea the first week that almost made me throw up one time, but nothing so severe since then), and for me, a tiny bit of dizziness the first two weeks. It stings a little to inject due to its higher acidity, but it's not bad. My weight has been stable, and Symlin generally leads to just a small loss of weight (5-6 pounds), and more importantly, better A1C levels. 

I'll definitely update on my journey in a few more months. In the meantime, I feel really privileged to be able to afford to try treatments such as Symlin, and I think it highlights the important of advocating for yourself as a patient if you feel you could be doing more to improve your health and your care. 

Why I Left My Career as a Physical Therapist

A few months ago, I announced that I was leaving my career as a physical therapist. This came as a surprise to some people I knew, and others, had been expecting it as I’d been talking about my disgruntlement with the career for a few years.

I spent years, over $100,000 in student loans, and sacrificed an immense amount of time and effort while exposing myself to dangerous insulin rationing during school all for this career that I thought would be my forever job. I’d climbed the ladder to regional management, and still, found myself finally unable to settle for continuing in this career. Why?

I’ve been meaning to write about it for a while, and while I have many more thoughts I could probably share, here is the story of what led me to leave my PT career. 

A year ago, I sat at my computer desk, nervous and sweating as I got on a teams meeting with my boss and her supervisor. It was two days before Thanksgiving. She had told me on Friday that we were going to have a meeting, and I spent the entire weekend stressing about it, feeling deep down that it wouldn’t be good.  

They let me know that due to the impending and Medicare cuts that I would be forced to take a demotion back to a Rehab Director. The building that I would be demoted back to had just been sold to a real estate developer, leading residents to move out in droves, with an uncertain future ahead. I would be losing my salaried job where I managed several buildings, to go back to this one building, where with the uncertainty and move outs, I would not be able to maintain a caseload, and would be paid hourly based on how many patients I saw. I saw the writing on the wall, swallowed my beating heart, and told them that I would be looking for other jobs. My boss called me so we could talk after the meeting. “I’m sorry”, she offered. “I didn’t want it to be like this, two days before Thanksgiving on a teams call. I wanted to tell you in person. I’m sure we can work something out. I’ll ask for the highest level pay I can get for you.”

My mid year review had been excellent, and while I had inherited some struggling buildings, we were turning things around. I had a great, loyal team that I loved, and I appreciated the ability to focus more on team building and employee empowerment and less on constant direct patient care. I had never aspired to management at this job, preferring to wait before I pursued the role with more experience, but my boss had pushed me to apply for the role twice, before I finally did and was offered the job. Ironically, I didn’t even get paid much more for this role. I was honestly so speechless, and I had little to say. “I’m going to do what’s best for me,” I told her. “And when I figure out what that is, I’ll let you know.” We awkwardly hung up. I went to Thanksgiving in a funk that entire week because the job I had spent three years being dedicated to was now gone. I was still naive and idealistic about jobs, thinking that the amount of effort I poured into them was tantamount to how highly they valued me as an employee. It was especially hard for me because I had given what I felt like was everything to this job, creating a successful rehab program with the highest grossing profit in my area (impressive for all independent living), all the while establishing a new clinic at the height of Covid as a new Rehab Director with no experience. I had been a good choice for the new area rehab manager role that absorbed my multi site manager role, and I knew it, even if my region had had a higher level of independent livings, which traditionally didn’t drive as much profit as assisted livings. I had shown up, through pandemics and divorce, and driven to Newnan 50 minutes away daily for 5 months without travel pay during the pandemic (“but at least it would give me hours”). However, the choice had been made to give the job to my coworker who had been with the company for three months. I was originally told that everybody with six buildings or less would be losing their job. But I found out on a teams call a week later. No opportunity to interview for it, and no one had taken the time to tell me. That’s when my disillusionment really sunk in, though to be honest, it had started along time ago. Being a therapist drained me. I had become disenchanted early on, as a new therapist in a nursing home, between being asked to come in to complete paperwork at 11 o’clock at night, to be called back in at 6 PM for late night Friday evaluations, to being completely and utterly disrespected when I tried to put in any PTO, because we had no one to cover me. Frankly, that was not my problem, and I was more than willing to be a team player that stayed late at night to accommodate when I was there. Holidays were worked, overtime logged. My PTO would get lost mysteriously, there was black mold in the office that management brushed off, and when the Medicare payer system changed, we were told that we would now be expected to work weekends, but at least we still had a job. The black mold? I ended up purchasing a mold testing kit after seeing my fellow employees coughing in the office for MONTHS. We had insisted that as the office had flooded at least 3 times before due to poor drainage in the area outside, that we really needed new carpet. Management refused. So we swabbed the vents, under the wallpaper, and the carpets, and when it tested positive for black mold, we presented it to our boss. Suddenly, we weren’t brushed off, and corporate flew all the way in from California next day to apologize and let us know that they were renovating the gym. Once it was renovated, I put in my notice and left that setting in the nursing home for a new opportunity in independent living and found it to be a breath of fresh air. However, after three years in this new role, it was dawning on me that the same problems that I experienced in subacute rehab were also becoming problems in the outpatient world. This was hard for me to reckon with because I thought that I had found my work home, however, the burn out still crept up on me, regardless of the satisfaction that I got from my job. I felt exhausted after long days, frustrated by the lack of flexibility, and frustrated by the lack of financial growth. The office chair patients sat in was peeling horrendously, and I asked for 4 months it be replaced, assured that it would but it never was. I bought black leather tape on Amazon to patch it. 

These companies would always blame reimbursement for the lack of raises and supplies, which I understand, especially after several roles in management. However, it doesn’t erase the fact that many of us have high student loans and are just struggling to make it by. With my demotion pending, I started looking for a new job, and within a week I stumbled upon one that I thought ended up being perfect for me. It was an area rehab manager job in Georgia, and I would manage all their Georgia clinics. It was a non-clinical role, which was a breath of fresh air, as previously I had been expected to manage five buildings while still treating 50% of the time. For reference, I expected most of my rehab directors to have productivity close to 65%. This company that I moved onto definitely had its issues. The tech issues were utterly obnoxious, and there were obvious instances of clinics not up to compliance standards or having made dubious financial choices.  However, I was more than thrilled to hand in my resignation at my previous company, and try my hand at helping these clinics to grow. 

Before I left my old job, I was told that I was required to give four weeks notice, not two, otherwise I’d be disqualified from working there again. Christmas was two weeks away, and I shrugged. “You didn’t even wait to hear about my offer,” my boss said. 

“I assumed you’d reach out to me about it,” I told her, figuring the onus should have been on the employer trying to convince me to stay. But she didn’t, and I told her that it would have been disingenuous to hear her out when I knew I wouldn’t accept anyways. I asked for feedback about why an internal interview process wasn’t given, and was told that “geographically this just made the most sense.” I gave them the courtesy of staying an extra days to help with coverage, but refused to be guilted by my boss, who told me “I just feel bad for all of those patients who won’t get their therapy.” I asked about severance - they didn’t offer any because they “technically weren’t laying me off”, even though the demotion they were offering wasn’t viable. I had to fight for my PTO payout and only received it after sending a scathing letter to HR stating I wouldn’t be leaving if it wasn’t for their decision to demote and and leave me in a position where I would have unstable pay and struggle to afford health insurance. I did also call to light their lack of an internal interview process…and my suspicions about discrimination. 

While settled into my new role, in February, I learned that my new company had been taken off the public market by a private investor. One day at the end of March, an unexpected teams call was added to my calendar. I had a sense of dread about it, because nothing good comes of unexpected teams meetings. I was also still reeling from the unexpected loss of my previous job. I could feel my hands tingling in the all too familiar tell of my anxiety and nerves as I heard that several clinics would be closed over the next three months and all new growth halted. I recall thinking to myself, which clinics am I going to lose? What pay cut am I going to take? However, I did not expect the unannounced teams call 20 minutes after the meeting ended where I learned that I was being laid off once more. I was in such a state of shock, especially considering that four months prior I had been essentially laid off at my previous job. While I hated what happened, and I was definitely frustrated about it, I did have three months at full pay, a severance package, and an incentive bonus to stay, so I appreciated at the bare minimum that I got that, at least, as it was generous for a relatively new employee. However, it was then that the disenchantment finally returned full force. I realized that operations was wearing at me, and that it was hard for what I had to do to sit in my conscience. It’s taken me a long time to realize that I really likely belong, long term, in the public service sector, and I butt heads with corporations. My personality is well suited for public servitude, and my passion for helping the underserved too strong for me to care about profits the way I should. The irony is that my second job - the one I was demoted at - was a not for profit company, although you’d never have guessed it. I have always valued people over profit, even when it has not made me the best friend of fellow operations directors. I stick up for my team, one of my golden rules is that when somebody asks for PTO, I allow them to take it, and I treat my employees with respect and dignity as should be the expectation. I level with them, I explain why certain decisions have to be made, but I am not there to make their life to be any more demoralizing or more difficult than it already is. If they needed a PT to cover because we were short staffed, I would step in. Low caseload? I’ll go screen door to door with you. Our job as a leader SHOULD be to sacrifice for our employees so that they have the best quality of life in their job possible. Yes, minding the business is why we have jobs in operations. But the business is nothing without its workers. Finding the nuance in that is what makes mid to high level management difficult sometimes, however, I felt a lot of reward in my responsibility as a manager. 

I felt in my heart that this was it. There was a finality to leaving my career this time. I couldn’t go back to a non-operations level job, where I was a therapist driving productivity, and having absolutely nobody and no one care about what quality level of care I was providing. It is demoralizing to work in fields where it doesn’t matter what continuing education you have, what empathy you provide to your patients, that you go the extra mile. It’s an afterthought to the one thing that does matter to so many therapy companies: productivity and contribution margin.

At the end of the day I was a number on a spreadsheet and I knew exactly what the numbers were because of my roles. 

In April, I received another little surprise in a cease and desist letter emailed to me by my previous employer stating I was violating my non compete by poaching patients and employees. I had had two employees from my old company I’d hired, one who was already PRN with my current company, apply for a full time position with us and leave her previous role, and another I had met once at a building I didn’t manage coincidentally apply to one of our open roles. I had written evidence of encouraging patients to stay with my old company because I was not practicing clinically, even though they contacted me. I wrote them back a scathing letter in response, never picked up the physical letter mailed to me from the post office, and never heard from them again. The clinic that they had offered me a demotion in ultimately closed that fall. 

I began the arduous role of trying to tailor my résumé once more for non clinical jobs. I had tried back in November when I went on an application binge after I learned about my first layoff. I did not hear back from a single one of them. I knew how hard this was going to be, and I put it off for a while, because I had time, to be honest. I struggled with knowing what I really wanted to do. And I played around with the thought of going back to school, if anything, because I just couldn’t stomach the idea of going back to rehab. I was burned out and felt that everything that I’d gone to school for was for nothing. No one cared that I had a doctorate, and it felt like no one saw past my clinical experience. But I used AI to help tailor my résumé, and I applied to job after job after job, hoping that I would hear back from something. Finally, after weeks of this, I had the idea to apply to a role that I had seen at work in my previous role. I liked the idea of account management, as my favorite part of my job was the connections I made with people, but I just couldn’t seem to break into it because I didn’t have any sales experience. However, I did have experience in therapy, and therefore I applied for an account executive position for a home health therapy company. The argument for why I would be a strong candidate was an easy one given my regional level experience. I sold therapy, in a sense, every day to stakeholders within my role. Within two days after the interview, I had a job offer. I took a day to ponder it, and then I accepted it. 

Four months later, I have not looked back. My quality of life has changed drastically, and while I still have days where I feel like I am on a steep learning curve, days I work late and stress, and I beat myself up feeling like I have to do better, I have learned so much in the past several months, and I know that I will continue to learn and become stronger in my role. The job flexibility has been absolutely incredible, and I can’t imagine going back to my previous clinical or even clinical operations life. 

My experience unfortunately gave me a lot to think about when it comes to the world of therapy. It’s probably obvious to many that I’ve become very bitter towards therapy. And I probably should’ve known more as a young adult about the career field I was getting into. I found myself feeling restless because I had very few job prospects for growth, and I was already getting paid at a level where I couldn’t expect to see further pay raises. Many of us are lucky if we get a .5% increase for cost of living and merit once a year all rolled into one. Many of us get nothing. And even that is at the discretion of companies who lately have been slashing rates and pay due to declining reimbursement.

After working in operations I feel very strongly that there are a lot of things wrong with healthcare. It’s no secret that workers are burning out. The for profit system is quite frankly burning all of us out, and workers are tired of being treated like a commodity with no humanity applied to the work that we do. Too few managers or corporations care about the value or the empathy we provide, but rather the profits we drive. Too many leaders are too far removed from clinical work and it reflects in the poor morale they create within their teams. And yes, I understand that businesses to an extent have to operate like this, but they deny time off for holidays, don’t pay for advanced ceu’s, give you $10 as a thank you for Christmas, slash your 401k match for the year, and freeze your pay while expecting more and more from us each year. Every second of down time in our day is criticized and counts against us. Employees are written up if they have to take the day off for sick kids. We’re treated as though client cancellations are our fault. Some companies expect 95 percent productivity or higher with no built in time to review a case before a new evaluation or assessment or to do the very specific and arduous level of documentation required for therapists to justify why insurance should even pay us in the first place. 

When therapists ask for new equipment, such as a Sara Walker in a SNF because we have nothing to assist us in walking high acuity patients, we’re told there is no money for it. When we needed new wheelchairs whose brakes worked, there was no money for that, either, even when these facilities were marketed as rehab facilities, and even when they spent a week training us on their proprietary “wheelchair management” and fitting program with the design of bringing more long term patients on caseload.

Broken equipment goes unfixed for months, you’re questioned for ordering more than one box of gloves, often forcing us to have to go to the store to buy our own if we run out, and we’re asked to market programs that companies won’t spend money on to ensure we have the proper materials to implement. 

We are expected to work holidays and take no time off around the holidays with no extra incentive or pay except for the goodness of our hearts (and we wonder why no one else is willing to cover the holidays when we offer no incentive to do so). When we do ask for PTO, we are asked by our managers if we have someone to cover us, even though it’s their job to ensure that workers have coverage so that they can take their hard earned PTO. For many of us, no N95 masks were provided until well after the pandemic wasn’t as life threatening, even though we had to get up close to patients daily. We don’t provide adequate rest periods or time off for healthcare workers who work in extremely draining and people forward jobs, and for the record, a lot of us don’t even get so much as a pizza party for employee appreciation. I was once given a $100 budget to allocate between 15 employees and 5 buildings for Christmas gifts. 

Is it really any wonder why therapists don’t want to be therapists anymore? Yes, there are still plenty who do, and I think some people were just born to be therapists. We need those people. And I’m not implying that my experience with my employers is indicative of all employers.

But then there are some people like me that wanted more, and just got burned out by this constant cycle of being gaslit by my employer for needing a raise or asking them how I can document point of care while grouping several patients or doing a hands on, manual therapy heavy evaluation and giving patients the face to face time they need to build rapport with them as opposed to having my head behind a screen. It doesn’t sit right with me to even continue to work my way up the management ladder when I know that I’m just perpetuating unrealistic standards for my employees that I’m somewhat powerless to change. Yes, I can and have advocated for my employees, but I am one person and will not change an entire company. 

Our reimbursement continues to be slashed, and with it, our pay, while tuition for schools increases. I make now what I made my first year as a new PT in a role that expects no more than a bachelors degree, with the potential for bonuses that many of my established coworkers enjoy, indicating that they are quite feasible.

Our lobbying companies lobby for us poorly and charge hundreds a year for a membership. 

Stability is few and far between as companies often pass hands, leading us to rocky stability in our health insurance coverage, 401ks, and quality of life.

We’re pushed to see people in “groups” in rehab facilities, leading to sub par care, and high patient volume and insurance dictating reimbursement has led to treatment times being cut short for certain insurance types, meaning you often can’t provide the care that you want to to patients. The high patient volume we are expected to see is exhausting and further perpetuates burnout.

Once you’ve reached your max pay, there is little to no room for pay growth, leaving you in a position where cost of living consistently erodes away at your ability to afford to live.

Insurance companies don’t see the value in therapy, and it’s frankly hard because of our model of requiring several visits from patients who many times have high copays. This has left many people to go to cash based, which if it’s for you, I think can be great, but is also difficult for those who cannot afford it, especially the geriatric population, whom I have a special place in my heart for. Technology has a real ability to transform therapy for the better, but few practices will take the time to invest in it or equipment proven to help maximize outcomes, leading to insurances still expecting more results in fewer visits, and many places unable to deliver, resulting in a model that many patients may feel is ineffective. 

So? I decided to walk away. It just wasn’t for me anymore. I crave growth, the ability for my time to be valued, and more possibilities than what the therapy world could offer me. 

I still keep up with some of my old patients and I’ve absolutely loved seeing the magic that therapy can do, but I find myself so much happier having removed myself from that world now. Am I letting my license lapse? Certainly not. But I also won’t be back any time soon.