Next up on our #OTSettingsSeries is Michael Ang, OTD, OTR/L, CNS, CSRS, CBIS, HTC, PAM, SWC, CKTP, CAPS. (Yep, those letters are an amazing mouthful…)Dr. Michael Ang created the Outpatient Occupational Therapy Program at St. Vincent Medical Center in Los Angeles, and is specialized in treating neurological and upper extremity conditions. He is currently a professor at West Coast University’s Occupational Therapy Program, and he previously taught at the University of Southern California. Michael also works for The Neuro Specialist Institute and is the primary instructor for the Certified Neuro Specialist (CNS) Certification course.
MEET MICHAEL (But out of serious respect, I will refer to him as Dr. Ang in the majority of this blog post!)
Name and credentials: Michael Ang, OTD, OTR/L, CNS, CSRS, CBIS, HTC, PAM, SWC, CKTP, CAPS
Number of years in practice: 13 years
OT setting/s: Primarily academia; private practice; home-based rehab; previously acute/inpatient and outpatient rehab
Shannen: Hi Dr. Ang, it is a great honor to interview you. I admire your love for teaching and neurological rehab, as well as your clear and compelling commitment to lifelong learning. This interview has been a long time coming (and I appreciate your patience with me); I feel so grateful to share it here. Will you share a little about your OT roles?
Dr. Ang: I’m currently a Professor of Occupational Therapy at West Coast University in Los Angeles. Being in Los Angeles, it’s definitely an urban setting with access to numerous resources. We partner with various facilities to expose our students to different types of occupational therapy settings – these range from traditional settings (hospitals, schools, SNF, etc.) to emerging practice areas (hippotherapy, homeless shelters, etc.). There are several OT programs in Southern California, and we do a significant amount of networking during state and regional conferences. In terms of working with other healthcare practitioners, our university has programs for physical therapy, pharmacy, nursing, and dental hygiene; therefore, we often run events that focus on interprofessional education. For example, we’ll assign a case study to a group of students from every discipline (OT, PT, nursing, etc.), and they’ll have to collaborate on the comprehensive treatment plan.
In addition to academia, I do home-based occupational therapy. To clarify, this is not home health therapy where the patients are “home bound.” The service I provide is similar to outpatient therapy, but it’s conducted in the patient’s home. These are typically private sessions where the medical team isn’t involved; therefore, I don’t really collaborate with other healthcare professionals unless the patient can benefit from some type of co-treatment. Home-based therapy isn’t really one of a kind in my area, but it’s definitely more rare than traditional therapy settings.
Shannen: Super impressed! Wow, living in Alabama – where there are only four OT schools – I cannot fathom the amount of OT schools there are in Cali!! Okay, where were we…? So, who benefits from OT services in your setting? And is your primary focus on neurological rehab within the home? Can you expand a little more on this home-based rehab (that sounds awesome)?
Dr. Ang: In terms of clinical practice, the referrals I receive are mainly neuro or ortho. I have a strong preference for neuro, specifically TBI, CVA, and neuro-degenerative conditions. Nevertheless, I feel that any patient can benefit from this setting because they’re receiving treatment in their natural environment. Because they’re already comfortable in their home, they don’t have to spend so much time and energy acclimating to an unknown environment. Their time and energy can be spent on rehabilitating specific skills, and you see incredible gains throughout the entire system – motor, sensation, cognition, mental health, etc. In terms of eligibility, I can see any patient who qualifies for outpatient therapy through insurance. I also see private, out-of-pocket clients.
Shannen: I can definitely envision the benefits of home-based especially in that the patients would literally benefit from the decreased cognitive load that comes with being in a natural environment letting them use more energy on the therapy itself. Okay, so tell me what value does OT bring to your setting specifically? Can you share about the value of “occupation”?
Throughout my career, I’ve worked in acute/ICU, inpatient rehab, outpatient rehab, transitional care, skilled nursing, and home health. My favorite setting is outpatient rehab, and later home-based therapy. The reason is simple – I have more freedom to work on whatever my patients want to work on. I’m not at the mercy of insurance companies or third-party payers who focus on ADLs, self care scores, standardized assessments, etc. When it comes to acute/inpatient, the focus is typically on bathing, dressing, and other ADLs. Don’t get me wrong, they’re extremely important, but they’re not my “best fit.” My patients have different aspirations.
This is a long story, but please hang with me…
Mr. K. had a stroke one year before seeing me.
He’s someone we would call “a high-level patient.” He’s independent with ADLs and he ambulates without assistance. His left leg is slightly weaker than his right leg, but everything else is pretty much intact.
What happens when a patient is labeled, “too high level?”
I’m thinking I should probably discharge him from occupational therapy and refer him to physical therapy; after all, it’s just his left leg that’s giving him problems. Otherwise, he’s functional. Even though Mr. K. was functional, he wasn’t satisfied. He had this aura of frustration that resonated with me, and it never left me.
During the evaluation, he said, “People tell me I should be grateful. That there’s nothing wrong with me…I can walk by myself and I can go to the bathroom by myself…so everything is fine. But I’m not fine. Just because I can walk and take a dump, does not mean I’m the same person. I don’t feel the same. And there’s things I can’t do.”
I ask, “What are the things you can’t do?”
He answers, “I can’t fly a plane…”
“I can’t fly an airplane.”
I respond, “Do you mean going to the airport, buying an airline ticket, and travelling somewhere…as the passenger?”
He replies, “No. I want to fly an airplane by myself… as the pilot. I used to fly small planes. It was my hobby. I can’t fly anymore because my left leg doesn’t have the strength to control the rudder. I can’t control both legs at the same time, and I need that to fly.”
After a long pause, I write on the evaluation form, “The patient’s occupational therapy goal… is to fly an airplane.”
I visit a hardware store, and I ask one of the workers to give me a crash course on woodworking. I bring him a little sketch of an airplane cockpit and I ask, “If I were to make an airplane rudder system, how would I go about doing that?”
The worker answers, “What’s a rudder system…?”
I say, “I don’t know. But I printed this picture from the internet.”
The worker just looks at me and says, “You don’t know what you’re doing, do you?”
“No. I have no idea.”
It took a while, but eventually we create a ‘rehab rudder system,’ which uses 2×4 blocks attached to a large wooden base. These blocks work like ‘pedals,’ and it gives the user the sensation of maneuvering an airplane left or right.
Mr. K’s right leg was slightly stronger than his left. The goal was to put equal strength, equal weightbearing, and equal coordination on both pedals at the same time. If Mr. K. were to fly a real plane, he would need to maintain this balance so he wouldn’t fly in circles. We also fabricated a ‘control stick,’ which was a bathroom grab bar that was duct taped to a single point cane. Finally, I had Mr. K. watch videos of airplanes taking off and landing while he practiced maneuvering the rehab rudder system and control stick at the same time. This was augmented virtual reality before it was even a thing.
It took 3 weeks for Mr. K. to reach a balance between the two pedals, and another 3 weeks for him to maintain that balance for an hour.
A few months after therapy, Mr. K. flew an airplane.
I share this because I want to highlight the very heart of occupational therapy, and that is…occupation. Oftentimes, we’re overly concerned with the status quo, or we only provide interventions that are safe and comfortable. But we should always provide opportunities for salient tasks. Our patients have gems of occupations hidden deep inside, and as occupational beings ourselves, we know how important they are. We should take the time to dig a little bit deeper. One day, that patient can fly a plane.Dr. Michael Ang
Shannen: I honestly don’t even know what to say but that story needs to be the new poster story of “what is OT”!! Amazing!!!!!! Wow, so impressed and inspired!
Alrighty moving on (although I feel like I need to print that story out to read it when I feel a twinge of burnout going on…)… So can you share a little more about that setting in regard to the frequency or duration as well as what theories or frames of reference you use? What about outcomes assessments?
Dr. Ang: In terms of outpatient or home-based therapy, I typically see a patient once or twice a week. Intensity is important, so I try to see them as often as possible. However, increasing the frequency/duration may not be financially conducive, especially if someone is paying out-of-pocket. That being said, I typically film our sessions so they can review and practice everything on their own time. Moreover, I never do the same thing twice – I like to work on something new each session so we can figure out which interventions work in order to optimize the treatment plan more efficiently.
In terms of theories or frames of reference, I must be completely honest here…I’m not entirely familiar with them. It’s embarrassing to admit (especially since I’m a professor), but my students know more about frames of reference than I do. The truth is, I don’t prioritize them. The only things that matter to me are my patients’ goals and outcomes. How we achieve them is secondary. That being said, it doesn’t mean my interventions aren’t evidence-based. Most of them are rooted in neuroscience and biomechanics. I just combine that with occupation-based training and a “try everything, do what works” approach – is that a frame of reference? If so, that’s what I use.
For assessments and outcome measures, I typically use something that’s specific to my population. The most common ones are the Fugl-Meyer for motor control, the Modified Tardieu for spasticity, the Rancho Levels for cognitive functioning, and sensory/perceptual assessments, etc.
Shannen: What certifications or specialties do you have? (Or what certifications do you not have may be an easier question jk, but wow…)Why and how did you pursue them?
Dr. Ang: Well… (***Insert Shannen’s face with the wide eyed emoji in prep for this answer)
- ADVANCED PRACTICE IN PHYSICAL AGENT MODALITIES (PAM)
- ADVANCED PRACTICE IN HAND THERAPY (HTC)
- ADVANCED PRACTICE IN SWALLOWING ASSESSMENT, EVALUATION, OR INTERVENTION (SWC)
- CERTIFIED NEURO SPECIALIST (CNS®)
- CERTIFIED STROKE REHABILITATION SPECIALIST (CSRS)
- CERTIFIED BRAIN INJURY SPECIALIST (CBIS)
- CERTIFIED KINESIO TAPING PRACTITIONER (CKTP®)
- CERTIFIED AGING-IN-PLACE SPECIALIST (CAPS)
- PWR!MOVES CERTIFIED THERAPIST
- NEURO-IFRAH® CERTIFIED THERAPIST
- INTERACTIVE METRONOME CERTIFIED PROVIDER
- SAEBO CERTIFIED CLINICIAN
To be honest, I never pursued any certification for the designation or “title.” My favorite population is neuro, and I pursued all of the above to improve my knowledge in that area. For example, I’ve never been a fan of hand therapy or swallowing interventions, but most of my neuro patients have a hand impairment or dysphagia. That’s the only reason I obtained the HTC and SWC – to provide advanced practice intervention without the need for supervision.
The one certification that’s very near and dear to me is CNS or Certified Neuro Specialist, which is a program I helped create. We found that there is a tremendous amount of variation when it comes to neurorehabilitation; the standard of care fluctuates greatly depending on one’s setting, training, and education. We wanted the quality of neurorehabilitation to be more standardized and evidence-based. We interviewed several neurologists and neuroscientists and asked them, “What do you want OTs and PTs to know about neuro, and what interventions do you believe have the greatest benefits?” Their feedback was invaluable, and it opened doors for us to investigate new interventions and technologies. We also have several therapists on our team who have experienced a stroke or brain injury themselves. They bring a unique perspective because they have that lived experience that no other therapist has. They provide incredible insight on what actually works because they’ve gone through the rehab process. All of this has been rewarding and exciting, and I’m proud we’ve created a certification program that covers interventions based on science and lived experiences instead of theory alone.
Shannen: So awesome, what a privilege it is for me and others to hear a little about your why. Also, it goes without saying I am pumped about the CNS certification although I really need there to be some Southern areas to attend the in person element:)!
Okay, so share with me a little bit more about some of your incredible moments in clinical practice…What positive changes have occurred in yourself in this setting?)
Dr. Ang: I have many stories to share, but I’ll try to be concise. I’ve seen some pretty incredible things in outpatient and home-based therapy. From virtual reality, to EMG, to ocean therapy, to robotic exoskeleton suits for spinal cord injuries, to professional athletes returning to work, etc.
The only thing I want to add is…I’ve been incredibly blessed. The airplane story I shared earlier…that experience took place during my first year as a licensed OT. I’m very fortunate it was a success story. It could have gone the other way, with my patient never flying an airplane. If that were the case, my career trajectory would have been very different. I would have played it safe and worked on more realistic goals. Because it worked out the way it did, I have a tendency to aim for things that are improbable, or even impossible.
Shannen: Can you share about any work life examples where perhaps you did not have the most positive experiences? What were the barriers and how did you take action???
How did you “get your foot in the door” to work in new positions or how did you know what you even wanted to pursue?
Dr. Ang: My first job after graduation was at a skilled nursing facility. It was a valuable learning experience. I was highly encouraged to increase my patients’ therapy minutes on a daily basis. The focus was on maximizing productivity and extending the length of therapy sessions, even if the conditions weren’t appropriate. I started to see the unethical (and illegal) aspects of therapy, and I became jaded with the reimbursement process. It was a soul-crushing experience and I quit after 10 months.
I had to re-evaluate what I wanted my occupational therapy career to look like. After a moratorium, I applied to an acute/inpatient position at St. Vincent Medical Center in Los Angeles. When the Director of Rehab took me on the tour, I noticed there was a huge outpatient therapy program for physical therapy, but no program for occupational therapy (the OT office was used as a storage room). I accepted the position on the condition that I could start an outpatient OT program. They accepted my offer. I will never forget that first day; in the OT office/storage room, I used a box as a chair. Nevertheless, I was thrilled at the opportunity to start fresh. I wanted the outpatient program to be everything the SNF wasn’t – client-centered, occupation-based, and ethical. Eventually, it grew to the point where we had consistent referrals and we could support a staff of OTs.
I transitioned to academia 4 years later. Initially, I wanted to dabble in academia. I reached out to my mentor at the University of Southern California (USC) to ask advice on an adjunct teaching position at a new OT program. I had concerns because the program was just starting, and I didn’t have a doctorate or teaching experience. Her response blew my mind. In a nutshell, she asked me to join her at USC, and she would mentor me to take over her courses after she retired. Long story short, I accepted a teaching position at USC. At the same time, they gave me a generous scholarship and stipend to complete my OTD and residency there. At this point, I had my full-time position at St. Vincent’s Medical Center; I was completing my OTD and residency at USC; I was teaching at USC; and I was trying to figure out how to launch my home-based therapy program.
Shannen: This answer about your compassionate mentor warms my heart!!! The kindness of that professor is tenfold. Wow! This an example of you taking initiative by reaching out despite not having a doctorate. And wow what a response. I feel this so much. I remember reaching out to my alma mater only three years after graduating, and yet having this compulsive desire to participate or “dabble” in teaching, too with “just my masters”. Anyone out there reading this – I promise you – you are more than “just your masters” – and YOU CAN TEACH with a masters:) … One day I am highly likely myself to pursue post professional education, but I just haven’t figured out in what realm and until then I will keep dabbling in academics until my passions (and the Lord) guide me to exactly what type of education I want to pursue… Okay that is an aside…thank you for sharing how you started in academics…
Where were we… Okay, so the infamous question… Where do you see yourself in 5 years? 10 years? How does working in this setting help you reach your personal professional goals?
Dr. Ang: I’ve had a very fulfilling career thus far, and I’m completely content with where I am. In 5 to 10 years, I hope I’m still doing what I love – academia, clinical practice, and other passion projects. I’ve been a speaker for several neuro conferences, and I hope to continue that trend because OTs don’t have a big presence in that arena. We’re also developing advanced courses at The Neuro Specialist Institute, so that’s something I’m very excited about. Most importantly, I hope to be a good father. My son is 2 years old and he’s definitely a feisty one.
Shannen: Feisty, but what a cute little kiddo he is! Share with me some specific “special skills” (like things you aren’t prepared from entry level OTA/OT skills) do you need to be successful in your setting?
Dr. Ang: I often tell my students they might actually be a better therapist the first day they step into OT school versus the day they graduate.
On day 1, they have an idealistic view of OT and they’re ready to take on the world. On graduation day, they’re unsure, timid, and even disillusioned. That’s a generalization, but I’ve seen it enough during my 8 years of teaching to know it’s becoming an epidemic. It can lead to massive burnout. They’re no longer doing therapy the way they should do therapy. They’re trying to follow a script or a formula instead of being themselves. It’s unfortunate because they become so indoctrinated with what they’re “supposed to do,” they forget the real value of occupational therapy is interacting with the client as one human being to another human being.
That’s not to say OT programs aren’t effective in creating confident or competent clinicians. However, we (faculty) have to be mindful of our feedback. We can’t nitpick every little detail because there is more than one way to do things. (Shannen: ****drops the mic****) We have to allow students to pioneer new interventions and develop their therapeutic styles organically. On graduation day, students obviously have more knowledge and skills, but it’s more important that they maintain their intrinsic qualities – the elements that make you, you. I don’t think anyone really needs “special skills” to be a successful OT. I think you need to be grounded as a person and know who you are at your core. That way, you can interact with your clients as the best version of yourself. My advice is…don’t offer “special skills.” Offer yourself. You should be enough.
Shannen: OMG I relate to this so much. It is like we are creating robots for therapists with the way documentation and all the “check offs” are these days…Where is the beauty in that? Pretty soon the world will be taken over by robot therapists…kidding…well, I hope that won’t be the case… I know your students appreciate you and value your teaching so much just by the way you provided your insights to this answer. You definitely validate the importance of therapeutic use of SELF.
So how do you deal with work stressors and promote your own version of occupational balance?
Dr. Ang: OT can be challenging; academia can be challenging; any job can be challenging because life is challenging. Anything that’s worthwhile requires persistence and effort. Remember the big picture and remind yourself why you wanted to be an OT in the first place. That underlying passion will help carry you through the dark moments.
I’m not one to say, “You have to find a healthy balance…or separate work from life.” Our work is life! It’s personal! Being an occupational therapist and utilizing therapeutic use of self is a very personal experience, and boy do we feel it! The trick is learning to navigate those feelings so it doesn’t debilitate you. It’s okay to feel what you feel, but channel those feelings into something healthy or productive.
Shannen: Preaching to the choir. Again, I relate to you so much. I negate to promote work life balance because truthfully sometimes there are times where there is more personal life stuff to deal with or vice versa… I recall last December when my parents got divorced – I know for a fact my work was placed on the back burner (***note: I am in no way implying that my patient care skills were jeopardized – more so saying I just got by during that period and recall doing zero continuing education during that rough season)… In the same breath, sometimes it feels like I am all work work work (but more so in a driven, passionate, eager way). Nevertheless, in reality, my personal perception is we are occupational beings and so the two can really never be separated. You speak this so well with your advice in regard to “the trick is learning to navigate those feelings so it doesn’t debilitate you. It’s okay to feel what you feel, but channel those feelings into something healthy or productive.”
Wonderful, alright, moving on – is there any specific advice you would give to someone thinking about / wanting to work in academia or starting their own practice? What do you wish you knew about this setting before you started?
Dr. Ang: When it comes to academia, be prepared for some late nights, long hours, and workplace politics. Nevertheless, it’s extremely rewarding if you have the heart to teach. There’s no financial or temporal advantage to teaching; do it because you love it. When it comes to starting your own practice, be prepared for a plethora of legal, financial, and logistical barriers. It will take more time, energy, and effort than you realize. Do it because you want the freedom to do things your way.
Shannen: Thank you for sharing your insights. I definitely hope that people go into academia with the underlying excitement and love for learning and students. Well, we have covered a lot and this has been soul enriching. Is there anything else your heart desires to tell the OT world about …?
Dr. Ang: OT can be the best job in the world.
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Finally, a humongous thank you to Dr. Ang for sharing insights into his journey and OT life through his unique perspective.