Student-led Lifeline
When your insurance ends but your physical therapy needs have just begun, several pro bono PT clinics offer help for a few patients backed into a corner
By Stephen Dark
Thanksgiving 2019, snow fell over the Salt Lake Valley. In Marcellus and Lidia Barrus’ South Jordan home, the couple had just put the turkey and trimmings on the table.
Marcellus, a software engineer, was finishing up in the kitchen when daughter Catherine rushed in. "Something's wrong with mom,” she said.
"I don't feel good,” Lidia told him. “I feel dizzy." The feisty project manager who always knew her own mind was unable to utter another word.
Fearing she had suffered a stroke, Marcellus asked her to lift her arm, but she couldn't. He asked her to move her hand. She couldn't.
Rather than wait for an ambulance, he drove her to the local hospital, which sent them to the emergency room at University of Utah Hospital, where his fears were confirmed.
Lidia had experienced a hemorrhagic stroke. It had occurred in the left side of her brain with symptoms manifested in the right side of her body. A neurosurgeon operated to relieve the pressure on Lidia’s brain before she was moved into neuro critical care. In the hospital, Marcellus sat by her bed and wept. He could not lose her. He stayed by her bedside day and night, living off bananas and vending machine pop tarts. Thank God we have health insurance, he thought.
A week later, Lidia moved into rehabilitation. Twelve days passed before she uttered her first word: “bathroom.”
She progressed slowly through daily sessions of speech, occupational, and physical therapy. At four weeks, she was about 10% back to her normal self. And then the rug was pulled out from under her and Marcellus.
A member of their medical team told Marcellus, “There’s nothing more we can do here.” Their health insurance had stopped coverage. Lidia would be discharged in two days.
Marcellus was terrified. His thoughts raced. How do I take care of her at home by myself? Where do I get a wheelchair? What are we going to do?
Once at home, the Barrus’ friends and colleagues rallied. Several came over to pull out and widen the doors in their home. When they left, they told Lidia they loved her. Lidia’s employer, with whom she had been just six months, sent over workers to remodel her bathroom so she could access it. Marcellus’ employer gave him extra time-off and allowed him to work remotely.
Another bright spot was that they still had health coverage for Lidia’s therapies at the new U of U Health Sugar House Health Center. But the frequency had shrunk from 21 sessions a week to three. Consequently, her recovery progress went from slow to a snail’s pace. And after eight months, the Barrus’ insurance company coverage ended.
A physical therapist at Sugar House suggested they visit a pro bono neurological physical therapy clinic managed by the U’s College of Health (COH). Run by student volunteers, the clinic would give Lidia a weekly session for free. Marcellus leapt at the chance, grabbing hold of the help like a lifeline in the roughest of seas.
The Least We Can Do
Marcellus and Lidia Barrus’ ensuing relationship with the pro bono clinic and the many students who worked with them to support Lidia’s battles to recover her lost motor skills underscores a philanthropic, humanitarian element in physical therapy’s service ideal. Yet the COH’s pro bono clinics are more than a last-ditch resort for a few lucky patients willing to work hard on their recovery. Established on a student-driven desire to provide physical therapy (PT) for those who couldn’t otherwise get it, the clinics evolved into a slender eco-system stretching across the Salt Lake Valley that are home to a remarkable exchange of gifts.
Students donate time, empathy, and emergent skills to help mend bodies and spirits. Patients see steady if incremental improvement, and through their one-to-one patient interaction students add depth to their abilities and meaning to their work that a classroom could never teach them.
The COH manages three pro bono PT clinics: a neuro clinic in the basement of the PT education building in Research Park, Salt Lake City, a regular PT clinic at the Midvale-based Community Building Community (CBC) nonprofit, and one at the Maliheh Free Clinic in Millcreek.
Misha Bradford, DPT, professor of orthopaedic PT, traces the clinics’ roots back to students in 2012 asking her for help in setting up a free clinic for the underserved. “They had heard a talk about the needs of the refugee populations, and felt passionate about being able to provide some service,” Bradford says. They also recognized the value of hands-on patient experience. At the time the PT department did not have the resources to pursue a sustainable pro bono project. Nevertheless, the seed of an idea had been planted.
In 2013, Bradford learned of U of U Health’s evolving relationship with the CBC, which is dedicated to improving the quality of life for residents in Midvale. Working with CBC’s managing director, Mauricio Agramont, the department offered the students an opportunity to open a student-run PT clinic.
The same year the CBC PT clinic started, Reva Rauk, PT, PhD, teamed up with U of U Health spinal cord injury guru, Jeff Rosenbluth, MD, to open a pro bono student-run clinic for neuro patients. The clinic treats patients with stroke, spinal cord injuries, multiple sclerosis, Parkinson’s disease, and other neurological issues.
The neuro clinic is staffed by two teams of students, made up of two first-years and one second-year. The first-years do the intake, taking blood pressure and other measurements, and second-years analyze the issues facing the patient and work with them on their therapy goals. Supervising licensed PTs or faculty keep a watchful eye.
What prompted Rauk was witnessing firsthand patients like the Barrus’ being discharged because their insurance coverage ran out.
The neuro clinic wouldn’t solve that chronic unmet local need, but it would help a few patients. It would also provide students valuable experience conducting treatment and help hone their communication skills. In addition, there were deeper lessons about duty.
Rauk hoped to seed in receptive students a desire to pursue their own pro bono clinics, serve as supervising therapists after graduation, or in some other capacity help address significant disparities in health care. “It’s our responsibility as licensed therapists to try to meet that unmet societal need," she says.
Students participate in the clinics either in a managerial role—recruiting patients and attending PTs—or in a treatment role.
While most students participate in the pro bono clinics, some like third-year student Peter Bogaard find immense value in the experience. He clocked up 160 hours at pro bono clinics, mostly at the neuro clinic as it is known. “Volunteering is a wonderful learning opportunity and it’s good for the patients,” he says.
An Inspired Choice
There’s an intimacy to PT, to working with other people’s bodies over a consistent period that requires and builds rapport. It can also be intensely rewarding to help patients help themselves get better as they follow the PT’s guidance.
Unsurprisingly perhaps, some students want to become PTs because of their experiences as patients or watching loved ones healing through their PT treatment.
Second-year students Caitlin Bubel and Robert Griffin had life-changing experiences with PTs when they were young.
Bubel was hurt as a 14-year-old athlete in Park City. Going 85 miles per hour down an icy luge track, she crashed and broke her ankle. She was off-ice rehabbing for six months. Her PT had an honest conversation with her about her injury, that if she went back to sliding too early and broke her ankle again, she might not run or walk properly. It was something she needed to hear, as coaches sometimes pushed athletes to get back on the ice too quickly. The PT’s impact on Bubel’s health and life led her to take exercise science and psychology classes.
She ultimately chose PT as her profession. Walking into one of her second-year classes for the first time, Bubel recognized the professor as her PT for the luge injury. She got to tell her, “I’m here because of you.”
Griffin witnessed PT’s slow-haul impact on his father, and it defined his adult life. His father, a triathlete, had been biking when he was hit by a car and suffered a traumatic brain injury. Over the next 18 years, Griffin watched his dad slowly improve with the help of doctors and therapists. The improvements in ability and function, much of them driven by his father’s work ethic and determination, inspired Griffin to sign up for a PT doctorate.
Personal Pronouns
For the last four years, each Monday during the PT school semester Marcellus and Lidia have worked with students, most of them new to her case. From the beginning, students asked about goals, marked her weekly progress on charts, and tracked how far they got to meeting the goals by the end of the semester. Weekly reports gave insight and guidance for the next student the following week.
One therapist warned them that students at the clinic lack experience. If that was the case, the Barrus’ found pro bono students nevertheless made up for it in all the ideas they are willing to try. Because new students didn’t know Lidia’s limitations, they often pushed her beyond her limits. Despite the challenges of confronting her own physical and pain limitations, Marcellus says with both pride and admiration, “Amazingly, she succeeds!”
If at first the clinic seemed chaotic, Marcellus says, “Now that we're used to it, it's normal for us that we're going to get different ideas, different solutions depending on the week because of the different thought processes of each student.”
Student Griffin acknowledges that constantly meeting new students can be hard for patients, especially if after a great treatment session their new PT student proves challenging to develop rapport with.
When students are stymied in how to move forward with treatment, that’s where the supervisor comes in.
When working on balance issues, Lidia was unable to lift one foot without falling over. The students were stumped, so the professor assisted.
“If you look at Lidia right here, how is she standing?” she asked. After analyzing, they gave an answer.
“So how would you fix that?” asked the professor.
They responded, and the professor encouraged them to try it out.
Rauk says that when a patient has a blank look on their face after being asked by a student to do something, that’s a great learning opportunity for the student to reassess and figure out how to communicate better. With patients who struggle to express themselves, students learn to wait and listen rather than put words in their mouths.
“Communication is key,” Rauk says.
But for Lidia the very act of communicating is hard. The stroke didn’t only clamp down on her ability to move her limbs and body. She was also diagnosed with expressive aphasia, which meant while she understood what people said, she couldn’t always say the words she was thinking.
Living her stroke recovery day by day, side by side for four years has required Marcellus becoming Lidia’s voice. When she can't say what she wants, she looks at Marcellus to be her voice. Sometimes they play a kind of charades so he can understand what she wants to say. When Marcellus then explains her story or what she wants in terms of her PT treatment, he says, “we,” not “her.”
“It's a testament to their incredible relationship that he can read her mind, so to speak,” says student Bogaard. “He knows what she wants to say.”
"When a patient has a blank look on their face after being asked by a student to do something, that's a great learning opportunity for the student to reassess and figure out how to communicate better."
The Midvale Connection
The pro bono PT clinics at Maliheh and the CBC are both orthopaedic-focused. Students there treat mostly work-related injuries to shoulders, knees, or backs with migrant backgrounds. Wait lists are long.
With so many CBC clients in the construction and service industries, many have benefited from the PT pro bono clinic. But for those who keep working despite untreated injuries the prospects are dim. In the worst cases, those injuries become so severe they have to go back to their home country with little prospect of work.
Being at the CBC, Bogaard says, “was a good learning opportunity to work with people who don't speak your language.”
Whether using a translator or relying on gestures and pointing, Bogaard says the CBC clinic is invaluable when it comes to learning how to educate, treat, and diagnose anyone, regardless of language.
One of the CBC’s employees, peer support specialist Felipe Cruz, used the pro bono clinic after he injured himself doing squats in the gym. He wasn’t overly consistent with the exercises they gave him, but the treatment helped strengthen his leg. “Because of them I know what I have to do to fix it,” he says.
The clinic’s long wait list for PT is evidence not only of the need in the community but also how clients feel about the care being provided, says Cruz. “A lot of undocumented people, those without insurance, the disabled or who've recently lost their jobs need us because we're one of the very few clinics that only accept people without insurance,” he says. CBC’s service costs are tailored to patients’ ability to pay.
He admires the sense of community he witnesses between clinic volunteers and patients. “Everyone works together to resolve the medical issue.”
At the hospital, Cruz finds the atmosphere at times cold and off-putting with regimented 15-minute appointments. “But because the students are learning, and the professionals are doing it for fun or charitable reasons, they usually give extra time and they make you feel comfortable, something I really love about the clinic,” he says.
One Step at a Time
Three years into her recovery, Lidia started to regain her independence and her voice. She and Marcellus began to share responsibilities again. She took over the nightly cooking, drawing on lessons from occupational therapy students.
“We’ve accomplished a lot of our goals because of the students,” Marcellus says. “They don’t realize the impact they’ve had on Lidia because they only get to see her once or a few times.”
If there’s one achievement the couple highlights, it’s taking on Lidia’s long-standing frustration with being unable to go up and down stairs normally. Then, in the late summer of 2023, they started working with Bogaard.
For several sessions, Lidia and Bogaard worked on climbing steps in a chilly stairwell lit by yellow, fluorescent lights in the PT building’s basement.
"It was always her least favorite thing," Bogaard says. She would lift one foot, then have to bring the other parallel to it rather than skip the step in a normal walk. Whether fear of failing or lack of confidence, breaking negative self-talk barriers are crucial, he says.
The Monday before Christmas, Bogaard worked with Lidia on the stairs again. This time he pushed her harder. She started at the bottom while Marcellus videoed. Bogaard sat on the stair above her top foot, moving up the stairs at every other step she took. As they progressed, he provided tactile feedback, trying to stimulate muscles that seemed to have forgotten their function. He poked them the way a doctor might tap a knee with a rubber hammer to engage a reflex.
The poking increased brain-muscle connection, reminding Lidia’s body of the muscles it needed to be working. He tapped the muscles in the front and the back of her leg so that she could lift her leg, put it down in the right spot and then use her quad muscle to help her get up to the next step.
Finally, she got to the top. It was like a switch flipped. “Oh my gosh! Look what just happened!” she said. “I had never been able to do that before.”
“You don’t realize what you’ve just done,” Marcellus told Bogaard in tears. “You’ve made her feel confident and comfortable in this process. You don’t know what it means to us; what it means to me to see her do something that she’s never done before.”
But Bogaard did understand what he had done. He’d built trust with a patient so he could get her to a place that, while uncomfortable for them in terms of the difficulties posed by her limited ability to control her muscles, nevertheless had to be done. Having that trust means, “I know she’s being honest when she says, ‘Hey, I can’t do that,’” he says. “It helps me develop plans and adjust them based on what she’s saying.”
Each success with her also boosted his self-confidence as a PT. "I can do this, I can be successful,” he remembers thinking. “I can meaningfully impact people’s lives.”
Seeding Vegetables and Dreams
Gratitude between PTs and patients at the pro bono clinic is very much a two-way street. “It’s kind of funny. Every time we go down there, the patients are thanking us, and we’re thanking them for coming,” Griffin says.
Bubel agrees. Patients educate them. “They teach us to be creative and, honest, and to think outside the box,” she says. “They teach consistency in always showing up week after week, and humility in accepting that sometimes I need to take a deep breath, recognize I haven’t communicated what the patient needs to hear and try again to get the request across in the simplest of language.”
The impact doesn’t stop there. Much as Rauk has hoped, many students want to do their own version of the clinic after graduating.
“A dream of mine would be to open a pro bono clinic to provide access to whomever needs it,” says Bogaard. “It's galvanized me to continue that passion and serve people who don't have access to health care. It’s a quality-of-life issue and it's something that we should all be pursuing, especially in health care.”
Griffin wants to go down a similar path, only his quest is to help close the gap of access to health care in rural communities like the one where his mother’s family lives. Once he graduates, he will move back to Missoula, Montana, open his own practice and start a pro bono clinic. “Starting a pro bono clinic there and giving back to the community that's raised me and made me who I am today, I think is a big goal,” he says.
"A dream of mine would be to open a pro bono clinic to provide access to whomever needs it. It's galvanized me to continue that passion and serve people who don't have access to health care. It's a quality-of-life issue and it's something that we should all be pursuing, especially in health care."
Life Goals
After five years, Marcellus says, Lidia is 30 to 35% back to normal. They volunteer at the clinic whenever they can or are asked by PT students or students from other courses. The opportunities to volunteer can range from being the subject of a grand rounds assignment, trying on a robotic exo-skeleton to learning with occupational therapists how to cook, brush her hair, put makeup on, and get dressed and undressed.
Slowly Lidia and Marcellus tick off goals they have achieved, like her being able to go camping with the family. Others remain though. She wants to walk around the neighborhood. “I want that so bad,” she says.
“You want to do more gardening outside?” Marcellus asks.
She nods. “I miss that.” Last year she tried carrots. She has new ambitions for her vegetable plot.
“Little by little I’m doing it,” she says triumphantly.
