Early-Career Advice from Pelvic Health Physical Therapist, Nicole Cozean, PT, DPT, WCS, CSCS

How did you decide to pursue pelvic health physical therapy? What is your background?

I hadn’t actually planned to specialize in pelvic health in physical therapy (PT) school or the first years after graduation.  My first interest in the area came in PT school when I was assigned the pelvis and pelvic floor for an anatomy project.  I was fascinated by the complexity of the region (and still believe a strong understanding of the underlying anatomy is crucial for a pelvic physical therapist).  About 15 years ago, Hoag Hospital asked me to create a pelvic health program. They allowed me to pursue a fellowship program with an experienced local therapist, and I was able to take amazing continuing education courses from some of the leaders in the field at that time.

Even while treating pelvic patients, I still had my foot in the orthopedic world, splitting time between the two.  I began to realize I was having a much bigger effect on the lives of my patients with pelvic issues than I was in helping people recover from sprained ankles or hip replacements.  The transition was punctuated by a patient who had been experiencing painful intercourse her entire life. For the first time in her five-year marriage she had pain-free sex with her husband, and broke down crying when she said that pelvic PT had saved her marriage.  After that, I threw myself headfirst into the pelvic PT profession, and haven’t looked back since!

Tell us about your practice. How do you work and what do you specialize in?

I founded PelvicSanity (www.PelvicSanity.com) almost three years ago, with the desire to bring the highest quality care to complex pelvic health patients.  We elected to stay out-of-network with insurance companies to provide hour-long (or longer) treatment sessions at each visit.  We now have five physical therapists working in the clinic (including myself) along with a massage therapist, and still specialize exclusively in pelvic health.

We work with a wide variety of patients within the field.  We see many pelvic pain patients, who may be diagnosed with interstitial cystitis, endometriosis, vulvodynia, chronic prostatitis, or who don’t even have a name for their diagnosis.  Many patients present with orthopedic issues, including low back, hip, groin, or tailbone pain. We work with the pregnant and post-natal population, making pregnancy as comfortable as possible and treating common (but not normal!) post-natal issues like low back pain, incontinence, diastasis recti, painful intercourse, and pelvic pain following delivery.

About two-thirds of our population are women and one-third are men. Since pelvic health conditions are still poorly understood and misdiagnosed, most find us after doing their own research, not as the result of a physician referral.  About 70% have been to at least one other physical therapist prior to treatment at PelvicSanity. We can really make an impact by educating others and having the confidence to know we have information to impart to medical doctors and other practitioners.

What do you do outside of treating patients?

One of the best things about our specialty is the opportunities that exist outside of direct patient care.  It is such a new and burgeoning field; we need more research, educational materials, social media presence, and especially awareness.  As you go through the first years of your career, I would encourage new graduates to also be thinking about how they can help more than just the patients in front of them.

My first venture to help patients beyond our clinic walls was our first book, The Interstitial Cystitis Solution.   I was consistently frustrated by all the other resources on the condition.  They were either written by physicians and focused solely on the bladder, or by non-professionals espousing unproven remedies.  We set out to create a resource for both patients and their providers that could improve the care for patients across the country and around the world.  In working with that IC community, I also got involved with the Interstitial Cystitis Association, becoming the first physical therapist to serve on their Board of Directors.  In that capacity, I can influence how the largest patient-focused organization presents information to its members and physicians. I’m glad to see more pelvic PTs being represented in both professional and patient-focused organizations – we need more of this!

We also think having a social media presence in the field is really important.  We want to normalize discussions of pelvic health; hopefully the field will get to a point where preventative care is widespread and the first phone call when symptoms arise is to a physical therapist.  Social media gets the word out and is a great way to raise awareness of our field and profession, as well as marketing our own services. We are active on both Facebook and Instagram where we collaborate and offer an online support group for patients.

All members of our team work in educating other practitioners in the field.  For me, that’s teaching a course on interstitial cystitis.  I also lecture at the local physical therapy schools, providing at least a basic education about the pelvic floor.  We’ve also lectured to physician assistants, educated Pilates teachers and personal trainers, and worked closely with physicians in the area.  And don’t forget that orthopedic physical therapists need education about what to be on the lookout for when it comes to pelvic health!

Finally, we have a remote consultation and out-of-town program.  In our remote consultations, we work with patients to help them understand their condition, evaluate their current treatment plan, and come up with an action plan moving forward.  This involves some information on musculoskeletal health, but also advice on finding medical professionals, medication options and other ideas for treatment.

Our out-of-town program is available for patients able to reach Southern California. We’ve now seen patients from five different continents, including from the countries of Saudi Arabia, India, Ireland, Italy, Denmark, Canada, Mexico, and more than 20 US states.  We offer week-long and two-week programs, though some patients have stayed for as long as six weeks and we’ve even had a patient move to the area indefinitely for treatment.

What advice would you give for early professionals in pelvic health?

Probably the most important recommendation would be to find a mentor or a way to collaborate with others in the field.  That might be easy if you’re in a specialty practice with an experienced team around you, but can be difficult if you’re the only pelvic PT at an orthopedic clinic or building a program.  I’d really encourage newcomers to the field to find a way to build a collaborative community. The Section on Women’s Health can be a great resource.  Find someone in your local community who has been in the field. We created a Facebook group to connect physical therapists from around the world. However you do it, guidance from more experienced PTs in the field can be an invaluable resource.

Another area I feel like is important for our field is to fight for hands-on treatment time with your patients and try not to allow insurance companies to dictate treatment. Again, this is easier in some settings than in others. We strongly believe that we need the hour-long sessions we offer for complex pelvic floor patients, but that may not be realistic in all settings.  If you’re in an insurance-based practice, fight for as much time hands-on with patients as you can get.

Don’t underestimate the power of doing your own research.  It’s fine to tell a patient that you don’t know the answer – just make sure that you go look it up, so the next time they come in you have an answer for them.  As a profession, we’re far to quick (in my opinion) to send patients back to a physician when we don’t have an answer for them. Unless you’re working with a great specialist that you trust to understand the musculoskeletal aspect of their condition, you’re probably a much better bet to help a pelvic floor patient than a physician.  After all, they’ve probably seen several doctors before they reach physical therapy – they shouldn’t just be sent back to medical management the first time they have a tough question. If you are sending them back to a physician, it should be for a specific reason – you have a test you think needs to be run or that they would benefit from pain management or another medical intervention.  We need to take responsibility for our patients. That doesn’t mean having all the answers, but it does mean working through the questions with our patients.

What do you look for when hiring?

New graduates may be encouraged to know what we aren’t necessarily looking for is experience in the field.  Much more important is a willingness to learn and take your professional development into your own hands. Continuing education courses are a great start.  There are many continuing education physical therapy courses offered out there, these courses are a great start.

We train all of our new hires – whether they have experience in another pelvic health setting or not – for at least a month in our practices and techniques before they even begin seeing patients.  Training continues with weekly meetings and collaboration with the other members of our staff, but we also expect our physical therapists to put in the effort to improve on their own. If a patient asks a question you can’t answer, it’s your job to find the information.  We want members of our team who are constantly learning and improving.

Perhaps the most important quality we look for is the ability to connect with patients. We can train techniques and knowledge, but the ability to meet a patient where they are and get them to buy into their treatment is what makes a great physical therapist.

Ancillary skills are becoming more and more important to our profession.  If you can write a blog post or craft a social media post, that brings value to the clinic beyond direct treatment.  Connecting with other professionals in the field creates a network of like-minded practitioners. Knowledge of yoga, Pilates, or personal training are all valuable attributes and can lead you into an area of expertise within the specialty.  Even just being well-rounded, with outside hobbies and interests, makes it easier to connect with patients.

Is there anything you’d like to say to new graduates?

I feel like the first five years of your career are incredibly formative in the direction of your career.  Do your best to build good habits and find mentors you respect. This is also the time of your career (and life) when you may be able to take a little more risk and prioritize your learning and professional development.  With the student loans we all have it can be daunting, but consider more than the paycheck when you’re looking for a place to work. Finding a position that challenges you and provides opportunities for growth can alter your trajectory for the entire remainder of your career.  Don’t be afraid to try different things and areas within pelvic health! One of the best things about this profession we’ve all chosen is the variety of career paths and opportunities it affords, and this is true even within our pelvic health specialty.

Best wishes to all of you!