I won't call it a trend, because I think we are far too quick these days to slap a label on something that has been around for years and dub it as a 'trend' just because it now has a catchy title to spread around the various media circles.
Instead, we'll just call it a 'repeating scenario.'
And here's how this scenario has generally been playing out lately:
Scene 1: Research & Contact: Prospective New Patient calls or emails to get the details of my practice. They are frustrated with the fact that they have been through the system for a long while, they have seen various Physician specialties and numerous rehabilitation and wellness practitioners. Some express seeing some improvement, others not so much, but all have a continued problem with pain. Along this journey they have now amassed numerous diagnostic testing, reports, and varying opinions. They are now confused. The various practitioners they have seen have all given them different explanations -- if they gave any explanation at all -- and they have been given a conflicting list of absolutes. Orthopedic surgeon says there might be something to operate on, but the imaging is not conclusive. Therapist 1 says "never do X, Y, and Z, and in these scenarios keep your glutes tight and your core tight tight and keep that pulled up feeling." Therapist 2 says "no, don't keep that tight, instead stretch these muscles, like this....and make sure you never do A, B, or C, and avoid D every other Thursday".
Like a house guest who's long overstayed their welcome, the presence of pain has them frustrated, irritable, and bordering on hopelessness. The conflicting information between various medical & non-medical advice they are receiving has them confused to the point where they are now at a stand still. They don't know what to do, they are still in pain, yet they continue searching for their answer. Their search has now pointed them outside the 'normal' insurance-based system, and find my practice. Or they find yours - let's be honest, there are others working in similar model to mine, but we certainly are not the majority.
Scene 2: The Initial Visit: Prospective New Patient phone call has now become New Patient Evaluation, as the patient arrives to the clinic. New patient paperwork has been filled out in it's entirety, and along with it comes a stack of reports the size of a local Yellow Pages phone book (that's like the paper version of the internet for phone numbers in your local area, if there area any millennials or younger reading this who've never seen a Yellow Pages phone book and didn't get the reference!). They are very concerned with the content of their various reports, why one doesn't reflect what the other says, "and home come X shows up on this scan but there's no mention if it on this one..." They don't understand why they have pain. They want to know what tissue is at fault, what movement or activities should they stop doing, and what things can they do to take it away and prevent it from coming back.
To this point, this is just all normal initial patient visit stuff. Nothing special, nothing we as clinicians haven't been experiencing our who careers. It's this piece that has been new for me:
Scene 3: The Struggle for 'Who Knows Best':
As a Clinician -- you've gone through the schooling. You've obtained the degree, and hopefully the clinic experience to make you an effective clinician. Hopefully you've also been diligent about continuing education, and not just doing the bare minimum required by your state to maintain you license. You go into these initial patient interactions feeling that, clearly, you know best.
Problem is, so did every other clinician this patient has seen. Yet here they are. Still in pain. Still frustrated. Still unable to do all of the things they want to be doing.
As a Patient -- we often hear a variety of statements pertaining to self-awareness: "I know my body better than anyone else." "I have a very high pain threshold." "I know what I need or think will help but nobody seems to be listening."
Can we argue with these statements? Not really. After all, if pain is an output based on perceived threat to the body, would it not be right to think that the same brain will need to process a context in which the threat is removed. Ultimately, it's the brain at a subconscious level that makes that decision - not the Clinician, not the degree, not the certification or approach, and not even the treatment. Sure, those may all be variables, but driving that ultimate decision is the brain itself.
"But wait, that sounds like placebo?"
Maybe. Maybe not.
Can you say with 100% certainty that the manual therapy technique, exercise, tape application, ultrasound, mono-filament needle are the sole reason for why the patient experienced a reduction of symptoms?
You're sure? Can you really?
Because, I don't think any of us really can. From a mechanistic view point, sure, you can rationalize and theorize how the application of your treatment worked. You may even be right some of the time. The ultimate question still is -- WHY? Not in a Simon Sinek "Start With Why" sort of way, though that is now the case in much of what I do, and is a blog post for another time. I'm simply looking for the 'why' an intervention worked or didn't. And lately, the more I look and the more I search for the answers to that question, the more I am left wanting.
I agree with needing evidence and a solid literature base behind what works and what doesn't. I just wish we had a more meaningful literature base that gave us more 'WHYs' and less 'HOWs'. Because when you really look at it, even the current Clinical Prediction Rules are still 'HOWs' -- you have patient with Low Back Pain, they fit these criteria, you can be confident that manipulation will be successful. WHY?
And here's another not so secret truth -- Our patients are also seeking out the WHY. Unfortunately for both them and us, they have access to the internet, the medical & non-medical opinions of their friends, family, and co-workers. They come from a place of often diluted information and Dr. Oz ridiculousness.
To Be Continued... Clearly, there is much to be done in our world of research and evidence-informed treatment, so there won't be a final scene to this story, but a continuance. I would say there are a few suggestions that I have learned over time that have helped ease the initial patient scenario and help to guide them through a successful outcome:
1. Listen to your patient. Let them have a voice - you may end up being the first and only clinician to do so.
2. Listen to understand, evaluate, and come up with the best course of action. Don't simply wait for your turn to talk so you can spout your opinions.
3. Disagree professionally. This may sound like semantics, but if you disagree with the information they have been given by prior clinicians, do not disregard the information and do not criticize or talk down on the clinician who provided it. Simply share where your view lies based on your training and experiences.
4. Explain what you are doing and why you want to do it. Yes, it can be a difficult task if we don't know all the WHYs behind treatment effect, but you at a minimum should have a strong, science & experienced based theory to work from (note the lack of emphasis between science & experience, they both matter!). The more a patient is aware of what you are doing and the direction you intend to lead them in, the more likely they are to go there.
5. Going along with #4: The patient must be the responsible, active party in the process. This is not a 'fix me' mentality that we foster here, it is one in which the patient recognizes that it is their body, and they have the power & control to improve their situation.
6. Educate, Educate, Educate. That doesn't mean a list of absolutes that they can or can't do. It means teaching the patient to be self-aware, to recognize what they need to do to manage & improve symptoms, prevent symptoms, and improve their function. It means giving them up to date information, and helping them shift their paradigm away from chronic illness and into health & wellness.
Looking forward to your thoughts and feedback!
Athletes Physiotherapy - Las Vegas
Thank you for stopping by the Athletes Physiotherapy Blog! Kristopher Bosch founded Athletes Physiotherapy in Las Vegas, NV. He is a Father, physical therapist, athletic trainer, pilates teacher, & perpetual student!
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