How concerned should I be about getting the diagnosis correct at the first visit?

I taught a weekend course in Flagstaff this weekend. The students were engaged and thoughtful.  We had a patient case study to go over the principles of diagnosis and treatment.

The set up was a perfect reflection of daily practice: confusing and unexpected.

After going through the exam, the discussion, and the diagnosis, one of the students asked me about how confident I felt about the diagnosis and plan.  I said something off the cuff about 90% that she would have a major breakthrough in pain and confidence.

I could tell she was very worried about that.

Here is the disconnect: she thought that it mattered that I was absolutely correct.

What I meant is that the presentation, the diagnosis and treatment were things I had previously seen before.  Based on that experience and my clinical expertise, there was a 10% chance in my mind that I would be off on the prognosis and plan.

The diagnosis is never written in stone with complex presentations. As a clinician, I always have to be open to being wrong.  That is why our clinic requires a change in plan of care if we do not see 80% improvement in 3 visits. When giving a diagnosis, the purpose is to draw a line in the sand to allow for prediction of improvement.  It is should invite critical thinking and constant rechecking.

It is dynamic and changing.

Diagnosis in musculoskeletal medicine must be constantly scrutinized and I put as many barriers in place to stop confirmation bias.  If someone is not improving, that is a big sign that either the diagnosis or treatment plan are not right.

Medicine is not certain and we need to be OK with that while being as transparent as possible with the patient about this uncertainty.  That means constant re evaluation and inviting the patient to be as honest as possible about what they are feeling.

 

Marketing: Providing valuable information to the community

As a medical professional, I felt above marketing when I started my business. I did not understand that marketing or the concept of branding.

My perception and bias was shifted after a long conversation with another business owner.  He explained that marketing and branding explain what you promise to deliver to the customer.  Instead of trying to trick a client into your service, you are giving a clear idea of what your value proposition is.

I try to educate my community at every opportunity and this has become our dominate method of marketing.

I search for where the questions during a session are coming from, lay out a method for a client to reference, and then get a video or a post out about it.

It is simple and has been effective.  Every time I ‘market’ it is really just another tool to help my community.  Here is an example of a tool I use a lot.

 

Educating up and coming medical, health, and fitness professionals

Medical costs are outrageous. No one (not those within working or those getting the care) feel that this growth is sustainable in the long term. The only defense as a practitioner is to get as good as possible because it gives you options as the system shifts and gets disrupted. The only way to make sure you progress is to have a plan.

So at our clinic, you may find a undergrad student figuring out their next step into medicine as they intern.

Or medical doctor in their residency spending a day shadowing as I work through the physical exam with them.

Or a physical therapy student on their last rotation before practicing themselves.

Or physical therapist who has been in the field for years and wants a new perspective

I always want to impact their learning strategy and study plan. It seems that a good portion have not considered the value of getting a study plan in place prior to their first day of real practice.  I found pretty quickly that if you do not have plan, someone else will give you one. Or worse yet, no one will and you will be the same practitioner 20 years for now and the upcoming medical disruption might crush you.

Providing Self-Efficacy: The key to appropriate exercise selection

A patient arrives at my office.  She is about 20 minutes early and appears a little uncomfortable as I come up where she sits in the lobby.   She is clearly in pain as she stands and follows me back to my office.

We go through the usual pleasantries and talk about how she heard of our small place, what keeps her busy, and how her morning has been. She starts to move uncomfortably again while sitting, constantly repositioning one way then another.

I ask what brings her in.

She quickly answers with “it’s my back.”

She has seen numerous people ranging from chiropractic care and physical therapy to more recently consultations with neuro surgeons.  To her, it is a hopeless case. At least 4 medical professionals have cautioned her to limit her activity and to avoid any unnecessary sitting or standing or movement.

There is an MRI report detailing a significant lumbar pathology.  “It is clearly pressing on a nerve.”

I ask if she has numbness, tingling, muscle weakness or issues with going to the bathroom.  She says no.  With more talking, is was clear she had no idea why the hell her back hurts when she is otherwise healthy.  She was even seeing the most highly recommended people for her issues with minimal improvement.

When I first started to practice, this would lead into an exam where I tried to pin down what is hurting, then manual therapy to reduce pain, followed by exercises to target sensorimotor control, then progress until the patient returned to full health.

The results were good if a little long to achieve.

With practice and reflection, I grew my initial discussion delved more into the processes of the other professionals before me.

Its a key question – “have any of your medical professionals given you a way to manage pain?”

And then a follow up, “do you feel like you can manage your pain?”

I have yet to see a patient in this situation that answers with a yes (which is why they are in my office).

When I hear her say no, my entire focus of the session is to clearly identify why she has pain and how she can reduce it by HERSELF.

In this example, she had discogenic low back pain. It was exacerbated by sitting and transitioning. Transitional positions seem easy, but with pain and lack of clear cause, moving from lying down to standing, or standing to sitting, or sitting to standing can be a nightmare.

She learned a technique, volitional preemptive abdominal contraction, to reduce pain while moving combined with better recovery postures during the day.

A week later, her entire demeanor had changed because she was no longer afraid of her pain. She knew that if she did an activity and now her back felt worse, she had tools to make it go away.  This is the power of self-efficacy and it is the best tool in pain management.

Long term development: What does professional development mean

Does professional development mean you attended a lot of weekend courses or get a bunch of memberships to professional organizations?

I know I used to think so. I even remember hearing a colleague brag about how much continuing education they had in one year.

Oh man, you had 85 hours of continuing education when only 20 were required?

You are going to a new course every month?

The implication is that the continuing education course or passive membership in a professional organization means you change your practice pattern for the better.  This means better patient outcomes. Unfortunately, this relationship is far from clear.  Its actually been studied with the results indicating educational meetings alone are not effective in changing patient outcomes.

In my own experience, I believe that building a long term study plan with a clear purpose for patient outcome improvements is needed.  When I sit down to line out my monthly study efforts, the first goal is to highlight an area of need based on reviewing my caseload of the previous month.

My thoughts go something like this:

“I thought this patient should have progressed slower with this adductor longus strain.”

Why was I off?

Was it a knowledge issue? (meaning I did not know enough about tendon healing times)

Was it a skill issue? (meaning did my exam screw me up or did I suck at getting all of the information from the patient)

Now I do a brief literature review and get articles pertaining to what I think the issue was.  I lay out actionable items for my daily practice (meaning when I with a patient) and I use the verbiage and skill obsessively.

Here is an example- I used to misdiagnose hip impingements with adductor tendon lesions.  My prognoses and outcomes were not consistent and I was finding it frustrating to see huge variations in my outcomes (If you are wondering, huge variations in the same diagnosis mean something is off with what you are doing.)  So I really dug into my exam.  From my reflection, I felt that I getting bad information in my exam and interview. My error was occurring during my interview process, resistive testing, and special testing.

I corrected this by being very clear on what consistuted each diagnosis, what I should feel during each exam, and highlighting every case where either of these pathologies were possible differentials.  The variations in outcome diminished I understood that I had been diagnosing adductor longus lesions as a hip impingement because of sloppy exam technique.

In my opinion, long term development requires more of this type of thinking. When someone talk about going to continuing education, I always ask what changes you are making to your practice based on it.  If you did not make a change, then it was a wasted class.  Further, the education plan you give yourself is more important than any class you could attend.

New grad conundrum: The conflict between making money, job satisfaction, purpose, mastery, and motivation

After graduating from school, the first goal is to get a job.  No one wants to continue living the life of a poor student.

Perhaps a look at the job boards or posting the resume on linked in.  I knew my job needed to be in outpatient and orthopedics, but I know it may not be that simple for everyone.  Money enters into the equation immediately, especially with the rising costs of tuition.

In my own head, I knew that I wanted to make enough money to live a comfortable life while focusing on my career.  Career planning was a small part of one class in school.  This focused mostly on residency programs which were getting significant support from the professional organizations. It required a pay cut or significant tuition costs with unclear results in performances.

So I decided to focus on getting into a clinic that seemed  to follow my belief system in practice model. The money was less than other places but I was more focused on job satisfaction.

I loved the job for the first 6 months. Then there was a shift in practice patterns with greater and greater focus on the billing practice.  Once my purpose of helping people took a back seat to billing, I started to lose motivation.

When I did not have enough time to focus on improving my craft and developing mastery, I started to loathe my job.  I never hated the patient care but I lost so much motivation that an 8 hour day seemed arduous where as now I can go for 14, 15, or 16 hour days without slowing down.

In the first job, the recruiters know to use language like mentorship and patient or relationship centered treatment.  In most cases, they are lying.  I believe a more useful approach is to find another employee that has been there for 6 months.  At this point, the honeymoon period is over.

Ask about how many mentorship hours they have had?

Ask about how they feel supported?

Are they developing mastery?

How many office meetings are about billing?

Ask about turnover and ask if the leaders of the company are trying to optimize their day to day activity?

Does there seem to be a focus on keeping the employee as happy as the patient?

Is there a session where an older, more experienced colleague will outline a study plan or career plan with you?

Do they expect you to be better every year? How do they test that?

I would suggest that these factors would be much more accurate in determining your satisfaction with the job.

The business of cash based physical therapy: It’s not about the money but motivation

Cash based physical therapy is popular – the new fad of physical therapy replacing dry needling as the new thing to do.  Last month I was asked to be on a panel concerning the business of cash pay practice.

AND it got me thinking – what do I like this type of practice? Why are other people interested it? Why do I have students applying for internships at our place? Why did I leave a solid and very busy practice in an insurance based clinic?

A book about what motivates us in today’s world, Drive by Daniel Pink, gives some clues and it’s not the money. Instead the psychology of motivation is key to understand.

Pink highlights 3 primary motivators (motivation 2.0):

  1. Autonomy – the freedom to direct our own actions
  2. Mastery – the ability to focus on getting better and better
  3. Purpose – the need to have engage in work that is important and matters

Cash pay physical therapy hits each of these for me.

Autonomy – I control my daily practice to the highest degree possible.

Mastery – My office has numerous tools that allow me to create a study plan, implement daily, purposeful practice with feedback (the keys to mastery and expertise).

Purpose- I help people that have typically failed treatment at other places. It is an incredible feeling.

My last job turned from being a very motivating experience to a soul sucking drop into the abyss.  Perhaps the most confusing part was that I loved part of the job. When I interacted with my patients, I engaged with my work at a high level, moved into flow states, and the hours passed by. But the most common clinic meetings focused on billing and the insurances companies controlled part of my plan of care.

In the billing meetings I learned all of the complicated in and outs of what to use for my ICD 9 coding along with what reimbursed the best for each different insurance company. Instead of spending my time on pubmed or reviewing my notes, I spent time reviewing the productivity numbers.

This actually began to morph what I viewed as my purpose; I became the incredible billing machine.  This was the metric that obviously mattered the most to the clinic not the research or the patient outcomes or even the patient satisfaction ( I am not saying this was the intent of the clinic, but the focus on these areas but the emphasis on this).

To take is a step further, the volume of people I saw made reflection impossible.

Combining this with constant interruptions (I counted 60 once in a 30 minute window while working) and the lack of control in who scheduled when and pressures from insurance on approving more visits, mastery and autonomy were both crushed.

The practice I have now is about maximizing these motivators because I love walking into the clinic.  I get better as a clinician, which means I help more people, which means I get more freedom, which means I focus more on more craft, which lets me help more people…………..and on and on.

Whats not to love?

Excellence is the only option, but it takes practice, reflection and a plan

When I teach a one or two day course, I always include a portion on expertise. This is partially selfish. I enjoy improving this part and continual update it based on new books or videos that I see.

It all started with an article by Anders Ericcson.  (You can find it HERE.)

In this article, Ericcson talks about automaticity.  As a practitioner, you can develop and improve over the course of your career or you can get comfortable and stay the same.  By the end of a 20-30 year career, your performance will swan dive and actually worsen.  So the first year would be better than the 30th.

This scared me. I heard from teachers that all I needed was experience seeing patients. I examined and treated 1000 people, then I would be better just due to the experience.

Well, Ericcson blew that out of the water. More experience does not mean more skill. When a patient comes in and talks about how so and so has 20 years of experience which is why they went with them, I cringe. Experience is only valuable if it comes with a plan, reflection and feedback.

I developed a study plan when I got out of school that helped to keep me engaged with the process.  I put in place examination principles that give me time to practice the nuance of an exam 5-10 times per day. I used frequent check to gauge my manual and keep myself engaged in research. This is all to keep me from being the same practitioner tomorrow.

I fear being the same practitioner, which is why I won’t be.

Mentorship in the real world: Value must go both ways

My mentors became my mentors because of a mutual, beneficial relationship.

During my first year of physical therapy school, I spoke with a faculty about a project using the Functional Movement Screen.  My excitement about this screening tool had to be irritating, but I can only guess that my enthusiasm was just enough to that the faculty gave me a chance.

With my limited experience, there was not really  much I brought to the table. It was not a chance for me to piggyback of their work.  It was a chance to show I could be valuable to the field of healthcare.

Initially, I did not understand that all I was getting was a chance to show value, persistence, and dedication. Seriously, my only value was how hard I could work because I was not efficient, my writing sucked, and I had no value in study design or stats. My first attempt at writing the background for the study was so terrible that it became the example of what not to do.  We had a talk afterwards and it was a wake up call. I rewrote the background, completed the methods, carried out a reliability study, and got it published.

It took about 30 revisions and two years.  I gave more effort than I ever thought possible.

BUT it kicked off one of my most valuable relationships because I realized that as a mentee, there is an equal responsibility of effort. It is not a one way contact where the mentee just takes and takes.

Now as I take the mentorship role, I find that many students and colleagues view the mentor as a the source and the relationship as one way. I look at my mentors now, I keep trying to think of how to keep giving them back more and more value because it comes back to me ten fold.

No one likes a leech.  Try not to be one.

Systems thinking: How I do the same exam over and over and over

A mentor told me, “Do the same exam, the same way, every time.”

It is something that I took seriously and implemented. I made sheets of the exam, laminated each test, and practiced with every person that came in (I used the International Academy of Orthopedic Medicine initially before morphing it into my own style).

AND I was awkward for the first month.  It embarrassed me that I would forget parts of the exam.  I also hid the sheets from my colleagues because I did not want anyone to know that ‘this idiot’ needs a cheat sheet.

After each visit, I marked on my sheet if I got all the tests in the right order.  After  2 months of doing this with the low back exam, I moved to the hip. After a month, I owned the hip exam.  One month later it was the knee, then the foot then whole spine, then the upper extremity.

Each visit I made a point to do the exam the same. This repetition was a game changer for my hands and skill.  I started to notice capsular patterns and empty end feels and muscle guarding.  I diagnosed an ACL tear then a posterior horn meniscal lesion. It was not that I knew exactly what those were but I knew what normal was across a huge swath of different people and presentations.  When something not normal came up, I knew it instantly and started to dig.

The digging is only possible after I knew what normal was.  I defined the exam and then gave myself the freedom to explore abnormal.

It is common to ignore normal presentations but for me it has been the most valuable of teachers.