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.

 

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.

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.

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.

Social media and the negative consequences on practitioner skill

So I do not like Facebook (or maybe I like it too much which is why I do not use it).

I mentor several students and new professionals. Each of these people have amazing drive and commitment to excellence.

They also have Facebook.

AND this is a problem. It is clear that each a community on Facebook that put up new articles and videos relating to their field. Instead being helpful, it shakes their confidence because they may be doing something different than a famous online personality.

I had a Facebook account when it first colleges back in mid 2000s. Like most people, I put up photos and interacted with family.  By the time I dove into physical therapy, I wanted to make sure I connected to as many other professionals in heath and fitness as possible.

I was convinced that these people knew everything. They had every answer with a depth of knowledge that blew my mind.

Then reality hit me. I presented research at biomechanics conference and spoke with one of these personalities. Surprise, surprise – they were human. Not only that, from the conversation I gleaned the holes in their thought process that was never present in their online process.

By the time I started to practice, I quit using Facebook. I trust my own deep thoughts and published articles more than any blog post or new training course.

Staying committed to a study plan has propelled me to heights that would not be possible if I tried to stay current with all of the garbage on Facebook (or twitter or instagram, etc).

Getting good with building rapport, writing, manual therapy, examination, or teaching takes reps with feedback following a plan. I suggest getting the study plan built, shutting down the Facebook profile (or unfollowing a lot of people), and put in the work to get better.

 

What type of relationship do I want to have? Community and lifelong commitment in healthcare

It may sound silly, but I hope I get to have the same patients for the rest of my career. I will take new clients, but I enjoy the relationship with my community and seeing people year after year, day after day.

When I first started my company, the commitment to the community was the major driving force. I wanted a tribe.  I needed to feel valuable my people.

I felt burned out by the ‘turn and burn’ philosophy (if you have not waited tables, this means getting the customer in and out as fast as possible so the next person can sit at the table). I wanted time.

Time to think and reflect.

Time to grow and mature.

Most of all, I wanted time to build a relationship that mattered.

In that type of relationship, I have to be honest.  I am compelled to tell someone I expect you to get better in 3 visits, but it may take 10.  Or if the pain resolves in one visit, I have to make sure I tell them it is OK to cancel the next because I know the trust is more important than the money another visit could bring.

There are some side effects.  In a community, you have role and if you do not live up to that role, the consequences are nasty. The members speak to each other and would know if someone received sub standard care. There would be a quick and negative repercussion.

BUT I think this is the future of healthcare.

Would you keep a friend waiting in the lobby for 45 minutes?

Would you double book a friend?

Would you stay late to make sure they get in the same day?

Would you value the relationship over earning more money?

Would you lie about your knowledge on the problem?

I hope the answer is clear. My interest is in the ongoing relationship and the commitment between the practitioner and client.

 

 

 

Strive for efficiency (not the most possible exercises)

During a conversation last week, we veered onto the topic of exercise prescription in therapy. I remembered the therapeutic exercise class in physical therapy school AND I repeated the mantra, “sets, reps, and how many times per day.” In class, I received a bad grade if the sets and reps were not clearly defined. Well, my opinion has changed.  I told my colleague that I try to give one and only one exercise. She was obviously surprised. I went further and stated I rarely if ever give a set and rep scheme along with severely limiting the amount of exercises.

Why?

  1. Efficiency is critical for compliance. Giving two when one is sufficient reduces the likelihood that either will be performed. Giving three when one is sufficient is guaranteeing non-compliance.  Giving more than three means you are most likely using an extender to allow for billing another unit.
  2. Clarity of purpose. When I give a clamshell exercise, I draw a line in the sand. I am saying that their gluteus medius is not active and needs to be. I make sure they are own this exercise. They go till it burns in the right place. When they come back, there is already a neuromuscular change happening.
  3. Progress is clear.  Either the exercise worked or it did not.  Now I can refine what I am thinking. I have yet to see a patient perform 10 exercises correctly. Sometimes one can be difficult.  For example, I changed up my practice of giving self mobs because patients kept provoking their pain. I knew that this was the case because I did not muddy the waters with other activities.
  4. Removing the negative is more important that adding the positive.  This helps me emphasize that there is likely something in my patient’s day to day activities that is driving the problem. Adding an exercise to counter this will never be as good as eliminating the negative activity.
  5. Sets and reps are less important that tools that they can use to self manage. I will admit that I like the long term development model.  Once pain is gone, I shift my clients to strength training professionals.  Here the sets and reps are critical. For my practice, I like exercises that can be used to manage pain or impairment immediately.

In the end, exercises are useful tool, but the mindless home exercise program that gives a patients 6 pages of things to do just cheapens the value of physical therapy.