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.


  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.