Ep 201: A note to my newly-graduated self, with Jared Powell

[00:00:00] The American Academy of Sports Physical Therapy and JOSPT are joining forces to bring you the second virtual SportsPT Conference on Saturday, the 2nd of November.

[00:00:11] This is the premier online event for people interested in sports injury rehabilitation in 2024.

[00:00:17] The three main blocks of content cover assessing and managing fear of re-injury, how approaches to pain monitoring have evolved,

[00:00:25] plus the latest in wearables and how to get the most out of wearables in your sports rehabilitation practice.

[00:00:31] You'll hear from world-leading clinician scientists including Drs Terri Chemielewski, Lori Mishner, Karin Silbernagel, Liz Welsent and Rich Willey.

[00:00:41] There's something for everyone at the Virtual SportsPT Conference so that you're in the best position to help the patients and athletes you work with.

[00:00:49] Join us on Saturday, the 2nd of November. Register now by following the link in the show notes and take advantage of the opportunity for up to 13 contact hours towards your continuing education.

[00:01:06] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice.

[00:01:14] I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy.

[00:01:19] It's great to have you listening today.

[00:01:26] The complex world of clinical practice in musculoskeletal rehabilitation brings many challenges.

[00:01:31] Some you might feel prepared for, while others, not so much.

[00:01:36] Today, Jared Powell is here to reassure us that no one expects you to have all the answers,

[00:01:41] encourages us to think critically and carefully when evaluating information,

[00:01:46] and to embrace a work-related niche that resonates with your passions and strengths.

[00:01:51] Jared is a musculoskeletal physiotherapist from Australia where he specializes in shoulder problems

[00:01:56] and is completing his PhD in shoulder pain.

[00:02:00] If you're early in your career or just about to graduate, you're stepping into a wonderful field.

[00:02:05] Here's some ideas on how to succeed as a compassionate and effective musculoskeletal rehabilitation specialist.

[00:02:12] Jared Powell, welcome to JOSPT Insights.

[00:02:16] Claire, it's a privilege to be here.

[00:02:18] Thanks so much for inviting me on.

[00:02:19] Thank you for saying yes to jumping on the podcast, Jared.

[00:02:22] It's really great to have you on board with us today.

[00:02:25] You've just written a letter to your newly graduated self,

[00:02:29] and the link to the paper is in the show notes for anyone who's interested in reading the full letter.

[00:02:35] What prompted you to share this letter?

[00:02:38] Jared Powell, MD, PhD

[00:02:38] I felt compelled to write this letter actually on the back of dozens,

[00:02:42] maybe if not of hundreds of messages over the years from often disillusioned students

[00:02:48] and new graduate musculoskeletal health professionals.

[00:02:51] And these individuals were expressing feeling lost, feeling confused and uncertain actually

[00:02:58] about how they should practice in the face of conflicting information from what they're taught at university

[00:03:04] to what they're reading in their own research and also what they're being exposed to online,

[00:03:10] particularly on social media.

[00:03:12] So there were a ton of friction points.

[00:03:14] I originally decided to write a blog covering advice about how to transition from being a student

[00:03:20] to an early career clinician from my experiences and reflections.

[00:03:23] But then I thought it would be more beneficial to get some other perspectives from my wonderful co-authors.

[00:03:29] So I got Jeremy Lewis, Chad Cook and Karen McCreech to come on.

[00:03:32] And then I thought this info is just too good to house in a blog.

[00:03:36] And in some ways, I think hearing that you are getting those messages from lots of people all over the world,

[00:03:43] and I hear from other leaders in our profession that they get similar messages.

[00:03:47] In some ways, I guess simply hearing that there are others in the same boat is a little bit reassuring.

[00:03:54] So I think that's one nice element of this letter.

[00:03:56] And also that you've gathered input from your wonderful co-authors, as you say,

[00:04:00] very experienced, great mentors in our profession.

[00:04:04] What are the key messages in the letter?

[00:04:06] I had like 20 talking points originally, and then you've got to trim all these things down to make it concise.

[00:04:12] Otherwise, it'd be an 8,000 word piece.

[00:04:15] I'll run through a few in no particular order.

[00:04:18] The ones that I think are really important.

[00:04:21] Number one, it might be a curious one, but it's embracing uncertainty.

[00:04:26] It's been really clear in the research over the last number of years that we as musculoskeletal clinicians,

[00:04:32] we need to be okay with uncertainty because uncertainty underpins a lot of, if not all of our clinical practice,

[00:04:40] because we're in the business of helping people with pain and pain is exceptionally complex.

[00:04:47] It's totally individual, private, rich experience that is influenced by almost an infinite number of variables.

[00:04:53] And that renders it very tricky, possibly impossible to be certain about.

[00:04:59] Having uncertainty shouldn't prevent action.

[00:05:02] You know, it doesn't mean you can't intervene.

[00:05:04] It doesn't mean you can't help.

[00:05:07] You absolutely can.

[00:05:08] But this, I think, should be done with a spirit of humility, of, you know,

[00:05:13] this might be wrong or this might need to be adjusted.

[00:05:16] And I think that's okay.

[00:05:18] You know, humans aren't machines.

[00:05:19] We are certainly not mechanics.

[00:05:21] And we often have to help people in this murky gray zone of evidence that, you know, this might help,

[00:05:29] but it also might not help.

[00:05:30] And we need to think on the spot, adjust and titrate the treatment as needed.

[00:05:35] You think you have, you know, a treatment algorithm.

[00:05:38] You have things that are guaranteed to be successful for anterior knee pain,

[00:05:44] for impingement syndrome of the shoulder.

[00:05:46] You could just keep going on and on and on.

[00:05:48] And certainly my, my early mentors in clinical practice, you know, everybody who came in,

[00:05:54] and this is no disrespect to them personally, but it's just the way that things were that traditional sort of

[00:06:01] patho anatomical or kinesiopathological approach to, to pain where somebody comes in with low back pain,

[00:06:07] you know, they've got tight hip flexors, you've got to stretch them out and mobilize a lumbar spine,

[00:06:11] and then do the core stability exercises.

[00:06:14] That was an algorithm that was given to almost everybody with every single presentation of low back pain,

[00:06:18] and some would get better and some wouldn't.

[00:06:21] And why they got better or why they didn't was a mystery to me.

[00:06:25] Or I just blame myself or blame, blame the patient early on.

[00:06:28] And that's not a, not a, not a good thing.

[00:06:31] Another point that we, we try to convey is using social media judiciously.

[00:06:37] I love social media.

[00:06:39] I use it every day, professionally and personally.

[00:06:43] I see its value.

[00:06:45] Social media content tends toward the extreme because you know, it's novel, it's captivating.

[00:06:52] It's like watching a train wreck sometimes, which people like to look at.

[00:06:56] But I think that new grads should be wary of these extreme narratives in health science,

[00:07:01] if they are online.

[00:07:03] And so in the paper we used kitchen's razor as a quote, which is what can be asserted without evidence can also be dismissed without evidence.

[00:07:12] It's just a really quick way that you new grads might consider for assessing the accuracy or veracity of a social media post.

[00:07:20] If somebody is just out there, you know, with no reference to any sort of evidence, then I think we can dismiss it pretty quickly.

[00:07:27] You know, not saying that all evidence is level one evidence and all evidence is sort of should be held equally.

[00:07:33] But at least if you're not going to bring in some evidence that you can use to actually do some further research on the topic, then I think we can dismiss that point of view pretty quickly.

[00:07:42] I also think new grads need to be a little bit aware of on social media of absolute strongly held opinions that are based more on personal bias and emotion rather than robust evidence.

[00:07:55] And I think this sort of ties in with the uncertainty point where we just need to hold our opinions quite loosely on a number of things because we don't have the evidence one way or the other often to hold these strong opinions.

[00:08:08] I think the therapeutic relationship is key.

[00:08:12] I think it's becoming increasingly acknowledged in research that the patient-clinician interaction can influence clinical outcomes at least as much, if not more, than the specifics of the intervention that they receive.

[00:08:26] So this might sound like a tritore, obviously, Jared kind of point of view, but I think new grad clinicians would do well to remember that much of their clinical success may depend on their ability to,

[00:08:38] to foster a strong therapeutic relationship with their patient rather than the specifics of their, you know, expertly crafted exercise program or manual therapy intervention.

[00:08:48] And I think that last point ties beautifully to the idea of bringing humility to that consultation, Jared, because if you are truly showing up with humility,

[00:08:56] you're open to listening to the person in front of you and accepting their story and validating their own lived expertise as important knowledge and wisdom to build into that encounter and that discussion that you both have to try to figure out, well, what's going on here and what do we do next?

[00:09:15] Totally.

[00:09:15] Yeah.

[00:09:15] Again, shared decision-making, patient-centered care, all of these wonderful things are so important in modern day healthcare.

[00:09:21] Yeah.

[00:09:22] And thankfully we're moving away from this paternalistic sort of authoritative approach to care.

[00:09:28] Jared, a lot of what we're talking about here is stuff that doesn't necessarily come through in a physio program or a PT degree.

[00:09:37] At least it certainly didn't when I was studying physio back in Australia.

[00:09:41] How long did it take you to feel comfortable in your skin as a physiotherapist?

[00:09:45] And I guess what helped you to find that sense of ease or that sense of comfort and balance?

[00:09:53] Yeah.

[00:09:53] Arguably, I don't feel confident still to this day, you know, and I think that's okay.

[00:09:59] I'm 15-ish years into my physio career.

[00:10:02] I'm still learning.

[00:10:04] I'm just about to finish my PhD, you know, and I still find myself feeling wrong every single day, both clinically and in a research perspective as well, which is okay.

[00:10:13] So, I graduated, yeah, like I said, about 15 years ago and I graduated full of beans and confidence as, you know, sort of mid-20s male as a physio.

[00:10:24] You've been through all of this education and you want to get out and I wanted to work in private practice and in sport.

[00:10:31] And so, I launched straight into a private practice career and I had a really busy caseload of like 60 to 80 patients per week straight out of university, which, you know, you do the math on that.

[00:10:42] And it's up to 20-ish patients a day.

[00:10:45] Sometimes, you know, for 20 to 30 minutes at a time, not including notes, not including letters to doctors and phone calls to insurance companies and all of this.

[00:10:56] So, it was an excruciating workload when you think about it.

[00:11:00] And so, I did this for a couple of years.

[00:11:03] Burnout happened as would be predicted.

[00:11:05] And so, I needed a bit of a lifestyle change.

[00:11:08] But throughout this time, I just had so much self-doubt, self-deprecating thoughts, which was unusual for me.

[00:11:16] You know, I didn't really suffer with any of that through university or anything.

[00:11:19] And at night, I would think about my patients and their clinical presentations incessantly, wondering, you know, if there was something that I could have done to get them better.

[00:11:29] Is it my fault?

[00:11:30] Should I have done this hip flexor release or quadratus lumborum release or this mobilization release?

[00:11:35] Or did I do the technique appropriately or for the right person?

[00:11:38] Or did I just miss, you know, one set or one rep of that technique, which would have helped them?

[00:11:43] And so, I had a little bit of a crisis after a couple of years and then I fled overseas to live in London, as every young Australian does just about.

[00:11:51] And then while I was living overseas, because I was commuting a lot, because I didn't have a car, I started reading a lot of research.

[00:11:59] And then also, this is around the time where sort of physio podcasts were coming out for the first time about a decade ago.

[00:12:06] So, I listened to a lot of these podcasts with lots of influential people from our profession.

[00:12:10] And then I remember distinctly coming across some research from Jeremy Lewis, challenging traditional approaches and narratives to shoulder pain, specifically rotator cuff related shoulder pain.

[00:12:22] And it really helped me because, not because it gave me any solutions or fixes, quite the opposite, you know, it proposes more questions than answers.

[00:12:31] But it helped me to realize that knowledge is always in a state of flux, you know, it's constantly growing, it's constantly changing, and that's science.

[00:12:40] So, that really helped me because if like seasoned theories and seasoned narratives around shoulder pain were wrong, then it helped me to be like, ah, it's okay.

[00:12:53] If that was wrong and we believed that for 50 odd years, then I'm okay, you know, not to have all the answers right now.

[00:13:00] And it's a process of learning and it's a process of continual growth and reflection.

[00:13:04] The philosopher Bertrand Russell says that the unwise are often cocksure whilst the intelligent are full of doubt.

[00:13:11] So, if any listeners are out there and they're struggling and they have doubt about the decisions, maybe you're just too intelligent.

[00:13:19] It sounds like it was a bit liberating to get to this point, Jared, where, as you say, you were reading a lot and then it's kind of liberating you to say, actually, I don't have to know all of the things.

[00:13:30] I don't have to have every single answer.

[00:13:32] That's okay.

[00:13:32] No one's expecting me to.

[00:13:34] Totally liberating.

[00:13:36] Again, it ties into that uncertainty point, you know, just being okay with being uncertain and being okay with having a trial and error based approach to care.

[00:13:45] You know, if somebody comes in, you have a hypothesis, you might test that hypothesis with an intervention.

[00:13:50] You know, you're treating the whole person.

[00:13:52] You're not just treating their pathology.

[00:13:53] All these kinds of things, going back to these interpersonal skills and communication skills, things that were certainly not taught or I certainly wasn't taught at university.

[00:14:03] You know, all of that stuff for me is really key and fundamental to being a good physio.

[00:14:08] So, yes, it was liberating knowing that you don't have to have all the answers and that you can operate successfully.

[00:14:15] And this is, I think, a key point.

[00:14:17] You can be a really good, successful healthcare professional by operating in this grey, uncertain zone if you just lean into the things that I think that really matter.

[00:14:28] It sounds, Jared, like those early days in your career were quite full of pressure, self-doubt you talked about, and that kind of cloying feeling of someone's going to discover that I'm not good at my job, which is a really awful place to find oneself.

[00:14:43] And I want to use this opportunity to talk a bit about mentoring, because I think we hear a lot about mentoring and everyone says, oh, no, you should have a mentor.

[00:14:51] But mentoring is one of those things, again, it's not really taught in university or in school, but I think it's one of those things that we could each recognize when it's done well, and equally, we could recognize when it's not done well.

[00:15:06] So what does effective mentoring look like for you?

[00:15:10] Mentoring and mentorships is exploding right now.

[00:15:13] Every social media influencer seems to have a mentorship these days, rightly or wrongly.

[00:15:19] It's not something I ever thought about up until a few years ago.

[00:15:23] My mentors have just been my bosses at work or my lecturers or tutors at university.

[00:15:29] It's not something that I've sought out specifically, and I wish that I did.

[00:15:33] Some have acted as, you know, researchers acted as a mentor to me, actually.

[00:15:38] And then sort of emailing researchers and authors of articles has really helped me.

[00:15:43] But it's not, you know, it's not been anything structured and I really wish I had engaged in.

[00:15:48] But good mentoring to me, and this is just my perspective and experience.

[00:15:53] Some people might want other things, but mentorship should be this like bi-directional relationship between the mentor and the mentee about wanting to get better, wanting to learn, wanting to progress, being open to being wrong, being open to change.

[00:16:12] With an appreciation of there's a lot of things that we don't know.

[00:16:16] And I think this has to come from both the mentor and the mentee.

[00:16:19] So it should just be this learning journey where the mentee is encouraged to challenge the mentor about their narratives and theories and certainly vice versa as well.

[00:16:31] This mutual spirit of criticism and critical examination.

[00:16:37] It's not criticism of anything personal.

[00:16:39] It's a criticism of ideas.

[00:16:42] And I think the aim of this critical back and forth should be progress and not victory.

[00:16:46] And the mentor doesn't have to win and they don't have to convince the mentee that this is what they need to do.

[00:16:51] So I think if you're a mentee or a prospective mentee and you're thinking about getting a mentor, remember that your mentor will have their own worldviews.

[00:17:00] They'll have their own biases.

[00:17:02] They'll have their own sociocultural background.

[00:17:04] They'll have their own prejudices.

[00:17:06] That will influence how they read the evidence.

[00:17:09] It will influence how they see physiotherapy.

[00:17:11] They're certainly not immune to thinking mistakes and cognitive biases that we all make and have.

[00:17:17] So don't put them on too high a pedestal.

[00:17:20] If you're looking for a good mentor, I reckon first try to make sure that the person is good, honest and decent.

[00:17:27] You know, it's tough to assess that.

[00:17:30] But I think, you know, that is a really good starting point with a proven record of thinking critically, impartially, who is reflective, you know, who thinks about things, about how they're doing things or how they made mistakes or how they could get better.

[00:17:44] And is capable of evolving and changing their views when confronted with appropriate evidence.

[00:17:48] Appropriate evidence.

[00:17:49] And I'd also tend to steer clear from those who are just yelling the loudest.

[00:17:53] I really like how you frame the knowledge journey and the bi-directional nature of mentoring.

[00:18:00] And I think that also ties into advice now is often shaped around having multiple mentors.

[00:18:07] Because as you say, different people have different worldviews, are coming from different perspectives, and we all benefit from having those differences in our lives.

[00:18:14] And I think it's perhaps a bit unrealistic to expect there's one person who can fulfill all of those roles.

[00:18:21] I guess the other thing to say about mentoring is that as the mentee, and you alluded to this, you are an active participant in this relationship.

[00:18:31] So sitting back and expecting that someone's going to find you and talk with you and somehow magically know what you need is probably also a bit unrealistic.

[00:18:40] So figuring out what is it that I want to get out of this is going to help you get the most out of that relationship, whatever it looks like.

[00:18:47] Whether it's Zoom chats or whether it's catching up in person or you see each other every day because you're in the same building.

[00:18:53] It's going to look different for different people.

[00:18:56] Yeah, 100%.

[00:18:57] And I've had some experience informally mentoring new grads and students and early career clinicians.

[00:19:04] And I learned way more from them than perhaps the other way around.

[00:19:09] Like I just love this like dance of ideas and the back and forth and that whole process of just like wrestling with a problem, whatever that problem is, you know, and just seeing where that whole wrestle and dance takes you.

[00:19:22] It's just one of my favorite things to do.

[00:19:24] And I really, I would encourage mentees to have to try and embrace that and have the gumption if, and your mentor should allow this and encourage and facilitate and promote this to sort of have that rigorous almost debate.

[00:19:39] I think it's really important.

[00:19:41] You're well established in your clinical practice.

[00:19:43] As you mentioned earlier, about 15 years now as a practicing physio.

[00:19:48] You teach physio students, you teach clinicians and you do research.

[00:19:52] How do you approach continuing to work on your skills as a physio?

[00:19:57] And I guess what do you do to make sure that you're not getting too stuck in your own ways of thinking?

[00:20:03] Early on, you know, it was about, you know, there's this real hunger to add to your skill set.

[00:20:09] And that is usually with like doing a dry needling course or an advanced manipulative therapy course or something, you know, and that's totally fine.

[00:20:20] As I've matured and evolved in my practice and I've been in the game a little while, just staying on top of research is what keeps me evolving.

[00:20:30] Because pretty much every theory or hypothesis or belief that I've had about some treatment has been falsified or challenged heavily over the last 10 years.

[00:20:42] And as we do more robust research, we're starting to see that a lot of the things that we hold near and dear in physiotherapy and in surgery and in lots of sort of musculoskeletal care is not as good as we once were.

[00:20:56] So that keeps me humble every single day.

[00:20:59] And in my PhD, I've had to like confront a lot of these uncomfortable truths and pivot and change my ways a little bit.

[00:21:07] So that's been really helpful.

[00:21:08] Also, just continual reflection, you know, like build a career on reflection and curiosity, but be kind to yourself and, you know, don't expect that you're just going to sail through and you're going to have the answers on day one.

[00:21:22] And that's what's expected.

[00:21:24] It's totally not.

[00:21:25] Like musculoskeletal care and musculoskeletal pain is so messy and complex.

[00:21:30] And you're dealing with so many factors which can influence outcomes.

[00:21:34] So I think just reflecting on that and being okay with that is a really good start.

[00:21:39] For me, being a good physio is like the basics.

[00:21:43] So it's be an expert diagnostician.

[00:21:46] It's be able to provide accurate information about prognosis and natural history.

[00:21:51] Be an excellent communicator.

[00:21:54] And to people from all walks of life and consider their specific health literacy as well.

[00:21:59] Don't speak to everybody in the same way.

[00:22:02] If you can, you know, like be this clinical chameleon, which is a real challenge.

[00:22:06] If you don't feel comfortable talking to somebody, then I think we should encourage that patient, that individual to go somewhere else perhaps.

[00:22:13] And that's okay.

[00:22:14] But if you can try and adapt the way you speak to individuals, make people feel safe and supported in your care and also empower them to take control of the health journey.

[00:22:24] So they're like big ticket items.

[00:22:26] So for me, upskilling is not just a matter of collecting new techniques or new treatments.

[00:22:33] It's constantly refining and mastering those basics.

[00:22:38] And so that's sort of where I've ended up as a physio 15 years in.

[00:22:42] It's not just collecting these new treatments.

[00:22:44] It's refining those skills that I really undervalued and perhaps didn't have early on in my career.

[00:22:52] And this is where good mentoring can help as well.

[00:22:55] If you have somebody who keeps you accountable, keeps sort of poking you and prodding you with different perspectives about a patient or a clinical presentation or a friction point that you're struggling with, then that can really help you as well.

[00:23:08] Jared Powell, the clinical chameleon.

[00:23:10] That's a pretty good moniker, I reckon.

[00:23:12] Jared, thanks for joining us for being a bit vulnerable, sharing the progression of your career.

[00:23:18] I think it's so refreshing to hear from people who we might look to and say, oh, I don't know how I could ever get there.

[00:23:27] I don't know how I could ever feel as comfortable in my skin as a physio as I perceive these other people.

[00:23:32] It's nice to hear that all of us share these common uncertainties, these common doubts in ourselves.

[00:23:39] So thanks for being vulnerable and sharing those with us.

[00:23:41] And thanks for joining me on JOSPT Insights.

[00:23:44] You're welcome, Claire.

[00:23:45] It's been a great conversation.

[00:23:47] Thanks so much for having me on.

[00:23:48] This is a great podcast, Claire.

[00:23:49] I love what you're doing.

[00:23:50] I listen to every episode.

[00:23:52] So keep it up.

[00:23:57] Thanks for listening to this episode of JOSPT Insights.

[00:23:59] For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice,

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