Balancing Best Practice and Business in Physical Therapy Practice

[00:00:00] Welcome back to another episode of the Modern Pain Podcast. This week we speak to Andrew

[00:00:03] Rothschild, a physical therapist who talks with us about some of the challenges clinicians face

[00:00:07] when balancing best practice with the business realities we face in healthcare.

[00:00:12] We know the business realities if you work for a private practice, you work for corporate,

[00:00:17] there are no, regardless of how you look at it, there are business realities of having to

[00:00:22] you know, cover your expenses, salaries, everything else. And we know that reimbursement is going down

[00:00:30] pretty consistently from many insurance companies. Physios coming out have increasing school debt,

[00:00:38] which is a big issue in our profession. We all want to get paid what we think we are valued at.

[00:00:44] Andrew gives us an example of lateral elbow pain and shows us how we can provide care

[00:00:47] that is high in value yet respects the realities of the natural history of the

[00:00:50] condition we're seeing at hand. You know, we have a conversation with the patient is letting them

[00:00:55] know upfront, this is likely how long this condition might take to heal. It does not mean

[00:01:00] you're going to be here for that long or see me for that long. But just so you know from

[00:01:05] the beginning, this is how long it really might take to get a significant, you know, 85 90%

[00:01:10] recovery. However, during that time, we can certainly work on things like improving strength,

[00:01:17] improving your tolerance to the things that are painful, gripping, lifting, you know, opening jars,

[00:01:22] all those kinds of things that are very classically painful with that type of activity,

[00:01:26] that type of condition, you know, symptom modulation, that we can help reduce some

[00:01:31] of that that pain level from a certain level down to a much more manageable level,

[00:01:35] improve your tolerance to exercise. We go over some sound business advice that has stood the

[00:01:40] test of time. Now if you treat the patient, you take care of the patient, the business will

[00:01:46] kind of take care of itself. Now that will drive all your business metrics. If you treat the patient

[00:01:52] the way they deserve to be treated, and that's something I really do believe.

[00:01:55] Andrew and I also discussed the difficulties clinicians especially our younger clinicians face

[00:02:00] when trying to navigate the polarizing opinions of social media. How do you see,

[00:02:04] you know, younger clinicians best navigating the minefield that is social media?

[00:02:09] If you're someone who struggles to rectify what you feel is best practice with the

[00:02:12] business side of healthcare, this episode is for you. My one favor I ask of you is to subscribe,

[00:02:17] comment, or review the podcast, wherever you listen or watch so we can help more clinicians

[00:02:21] help more people. Enjoy the episode. This is the Modern Pain Podcast with Mark Cardula.

[00:02:29] Welcome to the podcast, Andrew. Thanks for having me, Mark. It really is an honor

[00:02:34] to be here. All the Physio podcasts out there, I used to listen to so many and have narrowed it

[00:02:42] down to four now on my iPhone and yours is number one. I mean that's high praise, man.

[00:02:49] I appreciate that. It's always humbling to come across Physio's and I respect all the work

[00:02:54] you're doing. I know you work with Erson Religioso and do some great things online. I see your

[00:02:59] work and your opinions online. We obviously share a lot of views on some things and we'll talk about

[00:03:04] those today. So thanks a ton for that. Great to have you on the show. I thought today we'd have

[00:03:10] you on and talk about some of the common issues that we're seeing with some of the younger

[00:03:14] clinicians that are coming up. You and I talked before this, it's a tough world to grow up in

[00:03:20] as a Physio with social media. There's a lot of pulling folks in 14 different directions

[00:03:24] and I often see clinicians who are struggling to figure out things. We're going to get into

[00:03:29] the social media piece but first I wanted to, one question we had in our community and one kind of

[00:03:34] challenge that one of our community members had was he was working in a clinic and really trying

[00:03:40] to develop maybe a different way of practicing. Some of his colleagues are I guess seem to be

[00:03:45] more passive care and doing things which again it has its place but he was struggling

[00:03:50] because he wasn't seeing patients for as many visits. He wasn't getting as many productive units

[00:03:57] I guess as his colleagues who are approaching it differently and the discussion was around,

[00:04:01] well hey natural history is going to take care of this thing. Why should I be intervening in

[00:04:05] over medicalization? I think those are fair concerns I think for sure. What are your

[00:04:11] thoughts on when Physios who are trying to maybe practice with more person-centered views

[00:04:16] and understanding natural history. I know you just had a discussion in your company about this

[00:04:20] so I'd love to hear kind of your perspectives on it. How would you kind of advise a clinician

[00:04:25] who's kind of toiling with the struggles of hey natural history and all these things

[00:04:29] yet I'm an employee of a company and I think there's a lot of value we can still

[00:04:34] provide within natural history. What are your thoughts on that? Yeah I would agree 100 percent.

[00:04:40] I think it's definitely a tough position to be in and I find myself also in that position somewhat

[00:04:48] as well from time to time because you do feel that pressure sometimes of you know you have

[00:04:55] to meet, we know the business realities if you work for a private practice, you work for

[00:04:59] corporate there are no you know regardless of how you look at it there are business realities

[00:05:05] of having to you know cover your expenses, get salaries, you know everything else.

[00:05:11] And we know that reimbursement is going down pretty consistently from many insurance companies.

[00:05:18] Physios coming out have increasing school debt which is a big issue in our profession. We all

[00:05:24] want to get paid what we think we are valued at so and those are big things and especially

[00:05:30] with larger companies there's a lot of other expenses that the average clinician doesn't

[00:05:35] know about other things that go into you know being a company whether it's a small

[00:05:40] company or even a larger company. So it is that you know you have that pressure of

[00:05:47] how do we get paid? We get paid by seeing patients I mean that's sort of the reality of

[00:05:51] it and then the challenge is at the same time if you're a conscientious clinician

[00:05:58] which you know people if people are involved in your community, people are

[00:06:02] active on social media it's very likely they are a very conscientious clinician and so they

[00:06:07] want to do what's best for their patients. They want to get to have the most up-to-date

[00:06:12] information you know so that's and that can be you know they're not always on the same

[00:06:17] wavelength in terms of how they apply to each other. So you don't want to over medicalize

[00:06:24] things like back pain we know are very often very over medicalized. So it is really a balance

[00:06:31] and it's always going to be somewhere in the middle right? I mean you can go to the extreme

[00:06:36] and if you're on the extreme of just letting natural history take its course and seeing

[00:06:40] patients incredibly infrequently it's going to be very hard to stay in business.

[00:06:46] At the other end if you're seeing patients unnecessarily it's also not good in terms

[00:06:51] of driving up health care costs. It's not necessarily a good reflection on quality of care.

[00:06:56] It's not necessarily good for the patient because there's a lot of you know what kind

[00:06:59] of value are they getting in terms of what they're having to pay out of pocket even

[00:07:02] with health insurance all these kinds of things. So the short answer is it's truly somewhere

[00:07:07] in the middle and the longer answer is you have to apply a lot of these things.

[00:07:15] This is the same for any kind of evidence-based practice. You have to

[00:07:18] apply that to your individual patient right? You have to see what's going to best fit their needs.

[00:07:26] Some of that could be you know depending on what the situation is what are their other health

[00:07:32] related contributing issues, other comorbidities they might have, other kinds of health issues,

[00:07:37] other types of lifestyle issues they might have in terms of exercise, sleep, nutrition,

[00:07:43] all these types of things that we know go into a good comprehensive plan but also can affect

[00:07:49] every type of musculoskeletal condition out there at the same time. So while the treatment

[00:07:54] that they might need for their musculoskeletal condition might have a very large natural

[00:07:59] history component to it, it does not mean that your intervention is not going to be effective

[00:08:04] in other ways. The other side of that coin is that what is the cost of not doing any

[00:08:10] intervention because sometimes even though the treatment might not necessarily speed up

[00:08:16] the recovery process for a particular condition, it also can prevent it from getting worse and

[00:08:21] sometimes the lack of treatment can actually make something worse or cause someone to seek

[00:08:26] out other types of interventions which could be a riskier, be more expensive, see nowhere near

[00:08:32] as effective and kind of send them down a potential you know wrong path so to speak.

[00:08:38] But then you can also have the treatment that you're doing working on cardiovascular fitness,

[00:08:44] working on general strength, working on balance. I mean we talk you know a big thing with older

[00:08:49] individuals not trying to stray too far off topic but you know fall risk, sarcopenia as

[00:08:55] you get over the age of 60 you know doing these kinds of things even if you're treating

[00:09:00] them for low back pain there's no reason why you can't work on leg strength, power,

[00:09:06] you know things that help them get up off the floor, help them get up out of a chair,

[00:09:10] improving balance, you know working on lateral hip strength is an important component from

[00:09:13] a balance standpoint. So you can address all these things which may or may not have a direct

[00:09:17] impact on the thing that they were coming to see you for but are going to be a big impact

[00:09:22] on their overall health. So I think that's where you can really justify treating someone with

[00:09:28] a certain level of frequency even in the context of natural history with a certain

[00:09:34] condition that it may not change it that much. There's a lot of value we can provide within our

[00:09:40] care that yes natural history is going to tend to you know do its thing but there are people who

[00:09:47] may not be doing things that are encouraging natural history they may be continuing to

[00:09:52] overload or under load or do things that don't really maximize the trajectory towards that and

[00:09:57] again people are going to you know nitpick well we don't have perfect evidence on that

[00:10:01] but that's again the n equals one situation that you have in front of you. You have a person in front

[00:10:05] of you who you can see are we making progress, are we getting them closer to their goals,

[00:10:10] are we getting them more to life, are they able to you know gain some of the other secondary

[00:10:14] benefits from our care so completely agree. One diagnosis and we kind of mentioned it before

[00:10:19] we went on there and I think it would be valuable for folks to kind of look at okay

[00:10:23] like lateral elbow pain it's a common one we'll see you know lateral pecondylgia you

[00:10:28] know we know there can be various things that that are impacting that. If you have somebody

[00:10:33] with that who walks in the clinic because the research as you mentioned you know it doesn't

[00:10:40] really appear that regardless of what we do it's going to really speed things up greater

[00:10:43] than eight to twelve months. I liked what you said about if we just decide to say hey yeah

[00:10:50] eight to twelve months and well you'll be fine and go on your merry way. I think we really

[00:10:54] put patients at risk right. I'd rather a patient be hanging out with me where I'm not going to be

[00:10:59] invasively invading their body with you know scalpels and things. I'm not saying there's

[00:11:04] any time and a place for it of course but I think obviously we sometimes over intervene

[00:11:08] when if we just gave natural history a chance. I think sometimes injections obviously have some

[00:11:13] sketchy support for their use in certain scenarios as well but if you have somebody

[00:11:18] with that that's coming in the clinic lateral elbow pain what would be some things as far

[00:11:22] as some ways you'd kind of still give that patient value person-centered care and yet still

[00:11:29] you know having an employer or a manager who's pleased that you're still maintaining

[00:11:35] somewhat of a productive workload. Yeah and that's a good example because it can be a

[00:11:42] fairly common condition. I think one part of it too is also the differential diagnosis of

[00:11:49] that condition because it can there's a couple things that it could also be referred from the

[00:11:54] neck right and even if it's not a direct cervical referral there is research that's out there

[00:11:59] that shows that about 30 percent of people who have lateral elbow tendinopathy have some

[00:12:04] underlying cervical component whether it's actually active painful neck pain or not but

[00:12:09] some sort of maybe mobility restriction soft tissue restriction in the cervical spine.

[00:12:14] You also need to differentiate between like a radial nerve entrapment and those kinds of

[00:12:18] things which can certainly change the prognosis and change the treatment. So the differential

[00:12:24] diagnosis piece is I think really really important for all musculoskeletal things

[00:12:30] but with like lateral elbow in particular the other piece that's still important is somebody's

[00:12:38] comorbidities health status those kinds of things make a big difference on the prognosis

[00:12:43] as well someone who's diabetic someone who's a smoker that's going to significantly change

[00:12:48] that time frame from a recovery standpoint and so that information makes a big difference in terms

[00:12:54] of how we educate the patient and help set up their expectations for recovery because if they're

[00:13:00] like I said someone who's a little older someone who's diabetic and they're like how long is this

[00:13:03] going to take well that six months through a year might actually be on the low end

[00:13:08] for someone like that because if we know how well they're they're going to be healing

[00:13:11] also depends on how well their diabetes is controlled met other medications how what their

[00:13:16] lifestyle is like from an exercise standpoint but I think given all that you know we

[00:13:23] conversation with the patient is letting them know up front this is likely how long this

[00:13:28] condition might take to heal it does not mean you're going to be here for that long or

[00:13:32] seeing me for that long but just so you know from the beginning this is how long it

[00:13:36] really might take to get a significant you know 85 90 recovery however during that time

[00:13:43] we can certainly work on things like improving strength improving your tolerance to the things

[00:13:48] that are painful gripping lifting you know opening jars all those kinds of things that

[00:13:52] are very classically painful with that type of activity with that type of condition

[00:13:58] you know symptom modulation you know we can help reduce some of that that pain level

[00:14:02] from a certain level down to a much more manageable level improve your tolerance to

[00:14:06] exercise for a lot of people not just with you know lateral elbow tendinopathy but they

[00:14:12] will have avoided or be avoiding lots of activities that are painful and we know that

[00:14:17] yeah for a certain point you may need to minimize some of those things that really

[00:14:21] exacerbate the symptoms but usually it's sort of the gradual exposure to those types of

[00:14:28] loads and stresses that is really important to from a recovery standpoint and from a even

[00:14:33] a functional improvement standpoint so really giving them permission to be able to move

[00:14:37] and realize that they're not necessarily causing any significant damage with a certain

[00:14:41] level of discomfort and a certain level of activity i think that's a huge key i mean the

[00:14:46] education piece i think people type i think it's easy to gloss over the education piece as

[00:14:51] something that's not a skilled treatment but i think it's so valuable like you alluded to

[00:14:57] before in that without that people can or left their own devices that kind of seek out

[00:15:03] information and that can be from not you know not very reputable sources whether it's

[00:15:09] through dr google or other people other people on on the internet instagram and

[00:15:13] youtube and these kinds of things we know the type of people that are potentially out there

[00:15:18] that might be some might be well intentioned i think some are not so well intentioned

[00:15:23] and can lead people astray into doing into other things that are really not helpful and

[00:15:27] potentially harmful so i think we have you know one of our jobs as pts is to be really

[00:15:33] well informed about all types of things not just in terms of what we do but some of the

[00:15:38] stuff that's out there so we can give people the best information so they can make the best

[00:15:43] informed decision and you can really still justify treating these patients at you know

[00:15:48] sometimes just once a week once every two weeks for you know sometimes you know a few months

[00:15:53] so they may get in you know six eight ten visits but instead of getting that in within

[00:15:58] three four weeks you're spreading that out and you're also because we know of the recovery

[00:16:03] times you're really seeing them through different stages of the recovery and different

[00:16:07] levels of function and helping them adapt along the way especially for someone who's maybe

[00:16:12] working at a higher level that wants to get back to a higher level of maybe physical

[00:16:16] activity sport those kinds of things so it's more you're giving them a lot of independence

[00:16:20] but you're also guiding them versus like overly intervening i think definitely excuse

[00:16:28] me definitely agree with that i i think you know there's there's this difficulty with the

[00:16:35] you know these false dichotomies that exist on social media we're going to get into that i think

[00:16:38] one other thing that when we have people that were kind of supervising the recovery

[00:16:43] we're we're checking in with them like not just physically how they're doing but we see

[00:16:48] how they're coping how they're managing like you know you see people where you can just see

[00:16:54] the frustration the anxieties the depressions and things like that and to me those are often

[00:16:59] the biggest trajectory predictors of anything i mean the research supports so much that you

[00:17:04] know psychosocial factors so just checking in with people as they're recovering and like you said

[00:17:08] sometimes we can move to once every two weeks three weeks or something to where we're still

[00:17:13] kind of having touch points with that person making sure everything's going well you know

[00:17:17] early on it's the whole calm it down maybe you're doing some supportive things maybe you're

[00:17:21] doing some joint protection stuff or some you know maybe even using some some things that they

[00:17:24] can use to kind of avoid you know continuously aggravating things and then just building things

[00:17:29] back up we know tendonopathies especially kind of are a load game you got to eventually get them

[00:17:35] tolerating load and it's going to be a process over time that as you mentioned as long as we're

[00:17:40] honest upfront i haven't met a patient who's like you know i've definitely had patients not

[00:17:44] the most excited to hear that it's going to take you know six to twelve months or eight to

[00:17:47] twelve months but the honesty of it and i've had frank discussions with people out and said

[00:17:53] that you know there's going to be an a never-ending line of people who will line up to say

[00:17:57] they can fix this sooner and you're more than welcome to have that if you want to give it up

[00:18:02] to i'm not going to stop you from doing it it's just there's ample research and i've seen this

[00:18:06] time and time again with patients that it's probably going to take this this time period

[00:18:10] and i think we can do some good things in here and you know some patients might explore

[00:18:13] some other things and that's fine but i think more often than not patients are pretty on

[00:18:17] board with your honesty and i've had earlier in my career you know when i wasn't really

[00:18:22] well versed on the research and evidence you know i had this six to eight weeks and

[00:18:26] things are going to be better just that generic tissue healing thing and then definitely setting

[00:18:30] up yourself for some failure with with patients with like a tendon opiate or things where we

[00:18:34] know that's going to be a longer term process i want to circle back a little bit to kind of

[00:18:39] the employer's perspective right i think there's probably some less ideal examples out there i

[00:18:46] guess of folks that are really layering on extreme amounts of passive care and things that

[00:18:50] maybe aren't super evidence supported but i think there's some passive modalities be it

[00:18:54] driving needling be it you know various other interventions that can help modify the pain

[00:18:59] experience to help people maintain engagement in their valued pursuits of what they need to do at

[00:19:04] work or home or in life that they want to do how do you see that as an as an employer i

[00:19:10] maybe i don't not i don't believe you're in business ownership per se but i think you you

[00:19:15] have you know some standing in your company i know they they invite you to speak on some

[00:19:19] of these topics i'm just curious if you're kind of looking down on this from as a as a business

[00:19:24] owner obviously i think as a business owner we have a responsibility to try to provide the best

[00:19:28] care possible that isn't just financially motivated that's you know person motivated

[00:19:33] because i think we if we point our our self to that i think our business builds because

[00:19:38] that's going to provide a lot of goodwill in the world and people will be you know reward us

[00:19:42] with their trust and and you know return when pain unfortunately as it does in life returns

[00:19:47] so what is your thoughts on on the perspective of somebody as a business owner or practice owner

[00:19:53] who's trying to navigate this similar natural history versus the demands of running a business

[00:19:58] and keeping things financially viable um and i have i have the advantage of i've been you

[00:20:05] know i've been doing this for 18 years i've worked for physician-owned clinic i've worked

[00:20:10] for three corporate practices two private practices i mean my most recent i worked

[00:20:17] for a private practice for over 10 years the owner just retired and now we're under the

[00:20:22] umbrella of a larger company and i'm in the position of being a you know clinical director

[00:20:27] kind of running our practice trying to keep it uh run the way it did under our owner and

[00:20:35] you know his mindset and something that uh some of them we know both know jerry durham has said

[00:20:41] is that you know if you you treat the patient you take care of the patient

[00:20:46] the the business will kind of take care of itself you know that will drive all your business

[00:20:50] metrics uh if you treat the patient uh the way they deserve to be treated that's something i

[00:20:55] really do believe it's always like a fine line i've been in corporate situations that were

[00:21:01] really uh not great for me in the way that i approach patient care and it it conflicted

[00:21:08] and it didn't end well um because there was that really significant pressure for volume

[00:21:16] and i think there's a lot of you know clinicians who find themselves out there in those in those

[00:21:20] situations where they're maybe expected to be seeing you know three plus patients an hour and

[00:21:26] i think that's a very unfortunate um thing for patient care i think it's very unfortunate

[00:21:31] for our profession so that's those are the situations that you know if if clinicians find

[00:21:37] themselves in and they really it's really enough of a struggle that it's affecting them

[00:21:42] from a personal and professional standpoint it's certainly worth considering trying to

[00:21:47] find another type of situation i think that's the not it's not an easy solution but i

[00:21:52] think that's a solution people need to consider from there for their long-term

[00:21:56] you know mental and professional um health because that's the big thing that's also

[00:22:01] driving a lot of burnout in our profession um i think the other part of it is the challenge

[00:22:06] of and i've also seen this in a couple different corporate entities is that they tend

[00:22:10] to look at things sometimes on a week a weekly basis like what are your numbers this

[00:22:15] week what are your numbers that week and that can be very you know that short-term

[00:22:20] type of thinking i think is not always a great option either because you know if you see

[00:22:26] somebody too frequently in a short period of time to drive to make those weekly numbers

[00:22:31] look good that could be a turn off for a lot of different patients from a financial

[00:22:36] standpoint from an outcome standpoint there are a lot of insurance issues nowadays where they

[00:22:41] are really cramping down on the number of visits they they give and if you burn through

[00:22:45] somebody's insurance in a in a time frame where that doesn't allow for adequate healing

[00:22:50] that can have a negative impact on their recovery and so it also just how their their their

[00:22:54] perception of you and your practice um and i think it's you know your patients are

[00:23:01] sometimes your best marketing sources right i see patient i've seen patients for years

[00:23:05] thankfully for different things but then i see their friends and i'm seeing their family and

[00:23:10] i'm seeing their their their neighbors these kinds of these networks are very important and

[00:23:15] not just from a again a business marketing standpoint but you treat people well that will

[00:23:20] have a big difference long term on terms of down the road you know again your business because

[00:23:27] patients will seek you out because you've done you've done them you've done by them in the

[00:23:31] right way and kind of like you said before you know i tell younger clinicians like it's

[00:23:38] it's not our job to tell people what they want to hear a lot of our conversations are

[00:23:43] telling things that they don't want to hear but like you said they the most people will

[00:23:49] will value that and respect that and appreciate that because you're not selling them something

[00:23:55] that's not really going to work just for just for money you know um and i think also going

[00:24:02] back to what you said earlier there is there is value in you know i'm i got i did my

[00:24:07] manual therapy fellowship in 2012 and there's a lot of value still in the hands-on care even some

[00:24:16] of those those you know quote unquote passive things because we also do know there is stuff

[00:24:22] beyond just what's happening at the tissue level from a from a from a manual therapy

[00:24:27] standpoint there's there's a lot of that trust building that comes from manual therapy it feels

[00:24:33] good patients that helps patients buy in and appreciate what you're doing you know it's the

[00:24:38] challenging the perception of physical therapy being quote unquote pain and torture

[00:24:43] you know so you go in you give them something that they want given some that they like where

[00:24:48] it feels good that's going to help kind of build build that trust build that therapeutic

[00:24:53] alliance which we know has a positive outcome a positive um effect on a good outcome

[00:25:00] and it'll also help you know it's a combination of giving people things that they want and also

[00:25:06] giving more of what they need sometimes but once you give them a few things they want it's much

[00:25:10] easier to say hey now we need to do this because this is really the stuff that's going

[00:25:14] to help you from a long-term recovery standpoint um so you know having said all that i think this

[00:25:21] is making this a very roundabout answer but um you know in terms of that balance with the

[00:25:29] the pressures of maybe certain of certain productivity numbers you're still seeing

[00:25:35] the patient you're still providing education you're still providing maybe manual therapy

[00:25:39] you're still providing exercise so you're giving them very high value care

[00:25:44] and it may not be again from the frequency that may you know if there's a corporate

[00:25:49] pressure to see people three times a week at a certain point i think there's a there's a

[00:25:56] rationale to challenge that with with potentially your employer because it's also looking at the

[00:26:01] number of visits the the duration that the the evidence you know if a if an employer

[00:26:09] was challenging me on one i'm seeing somebody at a certain level for a certain frequency

[00:26:14] for a certain condition i have a lot of data to support my clinical decision making

[00:26:19] and so then it then it comes down to having that you know having that conversation with

[00:26:25] whoever needs to have that conversation and see how well it goes from a support standpoint

[00:26:30] and if you're not being supported as a clinician when you're providing high quality

[00:26:35] care this kind of goes back to my earlier point is that maybe that's also not the right

[00:26:40] fit for you too and so and that's a very challenge when you're a young clinician you have debt you

[00:26:44] don't want to be without a job it's hard to find that that that that's the right spot sometimes

[00:26:52] but sometimes it takes a little bit of you know you really don't know sometimes how well

[00:26:57] the places fit for you where you work until you've you know especially when you're pretty new

[00:27:01] and unless you've tried out a couple of them yeah sometimes the best way to find the right

[00:27:06] spot is find a few wrong spots and better identify what the right spot is for you for sure i would

[00:27:11] wholeheartedly agree i think there's opportunities to really have show you that you're really

[00:27:18] providing care that's highly supported it's not like you're going way off the playbook of best

[00:27:23] practice evidence-based care especially if you're getting your pressure and i agree there's a

[00:27:28] time and a place where eventually if you're portraying and you know backing yourself with

[00:27:33] all these things that we spoke about and you're not getting that support then yeah maybe there's

[00:27:38] some tough decisions that need to be made on the clinician's part and and and maybe finding

[00:27:44] that right spot for you for sure let's bring this to what we talked about a little bit earlier

[00:27:50] and it goes to social media because you and i had a little bit of a chat about this before

[00:27:55] we went on air and it is a tough world and we've had this discussion a little bit in other

[00:28:00] episodes of younger clinicians and some of these really false dichotomies it's either this or that

[00:28:08] and we mentioned jeff more you know one of our friends and a great influence here in

[00:28:14] our profession so shouldn't be this or that it's an and thing right it can be an and thing

[00:28:19] in our profession and being able to kind of understand the nuance of things instead of

[00:28:24] making these massive polarizing dichotomous false dichotomous statements on on best practice

[00:28:30] and what you should do or what you shouldn't do and and then really i just don't enjoy how

[00:28:35] we portray other folks even if i don't agree with the way somebody's practicing i'm not going to

[00:28:39] you know insult them personally or call them you know you know demeaning names and stuff

[00:28:43] like that i don't think that serves anybody personally but it's out there it is what it is

[00:28:48] i'm wondering what's your advice or thought process when you see social media evolving to

[00:28:54] what it is today and then you've been out for a bit as well to where how do you see

[00:29:00] you know younger clinicians best navigating the minefield that is social media

[00:29:06] i think it's it's very tough you know um i've gotten caught up in things myself

[00:29:12] yeah even even as a seasoned clinician because it's you know we have certain beliefs we have

[00:29:17] certain biases and when they get challenged and maybe challenged in a negative way or there's

[00:29:23] things out there that we were considered to be not really appropriate care it's hard not to get

[00:29:28] upset by it but at the same time i find social social media twitter instagram podcasts have

[00:29:36] been incredibly valuable for me even as a clinician in my growth just because you

[00:29:41] have access to great clinicians that you would otherwise not have access to from all over the

[00:29:48] world australia england you know here in the states um you have you've accessed you know to

[00:29:54] authors of research papers who will post their stuff or if you can contact them they'll send

[00:29:58] you it for free so you don't have to try to reach it behind a paywall so you have these

[00:30:03] great clinicians that you know are out there having conversations and giving information

[00:30:10] that you can really grasp and incorporate into your into your practice and into your

[00:30:16] knowledge base but at the same time you also have people with very strong opinions people who are

[00:30:20] very charismatic they can easily sway opinions into another into other areas and a lot of these

[00:30:28] clinicians i think are very well meaning a lot of them are you know have done a lot of great

[00:30:32] work whether it's research or have a lot of experience in clinical practice and so as a young

[00:30:37] clinician when you don't maybe have the experience or the full knowledge base it's hard

[00:30:43] to know who sort of to you know hit your horse to who to believe who's right who's wrong where's

[00:30:49] this and that and again the answer sort of is it's it's it's it's it depends right it's

[00:30:56] either or it's all of it they're all kind of right they're all nothing is 100 percent um

[00:31:02] you have to kind of figure out a little bit for yourself and explore and i think you have

[00:31:07] to quit certainly being open-minded and being accepting of a lot of different beliefs

[00:31:12] not being too entrenched in one kind of camp i think that's been a problem historically

[00:31:18] maybe a little less so nowadays with physical therapy when there was the sort of the guru

[00:31:23] driven aspect of pt practice you had like your mateland camp you had your mckenzie camp you

[00:31:28] had your paris camp your all your other different camps and it was very like us versus them

[00:31:34] uh kind of approach and i think they all have merit they all have great things about them none

[00:31:39] of them are completely comprehensive they all are lacking in certain things and

[00:31:43] i did my fellowship through the ola grimsby institute we didn't get it really into anything

[00:31:48] with sleep related or other type you know certain thing we didn't get into the nuances

[00:31:52] of pain science sort of as we know it now it was a much more sort of pathological tissue

[00:31:58] specificity driven model which again is very valuable in some ways but also not valuable

[00:32:04] in other ways it could be overly if people overly go into that approach you can be missing

[00:32:10] a lot of stuff from the psychosocial aspect of of people's experience um so i think it's

[00:32:16] you know kind of like what bruce lee said in that you kind of figure out what works for

[00:32:21] you and discard what doesn't work and then kind of work it into your own sort of

[00:32:26] what you're what your own sort of values are and what your own experience has taught you

[00:32:30] and see how that applies best it was a little bit of trial and error i think

[00:32:34] with all these different things and kind of seeing what works for your patients and

[00:32:38] you have to constantly be sort of reflective in your practice without being overly you know

[00:32:44] it's it's easy to get you know when something happens good that is because of what you did

[00:32:50] on the same side if something doesn't go well it's not always because of what you did

[00:32:55] so you have to kind of be able to take a little step back i think and approach it

[00:33:00] sort of agnostically in how you're treating patients and kind of really seeing what works

[00:33:05] from your approach because in some patients you know maybe they don't need any hands on stuff

[00:33:11] and you can be a very much high exercise component person but in some people it

[00:33:16] actually means there are conditions where it's really not appropriate to do a lot of exercise

[00:33:21] um depending on what depending and also depending on what the individual's expectations are what

[00:33:26] their beliefs are so it is tough it is tough and i think part of it is when people post stuff

[00:33:34] the other thing is you need to also research it for yourself you can post little tidbits from

[00:33:40] an article which sound really good but when you go into the actual article it's a lot more

[00:33:46] nuanced than what that person may have claimed online the quality might not be actually

[00:33:51] representative of what the actual information is it may not truly be as positive as it sounded

[00:33:59] it's this is a funny example of i remember this is years ago when it was i think it was a

[00:34:06] british a local british tv station was talking about an article in which like two

[00:34:12] alcoholic drinks were just as effective as like you know strong pain medicine for you know for

[00:34:18] pain relief and it was presented in a positive light as an hey look you got two beers and

[00:34:23] you don't throw and it's just as effective as you know strong opioid pain medication i went

[00:34:28] and looked at the article and it was that negative article it actually led to increased

[00:34:33] alcoholism as a result you know so it's like no it was presented very positively but the

[00:34:39] actual article was not positive at all about about the conclusion so i think that we're just as

[00:34:45] guilty of that too especially when something meets our bias we want to present it in the

[00:34:51] positive light so i think that's the hard part is for clinicians you want to pick you want

[00:34:55] to it's finding people who to trust right i think that i can't remember who said it but

[00:34:59] it's like there's so many people out there you can't possibly read everything yourself

[00:35:04] either it's just too much but if you find certain authors of research that seem to be very very

[00:35:12] consistently good and thoughtful and unbiased and follow them people same thing with people on

[00:35:19] social media you'll find certain people who present things very uh you know or less

[00:35:25] biased at least very thoughtfully and it's really more following them more than the people

[00:35:30] who are on the extremes of either one or the other yeah it's it is it is hard and it comes

[00:35:38] down i think you you mentioned a few things there with like this whole reflective practitioner

[00:35:42] thing i think thinking about your decision making and what you're doing and kind of

[00:35:47] being purposely reflective on you know doesn't mean you have to do it with every single

[00:35:52] decision you make but maybe you pick some cases where you're really thinking about your

[00:35:55] decision making i mean we should be doing it within every case a little bit of it

[00:35:58] evaluate hey is this the right decision am i getting the right response um what did i have

[00:36:02] some bias going into this decision you know having some of that we call it that metacognitive

[00:36:06] where you're thinking about your thinking and really having that process and to me it's it's

[00:36:12] you're not going to be able to learn that in school i just it just doesn't happen that's

[00:36:16] not the place that you learn that on the front lines in the clinic i feel and i've been

[00:36:20] this clinician where out there i didn't have anybody helping me develop that process i felt

[00:36:24] for a good eight to ten years prior i got in the fellowship the clinical process thing was just

[00:36:30] toss a chunk of you know the you know the bucket of mud against the wall see what sticks

[00:36:35] and having no idea with what parts of that mud were making the change and then really getting

[00:36:39] more honed in with a good clinical reasoning critical thinking framework really allows you

[00:36:44] to kind of zero in on that and become a much more effective practitioner and it comes down to

[00:36:49] me mentorship and excuse me maybe you get mentorship in a formal program like a residency

[00:36:54] or fellowship that's great if you have the options to it you have the access to it you

[00:36:57] have the finances that allow it i think students are in a challenging situation where

[00:37:04] you know they're coming out with some significant financial load and burden when it comes to

[00:37:08] student loan debt and then to and i have these discussions with with students like

[00:37:13] regularly and like i'm thinking about a residency but man i got to take a significant

[00:37:17] pay cut and and i i don't pretend to think i'd always be able to make that decision i

[00:37:22] you know i think sometimes you know you take a little pay pay decrease but it's man that to me

[00:37:28] it's like your your it's an investment in significant opportunities for for growth what

[00:37:34] what's been your experience with mentorship and where do you see that fitting into

[00:37:39] especially when you have this dichotomous no or yes yet yet in the clinic it often becomes

[00:37:44] it depends and it depends depends on a clinical process to be saying in this n equals one

[00:37:49] situation with this person with where they're at psychosocially with where their condition is at

[00:37:54] severity irritability all those things that we think about what's the best decision i can make

[00:37:58] today that's a hard situation to grasp when you don't have somebody that kind of helped

[00:38:02] guide the way what's been your experience with mentorship when it comes to that

[00:38:05] developing those processes that you spoke of i think mentorship is key um i think it's so

[00:38:11] important i think it's it's hard for young clinicians again depending on what their

[00:38:16] employment situation is does their employer offer any kind of mentorship type uh structure like a

[00:38:22] true structured mentorship i think a lot of places will claim oh yes we have mentorship meaning

[00:38:27] there's somebody there who's an older clinician that you can ask questions to

[00:38:31] but it's not really like any kind of formal structured program and that's one thing i've

[00:38:36] done uh where i work several years ago kind of started developing things sort of a very

[00:38:41] structured with a six month structured mentorship program if we hired new grads kind of bring

[00:38:47] them along so they weren't just thrust into a high volume of you know patients it was

[00:38:52] they started off at a lower volume we spent several hours a week one-on-one meeting

[00:38:56] going over cases going over specific conditions these kinds of things

[00:39:00] but like i said not a lot not a lot of places will offer that specifically so certainly

[00:39:05] for you know people coming out new clinicians new grads i think that's really important to ask

[00:39:11] your potential future employer about if they have any kind of program like that i think

[00:39:15] another big advantage of social media and just technology over the last you know 10 years has

[00:39:21] been um the development of online mentorship programs like i said i'm involved in one

[00:39:27] with dr urson relief yoso i know you're involved in one there's ice physio there's a

[00:39:31] whole handful of ones out there that are all really really good so there's those kinds of

[00:39:36] opportunities which are just come at a much lower cost and people who are willing to sort

[00:39:41] of put in the time and effort outside of work to really work with younger clinicians and help

[00:39:47] them along i think that's a big a big advantage nowadays that wasn't available when i was

[00:39:53] coming out of school um and i think it's so hard you know that's one reason why i sought

[00:40:00] out sort of a residency fellowship is that i i do very well with with structure so you can take

[00:40:06] a lot of weekend courses and get a little bit of information from all of them you can always find

[00:40:11] you know some good nuggets from any weekend course i think but how do they all fit comprehensively

[00:40:17] into a clinical reasoning framework uh can be it's just sort of like you're just piecing

[00:40:23] things together and for some people that might work but i think for a lot of people having

[00:40:27] some sort of um consistent framework uh consistent clinical reasoning process that goes throughout

[00:40:34] the entire sort of curriculum i think is really important um and that's something that took me a

[00:40:40] while i was out for four or five years before i started getting into sort of residency

[00:40:44] fellowship and even you know expanding beyond them because it is it's my knowledge base has

[00:40:49] improved so much since then just from other types of things um i think and i think it's

[00:40:54] people are people seek out i think what quote unquote the sexy stuff is manipulation

[00:41:01] dry needling i mean those are the most popular courses um in any i'm sure kind of program

[00:41:06] because it's it's it's fun to do um you know i think patients see see some value from it but

[00:41:14] it's it's still not nearly as important as i think clinical reasoning um differential diagnosis

[00:41:21] i think because if you don't have those two right everything else after that is going to be so much

[00:41:27] less effective you know knowing manipulation is great but knowing when not to do it and when

[00:41:32] it's really inappropriate to do it is really important um that could be a difference between a

[00:41:39] a very serious situation happening or not happening um but it's also like if you don't

[00:41:45] have that clinical reasoning process that that good evaluation process that really affects the

[00:41:50] quality of the treatment going down down the road in terms of if you're not going on the right path

[00:41:53] or not and also being able to correct if you're all realize you're on the wrong path how to just

[00:41:57] kind of correct back into it because we're all going to do that regardless we're all going

[00:42:01] to miss some things or whereas things are different than what we thought coming in but

[00:42:05] if you don't have that framework going in i think that's that becomes really a detriment

[00:42:10] in terms of your clinical practice the other part of it is some of the other quote unquote

[00:42:15] soft skills like the patient management skills like how you talk with a patient how you have

[00:42:20] questions you ask how you ask questions um you know with a patient you know in terms of you

[00:42:26] know growing that that um that clinical relationship i mean these things are i didn't

[00:42:31] get that stuff taught in school i didn't get that stuff taught in residency or fellowship you

[00:42:36] know so i think those kinds of you know some people are naturally just very good at it

[00:42:41] i think some people can just need to be taught it a little bit better

[00:42:45] because it can still be a skill just like anything else you can still get better at

[00:42:49] doing certain things but managing that is the managing the patients taking managing expectations

[00:42:55] now these kinds of things that adapting to different types of personalities you know the

[00:42:58] motivational interviewing you know all these different little things that you know we can

[00:43:02] learn and how to sort of incorporate them in uh to a treatment plan i think is having

[00:43:10] someone who can sort of help you navigate through that stuff is really really important

[00:43:17] it's it's so hard to to get and i know it was hard for me to coming up to see the value of

[00:43:23] those soft skills that you you speak of because i definitely fell to the allure of manipulation

[00:43:28] we didn't have dry kneeling but that seems to be the the popular thing and again it's not

[00:43:33] wrong and it's just but i think i sometimes wonder if clinicians just need to see that

[00:43:38] that's not the secret sauce of what we do it can definitely be a benefit and it can help patients

[00:43:43] navigate things but i just remember seeing master clinicians you know folks that are really

[00:43:49] highly respected in practice on a high level and they didn't often do much of that fancy

[00:43:55] like stuff that you know gets thrown on on social media they were just

[00:43:59] supremely in command of the patient encounter and the and really amazing at establishing great

[00:44:05] relationships with patients that were fully bought in and fully engaged and invested in they

[00:44:11] were creating clinical scenarios where they were you know masterfully demonstrating these soft

[00:44:15] skills to be able to get a patient who's and them who are in a really good relationship strong

[00:44:20] relationship of trust um and using that expertise but also giving the stage for that

[00:44:25] shared expertise where they're really incorporating the patient's unique values and the patient's

[00:44:29] unique goals and the patient's unique psychosocial status and weaving that into an encounter

[00:44:34] uh i definitely that's the whole reason we created our online communities because i just don't think

[00:44:39] one there's opportunities for all students and and folks coming out to get into a residency

[00:44:45] and fellowship it's improving expanding don't get me wrong but there's some obviously financial

[00:44:49] things and different things that just that aren't able to do it so we need to give

[00:44:54] clinicians and i would agree modern day and age where you can create online communities weekly

[00:45:00] office hours where we're talking about cases and and doing all these things and bouncing

[00:45:03] ideas off and help and guide clinicians on some of these tough situations because again

[00:45:09] i i think they start developing this process and to me it doesn't mean that the toolbox

[00:45:14] we're throwing everything away but i think it really streamlines it to where you're not

[00:45:18] feeling like you need a million tools you can have you know some tools that really work well

[00:45:22] for you and your you know your worldview and your biases that we all have as clinicians

[00:45:27] but it's you really can weave that very specifically to the unique situation and

[00:45:32] in front of you has that been your experience with it too is have you felt like

[00:45:36] there was a need to add more letters or tools after your name as you've developed these

[00:45:40] processes or has it been more you know honing in on these kind of like i said soft skills

[00:45:46] really it's been it's been the soft skills and i think i mean just speaking for myself it

[00:45:51] was never about adding letters or that kind of stuff it was really always about the

[00:45:56] knowledge and the information no i just i just want the information i want the knowledge you

[00:46:00] get the letters that's great whatever it speaks to maybe putting in some time and effort and of

[00:46:05] course money to something but you know it's you can have the letters and still not be a better

[00:46:11] clinician if you don't know how to apply it appropriately you know but i think at the end

[00:46:15] of the day it's really about acquiring the information it makes me think of like are you

[00:46:21] familiar with Seth Godin he's like the uh because he has his like special like he has

[00:46:26] this MBA program but you don't get an MBA you know it's you don't actually get an MBA

[00:46:32] but you get a hell of a lot of knowledge and information all these kinds of things to apply

[00:46:36] in a business standpoint because his sort of philosophy is the same thing um i think a

[00:46:40] lot of clinicians look for things to get letters after their name which again it's

[00:46:44] good to you know if that's a motivating factor to increase knowledge then great but

[00:46:49] at least for me that's never been my thing it's just more getting the information

[00:46:53] and i think you know for me now it is really those acquiring those some of those soft skills

[00:46:58] those patient management things like you know someone like you watch someone like Peter

[00:47:02] Peter O'Sullivan and he's just a master with the soft skills and talking to patients and

[00:47:08] getting at these things and it's just you know it's like seeing a great stand-up comedian

[00:47:12] it makes it look so effortless but you know it's been years and hours of practice and

[00:47:18] failure and repetition and changing it up and you know it's hard because you it's

[00:47:24] with patients you have to change every time right every half hour however often

[00:47:28] you're seeing patients if it's every half hour it's you have to change the style every

[00:47:32] half hour right because it's how is that patient uh how is that patient's personality

[00:47:37] compared to yours in terms of how they receive information how they some people want to be

[00:47:42] told what to do right some people want you to fix them some people want to be you know they

[00:47:49] they have their own opinions and you have to go and navigate how to how to approach that in terms

[00:47:52] of not being too maybe kind of um uh you know controversial in terms of like going you know

[00:47:58] challenging them too much with certain things and sometimes you realize you need to challenge

[00:48:02] those there's certain people want to help them change their beliefs so it really is the that's

[00:48:07] the art part of it too because there's no real specific guide on how you're going to do

[00:48:11] this so i think that's been my thing lately you know my last you know i guess half you know third

[00:48:19] of my career has been really trying to improve those kinds of things um in terms of really

[00:48:24] understanding you know people psychology patient management uh i think that's been a big key

[00:48:30] for my because again the the quote-unquote hard skills you know it's it's definitely nice is

[00:48:37] great you know i do dry needling i do manipulation i do all these things but it's that's sort of like

[00:48:45] i'm trying to think of a good a good metaphor for it but um it's kind of escaping me right

[00:48:49] now but it's like that's the tool while it's important to have the tools so you can kind

[00:48:54] of you can apply different things and you can adjust if certain things that you would do

[00:48:59] is necessarily working if you don't have the foundation again it comes back to like the

[00:49:03] foundation of um people skills clinical reasoning you know everything else everything else becomes

[00:49:12] so much easier once you have these things but it's a really hard it's hard to teach it i think

[00:49:17] it's hard for clinicians to to seek it out um and it's hard to implement sometimes it's very

[00:49:23] hard to do and it can be i've gone through a lot of pain dealing with patients it's failing

[00:49:28] a lot especially when you know with things like pain science and i was first really getting into

[00:49:34] some of that stuff and trying to convey that information i had a i had a lot of

[00:49:38] crash and burns on that one and you just let you just learn from it i would definitely share

[00:49:45] the lumps that you've taken and that's part of being a clinician right there's going to be

[00:49:50] times where things just don't go well we have cases that man just head south despite

[00:49:55] our best efforts and i always share some of the my pain science similar crash and burns that you

[00:50:01] speak of um and it comes down to again i think we all have to have our journey of realizing

[00:50:06] that maybe it isn't the tool and technique and i would encourage those of you who are

[00:50:09] listening just find some folks that are you know feeling like they're practicing or you see

[00:50:13] their practicing at a level you want to do and just see if you can hang out talk to them

[00:50:18] you know shadow them in the clinic maybe say do you mind if i grab like 30 minutes with you

[00:50:23] on zoom i have some patients you'll be surprised how you know generous a lot of folks are with

[00:50:28] their time to help you kind of get your bearings and maybe prioritize where you need to go to

[00:50:33] start really getting to where you want to be as a clinician i think for me my journey was

[00:50:38] i definitely wanted the knowledge i wanted to be the guy that people referred people to

[00:50:42] and i thought for me it had to be more courses more things and a lot of it being

[00:50:46] more focused on the hard skills right the technical stuff that we speak of

[00:50:51] when i really think you know definitely being technically sound is important but

[00:50:56] i honestly think it's probably more 75 percent of how do you establish a relationship with

[00:51:01] somebody who believes trusts and and navigates into some of the challenges that they're dealing

[00:51:05] with with pain in a way where you're supporting them and and they're they're able to start

[00:51:10] knocking things down that get them back to the values that they want to live by

[00:51:14] andrew we could talk about this stuff and talk shop you know probably for another couple

[00:51:18] hours but i want to respect your time and i just wanted to thank you so much for

[00:51:22] for your time today if folks want to see you online or kind of get to know

[00:51:26] kind of what you're all up to where can they find you best place is either twitter or instagram

[00:51:32] aroth child pt that's the easiest place to find me and i kind of like you said i could

[00:51:38] talk about this stuff for hours and days mark and i think i could echo what you just said

[00:51:44] with younger clinicians reaching out people who like yourself and myself if clinicians reach out

[00:51:51] to me and ask questions that is you know that that motivates me you know i will give up time

[00:51:57] to to to reach out and talk to people because that's that gives me that gives

[00:52:02] me energy too and you'll find a lot of clinicians will be that way as well in terms

[00:52:08] of they just they're just some of us with seasoned clinicians are just you know we love

[00:52:14] to find those young motivated clinicians who just want to learn and we just that will give

[00:52:18] us energy and that's the kind of people we want to you want to talk with and work with and kind

[00:52:23] of help help grow and develop you know so i can't emphasize that enough and and we'll link

[00:52:29] andrew's contact information in the show notes and i definitely echo what you're saying it's

[00:52:33] it's that's what kind of brings me i mean i love patient care don't get me wrong i still

[00:52:36] work with patients primarily but i really enjoy the whole mentoring of clinicians and seeing their

[00:52:41] growth and hopefully as you've listened this podcast prevent you from maybe encountering

[00:52:45] as many of the lumps and crash and burns as andrew and i've both experienced in our career but

[00:52:49] that's how you grow right you you hopefully get mentors who can help you avoid some of the the

[00:52:54] maybe missteps and things that they've had along their journey and that's what you know

[00:52:58] kind of pain it forwards all about uh so thank you all for listening this week if

[00:53:02] you're listening on a audio device we'd love for you to subscribe to the podcast if you'd

[00:53:06] even leave a review that would be huge for us that helps us spread some of this message to

[00:53:10] maybe some other clinicians who are struggling to kind of figure out their grounding in the

[00:53:13] profession as they're coming up if you're watching on youtube we'd love if you subscribe

[00:53:18] maybe like especially so we can get this distributed to more people but we'll leave

[00:53:21] it there this week we'll talk to you all next week this has been another episode of the modern

[00:53:27] pain podcast with dr mark cartula join us next time as we continue our journey to help

[00:53:33] change the story around pain for more information on the show visit modernpaincare.com this podcast

[00:53:39] is for educational and informational purposes only it is not a substitute for medical advice

[00:53:43] or treatment please consult a licensed professional for your specific medical needs

[00:53:47] changing the story around pain this is the modern pain podcast