CEU Review: DN-1 & DN-2

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I recently attended DN-1 & DN-2 by the Spinal Manipulation. The courses were fantastic experiences and have provided me with new means of addressing a variety of conditions in the clinic. Both courses surprised me on two fronts:

1. The Research. I wasn’t expecting so much time spent on discussing the research and how it guided their approach. The amount of research presented simply blew me away. Research is research regardless of which geographical region of the world it was done and in which professional journal it was published. And so, they pulled research from all over the planet and thought a decent variety of disciplines. This was strangely refreshing. The lectures were quite heavy on the current relevant research; and, it was presented fairly in that both positive and negatives were mentioned. I don’t know about the nuances & specifics of these studies, but the fact that they exist and haven’t been explored in other courses is very interesting.

2. Pain Science Lectures. Yes, I know what you’re thinking…it’s a dry needling course and they’re presenting lectures on pain science? Oh, yes they did. The phenomenal lectures on pain science as it relates to Dry Needling also caught me completely off-guard….in a very good way! I gotta admit: pain science talks in both courses were in-depth on biochemical and mechanical levels as related to dry needling. It was fantastic and convincingly presented. Very convincing. Tommy presented a very detailed & balanced lecture, and Ray bled passion during his lecture.

Now onto specific critiques on the courses themselves, as well as recommendations for future attendees.

The Negatives.

About 40% of the manual was summaries of research reports. While this provides a nice foundation of research on which to base Dry Needling treatments, it could easily be converted into a PDF to be emailed and downloadable to course attendees. Another issue with the current manual (DN-1 2016) is that it didn’t always correlate with the material presented. In other words, material was presented that wasn’t in our course notes, and there was no way to obtain an updated manual. Why? Apparently the new manual wasn’t yet approved for publishing. It would be fantastic to make this information accessible to 2016 course attendees (with a reduced price) when it is available. Maybe you could save paper and simply email/download it in PDF form; printed manual could be an extra charge.

The manual had a couple more short-comings. 1) There was very limited space to take notes. 2) The semi-standard protocols weren’t to be found; however, there is ample instruction on palpation, needle placement, and needle technique. It would’ve been nice to have drawings/pictures of the protocols alongside written instructions for future reference within the manual itself.

When it came to lab time, there was often ran into extremes of either excessive or short practice periods. This was the first Dry Needling course for a number of attendees, and spending a little longer on basic needling practice would’ve been more beneficial. Then again, maybe I was just too slow to get comfortable before moving on to labs 2 or 3. DN-2 did a much better job of managing lab time.

Finally, there should’ve been more time spent on the technicals of employing Dry Needling in the clinic – things like how to bill insurance for it, how it’s incorporated into a cash practice, orchestration of Dry Needling into the Plan of Care to address questions of stretch after/before or skip exercising entirely. All these items should be addressed up front and as clearly as possible. I had these questions addressed in DN-2 by asking the instructor during lab time. Be sure to ask this question to multiple folks – instructors & other DN practitioners.

Some Tips & Recommendations.

Take lots of pics from a variety of angles – at least 2 different angles. This will allow you to get a better appreciation of needle placement when you’re practicing it on your friends, family, and coworkers after the course.

If you’re a visual learner like me, then it might be a smart idea to sketch out the lab demo with all the insertion markings. It might also be useful to re-create this on your own after the course is over. This way you feel more confident about inserting the needles, and know exactly what you’re doing before you start poking your friends, coworkers, and/or family members.

Let’s stick with the lab demo for a bit longer. As I mentioned earlier, the course manual provides very little room to take adequate notes. So, it’s a really good idea to jot down instructions/sketches during the lab demo into either a separate notebook or sheets of paper. Using a clipboard with unruled sheets of paper works best for me. This allows freedom to sketch and jot down info as it suits my visuals without the constraints of ruled pages.

Consider reviewing the relevant anatomical regions prior to taking the course. Here’s how I would’ve done it: cover the insertions of major/important muscles and their innervation, trace major nerves (for DN-1 think brachial plexus), and, finally, roughly familiarize yourself with the “spaces” (for example, the quadrangular space) that are created by the framing muscles and/or other structures – no need to be very meticulous about this, just consider the obvious ones.

Finally, bring some cash. They tend to supply needles like your grandmother would supply dinner items: better too much than too little. This allows you the opportunity to purchase some needles right after the course and start practicing right away. $50 worth of needles should be a nice start.

The Positives.

Their conceptual application of combining spinal manipulation and dry needling certainly peaked my interest. It made me want to explore these “segmental effects” deeper on my own prior to taking a spinal manipulation course. I really appreciate the work behind creating these protocols (much of which was lifted directly from research articles).

Both instructors were knowledgeable, presented the material well, AND presented it fairly. They pointed out studies that showed both sides of the argument. Their perspectives on utilization of the literature was refreshing and made me open my eyes a bit more toward how some (many?) folks view the literature through tainted lenses while wearing blinders. 

This course provided me with incorporable content and manual intervention options that can dove-tail nicely with my current clinical framework. While I don’t think wearing the “osteopractor” label is in my future, the concepts were intriguing and definitely warrant more of my curiosity.

Final Take.

I came away from this course with much more appreciation of an intervention that I had ignored just 4 years earlier. Dry Needling seems to have the potential to address multiple fronts at once: save my hands, access structures that are difficult to reach/treat with manual palpation, provide another route to address chronic pains, and provide me with another differentiator with which to market my services for the benefit of my future clients. Good content. Engaging instructors. Worth the time.

Premature Accumulation

I once heard a well-known founder of a Physical Therapy specialization certification program state that some clinicians who passed the Certification Exams prepared merely for the exam, and the process of preparation didn’t necessarily make them better clinicians. This made me wonder about those individuals who have accumulated a string of acronyms after their name, but weren’t able to efficiently integrate their achievements. It also reminded me of those clinicians with 1, 2, or no certifications who applied their learnings and are, consequently, more integrated & effective in the clinic.

Letters, titles… For what purpose? Why & for what goal? How has it changed you & your outcomes?

Most clinicians sacrifice time & energy to attain their titles with the intention of sharpening & expanding their clinical skills with the goals of achieving better patient outcomes, and, consequently, greater job satisfaction – among other things.

The decisions of which philosophy and framework of practice to pursue often bottleneck down to whether or not “the juice is worth the squeeze”. “The Juice” is usually some blend of curiosity, cost, continuing education credits (poor reason, but it is unfortunately the only reason for some), and clinical application.

One route some clinicians travel involves certain Clinical Specialties requiring sitting for a computerized exam. One example is the OCS – Orthopedic Clinical Specialist.

Allow me to rant about the OCS for a bit. Feel free to skip ahead…


The OCS is a regurgitation of dated material. I know this to be true because I was preparing for it last year. Although I decided to put it off until some time in the future, I appreciate the amount of time & effort it takes to memorize the required information for the test. Now, why anyone would want an OCS rests mostly on 2 legs: 1. Public Perception 2. Requirement for APTA Credentialed Residency programs. I find both of these reasons false & inadequate. Let me explain.

When it comes to public perception, it misleads the public into thinking those without an OCS are incapable to evaluating and addressing orthopedic concerns. This is blatantly false considering that a majority of our training in PT school is geared toward orthopedic assessment & treatment. Moreover, memorization and regurgitation DO NOT equate to better clinician reasoning skills. This might be one reason many (but, not all) folks are not better clinicians after attaining an OCS.

As it pertains to APTA Credentialed Residency Programs, the last thing you want as a requirement is rote memorization. It should be geared toward clinical reasoning and patient outcomes. An OCS does a mediocre job on this. How can studying for 1 weekend exam compensate or replace the achievements/efforts of year(s) of dedication and practice? It simply can’t. However, it is a nice recurring revenue generator to require Mentors have an OCS in order for a Residency to be APTA credentialed.


Given the benefit of retrospection and conversations with colleagues who have taken a fair number & variety of Continuing Education courses, I feel fairly confident with what I’m about to say.

If the contents of the course do not add to your clinical effectiveness or efficiency, then it probably wasn’t worth your time & investment. Additionally, if it didn’t inspire you to become a better (how ever you define better) Physical Therapist, then it most certainly wasn’t worth your time.

Maybe you’ve just experienced a life-altering Continuing Education course, and you’re excited about representing a movement that drives you to practice at the peak of your licensure. Now you’re nervously excited about the certification exam and are wondering if you really should pursue it.

Ask yourself: What are those letters after your name worth to you? To your patients?

Maybe the answer is, “those letters mean nothing to me. All I want is to learn the content, help my patients, and improve my clinical practice.” If that’s your response, then congratulations! You just saved yourself a shitload of stress and expenses by avoiding the brain-bending experience of studying for a certification exam.

If your response is, “I want to know that I’m applying the content effectively and at the highest level possible” then the letters might be worth the effort. If you believe the letters will provide you with leverage in clinical outcomes and evangelizing the Physical Therapy Gospel of the potential to live functional lives with zero-to-minimal involvement of pharmaceutical drugs and surgery, then the juice might be worth your squeeze.

The practicality of accumulating letters can distill down to a signaling mechanism that shouts “I know what I’m talking about!” Or maybe it says “I still haven’t found what I’m looking for!” (say it again with your best Bono impression). Maybe s/he is a genuinely curious individual with a passion to learn & grow as a professional.

Me? Well, I would go with the “Bono option” – I still haven’t found what I’m looking for… In retrospect, my certifications (so far) have been a boon to my clinical practice and experience. It’s been a cumulative and catalytic accumulation that provided me with a foundational conceptual framework on which I can mold my future professional growth.

I’m sure you’ve met individuals with an alphabet soup of letters after their name who do not practice at the top of their licensure/certifications. Even worse, they might have completely abandoned the teachings of these certifications, but continue to grace their business cards with these aching acronyms. False advertising, perhaps. Or… a premature accumulation of efforts with nothing to show for it other than limp advertisement.

A possible cure for this premature accumulation: finding a framework that you believe can last the test of time. This is significantly more valuable than a random accumulation of certifications.

P.S. – As many of you are well aware, I enjoy reading books. Early March 2016 saw the first edition of my Quarterly Readings Newsletter. It is an update on some of my favorite reads of the quarter. Email me with “I love to read!” in the subject line, and I will add you to the email list. 

Mea Culpa

2016 exploded onto the scene, and there’s no looking back. A couple milestones await for me in the next few months. One of them is a Physical Therapy Class Reunion. No, I’m not going to mention how many years have passed, but let it suffice to know that I’m more excited about our profession now than ever.

Emotion and Experience were vital components to my growth as a Physical Therapist thus far, and they will likely continue to play their vital role for the foreseeable future. Emotion and Experience are also vital components of our growth as human beings. Perhaps the Environment we grew though, and will continue to grow in/through, is an equally (or more) significant determinant in our Emotional and Experiential growth.

Either way, here are some thoughts that are crossing my mind in this period of critical change. I hope you find them as useful as I do.


Don’t shy away from asking yourself “What the fuck am I doing with myself?” Don’t shy away because there’s no wrong answer to this question. The reality is a very small percentage of you (no, it’s probably not you) are following a life-plan penciled perfectly in high school. Asking yourself this question is more about self-correcting than proselytizing. It’s a series of continual adjustments based on your long term vision.

Entertain yourself. It’s more fun than you can imagine.

Don’t shy away from intentionally disappointing someone if you know that there’s a high probability that the bread is about to fall jelly-side down. This doesn’t mean you have to be memorably offensive. Saying “no” effectively without crushing relationships is a skill worth developing.

Don’t worry about what people think of you. This simple life-hack will free your mind more than almost anything. Also, it clears your lens on life by allowing you to see how clever or transparent people truly are. You’ll be tempted to gain and keep the recognition of those smart people you think you identify with. The reality is you’re probably fooling yourself into building a self-image that is ultimately painfully unsustainable.

If you aren’t any closer to your desired lifestyle this year than the last year, then hop on that horse and make it happen. It’s incredible how 1 year turns into 3, and before you know it you’ve been treading water…at best. This simple fact will continue to boggle your mind in real-time and in retrospect. Some smart guy once said: “The best way to predict the future is to invent it.” He might be right.

Health is wealth. Yup, the oldies were right. Health truly is wealth.

Consider the impact of all the non-renewable resources in your life. “Time” deserves to be very high on that list.

One of the few constants other than Time is Change. Don’t be afraid to change. It’s going to happen anyway, so why not take the wheel rather than handing it off to people you don’t really know – employers and their management teams, especially their management teams. Don’t be afraid to take the wheel and change lanes.

Sleep. Sleep because feeling well-rested is a glorious feeling.

Don’t “grow up”. I’m still not sure what that term means, but avoid it as much as possible. The “grown-ups” tell me it’s overrated.

Be nice. The world is getting smaller every year…which means Karmic paybacks happen quicker and/or with greater intensity today than yesterday.

Simplicity is priceless. If you can’t explain what you’re doing to a 12 year old, then you’re carrying around unnecessary baggage. Lighten the load, and clear your plate down to the bare essentials. At the very least, simplicity makes it easier to smile.

You can’t outrun your fork.

And, if you’re riddled with indecision, then apply the Regret Minimization Framework.

As many of you are well aware, I enjoy reading books. Early March 2016 saw the first edition of my Quarterly Readings Newsletter. It is an update on some of the more interesting reads of the 3 months preceding publication of the email Newsletter. Email me with “I love to read!” in the subject line, and I will add you to the email list. 

An “Anecdote” on Dry Needling by Dr. Justin Dunaway, DPT

Want to do something that you’ll feel good about forever?? Then donate RIGHT NOW to Justin’s fantastic Kickstarter project@StandHaiti is very close to meeting their goal, and you can make it happen.

Physio Twitter is getting it’s panties in a bunch over Dry Needling. Take a chill-pill & soak in this much-needed Point Of View by Dr. Justin Dunaway. In case you aren’t already familiar with him (who isn’t??), then check out my interview with Justin here & here.

Enjoy!


 

An “Anecdote” on Dry Needling

With all this talk about RTCs, efficacy and effectiveness, and the necessity or futility of clinical experience… I’d like to share an experience, one that I feel matters more than the research, more than opinions or my clinical experience: a patient experience.  While I am very well read on the needling literature, have a strong foundation in physiology and a deep understanding of placebos, nocebos, and non-specific effects, as well as very strong opinions on all of these things…I’m going to leave them out of this discussion. I feel as we delve deeper and deeper into this rabbit hole of which research is better, who has a stronger understanding of its nuances, and the over reaching value of the research, we are forgetting about why we do it all. Each year of schooling, the piles of research, and the endless debates… aren’t about the stats or publications, and certainly are not about the paycheck. It was, is, and always should be about the patient first.  I want to share this single anecdote, keeping in mind the current debate between Dunning et al and Ridgeway/Venere et al in regards to the effectiveness and efficacy of dry needling.

This is the story of Sandy. Sandy is a person, not a statistic or a subject in a well powered RTC that wound up in a systematic review with a metanalysis showing strong evidence in support of my treatment choice, but a human in a very debilitating amount of chronic pain.  A human with loads of bias, confounding variables, and expectations.

Sandy (who is now 70 years old) was in a car accident 20 years ago, leaving her with chronic neck pain and headaches. Like many patients, she received radiographs, medical interventions, medications, shots, and legitimately good PT. As all these interventions failed and her condition worsened, she became depressed, decreased her activity due to pain, took increasing amounts of pain meds, and her condition ultimately deteriorated. She ended up having a cervical fusion (which was unsuccessful) that launched her into an even more pain and deeper depression and was prescribed methadone 3x/day. At this point, she was spending 90% of her time crying in bed, her medical team had given up on her and she on herself. Sadly, we’ve all known these patients.

When I first met Sandy, I just let her talk. A quick objective revealed neck joints and musculature that had clearly not moved in over a decade and a human feeling hopeless about her situation, just as you’d expect. After talking about treatment, she agreed to give dry needling a shot. I placed 10-15 needles in her neck, upper traps, back of her head, and a few points in her hands and applied electric to the needles for 20 min.

The next day she called to tell me that she had had her first good night’s sleep in longer than she could remember. I saw her twice a week for a few weeks and primarily performed DN. Within a month, she was going to the store, having family dinners, and playing cards with friends. Within two months, she was hiking the grand canyon with her new boyfriend pain free.  All from an intervention with no therapeutic value.

I realize this is anecdotal, Level 5 evidence, clinical experience, or whatever you want to call it. I understand that it is full of bias, confounding variables, “placebo”, “non-specific effects”, and other terms we use to discredit the things we don’t understand. But really, this is a human, a person who lost her life and then got it back through physical therapy. Sandy has regained her life because of an intervention. The choice of this specifically was guided by clinical experience, which may or may not be backed solidly in the literature. No RCTs have been written about the Sandys or the countless others with similar stories and certainly, if I practiced “Evidence Blinding Medicine,” Sandy would still be in bed, lonely and miserable.

I am not writing this to stoke the fires of the current debate on needling, what it means to be evidence based, or where clinical experience falls into the mix. I write this as a reminder that we treat humans, not statistics, and we should not forget that. We cannot be so focused on the PDF on our laptop that we forget about the human on our table.  Let the evidence guide you, but not blind you. Clinical experience, while full of bias and confounding variables, is absolutely paramount in treating the Sandys of the world. As promised, I will not cite any literature, nor will I reference any gurus or experts in the field. But I will leave you with this quote, one that we continue to get further and further from as we “advance” our knowledge, education, and research skills…one that speaks to the human element of what we do and the need for clinical experience and expertise.

“I would rather know the person who has the disease than the disease the person has.” 

–Hippocrates 460 BCE – 375 BCE

President

 

You may also enjoy this related post.

I am Cinema.

The Evidence on Evidence-Based Practice

There’s a funny underlying double-standard that exists when conversations arise accusing someone of not playing along with all the thrills & frills of Evidence-Based Practice.

While EBP apologists continually point out the lack of evidence for applying certain techniques and approaches, there is a distinct lack of self-awareness on the porous nature of the majority of medical (& physical therapy?) evidence. In case you missed it, the Editor-in-Chief of The Lancet recently stated,

Much of the scientific literature, perhaps half, may simply be untrue. Afflicted by studies with small sample sizes, tiny effects, invalid exploratory analyses, and flagrant conflicts of interest, together with an obsession for pursuing fashionable trends of dubious importance, science has taken a turn towards darkness.

And, Dr. Marcia Angell, who served for more that 2 decades as the Editor-in-Chief of the New England Journal of Medicine says,

It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines.

Nevertheless, EBP apologists make little haste using words like “woo” and “quackery” with supreme confidence. Does EBP exclude “quackery”? Don’t be so supremely confident of that.

The boundaries between quackery and EBM that clinicians are faced with are not so clear-cut. There is a need for doctors to acknowledge their share in quackery…

Let’s not forget the publication bias toward positive results. We hardly see the ones that didn’t work out. At least some steps to limit this massive bias have been taken. 

Odds are that you’ve already seen this important TED Talk by Ben Goldacre (his fantastic website is a must-read), but in case you haven’t, here’s your chance! The biases, tendencies, and habits mentioned apply across the healthcare spectrum.

Given that up to HALF of all published medical literature could very well be flawed, does it have strong legal standing? Well, not quite.

Evidence-based medicine and the use of CPGs won’t protect patients or physicians from all undesired outcomes or lawsuits, though they can be helpful in defense. They can guide decision-making, but can’t replace experience and judgment.

What about the applicability of published evidence? As Trisha Greenhalgh & company says,

The patient with a single condition that maps unproblematically to a single evidence-based guideline is becoming a rarity.

Well, there you have it. The “E” in EBP doesn’t translate efficiently into the clinic, will not protect you in lawsuits, and has it’s own inherent (even worse, hidden) biases. On top of that, it could make you delusionally overconfident, despite at least 50% of it being false.

What are the odds of these massive gaps existing in Physical Therapy’s published literature? Considering the severe lack of study reproductions, I’d say it’s very high.

If Evidence-Based Practice were a set of clothing you’re wearing, then you’d be no less than half naked.

Look here, here, and here for a few ideas on how to work with the inefficiencies of the “Evidence” in EBP and guide your practice perspective.

– @Cinema_Air


Image Source: http://www.4sportboston.com/2010/03/the-girlfriendwife%E2%80%99s-guide-to-march-madness-a-sports-nut%E2%80%99s-month-long-holiday/

5 Lessons Physical Therapists can Learn from Bruce Lee

I wrote a guest post for Strive Labs. Check it out:

“Bruce Lee is one of my personal heroes. While there are many reasons I admire him, I find his philosophical approach to everything the most salient and magnetic feature of admiration. We can learn numerous lessons from his life. Here are 5 lessons that apply to Physical Therapists as individuals, and Physical Therapy as a profession.”

Continue reading…

What’s so special about Physical Therapy?

When it comes to outpatient Orthopedic Physical Therapy, what does Physical Therapy offer that is intrinsically unique from other “overlapping” professions? I posed this question via a horribly worded tweet that lead to an interesting and very involved conversation. Check it out here.

Many of our treatment modalities are not confined to the domain of Physical Therapy, but are utilized by a broad spectrum of professionals. In terms of competitive advantages, exercise might be the weakest of our modalities. It has one obvious glaring shortcoming: the landscape of exercise is becoming flatter everyday. You can learn proper efficient exercise from any smart & experienced individual. They don’t have to be a Physical Therapist. They could be an athletic trainer, personal trainer, chiropractor…even your local gym rat. Information on exercise is becoming so ubiquitous that you could simply pull up a Youtube video to coach you through “corrective exercises”.

What about Ultrasounds & Electric Stimulation? Let’s put aside any knee-jerk reactions related to their effectiveness and think along the lines of Competitive Advantages. There is nothing stopping a chiropractor or athletic trainer from using these modalities. Even worse, utilizing these modalities requires a very short learning curve. Everything that involves binary decision-making combined with the potential for technological adoption will further flatten the competitive landscape and be vulnerable to outsourcing. Ultrasound & Electric Stimulation are no exceptions to this concept.

What about various joint & soft tissue mobilization techniques? The advantage will last only as long as the material is taught specifically only to Physical Therapists. Since Continuing Education is a capitalistic enterprise, these courses are usually offered beyond the confines of Physical Therapy. Therefore, any advantage conferred by these “techniques” is arbitraged against time. I believe Dry Needling fits under this umbrella. Once these “techniques” are utilized by other professionals, the advantage will moderate.

Is there any Evidence to “prove” our unique effectiveness as Physical Therapists? This article from 2001 was the only one brought to my attention. Notice that none of the main points are encouraging from an Outpatient Orthopedic point of view. According to the article, the only advantages conferred by being a Physical Therapist lies in niches.

Speaking of evidence, more evidence doesn’t mean more effectiveness. It simply means “more evidence”. The data is democratic, and the evidence can be applied by anyone of any profession, regardless of who did the research and produced the evidence. Simply because we may claim to be the profession that produces a sizable amount of neuro-musculoskeletal research, that doesn’t mean it is applied exclusively within our domain. Evidence has a level of promiscuity that should be appreciated.

The twitter thread mentioned earlier turned into an octopus and grew in different directions. This one was interesting because it eventually hit on something I had in mind. It’s about the Framework of approach that might be unique to Physical Therapy.

According to Tim, our uniqueness lies in our integrative framework to address functional deficits of any individual. Based on this perspective, Physical Therapy isn’t about “what” we do as much as it is about “how” we do what we do. While this sounds powerful (which it is!), the tricky part of it is the variety of philosophies & approaches within the profession don’t seamlessly lend themselves to a unifying framework. Other professions also view themselves as systems that incorporate different perspectives into a Plan of Care. After all, “integrative” is quite the catch-phrase these days. A unique & integrative framework will only remain a unique advantage as long as the process to understanding and utilizing the framework requires substantial achievement and effort. Once these hurdles are either lowered or removed there will no longer be a unique value proposition.

Even worse, here’s what the research says about perception of Rehabilitation Professionals:

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So, we don’t “own” any treatment modality, and we don’t have evidence to back up our unique effectiveness. Are we in a rat race against “sameness”? Back to the initial question:

What’s so special about Orthopedic Physical Therapy?

What are your thoughts?

@Cinema_Air

P.S. – There was a #solvePT discussion that revolved around the central concept of the post you just read. Check it out here.


For Further Reading:

  1. http://www.evidenceinmotion.com/blog/2014/03/24/what-differentiates-physical-therapy/
  2. http://www.evidenceinmotion.com/blog/2014/03/16/trigger-point-dry-needling-tdn-is-not-physicaltherapy/

Track & Field

Finding out that your hard work didn’t pay off is a terrible feeling – especially if you’ve put in the time & effort to allow for success. I’ve hesitated publishing this post since last year, but this feels like the right time.

I failed a second semester course in grad school. Many hours were spent studying for this class because it was my hardest. I knew my test scores didn’t quite measure up – let alone reflect how much I actually learned. Finals were coming up, and like a predictable movie everything hinged on the final. I missed the score by 2 points.

What followed was a terrible experience. I had to drop back a semester just to re-take this class. This meant that I wouldn’t graduate with my incoming class. It also meant I wouldn’t take the same classes they would; which means our schedules would differ and it would be harder to enjoy off-time with them as well. The next semester was incredibly difficult on an academic and internal basis. The class wasn’t any easier the second time, but I managed to pass (by 2 extra-credit points). I hear the class has been re-formatted since I graduated.

Looking back on this with years of hindsight I’ve realized that it truly meant nothing to me. In fact, the materials I learned from that particular class have been generally discarded – except for the basic framework of conceptual application. Today, I literally use less than 10% of the contents of that class. So, why am I re-living it?

Because it reminds me that all of us have the capability of perceiving little failures as the Himalayas – making mountains out of mole-hills. The real questions I should have asked myself:

A. Why did this fail? Not “why did I fail?” If you put in the time and effort for this to succeed, then you’ve positioned yourself to learn a great deal from this experience. Take the time to reflect on why IT failed, and what you would do differently the next time. Separate yourself from the event and give yourself the advice you would offer others.

B. Will this keep me from my long term vision? Usually the answer is NO. It’s been almost a decade since I failed that class; and today I am a much better clinician than ever. In fact, when I took my Boards I passed on the first try – many students with much better grades didn’t make it. If you don’t have a long term vision, then ask yourself: “where do I want to see myself in 5 years?” You’ll quickly realize that there are many ways to get there.

C. How could the failure have SAVED me?? Who’s to say that things would be better off today if I hadn’t stumbled on this hurdle? I may have never found my current interests. Which means I would not be where I am today – in the company of some incredible clinicians and individuals. In fact, one core components of that class is my bread & butter in the clinic today. I will always have room for improvement, but it’s nice to recognize the distance I’ve covered so far.

D. Why did you even try in the first place? There’s more to this than a simple PASS/FAIL Your profession requires you to jump a few hurdles before you reach the starting line. That’s right. Once you’ve finished graduate school, you’re now positioned in the sprinter’s stance with your professional track(s) awaiting discovery. Make it to the Starting Line. And, as you’re crouched down waiting for the gun, remember why you chose this track.

DPT students across the country just took the National Board Exam for Physical Therapy. Some of you made it through on the first try. Congrats!

To everyone else: can’t wait for you to join me on the track.

@Cinema_Air

Turning Machiavellian

Outcomes… It’s what our patients want; it’s also what clinicians want. It isn’t unusual for a patient to say, “I don’t care what we do, I just don’t want this pain anymore.” In fact, it’s what drives clinicians to deliver better patient care – better outcomes more efficiently. Better patient outcomes & experiences creates a self-reinforcing virtuous cycle of greater efficiency and consistent outcomes. It is something worth leveraging.

As far as patients are concerned, many just want to feel better. To them, the end justifies the means. They want to get well & stay well. What about the clinicians? Does The End (outcome) Justify The Means (treatment/interaction)?

Being able to justify your treatments and interactions requires the ability (& willingness!) to determine the effectiveness of your plan of care. Consistent measurement of outcomes plays a significant role here. If you aren’t continually reassessing your outcomes – both positive & negative –  then you aren’t doing yourself or your patient much justice. Determining the efficiency & effectiveness of your service is an important component of the value proposition of every clinician. The question that comes to mind is, “Am I delivering the best value that I can?”

On what basis would you answer that question? By what your boss says? By what your colleagues say? By what your patient says? Or could it be based on contemporary (latest) themes of scientific understanding?

Let’s tackle that last one first. Science always changes. The tides of data, winds of politics, and the drive of capitalism continually shape and direct the future of science. And, let’s not forget inherent biases within Scientific Research itself that funnel & lead Scientific Conclusions that both the public & private sectors leverage for their own interests. Even if we ignore the financial levers in scientific research, it’s difficult to account for the personalities involved and contemporary zeitgeists. Here’s how Craig Venter puts it in his biography A Life Decoded:

Too many times I had seen science driven less by data and more by the force of a particular personality or the story on which a professor had built his career.

Could this rising tide of Data overwhelm our ability to Keep up with The Scientific Joneses? Maybe. Here’s a study that says that there are too many studies! While some clinicians may do their best to keep up with the latest literature, many clinicians rely on webinars, weekend courses, and other aggregators of latest research. Given this, all clinicians should be familiar with Academese (Academic lingo) to help them navigate the labyrinth of terms, interpretations, limitations, and applications of research papers. Most clinicians do not (and, maybe, can not) keep up with the growing avalanche of peer reviewed literature.

In many instances, what your boss or supervisor says is coloured with the tinge of achieving pre-set numeric hurdles that may or may not involve your progress as a clinician. To a certain degree a better clinician yields better outcomes on the bottom line as well, but that could depend on business models and practice settings. In essence, reaching a target Units Per Hour does not make you a better clinician. Neither does juggling 3-4 patients per hour make you a better clinician.

What about what your colleagues say? Maybe a majority is simply Noise, and some of the rest of Signal being unintentional more than intentional. How many of your colleagues have contributed to your improvement as a clinician? While many co-workers and colleagues come & go, there will be those few that are worth holding onto; continually renovate and fireproof these bridges. Coming back to the main issue, a majority of co-workers (a few exceptions excluded) don’t necessarily make you a better clinician. At best, what you are receiving is external locus of control (creating dependency) versus internal locus of control (fostering independence).

Given this never ending climate of continual change and murk, what can we (you & I as Clinicians attending to individuals with various physical dysfunctions) do to maintain a sense of direction? Maybe we could look for things that don’t change: Nobody wants to live in pain; Nobody wants painful movement; Nobody enjoys the inability to move or return to work due to painful experience with sitting, standing, etc. Nobody is pleased with his/her difficulty walking, lifting, having sex, pushing, pulling, carrying, holding their grandchild, etc. No athlete doesn’t want to return to their favorite sport. She values the End (a pain-free functional life) regardless of a complete understanding of the Means. Many Grandparents don’t even care about how you get them to lift, carry, and hold their Grandchild, as long as they can lift, carry, and hold their Grandchild! Their desired functional Outcome generates significant value to him/her.

My basis to answer the question “Am I delivering the best value that I can?” is this: It Depends on My Patients’ Outcomes. Outcomes includes more than reaching their individual goals in Physical Therapy, it also involves referring him/her to other clinicians who could assist in their progress or take over her case, if that’s what’s needed. What patients want is to return to a pain-free life that allows them to provide for & spend time with the ones they love, to be independent, to re-experience the joy of movement, to get back to the life they once had.

As a clinician, I want to leverage outcomes to demonstrate my value to more than just my employer(s) and the insurance companies (purse holders). I want to leverage these outcomes to demonstrate my value to current & potential future patients.

Consistent & Repeatable Patient Outcomes has become such a directional indicator for me that if someone were to call me Machiavellian in this respect, then I’d take it as a compliment.

Related: This podcast by Therapy Insiders with Jerry Durham is worth your time. The last 10min or so rhyme with the post you just read.

@Cinema_Air