It’s Time for Change – Lessons from the Origins of Pathoanatomy

Recently, there has been no shortage in the peddling of structuralist misconceptions. Patients continue to fall prey to misguided efforts by healthcare workers to address their aches and pains. You see bizarre tendon lengthening surgeries, talk of ring shifts and sacral torsions. Worse than all of this, clinicians continue to fall prey to these delusions as well. They take courses taught by gurus with widespread acclaim, but little support for their actual claims. This is where we find ourselves in modern medicine–in the midst of an ever growing debate, discussion, argument (or worse) surrounding the the plausibility or lack thereof for such theories.

We tend to argue our points from research and “evidence.” Which tends to be met with other “research and evidence.” Some take more aggressive maneuvers to call out non-sense, but ultimately clinicians continue to choose to follow these misguided beliefs and practices. And it begs the modern philosophical question, Y tho? And what can we do to move our profession forward?

To understand our present situation, I think

Restricted Thoughts

 

Say a child doesn’t have the legal right to drive (we’re talking about an 8 year old). Ask the kid what they want to do, most of the time that task or activity will be restricted to their home. Some people may argue differently,and say, “that’s not true, my kid always wants to go the park.” (or fill in the blank with something else). Maybe that’s true. Maybe that child’s thought process involves things that are outside of his or her control, but maybe that child has an active and willing participant (i.e. the parent) who has made this thinking possible. The parent is actually asking the child what they want to do, taking into consideration the child’s opinion/desires for the best possible outcome for everyone.

What happens, however, when we turn this scenario? What if this is the parent who does not cooperate with the child’s desires? What if the parent is actually a really bad individual, who doesn’t really value what the child thinks? What if the parent has had a long day of driving and doesn’t feel like going back into the car? What if the parent doesn’t have a vehicle? And the biggest question of all, what if the parent does this consistently? Day after day, week after week, year after year? The child’s desires and thought processes are likely to change. They are likely to become narrowed. Instead of going to the movies, or going to get ice cream, or for a day at the park; the child will start only thinking of things to do at home. Like play outside, watch a movie, or read a book (…maybe that’s a stretch).

You can see this happening in real life. I wouldn’t be surprised if there was some bit of academic research on the topic. How children’s minds are shaped, and likewise their thought patterns, by the constraints or liberties placed on their actions. Some people may say, well that’s not a huge issue, especially if the child has a good home. They can stay and play at home all they want! Which might actually be true, but what happens if this scenario is turned into the healthcare field? Lets swap the child for a physical therapist/physio and the parent for the

Two Tales of Cognitive Diagnostic Error

Health care is busy! We have patients on patients on patients. They come one right after the other, and we have little time between to catch up on documentation. As a matter of fact, most clinics/companies prefer you document while you’re with the patient. All of this leaves little time to reflect on your decision-making with each patient, and this might be a bigger problem than you realize.

Here are two case reports that illustrate examples of cognitive diagnostic error perfectly, both experienced just last week* by yours truly. One, I caught and helped; the other…

Trees are AWESOME! So is PAIN!

http://contributors.pressherald.com/wp-content/uploads/2015/01/forest.jpg

Have you ever allowed someone else’s enthusiasm get you wrapped up and passionate about an otherwise “boring” topic?

The Person Sitting in Front of You

Image Credit: https://muhc.ca/glen/feature/glen/gallery

I saw my patient walking up to the door as I pulled up to the clinic. A tall and very thin woman. She was heavily dependent on her rolling walker, I saw that immediately. It struck me. Saturday hours at the clinic were supposed to be simple post-op patients. Quick in and out’s. I think I was even slightly pessimistic at this first glance…because I could tell she was struggling. I estimated this was more work than I bargained for at 8:30 am eval on a Saturday. Four weeks status post a

On the subjective nature of pain

Image Credit: “Inverted qualia of colour strawberry” by made by Was a bee. – Original strawberry’s image is from Image:Fragaria_Fruit_Close-up.jpg uploaded by User:FoeNyx,and original man’s image is from Image:Munemitsu Mutsu 2.jpg uploaded by User:Ueda.H,and I User:Was a bee combined it in one image.. Licensed under CC BY-SA 2.5 via Commons – https://commons.wikimedia.org/wiki/File:Inverted_qualia_of_colour_strawberry.jpg#/media/File:Inverted_qualia_of_colour_strawberry.jpg

Some things in life are definite. Some are definitely not. And some are somewhere in between.

Same goes in healthcare and medicine. When you see a hyperactive deep tendon reflex or produce an upper motor neuron sign via Babinski or Hoffmann’s, its pretty obvious. Usually, there isn’t much debate about its existence. There may be some back and forth about the degree to which it exists or to its implications; but, again, most parties will agree “that just happened.”

Same goes for an infected wound. One look, maybe one smell, most people can agree about the degree of bacterial colonization (i.e. infection or no). We can take this further with abnormal heart sounds, clubbing of the digits (indicative of lung/heart disease), or yellowing of the sclera indicating jaundice. The list can go on, but it doesn’t need to. There are a host of objective signs that indicate the presence of disease or pathology. We can even go further with laboratory diagnostics and imaging studies to attempt to confirm or rule out suspicions about the presence of a disease processes.

We have quite a body of information and resources at our disposal when trying to figure out what is wrong with the patient sitting before us. Even more than that, we have gained enough knowledge to decipher and utilize people’s reported symptoms, their subjective report, to aid in this process. As fraught with bias and inaccuracy as an individual’s own perception of their situation could be, we still have found ways to weed through the minutiae and find bits of key detail that aid in the diagnostic process. It could be how long their symptoms have been present, or what activities exacerbate their symptoms. You might ask, “Do you have any popping or clicking? Or feelings of instability?” Or if the patient reports numbness or tingling in a certain area. All of these details paint a little more of the broad picture of the patient’s condition. And one of the most helpful details when painting that picture

Manual therapy continuing education – What’s the point?

My first month off following graduation was spent interviewing for travel positions. I was looking for a way to pay off some of my six figure loan debt effectively, and travel PT provides that opportunity. I ran into some interesting situations during the interview process.

Many companies wanted to know what skills I could bring to the table (i.e. what hands on skills [i.e. what manual skills]). I may have fumbled

The Crossroads of Philosophy and Physiology (Part 2): Where We Missed the Mark on Pain Education.

 

And you’d be surprised… the answer goes further back than you might think.

So if you read Part 1, we left with a series of questions — all boiling around the conundrum of what I will call “the pain education lag.” This can be defined as the time it takes for the education to take an effect (i.e. reduction of aberrant pain). Essentially, you provide a treatment, but it’s possible for no effect to be seen immediately (and its also highly likely for this to occur in such a delayed fashion). And this is something that is significant. Other treatment effects take place immediately. Yet, with pain education

The Crossroads of Philosophy and Physiology (Part 1): The Pain Education Revelation

 

Remember when you first began practice? Patients came to you for help. You were the solution to their pain..or were you?? Admittedly, you might have been a little scared…not entirely sure of how to deal with your first complex patient of the day. He had chronic LBP for the past 8 years…heck maybe for the past

The Therapeutic Exam

“But I have               in my spine.”

“Oh I can’t, my                is really bad.”

“I guess I’ll just have to live with this                  .”

Fill in the blank with your own patient comments, but they are all essentially the same. Some gigantic, devastating, destruction is occurring inside of their body…and there’s no hope.

I don’t know if it’s funny or just sad, but the fact that such a large amount of patients respond to such “terminal” (i.e. chronic) conditions with statements like