I’ve come back from physician visits without a clear idea of what my physician thinks. I think I’ve found a problem, and I believe it’s communication.
The push to be patient-centered and take all patient preferences in to account has morphed in to a wishy-washy communication style which boils down to the clinician saying “Well, whatever works for you. What do you want to do?” This, in turn leads to conversations at home with spouses and friends of “I don’t know, I wanted my doctor’s professional opinion and they told me I could do what I want. They gave me options but not direction”
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 Continue reading
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 Continue reading
You receive a call from your friend and fellow DPT classmate to evaluate her neck… the patient herself is a physical therapist by occupation. A healthy and fit 29 year old female, 5’0″, 115lbs. She reports she is having some cervical musculoskeletal issues going on. She has an achy pain in the bilateral upper traps., levator scapula, and peri-cervical muscles. She is limited by pain with the following cervical motions: right side-bend, right rotation and extension. No signs of central or peripheral neurological issues.
You are an experienced PT and have completed many cervical manipulations on a patient like this and it’s the end of your day. So you are going to do a quick favor for a friend and manipulate her neck, complete some STM, and maybe some PROM/SNAGs/isometrics/METs or whatever your favorite manual therapy technique is. What could go wrong? She’s a therapist herself so she wouldn’t miss anything serious. Being that you are friends you want to do some “magic” giving her some relief of symptoms. So… snap, crackle, manip. You move into some PROM and she reports severe vertigo, nausea, double vision, and you notice hemi-facial asymmetries as she talks about her onset of symptoms. Now what? Your table, your hands, your patient. Continue reading
There is no more credible a thing than an image. Seeing is believing. I’ll have to see it to believe it. A picture is worth a thousand words. Vision trumps other senses (McGurk Effect).
How are the words you choose to use, in the healing context of your presence, going to combat the fact that it has been visually shown that things are “messed up in there” ?
It is not our fault, us humans. Wilhelm Conrad Roentgen developed this lovely technology. About a month later, humans were using it clinically. It is amazing. And I mean X-ray, CT-scans, MRI, fMRI, UltraSound… it’s all incredible. It was developed so we used it. We used it on people in pain, people with broken limbs, people with ailments of this nature or another, and that is the vantage point from which our opinions were based. We saw people with pain have strange looking images. We therefore conclude, that the changes we saw were the cause of the pain, and here we are today.
Post Hoc, Ergo Proctor Hoc. After this, therefore because of this. It is all in the development of the tool. We pointed our delicate and precise imaging tools at the sick, and we found sickness. Continue reading
“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 Continue reading
After a few weeks back in the out patient physical therapy setting I am re-confronted with the pathoanatomical-ness of diagnosis.
The battle for language and context of explanation rages on: full strength, full power, full speed. Whew, just trying to hang on. Daily I must combat the destructive thoughts of a fragile body, or a decaying joint, a shredded tendon, or a tear from here to there.
Sometimes it is very true. Others not. But trying to de-fixate an individual’s thoughts off of the negativity of their structures is unaided by visual proof that they are internally “disfigured.”
Congratulations! If you’ve made it to this point, you’re one last step closer to becoming a better clinician, more adept at logical and critical thinking — and probably a better person overall;)
Today, we will discuss the best special test out there. This one test can Continue reading
So we all know that our patients experience pain relief from many placebo based mechanisms. A little bit of joint cracking, needle tapping, and (insert modality here) can go a long way towards providing a patient some temporary relief which gets us to our main goal of restoring movement.
There has been decades of research on the aspects of placebo:
- 2 sugar pills better than 1 for reducing gastric ulcers(1)
- 1 injection better than 2 sugar pills for reducing gastric ulcers(1)
- Higher priced items are more effective than cheaper ones, but only when people know they are the higher priced meds.(1)
Just more fun facts… Continue reading
Short answer is: yes, more than you know.
Bias is so prevalent, it’s almost Continue reading