On Difficult Cases

There was a discussion recently in a Facebook group regarding frustrations with difficult patient encounters and advice on how to best manage these cases. Here below, I have provided a brief list of advice imparted onto me by mentors of mine. Hopefully this helps…..


One of the best pieces of advice a professor of mine gave me was “that you cannot control how people act, you can only control how you react”. This simple quote or credo is so incredibly true and is a great approach to life in general. People can be irrational and their actions frustrating, both of which may become magnified surrounding episodes of poor health.

Another thing to consider, which is a message I’ve adapted from an icon of mine Cael Sanderson, is that every challenge that you face is an opportunity for growth and that we should look forward to challenges; they make us better. Difficult patient encounters are opportunities to learn how to manage difficult patient encounters and it will get easier. It’s also always important to consider that the people we serve could choose elsewhere. They don’t have to be in our clinics. Even in public or federal systems, the patient can still choose to not show up. Take it as a privilege that YOU get to SERVE them and even though they may state that they don’t want to be there, they still decided to show up. Also realize, (and I’ve learned this working with many disadvantaged populations) for many people, even getting to the clinic may be more difficult than you may ever realize.

Regarding verbose patients; there are many people who come to our clinics who have never had the opportunity to speak to a healthcare provider about their problems. Some may not have the opportunity to share their frustrations with anyone who cares or has concern for them. This issue of social isolation and loneliness is a real and growing problem in our modern society. Therefore, consider it a privilege that they are comfortable enough to be verbose with you. Just taking time to listen to them can go a long way. In terms of managing verbosity, because there are time constraints to clinical practice, what I have found to be useful is to try to steer their conversation around the goals for the session or intercede with questions that may help redirect it.  Always try to acknowledge what the patient has said before talking, this helps convey that you did listen to them (you really should be), which is important for building trust and rapport. This process can be difficult but it gets easier over time as well.
Regarding patients who are difficult to convince or establish buy-in for your plan of care, especially those who may believe in more liberal interpretations of physiology, be persistent and steadfast but always be respectful and considerate. Remember that few people possess the specific knowledge of human physiology to determine a falsehood from truth as it pertains to disease and 88% of US population is insufficiently healthcare literate. Given these factors, and others it is incredibly difficult to change someone’s views once they have internalized information; ie “You can’t sell meat to vegans and you can’t convince a carnivore to eat vegetables”. If their views interfere with your best judgment as a provider, consider referring them elsewhere; it’s probably best for both. We as a profession and field (healthcare) need to do a better job addressing this process of translating knowledge to our communities both at the clinic level and institutional level. But it all starts with a conversation and re-framing expectations with each individual. At the fundamental level, a clinician is an educator and motivator.

These are just some recommendations and tips. I don’t practice as much now but can recall how difficult it can be in the clinic and realize that things are rarely ideal and we all have our limits. However, if you consider some of these basic principles and perspectives, it helps make difficult situations a bit less stressful when they do occur.

 

(Image courtesy of Gomerblog.com)

On Argument: Quick Tips

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A little advice regarding the nature of discussions in this forum and elsewhere:

If one posts anything publicly, or really anywhere to a broad audience, one must realize and understand that individuals will offer both support and criticism. It’s part of the process and not everyone will view things the same way, for many reasons i.e. Knowledge base, biases, experiences etc. Few things in life are dichotomous in nature, where there is an absolute truth and false. Public discussion in any setting is NOT for the meek of heart. If one doesn’t possess the gumption to handle criticisms or contrarian views, they should perhaps reconsider participation in public discussion. Furthermore, if what one posts is so easily criticized, perhaps one should consider heeding the criticisms offered or at least reconsider the merits of what one one has posted. I would also wager (no empirical data to support this, this is based on the multitude of professional discussions and arguments I’ve participated in) that most people who decide to criticize (especially peers) do so out of genuine concern and a desire to improve.

Now I do agree that there should be some ground rules to discussion/argumentation for the sake of decency and purposeful argument, ex. criticisms should be purposeful, valid and follow a sound logical framework. One should also consider how incredibly difficult it is to change someone’s views on any topic, much less when those opposing are steadfast in believing their views to be true and when argument is done via textual mediums of communication. Being outright rude makes that task even more challenging. Why work against yourself? However, not everyone agrees with the same ground rules as I or anyone else; which one must also understand. However, one doesn’t have to respond to criticisms offered either, there’s always a choice.

You could heed this advice or not and continue to become overly offended and attempt to silence others who offer views that differ or continue to be unprofessional in discussions with peers. Ultimately it makes no difference to me, I will still continue to go about how I have regarding discussions. Just some advice. We accomplish little with categorical and unconditional agreement, iron sharpens iron. However, nor do we with shouting matches instead of purposeful, respectful yet incisive discussion.

Also, one should consider entering discussion or argument under the condition that what they argue may be wrong. One should be prepared to argue their point vigorously but be willing to concede when what they argue is shown to not likely be true. If one is not willing to make that concession, there is little point to engage in argument. This is actually a cardinal rule of formal argumentation. This cardinal rule is also something to consider, before posting publicly or one will have a hard time due to the nature of public discussion described above. One should also consider realizing their limits to the value of their opinion and degree of expertise, ie, acknowledge what you know, what you don’t know and that there are people who might be more versed on a given topic. Quick tip, if I engage with someone, I haven’t encountered previously, I usually do a quick search on who they are so I know who I’m discussing with and if I might be out of my league. That’s not to say that we should view the thoughts and opinions of experts dogmatically but it should be in the back of one’s mind that perhaps their opposition might know a bit more on a topic than oneself.

10 Quick Tips for Staying Up To Date

Following some of the conversations that came out the #SocialPT talk I gave at CSM 2017 with Ben Fung, Greg Todd and Brett Kestenbaum(video via UpDoc Media), I felt it would be useful to create a resource to help students and clinicians stay up to date with the evidence. As an emerging researcher and academic, I am passionate about serving this profession as both a purveyor and guide of knowledge to help inform the care provided in our communities. No more ivory towers and no more “knowledge obscura”. We are all our profession’s keeper and the better informed we all are individually, the better off our profession will be collectively. In the list below, I have provided 10 easy tips to help clinicians and students stay current through a variety of different methods, many of which only require a small addition to a typical day. 90% of them are completely free and 100% are of no additional cost for APTA members. Choose one or choose all 10!

1) Use the APTA PTNow website ($)

PT Now is a resource designed for APTA members which provides summary findings on clinical questions, access to clinical practice guidelines, validated outcome measures and an article search function. Also be sure to check out the APTA PT Outcomes Registry. This project will allow clinicians to participate in the research process by contributing outcomes data to a national registry. The data from this project will be instrumental in advancing care for our patients and creating leverage with legislators and policy makers.

2) Create a PubMed MyNCBI account and create saved searches (free)

This will allows users to track research topics, questions or relationships that interest them. Users can then schedule email reminders on these topics as new papers are published. Though these are only abstracts, it’s a good start and often once the PubMed link is obtained most people have an easier time finding the manuscript. There are also many articles available through PubMed Central, a database designed to host biomedical information free to the public. I have included a YouTube video of how to set up a MyNCBI account and saved searches as well as a step by step instruction with pictures.

YouTube Demo

How to set up “saved searches”

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Step 1. Create a MyNCBI account

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Step 2. After creating a MyNCBI account, log in and perform a search on a topic that interests you; i.e. “Back Pain”

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Step 3. After the search is performed, click on “Create Alert”

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Step 4. Create a saved search with scheduled reminders delivered to your email at a frequency of your choosing.

3) Push notifications” from Journal Twitter accounts

This will push notifications to your phone whenever the Twitter account for a selected journal posts. Many  of these Twitter accounts also have public “lists” of journals, clinicians and researchers they follow which may help structure your search, as an examples the Cardiopulmonary Section’s Twitter Account has two (one cardiac and one pulmonary/critical care). I have included a step by step instruction with pictures for both.

How to “Push Notifications on Twitter”

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Step 1. Click/tap on the notifications icon

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Step 2. Select “All Tweets”

How to subscribe to a “list” on a Twitter account

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Step 1. Click/tap on the settings button.

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Step 2. Select view lists

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Step 3. Select a list you would like to subscribe to.

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Step 4. Click/tap “subscribe”

4) Subscribe YouTube channels and Podcasts (free)

These platforms provide synthesized content on research or clinical topics. The content on podcasts will generally be audio only and Youtube Channels will usually use both visual and audio. These resources are great since they can be listened to while doing something else, such as the ride to and from work or while exercising. Podcasts are particularly great because if users have the podcast app for iTunes, updates to podcasts they subscribe to are automatically pushed to their phone. I have compiled a good list of YouTube Channels and Podcasts for physical therapists here but be sure to perform your own search to find channels or podcasts that interest you. A few of the YouTube channels I subscribe to are the New England Journal of Medicine, British Journal of Sports Medicine and Heart by the British Medical Journal. Also don’t forget to check out the Cardiopulmonary Physical Therapy Journal Podcast!

5) Register/Subscribe to a journal email list (free)

This allows users to receive an updates on new publications and papers published ahead of print. I have provided a step by step example for how to do it through the New England Journal of Medicine, a journal that also often publishes open access (free) manuscripts.

How to “Register/Subscribe to a journal email list”

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Step 1. Click “Register”

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Step 2. Fill in your email and select a password to register. A confirmation email will be sent to you.

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Step 3. Select the “content alerts” and specialty areas you would like to receive emails about. Some journals may not have multiple options.

6) Follow Facebook pages for journals (free)

This tip is similar to “pushing notifications” for twitter. However, an advantage of doing this through Facebook is that more people both have Facebook accounts and check them daily than Twitter. One of the easiest ways to keep up to date with the evidence is make it a component of your daily life.

How to “Push Notifications on For a Facebook Page”

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Step 1. Click on the “Following” button

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Step 2. Click/Tap the notifications tab, then under “Posts” select receive notifications from “All Posts”

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Step 3. Click/Tap the “News Feed” Tab and choose “see notifications from this page on your timeline first”. This places posts from this page at the top of your timeline (not necessary but useful for many)

7) Follow individual researchers (free)

Many researchers have social media accounts and a large portion of them are fairly active, especially on Twitter I actually made a list of some of these accounts worth checking out. Users can also, “push notifications” from their accounts too! I would also recommend signing up for researchgate, this site is increasingly being used by both researchers and clinicians alike. On this site many researchers provide full texts of their papers that can be downloaded, usually 1 year post publication. Users can also request papers from researchers that aren’t publicly available yet on researchgate.

8) Join in the discussions on twitter (free)

To join in these discussions follow hashtags such as #solvePT or #BackPain. To be more specific, I would also recommend using Symplur , a free healthcare hashtag aggregator to help find topics that interest you and even monthly twitter journal clubs such as BMJ Heart’s “Heart Journal Club” #HeartJC .

9) Join in discussions on Facebook groups (free)

One of the best ways to stay informed is to regularly participate in professional discourse. This allows clinicians to appreciate different perspectives from colleagues and to have their biases potentially challenged. Even if you don’t participate, observing some of the discussions from a distance can be useful too! Doctor of Physical Therapy Students or Physical Therapy Practice Education and Networking are two of the largest and most active groups. These groups are also great for asking questions and sharing information.

10) Create a system to manage your citations (free)

As you begin to accumulate resources, especially published work it is important to keep track of them in an organized fashion. This allows you to quickly reference papers and to search for them later. I use Mendeley and Google Drive; both are free to use and excellent software solutions! Mendeley also offers a google chrome extension that allows me to cite resources as I browse. Google Drive has a desktop app that allows me to save files locally on my hard-drive while also continuously and simultaneously pushing files to a cloud based folder which can be accessed anywhere with internet access; even on my phone with the Google Drive App.


I hope these quick tips will provide a better infrastructure for both finding research papers and regularly consuming evidence. If we are all individually more up to date with the scientific literature, better informed decisions can be made for the people and communities we serve!

On Providing Discerning Opinions: A Vlog

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Following the Olympics this past summer, the utilization of interventions (see cupping) that possess paltry or inconclusive scientific support became rather prevalent. This discussion highlights a larger issue within rehabilitation and medicine over all; which is offering a discerning opinion to our patients and subsequently the tacit approval of interventions lacking sufficient scientific support from not offering said discernment. This is certainly a complicated issue but I feel that as a profession this issue needs to be discussed amongst our profession, if we are to continue to move forward as a profession. I discuss this issue in my first Video Blog (Vlog) embedded below, Please feel free to comment and share.

Let’s start talking!

 

 

The Role of the Clinician in the community; selling meat to vegans.

Following the most recent media craze around cupping and other alternative medicine in MSK rehab, many in our profession have provided commentary on this issue. I feel that this most recent event highlights a bigger issue within our profession, which is the role of the clinician. My opinion on this matter was requested by a colleague of mine on a thread, which realizing how long it became, I felt might be good for blog post. Please, enjoy and let me know what you think!

Though I am more in the lab and lecture hall now as an academic, I still see a few patients and serve as a clinical educator to both students and practicing clinicians. This is my general view of the role of the clinician in communication with patients and the community:

A clinician should be confident in their understanding of the human body, based on the current accepted body of knowledge, while humbly accepting their personal limits of understanding and the current gaps in knowledge. They should also avoid filling those gaps with ideas that escape the realm of scientific plausibility, especially when interacting with patients and their community. The reasoning behind a given treatment is almost as important as the physical act. Our thoughts and words matter, a lot. This is a particularly important concept to bear in mind. Remember when interacting with a patient or the community it is from a position of authority (a clinician is viewed as an expert), in that power dynamic people tend to believe what is told to them. Therefore it is imperative that we strive to ensure that the information which is communicated to patients and the community is as truthful as possible. More on the consequences of failing to do so by my colleague Kenny Venere PT, DPT (FYI he’s a bit blunt).

Clinicians should remain committed to becoming excellent in their field and learning more throughout their career and most importantly doing right by their patients. Sometimes that means being a discerning yet respectful voice of reason to the patient and in community to the nonsense that is perpetually disseminated by others, for whatever reason. A clinician at the core is a motivator and an educator. As an educator sometimes what’s right isn’t popular and it’s not easy to tell or convince someone that they’re wrong. However if someone is wrong it’s important that they are told so but it should be done in a respectful manner. Changing someone’s opinion on anything is incredibly difficult and it doesn’t become any easier by being boorish and discourteous. Always remember to be tactful and be mindful that some people just won’t change, despite how well informed a counter argument might be or the degree of cognitive dissonance present. Clinicians should also learn to effectively communicate, empathize and relate with the different types of people entering into a clinic. Communication and use of language is probably a clinician’s most important tool after what’s between the ears.

Lastly, the majority of patients arriving at a clinic already are confident enough in a providers abilities, as they likely wouldn’t be there otherwise. Even if a given clinic is the only one covered by a patient’s insurance, most have the option of not showing up (trust me I’ve practiced in systems like this and people still don’t show up). Therefore they don’t need to be sold on some esoteric and novel for the sake of being novel treatment, they just want to get better. They are seeking the help and guidance of a clinician to do so and they also want to be listened to by someone who cares. Listening to a patient is not synonymous with doing whatever they want so that they feel better. Listening is using the information they’ve provided to develop the best choices for them to make, we’re providing them guidance and options that they have to choose. It’s a give and take but the role of the clinician is the adviser, that’s why a profession requires so much schooling, training and licensure. Also factor in that most MSK injuries are self limiting, we don’t really need to make rehab too complex or creative. It just needs to be intense enough so the patient progresses to meet their goals in the most effective and efficient manner and creative enough to keep them interested.

In short, keep it simple and use the body of knowledge to inform and guide decision making (not replace it), stay current, be an adviser for patients and community, be careful with use of language and have the courage to offer a discerning opinion and humility to accept one. This is not always easy to do in the clinic while working with individuals with health related problems (who we all want to help get better) who may have been exposed to all sorts of information/misinformation and may take some convincing. However, if a patient doesn’t want to listen to a clinician’s advice they can always go somewhere else. We aren’t short on people needing help and if a patient doesn’t buy in they probably aren’t going to have too much success with that clinician anyway. This is basic marketing/argumentation/social theory, as an example people who are vegans aren’t interested in people trying to sell them meat but there are plenty of meat eaters and they are sure to find those selling meat.

Image: Courtesy of Deborah Dunham 2012; cavementimes.com

 

On The Cause of Diversions

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Each time I encounter a post or comment by a clinician regarding an approach to rehab or an explanation for treatment effect or diagnosis, I wonder what experiences led them to their decision and perspective. I analyze this for all posts irrespective of accuracy and my own biases. Overall, the majority of thoughts appear to subscribe to contemporary scientific explanations. However, there is a significant faction within our field that does not. (Bear in mind this analysis acknowledges that there will be slight differences in approaches which can be substantiated by evidence.  This is both expected and good for the profession.) Given that for the most part our education/training are similar from primary school through graduate school, access to scientific literature is fairly available to all and clinicians must stay current with CEUs, what are these deviations attributed to? What is the cause for the pseudoscience and in some cases anti-science pervasive within our profession?

However does this matter? Is there actually an ethical dilemma?

Clinical outcomes are important, as are experience and findings of research report typically represent the significant averages. There will always be individual variation and guidelines are meant to be just that, they are not intended to replace clinical decision making. In a sense summary findings of a meta-analysis or clinical practice guidelines should not be viewed as dogma and unalterably infallible. However, ascribing a treatment effect or diagnosis to something factually inaccurate and contrary to the contemporary understanding of physiology is not ideal. Especially considering that an explanation of observed responses to treatment should be disseminated to the patient throughout the course of care. If we are not providing patients and the community accurate explanations for what is occurring with treatment yet they still improve is that ethical is that justifiable?

Case example of many…..

A patient is referred to a clinic for chronic headaches and the clinician provides cranial sacral therapy which results in a positive outcome for the patient. The clinician attributes this beneficial effect from the cranial bones being misaligned and then subsequently being reduced with this treatment. Though the patient’s status improved, the explanation has no substantive evidence to support what was disseminated by the clinician. Is that ethical despite the good outcome? What would the best way to explain the response to this treatment?

 

Let’s hear your thoughts!

On Truth (Quick Post)

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I came across this photo earlier and after viewing some discussions regarding EBP I decided to write a brief post on it.

 

People often attempt to conceptualize and understand complex topics to fit their world view and biases. This is human nature; as it is difficult to deconstruct information and assess it critically while acknowledging and remaining critical of one’s own biases. This is true for both patients and providers. The attainment of truth and knowledge is a difficult task but necessary. However in this current healthcare system untruths, oversimplifications, obfuscations, conflations and care lacking a trace of plausible evidence is reimbursable. Obscure, esoteric and novel (for the sake of being novel) methods and treatments are also easier to market; as are panacea. Imagine the perspective of the patient and their expectations. This is why the guru and missing link nature is so prominent and pervasive, which is not isolated to chiropractic. Until this issue and it’s multiple components is addressed as a society this issue will continue to perpetuate.

 

Simply put: “The truth defies simplicity”