Photo Credit: phoenixmanualtherapy.com
1. What influenced your decision to start a private practice?
The primary drive behind the decision to start a private practice for me was that I had invested completely in becoming skillful at what I did, I saw no plausible rationale for pursuing a profession at an average level. I found myself however, working in environments where the primary emphasis was on the metrics of billing. Patient charges per man/hour were emphasized over the quality of what we held ourselves out to be delivering and which the patient thought they were receiving. Paradoxically these places sought me out for their clinics because of the very skill set that they now wanted me to compromise on. It became clear that they wanted the appearance of expertise, not the commitment to the reality of it but the luxury of marketing it so that they could get the patients per man hour turnstiles moving. In short I found that not only was I burdened by the specter of being told how to deliver PT by people whom I was far more skillful than at doing so, I wasn’t capable of succumbing to such a hypocritical existence.
2. Manual therapy plays an important role in your patient care. What changes can our profession make in order to help further develop this intervention in practicing clinicians?
This is a dilemma. Manual therapy is a psychomotor skill that requires good psychomotor teaching and practice from those who actually do it. I often parallel this to playing a musical instrument. We can learn to read and write music but until we learn to produce the physical motions in synchrony with the instrument that we are playing we cannot produce the music. Our present educational system emphasizes immersion with those whose expertise is in teaching. They can teach us to read the music & write the music but those who are teaching it cannot be experts in everything and hence cannot actually play the music. Academicians & researchers have done what they can to prepare their students. Yet we as a profession have yet to acknowledge that there is a difference between education and training. We leave school and delude ourselves with our knowledge base as being young experts when in reality we are simply now ready to really learn.
How do we change that?
Educators and researchers are doing their job. Some dramatically better than was the case in my early days in the profession where the research was dominated by isokinetic musings. Clinicians should be the ones who teach the fledgling practitioner how to turn knowledge & skill into the art of treating patients. We need to openly embrace that this profession and manual therapy in particular is an artistic application of our intellect. Clinicians need recognize that without them there is no profession and no matter where they are in their development there is someone trailing them and someone beyond them, both of whom they should be interfacing with regularly.
There are many ways to do this, residency & fellowship training are but 2 of them. From these programs I have seen a disturbing emphasis on more academics with inadequate hands on training time to genuinely allow for the student to advance in their handling skills. Environments where learning alongside a master clinician can be arranged have something to offer that is absent in the majority of the formal programs which often look to be yet another business model for selling higher levels of unconscious incompetence.
photo credit: phoenixmanualtherapy.com
3. You have had an opportunity to mentor many fellows in training at your Phoenix clinic. Have you observed common areas for improvement in these clinicians?
The most common deficits are intellectual freedom and manual dexterity. Lets start with the former.
Absent confidence in their ability to guide the patient from where they are presently to where they need to get next, the fellow in training (FiT) seeks certitude. They find certitude in supposed established knowledge, current best evidence, test item clusters, CPRs, etc. rather than in their own thinking which they then check with their command of all of the aforementioned safe grounds. This is what I refer to as evidence driven practice as opposed to evidence informed practice. I am not a nay-sayer on current best evidence! Genuinely I see that it finally informs third parties about what they are buying when PT is covered yet they never see what is delivered. Additionally it drives the low and marginal practitioners up toward the middle of the bell curve for an elevated standard of care. However the heavy handed bias that is disseminated from the current posture of the profession seeming to have an absolute need for certitude drives the other side of the bell curve populated by the intellectually analytical who are engaged in the emerging data while treating down toward the middle of the curve and suppresses the potential rise of the fledgling brilliant clinician.
To be completely forthright, I am a clinical coal face, I have spent well over 50 hours/week treating patients for the better part of 4 decades. What I have seen over the years is current research about that which real clinicians were talking about decades ago. I love the fact that these things reach the printed word and affect practice patterns so much more broadly than the 1:1 real time teaching can. The reason I raise the point is that suppressing the clear thinking, focused clinician facilitates placing a lid on our growth potential. What if Bowling & Erhardt had never freely discussed when they do or don’t see value in manipulation, or if McKenzie had decided that the current best evidence of flexion exercise is how he should continue practicing.
The other aspect of thinking that is commonly deficient is the recognition of that which needs passive movement and that which does not. Manual therapy can be delivered with patient participation in a completely passive fashion. It is not the solution to all problems and should always be a means to working toward establishing independent patient management. I see an over reliance on attempting to use manual therapy as the treatment of choice because the FiT is a manual therapist. First and foremost we should be physical therapists with an intellectual curiosity about what the nature of a patient’s problem is and how we can best assist them. The current psyche of the profession seems to be driven by the need to do passive intervention or generic exercise that a patient could learn themselves with a little online study. We self proclaimed ourselves to be the movement experts in our 2020 vision statement and seem to have completely abandoned the desire to design and implement genuinely therapeutic exercise preferring to relegate that to some support personnel, as if it were beneath us.
One of my mentors discouraged me from trying to make people think. It was his position that thinkers can’t help themselves and neither can non-thinkers. Fortunately my primary mentor was a thinker & so was I. She instilled in me a belief that you can model the thinking and demonstrate its’ results, thereby encouraging the clinical reasoning process. Those who are curious about how they can get the same results that they have seen modeled will naturally become curious about the setting of the stage through thinking and responding to what actually emerges.
The second item that I cited as in need of improvement is manual dexterity. Faculty cannot be expected to teach that which they don’t do, neither can researchers. Clinicians generally cannot teach someone to design an ideal research study either for the same reason. What the clinicians should be expected to be able to do is teach handing skills. The aspiring manual therapist needs to develop curious hands to match the curious mind. The handling of a patient should be performed in much the same way that the subjective inquiring is handled, with a curiosity that naturally leads one to the next most important question to be asked manually. The FiT needs to develop a tactile vocabulary in their hands. They must begin to accumulate normative data in their manual assessments as to what the usual feels like, then the usual in this body type, the usual in this type of presentation or this type of injury, the quantity of range, the response to moving the structure through the range, the end feel of typical joints, abnormal joints, soft tissues, the list goes on but the point is that they need to be able to determine what is amenable to change, how that change would best be gained and how to retain it. Again this requires hands on training and practice in clinical environments rather than more reading or listening in educational environments.
4. One of your strengths is clinical reasoning, how can practicing PTs best develop this part of their practice?
The most essential thing is innate curiosity. We enter a patient encounter devoid of any idea why we are here and what we will do. The patient should drive the initial framing of the problem with the clear statement of what seems to be their problem and what they hope to gain from working with us. Our immediate thought process should go to how it is that we can meet their goal. In other words we should begin to plan getting them out of PT and onto independent management of their problem or the elimination of it.
In both circumstances the end should be considered first, how do we get them successfully out of care & back to the function that they desire. If we can see the whole picture we can then set ourselves to the task of determining which components of that whole function are preventing them from being independently capable now. If we can prioritize what they need to accomplish first in order to enable the next step in sequencing to obtain the whole, we can make better decisions about what we should do now.
In other words if I know what I need to accomplish as a final goal it is easier to determine what do I need to know in order to determine where we are now and what the order of progression should be. I think in terms of PT patients falling in a set of classifications. In each phase I think about how can I drive them to the next higher level to the final level of independence.
Intervention: This implies that the patient cannot accomplish something without our assistance and we need to determine what intervention they need which we can offer.
Rehabilitation: The patient needs physical, psychological and intellectual assistance but they must participate for this assistance to be progressively moving toward their goal.
Management: The patient now needs intellectual assistance more than anything from us, a guide to what they need to do. This requires direction from us & discipline from them.
Prophylaxis: The patient needs to understand what they must do and what they must avoid in order to prevent recidivism.
Independence: The patient only needs to understand what signs or parameters would indicate need for any future interface.
5. You have often said you want to leave the profession in a better place than you found it when you started. Where do you see yourself having the largest impact on the profession?
This is clearly through affecting as many PTs as possible and hence through teaching. I can change lives one at a time through treating but exponentially through teaching many who then treat a greater number of patients and pass the knowledge that they have learned on to other PTs who are behind them on the learning curve.
The message that I most hope to impact the profession with is the need for genuinely therapeutic exercise. There are some inescapable facts that go along with human existence amongst them are the influence of gravity, physiology & time on the body.
If we persist in giving all populations of patients the same exercises because they fit in a given category, then we are no more than personal trainers with an expensive albeit unapplied education. If we do not guide the individual who has lost the physical capacity to overcome the constant force of gravity, the effective ground reaction force and the resultant interface on the body then we turn a blind eye to elementary physics. If we continue to ignore that all human motion was created by that individual’s self generated movement as the neurologic system stimulated it to enhance function so that the body might flourish, then we will continue to ignore the means by which all living creatures establish & sustain function.