- Dr. Piotr Solowiej PT, DPT
Master the Basics
Embarking on a semi-solo adventure this year, co-founding a clinic, makes PT school feel like it was ages ago. Time since graduation has been filled with all kinds of learning experiences, both formal and some the hard way. It has all resulted in significant growth as a professional, and it's easy to forget I haven’t even been licensed for 2 years yet. However, in the eyes of physicians and patients, I sometimes feel like that is all they see. A kid, so to speak. Still a professional, but in his infancy.
I can see how it would be easy to brush me off as just another eager newbie. I imagine similar feelings drive many young professionals to chase accolades. Doing whatever they can to add letters to their name and gain notoriety. I totally get it. I’m all for education. Never stop learning is a motto I live by.
But is the collection of initials at the end of a signature a true sign of competency? Does is accurately represent understanding of the human being before you? That is the aim, but it doesn’t always work out that way. I think a major issue is once school is completed, the foundations of the profession - examination and assessment - often fall to the wayside in light of the more sexy intervention based continuing education.
I’m writing this as a word of caution - out of my own mistakes in drinking the Koolaid - to other newbies, soon to be newbies, and even some vets. Accomplishments in the form of skills or certification are both deserved and impressive, but they shouldn't define you: don’t be a hammer, be a Swiss Army knife.
If you’re a hammer, everything becomes a nail
A knife is a bit of an ironic metaphor, as it is often the antithesis to the profession. We're supposed to help people avoid the knife, right? The cliche above rings true in the healthcare industry, and especially in PT. I’m seeing a trend of moving towards specialization.
Special skills have their place, and offer a valuable service. That's why they exist. Chances are if you're a specialist and someone was referred to you, it was done for a reason. Your skill has a chance to help that individual. However, approach with caution.
Certifications and specialization take time, money, and hard work to achieve. It's natural to want to use them, but not on every single patient on your case load. Interventions shouldn't be used for the sake of using the skill and then hoping it works. How do you determine if a particular situation indicates a good candidate for your certification/speciality? A framework for inclusion/exclusion must be in place.
Is my tool appropriate for this job? Is intervention "x" appropriate for that patient?
I want you to participate in a thought experiment. Here it goes:
Let’s say there is an ad for a job. The job requires the potential employee to construct a bridge. The bridge must be made out of wood, but other than that, no other special requests and any other materials needed for assembly can be provided.
You are in the bridge building business and would like to apply for the job. The posting asks applicants for a resume, including special skills, tools you will be able to provide for the job, and evidence of experience with bridge making in the past.
What tools and skills are most important to include on the application?
List them before scrolling down. Really. Do it.
What was on your list?
I can tell that you wouldn't be a good fit for the job, even without reading your list. If the section title wasn't enough of a clue, here’s why.
The job was to construct a bridge correct? Well the bridge doesn't necessarily exist. Not in a physical form. More so as an idea. The job was to “build” or “construct” a bridge, but from design. The job posting was actually a better fit for an architect or engineer, rather than a construction worker. Which I assume many of you pictured as you developed a list of tools and skills. (This also brings up an important point about the unintended misinterpretation of language, but that’s a tangent for another time).
You’re probably telling yourself that it’s not fair you didn’t have all the information. If you had all the information then clearly a hammer, for example, was inappropriate for this particular job.
But why did you jump to that conclusion in the first place? Why only consider other possibilities after the fact? Why not ask more questions before making the list to see if you could tailor your response to put yourself in the best position to be successful?
This is best example and argument I can think of to demonstrate how a thorough and unbiased assessment is paramount to a physical therapy evaluation. You don’t want to bring the wrong tool to the job. It may walk like a duck, quack like a duck, but until you prove that is not a chicken wearing a duck costume you can’t be sure it’s not something else.
And we all know you shouldn’t count your chickens before they hatch. And that you shouldn’t put all your eggs in one basket. And that sometimes baskets can’t be bought. Unless the shot is money. What's with the pump fake? How did we get to basketball?
Okay, enough metaphors. Anything can basically be anything until proven otherwise. In physical therapy, a framework of assessment and examination needs to be in place in order to sift through all the possibilities to narrow them down as much as possible. The framework should help rule things out: weakness, structural instability, neural tissue, the spine, limitations in other joints, non-musculoskeletal findings, etc.). This is a better starting point as confirmation is subject to false-positive findings and bias - and in my opinion - even more so with special skills. Proving something wrong, or ruling it out, however is quite definitive. It's significantly more difficult to make an argument for something that has been proven irrelevant. Through this process, you ought to substantially and more accurately narrow the possibilities of potential beneficial courses of action.
Again, I know I’m a newbie. But it just doesn’t make sense to me to chase interventions this early on I’m my career. Reason being is that interventions courses teach you how to execute skills. From the cources I've attended, and from what I hear reported at others, they pretty much stop there. (Maybe I've only had experience with shitty courses. Also a possibility.)
Very few of them go in depth on when to identify specific situations for when the skill is appropriate to use. It's very easy to fall into the trap of using the skill ubiquitously in a caseload. So if I'm the best at manipulating a lumbar spine, but if I don’t know when, and more importantly when not to use it, I’m not going to be an effective clinician.
All low back pain patients don’t need a manipulation. All stiff patients don’t need IASTM. No one needs ultrasound. Okay maybe even some cases benefit from ultrasound. I did a wound care rotation during school and we used it a lot. Saw some benefit but I’m still not convinced as time could be a confounding factor there. The point is that most interventions work, some of the time. The trick is in identifying those times.
If any patients or physicians are reading this, here is the reason why you should consider me to be your physical therapist: a relentless pursuit of the basics. I may not have flashy initials behind my name yet, but I don’t necessarily need to. With a sound assessment, I often find interventions and plans of care create themselves. There is minimal guessing and hoping involved.
The assessment is where it’s at. Master the basics, first. Then add more tools.
I’m also not saying I’m perfect but I’m sure as hell going to try to be. Missing basic information can result in some funky conclusions and patient responses that get really dubious to guide.
Preparing for a Specialist Appointment
If you’re operating principle is the ability to execute high level interventions, great, that requires a lot of skill. But to me it’s a sign of a more narrow lens, and greater potential for missing the forest for the trees.
If you’re a patient and you’ve been referred to a specialist, it’s because someone decided they may be able to help you. They very well may, that’s what they’re there for. But as a patient you need to prepare yourself for that interaction. Be your own best advocate.
A game plan must for all patients is to inquire about how the provider will know if their unique situation is appropriate for provider's skill set. I think it’s completely inappropriate for a provider to tell a patient they’re the best at “x” so they’re only going to do “x” regardless of any nuances the patient presents with. They’ll just have to wait and see what happens.
If this happens to you, run. Run away and get a second opinion.
P.S. - I realize this may be coming off as a "down with the specialists" type of post. If you want to specialize in something - phenomenal, go for it! But please realize that a transition to a specialty by definition, means you will be effective in a more narrow scope. It's a bit ironic as a specialist is considered to be at the top of the field, but the tradeoff exists.
My two cents at least.