Letting go of traditions in physical therapy

Every Christmas eve, my Sweden-born grandmother would prepare an authentic Scandinavian dinner, complete with a variety of meticulously made cookies that only a grandmother could bake.  It was a tradition that my entire family eagerly awaited each year.  Although I didn’t care for some of the items on the menu—pickled herring on rye cracker hors devores–and others I did not even try until I was much older—kaldomar, for one, if a single item was changed, or heaven forbid omitted, there would be a general discourse from the entire familj.

Traditions are not only events that occur within families.  Traditions can be habits, belief systems, religious practices, and even standard practices in medicine.  Traditions can be accepted as ‘the way’ or rejected as ‘the highway’.  Which ‘way’ you go depends on your own biases, boredom or even resistance to change— how many times have you heard “that is how we have always done it”?

Assuming you, the reader, follow Twitter.  One frequently occurring topic Is the identity crisis within physical therapy.  Who are we and what is it we do?  Impossible to define, because we all “do” different things… and bicker about it endlessly!  “Physio Will Eat Itself”, a tongue in cheek reponse by Roger Kerry @rogerkerry1 to another good read by Dave Nicholls entitled “Should we give up physiotherapy?”  If you haven’t read them, do it now!

Identity is not our biggest problem.  What about resistance to change?

A recent RCT on total hip replacements and a systematic review on total knee replacements both conclude “we” are not necessary for a good outcome.  Unless this is your entire caseload, keep calm and move on.  If it is your caseload, you can keep calm and move on too.  Traditionally, we have seen many of these cases.  And many of us would agree we helped them.  For those of us that have been around a long time, remember when there was no Medicare Cap, no pre-authorization, and endless amounts of insurance funds available to us at our disposal.  When Medicare added a cap, we all gasped with despair—“how can we get this poor person better after such a major surgery on only $1800? Damn you, Medicare!”  But really, it ended up not being a big deal.  We adjusted.  And now, we might not even be necessary beyond setting patients up with a good home program.

In our desperation to find our place, we are MAKING ourselves needed.  Whether it be offering an outrageous explanation for someone’s assumed dysfunction—“well, Mr. Jones… it seems that your foot pain is caused by a facilitated segment at L5 and a manipulation to this joint will restore your gluteus medius’ ability to control your pelvis.  Because it can’t control your pelvis, you laterally lean and force your uncompensated rearfoot varus into a zone it can’t go and– voila!–your foot hurts!”—or even the trending “tool” of the year, often proprietary to a physical therapist that believes in blowing up balloons, cups, needles, scraping, taping, and more, all the while making a shit ton of money.

We might even claim that we are BETTER than surgery.  We are BETTER than opioids.  We should be CHOSEN first!  Not only does it somewhat demonize surgery and frankly, the hand that feeds us,  it makes sense that we would be obvious choice when compared to something that most people don’t want.  It’s like saying– “yes!  I prefer the broccoli over dog food”.  You get the picture.

Traditions need change.

My grandmother sadly passed away in 2001, shortly after I received my degree in physical therapy.  My mom tried her best to keep the Christmas eve dinner alive, but it was just not the same.  The single most important ingredient was no longer there—my grandmother.  And so it was, we made new traditions, and as painful as it was, we moved on.  While some may embrace this as a fresh start, many prefer to continue to do things as once was because doing otherwise defies the boundaries of their comfort zone. And perhaps, much of their money and time, even most of their career, was spent doing things the way they have always been done.  Waiting for that return on a very large investment.

Our profession is scared to death of simplicity– we are smarter than that, aren’t we?  While budgets are tighter and people are busier, it makes much better sense to offer simple, sound advice, even reassurance.  Also offering an alternative—you CAN do nothing!—is accepted  by patients.  OMG!  Did she really say that?

Why are we here?

It IS the advice we give.  Simple to us?  Yes.  To others?  Maybe not.  Unless you under-load your patients, and give them shitty advice, like “don’t do that anymore” or “rest” or “sit up straight!” in addition to the extensive 45 page home program with 3 sets of 10 exercises that they will never do anyway, you are still needed!  Much can be accomplished and not replaced, in the first and sometimes only encounter.  Tendinopathy is a perfect example.  This person is not likely to improve in the 2x/week, 4 week referral session.  Manage their load, give 1-2 exercises, and follow up for a recheck in 1 month.  Teach them how to take care of themselves.

We should spend less time “doing” and more time “educating” if we want people to say “I am going to a physical therapist” rather than “I am going to physical therapy”.  Got it?  If you don’t, read here.  This is the change needed in our profession’s traditions.  I have no problems with this.  In fact, I find it much more satisfying to foster self-efficacy than anything else.

My mom continues to make fattigmann every year.  I hate to admit it—never cared for fattigmann (mom, if you are reading this… sorry!).  I always went for the Swedish Heirloom cookies, or even the krumkake.  There was also a toffee-like cookie that was amazing.  But, I am always willing to try a new cookie.  I might even stop eating cookies all together.

 

Thanks for reading.

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4 thoughts on “Letting go of traditions in physical therapy

  1. I agree with much that you say but what I feel is missing is the idea that not all patients will fit into how the average person performs. I see patients that have been discharged with no recognition that they are limited in their function/mobility and are having difficulties. The system tells us that they should be better but if no one checks or follows up (and that is unlikely without a study being conducted) then these patients are not supported. Traditions? I like to think that our job is to assist a patient to return to the best normal function that is reasonably possible. In these days of avoiding examining patients, avoiding follow ups and not being wanting to spend money on ‘unnecessary’ treatment we have to potential to fail those who historically depended on us. Yes do not make patients dependent but at the same time why not help them to gain a reasonable level of recovery? There was a definitive study done in Britain years ago that showed that patients with LBP all recovered after 6 weeks. When someone decided to ask the patients instead of the practitioners they found out that the patients just went elsewhere for help when the medical system didn’t seem interested. If you are looking for ways to have physiotherapy replaced by advisers/educators rather than people able assess physical dysfunction you are moving in the right direction.

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  2. Are you suggesting that physical therapy is not necessary following a total knee replacement? Am I reading that correctly?

    One fall resulting in an ER visit costs Medicare more than a dozen patients receiving physical therapy following major surgery. If PT can help keep people out of the ER, it is serving its purpose and saving Medicare boatloads of money.

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