Is this you? Same treatment repeated expecting a different outcome = neurosis

[Michael McMurray]

https://www.washingtonpost.com/national/health-science/a-doctor-with-a-bad-knee-runs-into-one-size-fits-all-medicine/2016/12/02/d5ba55c0-a6a2-11e6-ba59-a7d93165c6d4_story.html?utm_term=.93a7e000aa8b

Again read this an post some thoughts.

[Kyle Feldman]

Great Read. I saw this on Facebook a few weeks ago but only glanced at it.

I can tell you that this is the reason I choose residency and fellowship. Most PTs can get someone “better enough” or work them to a point. However it takes a higher thinker, a more caring person, a practitioner that puts the patient first and truly listens that will find what is needed for THAT patient to get them above and beyond.

I know that each of us would be reflecting throughout the process and knowing that after a few visits we were not seeing gains we would have tried to switch up the method. Keeping the ego out of it is the most important aspect of being a truly good practitioner from what I am learning now.

“The secret of the care of the patient is caring for the patient.” I loved this quote. One thing I struggle with is caring too much. And by that I mean thinking about them long after they left, second guessing what I did, and worrying I am missing something. It is great to reflect and never be satisfied, but I know that I need a balance and to trust that I am doing the right thing because I am using the best evidence based practice and constant reflection.

We are all on the right track. We just need to make sure we are never satisfied, letting ourselves get in our own way, and caring about how we care for the patient.

[August Winter]

Kyle, I would say that what your sentiment on second guessing treatment decisions is mostly what I drew from this article as well. Just the week before I had a prolonged conversation with Michael regarding a patient during mentoring time who we had seen at eval with what appeared initially to be reactive adhesive capsulitis following a flu shot. Michael and I were discussing my treatment plan and progression of activity, which eventually led to the topic of this article. My biggest fear was that I was being too aggressive and was continually re-aggravating her shoulder. I think your comments and this article really highlight the importance of reflective practice and constant re-evaluation.

Also if anyone has extra time on their hands/wants a good laugh then you should read the comments on the article, some very interesting opinions in there as well!

[Kyle Feldman]

August, Great reflection on your experience. Less is more and it looks like you learned that from this patient. You can always add, but it is much harder to take away once you do something.

Great post

[Erik Lineberry]

How does everyone work with patients that are referred from a surgeon that requires a specific protocol? The article talks about exercise protocols that the PTs were giving him and I can empathize with how this must make patients feel, but I also feel limited by certain referral sources based on the protocol they give me. This is a major frustration of mine for the very reason the author of the study brings up. It limits me from personalizing a PoC for my patients and it makes it difficult to progress and regress interventions for patients that may benefit from this.

[Michael McMurray]

Protocols are guidelines not prescriptions – they should help guide some decision making for tissue healing – but obviously have significant variability based on the specific patient presentation in front of you.

For example, if you read 10 RTC repair operative reports; there should be information in each one that guides your decision making to “accelerate or delay” the post op “protocol” – patient specifics, tissue specifics, surgical specifics.

That is what makes us skilled clinicians versus technicians following a recipe.

[Erik Lineberry]

There are things that we see that key us in to how to progress our patients based on the subjective and objective findings we collect. What I articulated poorly was the difficulty I have found in communicating with physicians that refer patients to us and expect us to follow their protocol. I have found that some doctors do not want to hear this, especially from a new clinician. I thought that others may have had experience with this as well and had some thoughts on how they have handled micromanaging from their referral sources.

[Kyle Feldman]

In past experience I have tried to actually articulate my thought process in the notes. If they had a problem with this I would have a conversation. If they are unwilling to listen to when I am trying to back the down and get them better (in this case the patient needed less, not more) then I think that referral needs a new place to send patients.
I think the MD is correct if they tell us that we are wrong for pushing the patient and going beyond the protocol because they are the one that performed the surgery and they know the quality of the tissue and the work they did. If they want us to do less, they have a reason.
However this article talked about the PT backing down and doing less to get the patient better. In my opinion, this is not something the MD would question if the patient is making gains.

[nhoover17]

I had a recent patient s/p RCR referred to us after failed PT at another local clinic. My pt reported that his dr was irate with this other clinic and had called to tell them he would never refer another pt there and that he was considering sueing them due to not following protocol and being too aggressive. He feared they had contributed to a retear. The script came with a complete protocol and instructions to begin at phase 3 for strengthening.

I was already terrified and thinking that I was going to have this dr breathing down my neck just waiting for me to screw up. I doubted myself before the objective exam even started. I found that this pt had TERRIBLE quality of motion and poor motor recruitment and in my opinion was not ready for strengthening.

I articulated that to my pt and explained as clear as possible in my note so the dr would hopefully understand. And I began working on ROM and movement patterns, with scapular motor control.

After my pt’s next follow up with the dr, he came back reporting that the dr was very impressed with my note and MY POC. He asked the patient to pick up a bunch of business cards so he could refer to us in the future.

What I learned from this is not that I am a great PT, but that I have been trained to see things and respond accordingly, and sometimes dr’s pay attention to that. I was nervous and thought about it for 2 weeks before I got that response from the pt/dr. I still struggle with confidence but I feel better about my decision making and trust myself more. I thought this story might be helpful for some of y’all if you feel the same way.

[Scott Resetar]

Good Job Nic! Yeah I remember like week 1 of an ortho clinical, I get a patient who was post op knee or hip… honestly can’t remember.

The protocol said at this point to start hip adductor and IR strengthening (along with a lot of other recommendations), so I did that.

My CI talked to me afterwards and said
CI – “Why did you give that patient IR strengthening and adductor strengthing?”
ME – “because it was on the protocol.”
CI – “Did you test IR strength and adductor strength?”
ME – “Not IR, but I did test adductors”
CI – “were they weak?”
ME – “Not really.”
CI – “You have a functioning brain, and should not follow a protocol blindly.”

Lesson learned!

I am still learning, so I follow protocols loosely right now, but I do varying as the patient presents differently

[Justin Bittner]

I feel that protocols are designed based on tissue healing of the repaired/removed tissue. So we should definitely respect the guidelines that the protocol lays out in those regards but also like Scott mentioned, use our functioning brain.

There was an article in May BJSM that showed post op ACL patients had a 51% reduced risk of re-injury for every month return to sport was delayed (up to 9 months). It just demonstrates that just because the protocol says the patient can return to sport, we need to make sure they have met return to sport criteria such as single leg hop symmetry, symmetrical quad strength, quad/ham ration, etc. Additionally, it demonstrates the benefits of delayed return to sport if the patient is willingly to delay return to sport.

Also, we need to think about progression of exercises in regards to protocol. Mike Reinold talks about progressing throwers to return to sport. If they have not performed 2 handed plyometrics, you can’t perform single hand plyometrics; and if you have not performed single hand plyometrics, you can’t start throwing. So just because a protocol says the patient can perform x,y,z we need to make sure they are appropriate and safe to perform that.

I feel like I just rambled on about nothing…But, in regards to the article, I thought it was great of the PT to individualize the patients care. I feel that some, if not the majority, of the public still view physical therapy as the profession that takes patients through “the preprinted sheets of exercises”. I hope this article helps to change the public’s view of PT in that regard.

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