I see patterns

I see patterns, quick flashback to the Sixth Sense.

 

“Nonspecific LBP accounts for the great majority of cases of LBP and is defined as LBP for which there is no identifiable cause (e.g, injury or disease). As a result, treatment recommendations commonly involve a one-size-fits-all approach.”

This is reality. When someone has back pain, it is a guess and a poor one at that as to what is the cause of the back pain. Herniated discs? Sure. Arthritis? Sure, why not. Spinal stenosis? Must be. Cancer? Naw, this one we could rule in or out with imaging. The sinister (read really bad) stuff can be picked up through imaging and is assumed to be the cause of pain. What else is out there? Lumbago…WTF is this about? My favorite is back pain. For real, this is how it works. The patient goes to the doctor with a complaint of back pain and after the end of the session, the doctor says…You have back pain. Here’s your script for back pain. See me in a few weeks.

The problem when we can’t identify different causes of back pain, then all back pain is treated via a “shake and bake” or cookie cutter approach. Is Suzy’s back pain the same as Johnny’s, probably not since the symptoms aren’t even in the same location, but it is still coming from the back so it must be treated the same way. There’s a reason that we as the industry of healthcare have failed in treating back pain…we can’t even define it.

 

“The current treatment classification system (ie, a small group [5%-10%] of patients with identified specific pathology versus the large group [90% -95%] with nonspecific LBP) is clearly not working well.”

Have you seen the numbers?! Not working well is an understatement. Here are some scary stats. The 5-10% that physicians can diagnose are those sinister (read really bad) problems.

“Subgrouping patients in LBP does not need to be complex or difficult”

Everyone subgroups patients. Tony Delitto has stated in an article (It’s late and I don’t want to go find it so trust me…I’m a professional) that everyone classifies patients, but the classifcation system may be very rudimentary. For instance, if someone comes in with a history of back pain and has failed at therapy elsewhere, we would say that this person may fail again. This is a way of classifying, albeit not a good one, but one way. There are methods of classifying back pain (don’t see this as diagnosing) based on signs and symptoms and response to movement or other interventions. This is a slightly more sophisticated way. There are methods that have withstood the rigor of research and demonstrate moderate reliability in the assessment of back pain.

 

“A good example in the LBP field is the STarT Back trial that used a simple prognostic tool (9 questions only) to match patients to treatment packages appropriate for them.”

I was fortunate enough to hear Nadine Foster, one of the authors of the original study, speak at a spine conference in 2013. The questionnaire can help clinicians, especially the primary care coordinator (Physician Assistant, Primary care physician, orthopedist, Advance Nurse Practitioner) determine if the patient may improve without treatment or if PT could be beneficial. The final category that a patient could be classified into is the inclusion of physical therapy with the addition of a psychosocial approach to pain.

 

“Clinicians are usually favorable to the idea of individualized treatments for nonspecific LBP.”

If all back pain were created equal, then I’d be in favor for all treatments being equal. When a patient comes in looking crooked with 9/10 pain, then that patient should not receive the same treatment as someone that has 1/10 pain and is looking to return to sports. Different presentations call for different solutions. There is an excellent book out there for patients and insurance companies called: Rapidly Reversible Low Back Pain by an orthopedic surgeon. He follows the thought and ideas of Robin McKenzie.

“Put simply, if there is a subgroup that does well, it must be balanced by a subgroup that does poorly.”

This research is out there, but because it doesn’t meet the stringent standards of most research studies, it is frowned upon. The problem with the study is that the authors of the study aren’t blinded to the treatments and patient classification. This means that the authors could be biased in one way or another. Aside from this, the study is a legitimate study assessing varying treatment for low back pain. There was one group that did very well and one group that did poorly. One group was in the middle of the two, but leaned more towards poor than well. Check out the study from Audrey Long

“Two aspects of human nature that could explain this situation (treatment effect) are that we tend to see patterns where none exist (patternicity) and that we presume we have more control over events than we truly do (illusion of control).”

This is great stuff. I actually printed off the articles so that I could read them later. I’d love to believe that this isn’t me…but wouldn’t everyone. I’d love to believe that I actually see dead people…I mean patterns and no, not the patterns that people create when they see a shadow and believe it’s a ghost. It does intrigue me though to learn more about pattern recognition.

“…we must conclude that in general, the current research initiatives and achievement in this field are far from optimal and not yet ready to be implemented in clinical practice.”

I wish I could agree with this, but then we are treating all patients the same. If we can’t give individualized instruction to each patient, then it doesn’t matter who the patient sees for their problem. It doesn’t matter that one person’s back pain started 2 years ago and hasn’t subsided or that another’s started this week and is expected to improve with time. Both patient’s would get the same treatment approach if we can’t classify.

 

 

QUITTER

QUITTER
“A recent survey revealed that 84% of employees plan to look for a new job this year ”
I actually think that this number may be higher in the physical therapy field. There are many people dissatisfied with the corporate structure of physical therapy, and I am among that group. I think that every year since 2010 I have reassessed my job outlook and searched for other opportunities.
“a US department of labor study revealed that the median tenure for the 55 to 64-year-old category is 10 years. For the 25 to 34-year-old category, the average tenure is only 3.1 years. ”
This one is interesting. There are multiple classmates of mine that worked 3 to 5 jobs within their first 3 to 5 years in the physical therapy profession. I have been out of school for about 10 years now and I I am on my second job. I have had multiple side hustles along the way, but I am still on my second primary job.
“The golden watch has become the other end of the golden handcuffs. ”
I recently received the silver watch. I’ve been at the hospital that I work for for five years and after five years one receives a Watch. I don’t consider the watch a handcuff, but it is a life ring from my perspective. There are many people that have been at this hospital for well over 20 years. Many people realize the problems within the institution, but few people want to change the institution. As much as I’ve tried to change the institution, I realize my power only go so far and that I will need to leave in order to create that change.
“There is a wiser way to get to your dream job, and it begins by keeping your day job. ”
In PT, I have a dream. Not that major dream from Dr. Martin Luther King, but a dream nonetheless. My dream is to see all patients receive quality care. There are many corporations that provide crap care to patients. I hear it from the patients every day. I recently had a patient who underwent 53 visits of physical therapy for her back pain. After two visits his pain was completely abolished and he rated himself as 100% functional. On the one he read it himself as 60% functional. This is a problem. Corporations should not be allowed to milk the patients. The reason why this continues to happen is because patients are under educated with regards to health care in the business of healthcare. If they knew that we get paid based off of how long they kept us they would start seeing themselves more as a $. Healthcare is a unique business because the patients place their trust in us to be altruistic. Unfortunately, the almighty dollar sign can override altruistic tendencies. 
“When you keep your day job, all opportunities become surplus propositions rather than deficit remedies. You only have to take the ones that suit your dream best. ”
I value educating people. I spend much time reading outside of work and I want to share that knowledge. If I would’ve quit my job in order to go teach at a university or community college, I would actually take a pay cut from what I’m doing today. This is why I do so much on the side so that way I don’t risk losing the pay that I currently have. If I want to quit my day job at the hospital, I would be very stressed for money and would have to take every opportunity that came my way. There are some things in the physical therapy field that I realize I don’t really enjoy doing. I love teaching students that are passionate, but I hate teaching students that are just there to check off a box, which is one of the reasons why I don’t see myself going into education long-term. I struggle to work with students who don’t share the same passion that I have for the profession. Students are spending 90,000 upwards to $200,000 in order to enter this profession, and it kills me to think that there are some students that are just checking off boxes and going with the flow. This is why I am very picky as to which schools I take students from. Some schools have better reputations than others for the quality of students that come out of the school.
“Dreams tend to challenge the status quo… At the heart of a dream is change”
Because my goal is to ensure that the most amount of people receive quality care, I realize that I have to leave the job that I’m at. I’ve been working on my side hustle now for years. This started with educating myself to become a better clinician. I finally feel confident enough in my clinical abilities and my leadership abilities to be able to step away from my job in order to create my dream.
“I’ve met hundreds of people who tell me they’ve never written their books because they are too busy. ”
Count how many times you hear ‘busy’ as the response when asking someone how things are going? How many of us would say ‘productive’? Is life truly busy or unorganized to an extent that it feels ‘busy’ and rushed? I stopped saying busy. I take at least 45 minutes to watch tv with my family per day. This is usually “Curious George”, but still unproductive time. I recently went to EntreLeadership 1 Day and the talk by Christy Wright was AWESOME. It had to do with prioritizing your top 5 priorities. I no longer feel that George is wasted time because it meets a priority of spending time with the family. I have more time now that I have prioritized my days. 
“You don’t ask the bottom less, ‘what do I want to do with my life?’ but instead, “what have I done in my life that I loved doing? ”
I have always been against bullying. I have always been the helper. I didn’t realize it at the age of 5, but that’s my earliest memory. There was a group of bullies that pushed a girl. I went berserk. Think of the movie A Christmas Story. It was kind of like that. They got me back later, but it was all three of them together to get me back. My point is that I stick up for people that are being bullied. The problem is that some people are naive or ignorant and don’t realize that they are being bullied. When I say “ignorant”, I literally mean that they don’t have the knowledge to know that they are being bullied. There are very few reasons that I can think to keep a patient in the clinic for over an hour and fewer still to keep them for more than 6-12 visits. Obviously there are some patients that will need more, but in an orthopedic setting we don’t tend to see that.
“A hinge moment occurs when you are planning to do something standard and normal, something you’ve done many times before… And then seemingly out of nowhere, something, a small detail usually, hinges you in a different direction.”

Way back 2009, I was offered a job by Mickey Shah. I turned it down. That was my hinge moment. I knew that if I had taken that job that I would be riding on the tail of Mickey my entire career. I wasn’t ready for that. I needed to take charge of my own education. I need to create my own presence. I need to create my own brand. And I have spent the last 7 to 8 years doing just that. 
“The things that you create and share will always outperform the things that stay stuck in your head or your desk or your laptop. ”
Last year was my step out into the public via a blog. I had 5,000+ views last year and already increased that by over 50% for the year, this year. Had I not done anything, the ideas would’ve taken me no where. I’ve met and conversed with many people this year and I believe it’s because of the writings. 
“You have the perfect amount of time each day for the things that matter most. The key is spending time on those things.”
Improving my role as husband and father

Improving my skills as a PT

Improving my teaching of PT to students and other professionals

Exercise

These are my priorities. The order changes as the seasons change. Some times I may have to devote more energy to teaching compared to learning. Some times I need to exercise because the other aspects have become too overwhelming. The average American watches 4.3 hours of tv per day. I may watch one hour of either news or a show my wife wants to watch. I find that in order to accomplish my 4 priorities, that there just is t enough time to know who married who or who got voted off the (insert modern reality tv show). 
“When enough people ask when you’re quitting, you start to feel dumb for staying. ”
This has started happening to me in the last year. I keep hearing “you don’t belong here…you think differently…you’re work ethic is different from everyone else”. Why have I stayed? The incentive to leave wasn’t greater than the safety of staying. The incentive just grew by leaps and bounds. My wife and I have a daughter with special needs. I don’t know what her future holds, but I have a responsibility to give her every opportunity to succeed. People say that money is t everything, but few people can prosper on social insecurity alone. Since her birth, I have driven the pedal down and pushed forward and harder than I have ever done in the past. My family is my inspiration to work harder now. I’ve always taken pride in being good at my job, but now I want the prestige and rewards that come with hustle and work. I’ve been grossly underpaid and have settled because of job safety for a long time, but that is rapidly ending. It’s time to leave the cave, kill something and drag it home, as Dave Ramsey would say. 
“Bad employees make horrible dreamers. You can’t loaf on your day job all week and then expect to magically throw the switch on the weekend and hustle on your dream. ”
I’ve always lived by a phrase “all hustle, no talent”. Obviously, I overstate the talent part, but I want to be known for work ethic. It’s one of the few things that I can control. In 2003 I was voted as employee of the year at Sam’s club and quit soon thereafter. The worst thing that can happen for me is to have no where to move up towards. I need a goal and an ability to continue to rise. I have no where left to transition to st my current place of employment and my boss is aware that I am leaving. I need to do bigger things next year than I did this year. I can say without a doubt that this has held true year to year. 
“The first thing you need is a passion. Like Malcolm Gladwell’s unquenchable curiosity to explore the unexpected relationships between things, you need a passion that will drive you forward.”
I’ve thought a lot about this through self reflection. What drives a person? Anger is a strong force and has driven me for a long time and continues to drive me. There was an interview with Lewis Howes (from The School of Greatness Podcast) on The Art of Manliness Podcast and he discusses how he was driven by anger for a long time. The problem with being driven by anger is that one is never fully satisfied because there is never enough positive to drown out the negative. I continue to be driven more by anger than by happiness. I see an injustice and I want to work to fix it. I see people being taken for a ride and I want to stop it. In PT, I see patients getting garbage care (if I could even honor it by calling it care) and I want to stop it. For every patient that receives garbage care (this means that the therapist is not providing treatment, but instead delegating treatment to someone unqualified, this means that the therapist is doing more harm with their words than good with their interventions, this means that a therapist is not empowering the patient to take charge of their health, this means a lot of things), I want to stop it because it gives my profession, and therefore me a negative reputation. 
“It’s not that difficult to be trans parent to a group of 10 readers. You realize that if you say something they don’t like and they all stop supporting your dream, you can always start over.”
This is something that I have struggled with over the last year. The movementthinker blog is finally starting to get readers, and the last thing that I wanted to do was to alienate any of the readers. Now, I don’t care as much about alienating readers as much as I care about me being me. If I lose readers, so be it. This is not meant to make me any money, but instead is an avenue to allow me to vent my thoughts. 
“It ultimately worked because I hustled… To push harder than the other person. To dream further. To work longer and faster… I don’t think any of the information in this book works without applying hustle to it. That’s the key. ”
This is the mantra to success. Some people are born into wealth and success. With that said, they have the blueprint from their fathers and forefathers for success. They have the shortcuts branded into them so that they don’t have to go through the heartaches of life. For instance, I started my career already 100K behind. I had to take jobs that paid the bills because I had a lot of bills to pay. My child won’t have to work for money the same way that I did, but they will have the privilege of learning from my mistakes and obtaining advices learned the hard way. I want my children to work and be successful, but I want them to be able to keep the money they earn instead of giving it away to lenders or poor investments. 
This is why I hustle. 
“Hustle is not hard.”
“Take it easy” is a phrase that gets said instead of goodbye. It kills me! I don’t want to take it easy. It took a lot of work to get to where I’m at in life, but that is the work that in used to doing on a daily basis. For me to take it easy is stressful. I have trouble not accounting for my time. I hear from colleagues that they wish that they could read as much as I do or invest as much time into the profession as I do, and I think BullShit! Everything we do is a choice. Hopefully, we have a list of priorities and are scheduling our day in order to maximize these priorities and minimize distractions. I’m okay if some therapists don’t prioritize their career or profession over other priorities such as family or religion, but to state that they wish there was more time is a fallacy. We all work with the same 24, but may work the hours differently. 
“I want the peace in knowing that it wasn’t for lack of hustle that I missed a target for my dream.”
When I was competing in powerlifting, I lived by the phrase ‘No regrets!’ I walked out of the gym on a daily basis knowing that I did my programming as best as possible to compete and place in the top 3. I’ve never been the strongest or the best at any one lift, but I worked my tail off. That work ethic carries over to everything that I do. If I were a street sweeper, which I’ve been, then I work hard to make sure I am among the best sweepers. That hustle comes from somewhere, but I don’t know where that hustle originated. 

“Hustle fills you up. Burn out empties you. Hustle renews your energy. Burn out drains it. Hustle impacts every other aspect of your life in a positive way as you learn to prioritize the things that matter. Burn out impacts every other aspect of your life in a negative way and your dream becomes the only thing that matters.”
Acuff J. Quitter: CLOSING THE GAP BETWEEN YOUR DAY JOB & YOUR DREAM JOB. Brentwood, TN: Lampo Licensing,LLC. 2011.

Get PT 2nd

“out of 137 patients, 100 had been recommended for spinal fusion. After evaluation, the group advised 58 of those patients to pursue a non operative plan of care”
There’s a slogan going around social media saying “GETPT1ST” I don’t know if I completely agree with the saying, but I can’t disagree with that either. The saying could just as well be get PT second. At some point a second opinion has to come in to play for a patient’s dysfunctions or pain. That second opinion, in my belief, has to come from someone without a financial stake in the surgery. This could be a physiatrist, PT, or a separate surgeon, which was done in the study cited. 
The take home point is that 58% of those recommended for spinal fusion were recommended to seek a separate form of care, thus advised to avoid the surgery initially. What this means for the patients is that a second opinion should always be sought out, because the person advising a plan of care is advising it from their perspective. I’d love to say that everyone has the patient’s best interest in mind, but I can’t. In that case, the patient must become more educated and advocate for him/herself. For instance, a surgeon does surgery, a physical therapist does physical therapy and a physiatrist does physiatry. We see problems from different lenses and therefore will advise different plans of care for varying presentations. Some patients need surgery and some don’t. Some patients need physical therapy and some don’t. We can’t say PT first because PT is not magic and can’t fix everyone’s issues. 
“As clinicians, we bring our own biases into the treatment plan for patients”
Want to decrease unnecessary surgeries? Have a multidisciplinary team do evaluations, researchers say. PT in Motion. April 2017:46.