Every day on social media I see many different views and opinions on how we should be managing our patients. I see some saying how we need to apply various manual therapy treatments. I see others explaining how we need to find diverse and novel ways for our patients to move. And then I see others discussing how we should explore the psychological and emotional issues our patients may have. However, I wonder just how many of these suggestions are actually used in the real world, and how many just talk a good game online.
Now I don’t know about you but my time is ALWAYS of an essence, and ALWAYS a limitation. For example, in my NHS role as an ESP in an extremely busy orthopaedic outpatient clinic I see on average around 20-25 patients a day. I get about 20 minutes sceduled for a new patient and 10 minutes for a follow up. In private practice I see a few less around 15-20 patients a day with about 40 minutes for a new patient and 25 minutes for a follow up.
In the usual 9-10 hour day I am often seeing patients back to back with rarely any gaps, apart from the odd cancellation or DNA, or for a 30 minute ‘comfort’ break which is usually just long enough catch my breath, have a bite to eat, and take a pee. And lets not forget the notes, reports, and emails that need to be done during the day. So it’s fair to say that most days I’m busy as hell…
Now I’m not complaining or moaning as this has been my routine more or less for 15 years as a musculo-skeletal physio, and its a fairly common workload across the profession, and there are other healthcare professionals who have even less time and even more patients, like many of my busy GP colleagues.
But what this work schedule does mean is that I have to be realistic in what I can do and say to my patients on a day to day basis. Basically I have to prioritise everything, and to put it bluntly most of these online suggestions on how I should be managing and treating my patients I find are nothing more than pie in the sky, delusional, wishful thinking, by those with no real world clinical experience.
For example, in the average new appointment I have to make introductions, take a detailed and thorough history, ensuring I give time for the patient to speak, as well as ensuring I ask all the questions I need to, whilst also attempting to build rapport and a therapeutic relationship. I then have to do a physical exam checking movement, neuro-vascular status, and pain provocation signs and symptoms. I then have to give my opinion and advice on the diagnosis, answer any questions the patient may have, offer reassurance, correct any misunderstandings and address any concerns or fears. Finally, I am then able to offer some advice and guidance on ways to treat and manage the said issue.
So I don’t know about you, but I find myself with extremely limited time to do any thing with a patient. OK in follow up appointments there is more time to do things, but with the average number of follow up sessions being between 3-6 visits, due to restrictions from both the NHS and private medical insurers, it means time is short to get anything meaningful done.
So to think that I can spend time with my patients on treatments such as massage, mobilisations, manipulations or any other manual therapy, and still have the time to give good sound advice and plan a suitable, comprehensive and individualised self management program that a patient can do easily and effectively is delusional.
To think I can spend the time with my patients in the gym in their yoga pants exploring interesting, novel, and unique ways to move, encouraging tri-planar vectors with over head rotational arm drivers is just applied functional fiction.
And finally to think I can spend the time to sitt quitely and listen effectively for long enough to develop a patient trust so that they tell me their deepest, darkest fears about a condition or painful issue, and then have the time to explore the barriers and ways and means to challenge and confront these is just psychobabble.
Keep it simple
Now that’s not to say I do not attempt to do ANY of these things before you all go and jump on the accusational band wagon, rather I just find myself having to do modified p, simplified versions of the above. Limited time also means I have to stop doing things that don’t help me or my patients that much. To be frank I can’t justify spending time on the 1%er’s at the sake of the 10-30%er’s
So this often means that after I have assessed a patient, ruled out anything sinister, got a diagnosis, I follow my three simple golden rules…
- Give good advice and education
- Encourage movement
- Load it
This means I rarely find any time or any benefit for ANY passive treatments such as manual therapy, electrotherapy, or taping, and is one of the reasons why I question and challenge therapists so much who do use them. I simply can not work out how any good therapist in this day and age can spend their time and limited resources on these kind of treatments and still find the time to talk and listen to patients, as well as plan, advise and demonstrate an exercise and self management program effectively. For me advice and movement is, and always will be, the first intervention, and will always be priortised as such.
I also find that rarely do I have the time to explore with my patients all their psycho-social factors, finding out about all their fears and concerns. This doesn’t mean I don’t explore some of them and find some ways to challenge and overcome them, just not as much or as in depth as some online experts advocate.
I also find that rarely do I have time to work out a kick arse periodised rehab program that covers all the aspects of strength and condition that I want to. Instead I often tend to pick just one or two exercises that work the area in question hard using simple large compound based movements such as squats, dead lifts, over head presses etc, and these are usually done with the basic principles of, do as many of these as you can, as often as you can, with a load that you find challenging but acceptable.
Now I often get criticised and challenged for this simplistic approach, which is fine. But what pisses me off is many think because I keep things simple I don’t recongnise or understand the complexity or nuances of strength training, or pain science, or psychological interventions, or the individuality of patients.
Well I do, so shut the hell up.
I am merely trying to be open honest in an online world where so many seem to talk a good game and I’m sure don’t do half of what they say they do! I am trying to be realistic in recognising that I and many other healthcare professionals simply can not offer in depth, individualised, detailed management to 15-25 patients a day.
So, yes I do find myself giving very simplistic exercise programs of one exercise done as much as they can. I do find myself explaining pain very simplistically using explanations such as faulty or sensitive alarm systems, with occasionally some pathoanatomical explanations, such as inflammation, weak muscles and lack of capacity. And you know what, I find it helps many of my patients. Not all, it’s not a perfect model, far from it, but it’s all that I can do.
So when I see more and more ‘online experts’ complaining about the simple approach in physiotherapy, criticising it for its lack of individuality, and thinking simple approaches mean a lack of knowledge or understanding, it annoys me immensely. In fact it fucks me off completely.
As a strong advocate of simplicity I can tell you that to do something simply really well is hard fucking work.
Also do not let others fool you into thinking that complex approaches are more effective or more skilled. Do not let others fool you into thinking simple approaches mean you know less, work less, or get less results. Do no let these knobheads take us back to the days where we focused too much on the details and missed the bigger picture.
So I will finish by asking if we could all please try and be a little bit more honest and realistic in our explanations about what we do with patients. Lets remember that ALL therapists and patients have limited time and resources to get anything done. Lets stop talking a good game about what we SHOULD do, and start talking about what we ACTUALLY do do.
As always thanks for reading
PS I never though I would end a blog with ‘do do’