Low-tier, Intermediate Level Medical Advice

For those of you not in the know, The Devin Townsend Project is a low-tier, intermediate level, progressive metal band fronted by [gasp] Devin Townsend. I have been a huge fan of Devin’s for the last 15+ years, ever since I first heard the first track from his first solo album, Ocean Machine. I show my fandom by buying every album and live release, subscribing to his youtube channel, and occasionally “liking” one of his tweets on occasion. Recently, though, I felt compelled to try to reach out to him and sent him a tweet; I knew it would go without a reply.

You see, a member of Devin’s touring crew (Zim) has been vlogging on youtube, posting tour updates almost daily. On September 7, Zim posted a video that showed Devin hitting the gym with the rest of the band – apparently, they try to stay in shape while on the road (some are more “fit” than others). In this particular clip, after warming up, Devin tries lifting/flipping a large tire at the gym.

(8:32 thru 9:25)

He went to see a PT the day after the injury, but had to continue down the road. As time progressed, his symptoms worsened and he asked for medical advice from an MD. You can view the clip here:

1:36 thru 3:00

I am sure that the gentleman was trying to help, and without assessing Devin, I wouldn’t dare to postulate what type of injury he had suffered or what the most appropriate approach might be to hasten (or at least not delay) the healing process. I will dare to postulate that Devin didn’t have a “Grade 2 anterior and posterior ankle sprain”, as was diagnosed by the well-meaning obstetrician (OB). [sigh]

Once I saw the video, I first shared my frustrations with my wife. Then I took to twitter:

@dvntownsend May be able to help you setup physio at stops thru SoMe. #nostringsattached Just a fan willing to help. DM if in need-#goodluck

— Keith, PT (@18mmPT) September 12, 2016

Alas, there was no reply. I wish he had replied – I know people – some who also know other people – in Philadelphia, New York City, and Toronto (3 of his next 4 tour stops).

He tried some massage at one point, but he was too sore to tolerate much more than the application “essential oils” from the massage therapist. Finally, 7 days after his initial injury and another 3 days after having his ankle evaluated by a guy who delivers babies for a living, he was visited by a podiatrist.

In my mind, I imagine a well-meaning fan (much like mysefl) laying in bed a few nights earlier with his all-too-warm laptop on his bare-belly watching the video of the OB assessing Devin’s ankle injury. I imagine him turning to his wife (who is probably listening to Adele through her still-wired iPod earbuds) and tapping her on the shoulder. After she rolls her eyes (not caring if he notices her obvious contempt at his interuption), she removes a single earbud and he asks her, “This can’t be right, can it?” After she views the clip, I then imagine her eyes opening-wide and shrieking, “Good God, no.” Then, somehow – probably working more diligently than sending a single tweet – this concerned fan works to arrange for his wife to visit Devin and provide an appropriate and professional assessment in what is her area of expertise. It turns out that in the opinion of a podiatrist, Devin didn’t have a “Grade 2 anterior posterior ankle sprain” after all.

3:14 thru 5:32

So, why should you give 2 shits about the foot/ankle of the front man of a low-tier, intermediate level progressive metal band? Because he fuckin’ rocks, that’s why.

But seriously – take a moment and think about all the times that you may have casually offered advice or a quick assessment for someone with an ache, pain, or injury without a fully-informed evaluation. Maybe you wanted to shut them up. Perhaps you really wanted to help, but didn’t have the time for a more comprehensive assessment. Irrespective of why you completed a half-assed evaluation, you may have – like the OB – tried to help but failed, miserably.

So, the next time you are at a dinner, or chatting with someone in the office and they ask for your advice, please remember that – whether you end up right or wrong – you will still make a difference.

It is up to you to decide what kind of difference you choose to make.

Be Less Stupid

[this post features quoted material from Malcolm Gladwell’s podcast series Revisionist History episode 2, titled Saigon, 1965]

LBJ used to walk around with a summary of Goure’s findings in his back pocket.

We all carry something special in our own figurative pocket. Each of us has a favorite text or journal article that provides evidence for what we do in the clinic. Of course, there is probably an equally compelling text or article that arrives at a different, opposing conclusion, but we elect to ignore that one. The reasons vary, of course: the sample size wasn’t large enough, the effects were too small, the findings didn’t reach statistical significance, the population isn’t representative of who we see in the clinic. Let’s be honest, the reasons [excuses?] are seem limitless.

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More than fifty years ago, when the United States was trying to figure out how to effectively intervene in Vietnam, they needed data. The wanted to understand their enemy. They hired the RAND Corporation to study the Viet Cong (VC) and the effect of Vietnamese/U.S. military intervention.

RAND is a place that prides itself on objectivity and rigor. Everything is checked, and double-checked, and fact-checked, and reviewed in-house before it’s released.

RAND hired Leon Goure to spearhead their project. He worked together with Mai Elliott to interview over 2,400 VC detainees. Goure’s report, over 60,000 pages in length and published in 1966, concluded:

“The survey of interviews completed in the spring of 1965 noted that the intensification of Vietnamese government and U.S. military activities had had a significant adverse effect on Viet Cong morale, operations, and expectations of victory. The interviews also indicated that the Viet Cong were losing the sympathy of the rural population … These trends have continued, and some have intensified … the Viet Cong are facing greater military, political, and economic problems, that in the experience of those questioned VC morale has become brittle, and that the combat effectiveness of some units seems to have declined. The tendency of the rural population to try to disassociate themselves from the Viet Cong has become more pronounced.”

.   .   .   .

Qualitative data is important, but we need to be very careful about how we collect and interpret the information. We need to keep in mind that information can deceive us, especially when we mistake it for data.

When a patient seeks your care or guidance for a complaint, how do you measure their progress, or lack thereof? Do you assess the patient’s complaints? Findings of strength or ROM? Validated outcome tools? How do you determine what approach should be most effective? Have you thoroughly combed through the relevant research and literature to answer these questions?

If you are looking at the research – and I hope you are – how many studies make great efforts to take mere information and selectively massage data from it? How often are we taking subjective information, and erroneously mining objective data from it? How often do the interpretations of the authors match your own?

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Looking back, there was one particular interview that Ms. Elliott conducted that has stayed with her all these years – you know, like that one patient who (for one reason or another) you will never forget:

“I walked into this cell and I didn’t know what to expect. And then walks in this man, middle-aged, very briskly, and he looked like a man of authority [he was a general]…I was afraid; I didn’t know what was going to happen, because I had grown up believing the communists were blood-thirsty … I had never met a communist before, face-to-face, so my curiosity just took over and I just asked him a lot of questions about him, and his background, and his beliefs. And he had devoted his whole life fighting the French and now he was fighting the Americans. And he seemed to have a lot of integrity. It really confused me, because I had believed that communists were thugs…someone who is not quite human.”

Malcolm Gladwell explains: “She saw the evidence with her own eyes, she did the interview with the general, but it wasn’t enough… She comes from a family of privilege and the rise of the Viet Cong in the north takes that all away. They end up living in a little hut in Saigon. The Viet Cong is not some abstract force, they were a personal threat to her family. “

The paper in LBJ’s pocket – the information that would guide the U.S. involvement in Vietnam – was informed (in part) by the interview that Ms. Elliott had conducted and that Mr. Goure would interpret.

.    .    .    .

It’s easier to be objective when you don’t have a personal stake in a situation and you can see the evidence … But when you have a deep, strong, personal stake it is a lot harder…

What is your preferred method? Has your method been proposed by one sole thinker or visionary? If so, how likely is it that this single visionary happened upon an idea that no one else had come upon after centuries of anatomic and physiologic study? How did they arrive to their conclusions? How invested are you in their ideas? How many of their courses have you taken? How much money have you spent to learn the method? How much time have you spent marketing these methods? How much of your successful practice is founded on these methods? Can you provide robust evidence, beyond personal and second-hand anecdote to support your method of care?

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Approximately one year into the project, RAND brought in another individual to work on the project, Konrad Kellen. Kellen’s backstory alone is fascinating, but not relevant to this posting. What is relevant is that Mr. Kellen was to review nearly 1,000 of the interviews earlier conducted and interpreted by Goure and his team. Kellen’s findings were in stark contrast to Goure’s:

One could also make a short statement regarding the enemy’s morale and motivation, such as: morale is high, and the enemy’s main motivation is his belief in the “Revolution.” But such summaries would not contain the essence of the interview materials, nor would summary statements actually made at the conclusion of each section reflect fully the content of the study. Only the complete text can give the reader the full flavor of the responses…

…It is well-known that totalitarian propaganda is often not ‘bought” by the lower levels, at least not in its entirety. There is usually considerable slippage. On the other hand, to the extent that it is accepted, often it is repeated in a parrot-like fashion, which may indicate brittleness…

…Only by immersing himself in these responses can the reader obtain a genuine feeling of how high morale or how strong motivation is on the other side, and under what circumstances these two related forces are likely or unlikely to disintegrate. The enemy’s picture of the world, his country, his mission, and our role in his country is remarkable by its simplicity, clarity, and internal consistency. And the tenor of his response is remarkable by the control of his passion, and by his matter-of-factness and clarity.

.    .    .    .

Again, Mr. Gladwell: “One interview with a Viet Cong officer. One fantastic bit of intelligence. An insight into the enemy’s mind, and yet everyone was in disagreement on what it meant, because everyone was looking at it through a different set of eyes. That is why intelligence failures happen. It’s not because someone screws up or is stupid or lazy. It’s because the people who make sense of intelligence are human beings with their own histories and biases.”

As I listened to this wonderful podcast, I couldn’t help but think of parallels between what I was hearing and my profession’s challenges when trying to tackle, grasp, or gain hold of evidence for therapy care. Sometimes we take subjective information and try to make sense of it. Other times, we analyze objective data for interpretation. We take outcome measures (based on subjective reports) and try to establish cause and effect after intervention.

Our intentions are good – we aim to provide quality care and we do our best to remain objective, but even when we exercise measured intellectual restraint and control, our biases remain ever present. We choose what to read, critique, and assimilate from the evidence. We all do so differently.

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Yes, Kellen had been right about the morale of the Viet Cong, but he hadn’t been without his biases. His biases had only aligned with the reality on the ground in Vietnam. He understood this, but what he didn’t understand was how others could read reports of the conflict and remain, somehow, disaffected:

“There were a lot of civilians around … who talked about casualties, for instance. They didn’t give a damn about anything. If somebody came back and said [there were] 50-60 casualties … a casualty is not a dead person. A casualty is something theoretical for these people.”

We read studies with subjects and participants; each is used as only a number to the reader. If the study is done properly to remove bias, the evaluator is blinded; they don’t know the individual’s personal history. It is their job not to care, but to act on or measure a person, they render a subject as object; the patient becomes an abstraction. Such data is used in qualitative studies, case studies, case series, randomized control trials, systematic reviews, and meta-analyses. Each is widely-considered to be distributed along a hierarchy of evidence with information culled from RCTs and SR valued more than data from single subject or small group studies. We necessarily view evidence in a hierarchy in an effort to avoid the same pitfalls Goure succumbed to, but if we look at the evidence with a closed mind, without seeing the person as a subject, we fail to live up to Sackett’s justifiably lofty expectations.

What we fail to recognize is that we carry the same thing in our pockets that LBJ carried in his: bias. But the more we lean on our biases, the more we fail to be good clinicians. The more we fail to be good clinicians, the more superficial the impact of science is on our care.

Decades after his research on the morale and motivation of the Viet Cong had concluded, Mr. Kellen looked back on his time with RAND with some disdain:

“The people that I knew who talked a lot about scientific this-and-that were the most unscientific people you can imagine. They just picked somebody and then if they agreed with him (or he agreed with them) then he was an expert, and if he didn’t agree with them then was not an expert and then they wrote it down. It was almost like a comedy, you know. So stupid.”

Have you made every effort to reduce your own bias, or have you become apathetic to your intelligent failures? Are you as smart as you think you are?

Don’t forget: the folks at RAND thought they were pretty smart too.

[Hat tip: The title of this post is very likely inspired by the words of Neil Maltby, who concludes his own postings with the phrase: “Be more human. Be less robot.”]

Elementary Education

Three nights ago AJ fell off his swing in the backyard;  he landed awkwardly and injured his 5th finger on his left hand. It swelled instantly and – while he was trying to put on a brave face – it was clear that he was hurting and worried when he re-entered the home.

“Why does it hurt, Daddy?”

I placed him in a chair. I sat on floor beneath him. I asked for permission before manipulating his (uninvolved) right hand and fingers while I tried to explain to him what was happening.

I explained that he has all of these little “feelers” in his finger that are sending messages to the brain all day long … he wasn’t following me yet and had no idea where I was going. Time to change tactics – quick. “Don’t lose him,” I thought to myself.

I asked him to concentrate for a moment and tell me what he could hear in the room (it was a nice distraction and refocused his attention away from the throbbing finger) – he could hear the fridge running. As we talked about how it is that he hears things, he recognized that his ears hadn’t suddenly worked to hear the fridge and the fridge had been running all along – his attention had become more pointed. I told him that the “feelers” in his finger worked all day and he usually ignored them (like the fridge) unless something caught his attention…banging his finger on the ground was sudden and alarming for those feelers, just like a loud thunder clap in his ear. His eyebrows raised … now he was with me.

[forgive the homuncular fallacy] The feelers – I told him – provide information to the brain like gauges on the dashboard of a stock car … more often than not, the driver is too busy driving to pay attention to what the gauges say until the crew chief asks him to look (just like the fridge running). But, occasionally, the gauge will start to flash colors to attract the driver’s attention, like a thunder clap. Sometimes the driver needs to worry about the flashing light (“Oh no, the car is over-heating!”) or you need to worry about lightning (“I have to get inside!”). But, sometimes the driver doesn’t need to worry (“Who cares? There’s only 2 laps left.”) and the lightning is of little concern (“Phew, I ‘m glad I’m not outside, I’d be getting soaked.”). In each example, though, the flashing light or the thunder clap is almost sure to get your attention. [/fallacy]

The pain in his finger was simply his mind’s way of getting his attention so that he could figure out if something else needed to be done. Sometimes it is clear what a driver must do, other times he may not know. Sometimes he needs to ask his crew chief for advice when the gauges are confusing or he lacks confidence. I explained to AJ that when his finger hurt like it did, it can be confusing, so he asks his crew chief (me) what is going on and what he needs to do.

[He was now agreeable to me gently assessing the finger, gently moving each little joint, finding where and when his pain was the most severe while I knew that the findings of my “assessment” were extremely unlikely to change the trajectory of his care.]

He was able to understand that that he has “feelers” everywhere in his finger – I showed him a picture of nerves in the hand and explained that the feeler’s job is to inform the rest of his body/brain what is going on down there. He appreciated that if noises are too loud, he feels compelled to place his hands over his ears to protect them – the feelers don’t tell him to cover his ears, his mind simply tries to find a way to reduce the noise.

I explained how the new messages from all the feelers started after they got banged around in a way that is not at all normal (possibly “jamming” the finger) and it is surprising for all these messages to be coming from these feelers that are usually quiet. I explained that the best thing he can do for it to feel better is to protect (splint) it initially, but occasionally to move it to tolerance – after all, the first clap of thunder can be scary, but if it is a long storm, we get accustomed to the sound of thunder before the storm completely passes.

I explained how the straps that hold his bones close together can become strained and that the feelers in the straps might be sending signals to consider that the straps may need some time for repair – “Kinda like when we fix the cracks in our driveway … if you patch and re-seal a driveway, you can’t drive a car on it for a few days. right? But you can walk on it without doing any harm to it.” Again, the best thing he can do for it is to protect (splint) it initially, but occasionally move it to tolerance.

I even explained how bones can fracture, but the same process is true for bones as it is for ligaments (straps) – the best thing he can do for it is to protect (splint) it initially, but occasionally to move it to tolerance.

No matter what was happening beneath the skin, the plan would be the same and he would likely feel a little better after splinting it with a popsicle stick. 3 days later, it is still swollen and a bit black/blue, but he is moving it more freely, going to camp, and playing with his new (unpredictable) puppy. He is not going to taekwondo tonight; he can’t yet make a fist, but he is feeling better. Perhaps it would feel the same today no matter what I had said or done that night. Maybe not. I don’t know and wouldn’t dare to guess – I know better.

What I do know, though, is how cool it is to watch the anxiety related to pain fade from my son’s face after a brief 5-10 minutes of conversation. And while I doubt the intensity of his finger pain changed, his breathing quieted and deepened, he slouched in his chair, and he even grinned a bit.

Kids get this stuff – it is intuitive. It just needs to be framed appropriately.

Thanks to Bas for inspiring this post.

Treetop Flyer

He hasn’t listened to much (if any music) since his accident. He used to listen to it all the time. It surrounded him. It was in the car, on his boat, and around his friends. Now he listens to TV-talk shows he doesn’t like, lying in a hospital bed he resents, surrounded by caregivers he pays to spend time with him.

Tomorrow, we’ll turn off the TV and listen to his favorite song; we’ll play it loud. He will rise from his bed; he’ll walk farther and more comfortably than he has in many months. I will remain mostly silent, but ever-present – he won’t need me to tell him how to put one foot in front of the other, only to be there with him as he tries.

Things will never be the same as they once were, but – tomorrow – I hope he rediscovers that music can help move him, still.

The Tinder Side of Physio

The situation can be ridiculous.

Too often, patients are stuck with a web-search to find their therapist. Who is nearby? Who is convenient? Sometimes, in the event that their complaint is acute and non-complex, the most convenient and closest therapist will do just fine. Often, if the patient is lucky, their needs are fulfilled in the short-term, and that is all they were looking for. They run a quick search, look at a few pictures, sometimes read a brief bio, swipe left, swipe right…go to their physio for a quickie: a brief 20-minute eval, a bit of manual therapy and a paper with some exercises on it. “See Joanne at the desk before you leave, she will schedule you next week [at the same time as 2 other patients] for a follow-up visit.”

Meanwhile, all too often, therapists are holding themselves to a ridiculous (and false) ideal. Rest assured, no one is getting all their patients better in a week, and if most of their patients are not coming back for the 3rd or 4th visit, it is because they are dissatisfied, not because the therapist is a miracle worker. Still physios focus on (and remember) their successes. Their web page shows the best and brightest pictures of themselves and their clinic. They write a little bio including where they went to school, what their professional interests are, and a few personal notes (e.g. their hobbies or favorite sports teams) to seem relatable. They mention their many success stories and offer testimonials. They try every way they know how to entice the next potential patient/client to swipe right.

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On a rare occasion, I may say or do something really stupid – it doesn’t necessarily put my relationship with my wife in an endangered state, but these occasions sometimes lead me to take pause and wonder what it would be like to be “out there” as a 40-something among all the other singles looking for what might make them (and me) happy. The premise seems less-than-promising.

I am not at all good at small talk. I don’t give a shit about the weather or what someone else’s kids are doing. Seriously, there is a whole bunch of stuff that my own kids do that I don’t care about – I don’t have the resources to feign interest in the mundane mindless bullshit of social convention. Say something interesting or don’t say anything at all. Can’t you just imagine how much fun it might be to hang with me at the local watering-hole?

Speed dating sounds good if for no other reason than neither party has to fabricate an artificial and polite way of ending an otherwise tedious conversation after I tell an unlikely suitor that my interests include philosophy, neuroscience, photography, professional cycling, and progressive rock music.

Of course, there is online dating as well. I could take my pick of virtual matchmakers – or I could just fly by the seat of my pants, cross my fingers, and log onto Tinder. What could possibly go wrong?

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Yesterday afternoon, my wife and I arranged for some “us time” later the same evening. My (very romantic) proposition went something like this: “Any interest in a quickie now, or (perhaps) something a bit more substantive later?” That’s right, I am Don-Fucking-Juan – be very jealous (or weep for her…whichever feels most appropriate).

So, she leaves in the early evening to go to a friend’s house to hang out with a bunch of girlfriends, drink wine, and color (you know, the adult coloring books that are inexplicably popular at the moment). I have no clue as to how this sounds like an appealing night to her, but she is more social than I and has far more friends than I do, so maybe the problem (in this instance) is mine, not hers. Anyway, I get the house tidy and the kids bathed/put to bed right on schedule at 8:30. Her friend – who wasn’t planning on staying long – drove her, so I was expecting her back at around 9:00.

Of course, 9:00 rolled around and she hadn’t returned home. 9:30 came and went…still…she wasn’t home. At 10:00, I found myself thinking, “At least there are some good basketball games on.” Then, at 10:32, the dog started barking and the garage door opened a few seconds later.

 
 
 
 
 
 
 
 

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This morning, I woke up considering the importance of context.

Sometimes it is best to go fast; other times it is better to go slow. Sometimes it is a good idea to talk; other times to shut the hell up. Sometimes a tender touch is needed; other times something more firm. The environment is incredibly important: the same act can be performed in a bed, on the living room couch, in the shower, over a kitchen counter, or on a park bench – each has the potential for a different result. The time and stress of the day has an impact. Did your favorite Pandora R&B Grooves channel just get loudly interrupted by an advert for a local used-car dealership? Sometimes these factors matter; other times they aren’t factors at all. The resulting confluence of all these variables will, inevitably be unpredictable.

This is what I tell myself…

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“The world would be a better place if people would just accept that there’s nothing new under the sun, and everything you can do with a person has probably been done long before you got there.” – Hooper

The PT blogosphere is full of folks who are willing to share their thoughts on the best way to do our job as physios. There are a countless number of blogs and courses that hope to teach us a variety of techniques, featuring gurus who demonstrate enticing (short-term) results; they want to teach us how we can do the same. We too can learn their overly complicated system of assessment and interventions and begin to implement what we learned on our first day back to work!

Of course, this is similar to looking to the tabloids at the grocery counter for sex advice, or comparing oneself to a porn-star to see if you are doing it right. NEWS FLASH: Cosmopolitan magazine hasn’t discovered “21 mind-blowing sex moves you’ve never tried before”, a guy need not have an 8-inch penis to satisfy his lover, a woman need not pleasure her freshly-waxed-self with (painfully) long-manicured nails to turn a guy on, and a small-town PT in Wichita didn’t just miraculously construct a new science-based system of care from his/her unique experiences and views of the human body, which (by the way) has already been studied with ridiculous detail for thousands of years prior.

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Our patients deserve better than what much of the physiotherapy profession has to offer. They deserve someone who is willing to listen to them, establish a relationship, and provide authentic, personalized, one-on-one care. They deserve to receive that care in an environment where therapists appreciate that context matters, the environment feels safe and encourages novelty, the music is carefully selected, and the therapist doesn’t do the same trick every time. That is how therapy, or any other relationship, thrives.

I wouldn’t consider looking for an understanding partner by swiping right or left on a screen after reading a <500 word bio and looking at 6 pictures, nor should a patient consider finding their therapist in a similar manner. Patients need the therapist to understand when a progression may be too fast, when listening is more important than education, when manual therapy is too firm, and when the context just isn’t right. They need a therapist that appreciates when the day has been long, or when the stress has been overwhelming.

Patients (and therapists alike) need an opportunity to develop a relationship based on mutual trust with shared goals; only then can either be afforded another chance to do better next time.

Pain & Torture (P.T.)

The thing that has made me lose heart is that this kid is still too frightened to run; in spite of all the education and the movement refreshment she has engaged in; all my coaxing is useless. Because, what she remembers is her ‘back is broken’ and that she has to keep her core tight…*sigh*. It is more than a ‘meme’ problem… it’s the tsunami of bullshit I have to swim against to try to convince her that she’ll be ok…She’s a girl in mid-adolescence; previously athletic, somewhat perfectionistic, high academic achiever and somewhat anxious.

She and I are dealing with the complexity of that – and I have the easier job; she’s still a kid.

I recently received the (above) email from a friend, also a physical therapist. We have communicated with one another on various social media platforms for the more than 3 years. I have never had the pleasure of meeting them in person, but fancy them a strong and informed thinker, as well as a passionate therapist.

My friend, however, is becoming disillusioned and frustrated – overwhelmed by a “tsunami of bullshit”, they are starting to ask themselves, “Why?”, and “What difference can I possibly make?”

Earlier in the email they explained:

She is an adolescent who has been experiencing low back pain for about a year. When I saw her, she had next to no mobility in her trunk. A combination of (1) doctor shopping because of her parent’s fixation with a biomedical cause and a ‘cure’, (2) an orthopod who gave her the spondylolisthesis (Grade 1) diagnosis without much more explanation, or telling her that it was essentially stable, or not altogether life-limiting, and (3) each physical therapist (there were 3 before me) she saw giving her some combinations of ‘core stability exercise’ or ‘clinical pilates’ without bothering to try to fit that into normal, everyday movement and physical activity requirements…they had petrified her into co-contracting her abs and paraspinals until she was stiff as a board.

Somewhere, there is a physical therapist telling yet another girl that she “can’t move that way anymore; it isn’t good for you.” She might feel better for a while and not schedule any additional visits; the physical therapist is validated. Of course, she might stop attending therapy altogether if it isn’t working, but the physical therapist won’t remember her then. No, it would seem that every girl with similar symptoms is going to hear a similar story with the same ending: “You can’t move that way anymore…”

I am reminded of something that I read earlier in the week – a thought and a vision that has stuck with me. The passage is from Albert Camus’ The Fall:

To be sure, you are not familiar with that dungeon cell that was called the little-ease in the Middle Ages…That cell was distinguished from others by ingenious dimensions. It was not high enough to stand up in nor yet wide enough to lie down in. One had to take on an awkward manner and live on the diagonal; sleep was a collapse, and waking a squatting. Mon cher, there was genius—and I am weighing my words—in that so simple invention. Every day through the unchanging restriction that stiffened his body, the condemned man learned that he was guilty and that innocence consists in stretching joyously.

A More Humanistic Lens

A few weeks ago, you purchased a digital single lens reflex (dSLR) camera for the first time. You were excited about all the pictures you were going to take – they were going to be way better than those pics you were taking with your cell phone.

Of course, there was a bit of a learning curve with all the buttons, settings, and adjustments, but after exercising your Google-fu and practicing a bit on your own, you learned quite a bit in a relatively short time and you are a bit proud of yourself. You aren’t a master photographer quite yet, but you have quickly learned that there is a relationship between a camera’s:

• focal length: the ‘35’ in a 35mm camera; the larger the number, the greater the zoom, and the greater the distance between the image sensor (‘film’) and the aperture
• aperture: a measure of how big the hole in the lens is, the hole allows light to pass into the camera. Measured in a fraction of the focal length (e.g. f/3.5), the larger the aperture number, the smaller the hole that the light passes through
• shutter speed: the amount of time the camera lens allows light to enter the camera, usually measured in fractions of a second
• ‘film speed’: perhaps you remember going to the store to pick up 200 ISO or 400 ISO film for everyday use, before the advent of digital photography…the larger the number, the more light sensitive the film (the values are standardized by the International Standards Organisation, thus ISO)

Fig 1. The cat in the foreground is overexposed.

You have been tinkering with the dSLR for a few weeks now, and you have a pretty good feel for things. You have come to realize that there is an ideal amount of light that needs to strike the image sensor (virtual ‘film’) to create a good picture. If too much light strikes the sensor, the picture will be over-exposed and will appear too bright (Fig 1). If too little light strikes the sensor, the picture will be under-exposed and will appear too dark (Fig 2). You now appreciate that the lighting in your environment dictates the ISO you choose (200-400 for daylight, 1000+ for low light conditions – but be careful, the more sensitive the ISO, the worse the noise). You realize that if your subject is moving, you need a faster shutter speed so that the picture isn’t blurred. You understand that a faster shutter results in less light hitting the sensor, so (in that instance) you would need to compensate by increasing the aperture size (ironically adjusting the value smaller, because it is the denominator of a fraction, whose value you wish to increase).

Fig 2. The building is underexposed.

Now imagine for a moment that you just purchased a new lens for your dSLR camera. The lens that you received with the camera (often referred to as your ‘kit lens’) quickly proved to be inadequate (you think) and you needed to upgrade so that you could take pictures with more flexibility than was afforded you by the simple 18-55mm f/3.5-5.6 lens you have been using. Some folks will go to a reasonably priced prime lens as their first lens purchase, but many (like yourself) decide to go with a bigger ‘zoom’, so they obtain what is termed a ‘telephoto lens’. In this instance, you have selected a lens that should work in most instances under typical lighting conditions: an 18-300mm f/3.5-5.6 lens.

If you are not a photographer, perhaps it would instead be easier (at this point) to imagine that you have just graduated from PT school and you realize all too quickly that – while you are now licensed to practice – your skills seem inadequate; you are not helping as many people as you may like, so you elect to go to a continuing education course. The course is designed to hone in on a certain aspect of your care and improve your expertise in that specific area. In doing so, you are improving your ability to ‘zoom in’ on a subject/patient. In other words, you have the basic know-how to operate the camera, but increasing from 55mm of available focal length to 300mm feels like completing the first 4 courses of a certification program – only (for $800 USD) the lens is considerably cheaper and is likely to bring you greater pleasure.

In many instances, though, while the telephoto lens helps you take pictures of things in the distance (i.e. birds or your kid playing a soccer game), you will quickly discover that the telephoto lens has limited utility. The farther you zoom in, the darker the picture becomes – the mechanics of the lens dictate that the aperture can move no larger than f/5.6. To compensate, you need to increase the ISO, which adds more noise to the picture. You could avoid adding noise by reducing your shutter speed, but now there is likely going to be increased motion blur in your picture. And then there is the issue with perspective…

What about perspective?

If you take a picture from the same angle each time, how can the perspective possibly change if it is taken with one focal length versus another?

Fig 3. Compressed Skyscrapers

Firstly, the picture taken with a telephoto lens will appear compressed or flattened. Look, for instance, at Figure 3, a photograph of skyscrapers which appear as though they have been built atop one another when photographed with a 300mm focal length. It is a neat effect in the photo, but the loss of depth is undeniable and often undesirable.

Secondly, the background of the subject photographed with a 300mm focal length from a distance is narrow; it is physically incapable of capturing the surrounding environment (see Fig 4).

Meanwhile, if you wish to photograph a subject in their environment, capturing context, you need to use a smaller focal length. You need to move closer to the subject, much closer. With a shorter focal length, the larger (f/3.5) aperture is now available so more light can come through the lens. With more light available, you can adjust down the ISO, reducing the noise in your picture as well. The closer you get to your subject (with your wide-angled, 18mm focal length), the brighter and clearer your picture can become and the greater your field of view.

Fig 4. The photo on the left is taken with a telephoto lens from a greater distance, the photo on the right was taken with a wide angle lens from close up

Of course, then you realize that your kit lens could shoot at 18mm too. Sure, every once in awhile, you may find a use for the 200mm or 300mm focal lengths, but (for the most part) you could have saved $800 and mastered the kit lens, instead. There are occasions when the extra focal length may be helpful, but you will not rely on it every day.

.   .   .   .

In a competitive marketplace where every continuing education purveyor is trying to get you to buy their special telephoto lens – each with its own special features – consider honing your skills with the kit lens first and foremost. The small focal length on the kit lens is what encourages you to stand closer to your patient and develop a relationship. Moving closer to your patient helps clarify the picture you are trying to capture; it reduces the noise. The different/closer perspective affords you the opportunity to see more variables that surround, stress, and influence a patient embodied in their unique environment with its particular circumstances.

Fig 5. A telephoto view of the patient

The telephoto lens encourages you to zoom in on one area, only to zoom out and back in on another. The telephoto lens directs us to look at the parts, in isolation. It is the telephoto lens that separates the biological from the psychological from the sociological. The telephoto lens has fractured and fragmented our patients. The world is filled with clinicians with 300mm lenses – far fewer have mastered 18mm.

My only question: can you be a wide-angle PT?

Fig 6. A wide-angle view of the patient

Passive Listening and Therapist-Centered Care

She had 2 falls yesterday, after the surgeon had told her that she can start putting more weight on her foot; after a month of toe-touch weight bearing, the x-rays had (apparently) looked good. She denies any pain, which is (hopefully) a good thing, considering her hip has already dislocated twice in the last month.

“Did I dislocate again?” she asked.

“Did your hip have pain when you dislocated last time?” I asked.

“No,” she replied, “but it hurt like a mother fucker going back in.”

I asked her to lie on her back; she actively moved from sitting to supine independently, without difficulty. Upon assessment, her hips were not overtly asymmetrical; her motion was within restricted limits (considering her dislocation precautions) and she was still pain-free.  She actively flexed/extended her hip without pain, but when she fully extended her hips/knees I noticed the obvious, “When you went in for surgery, did you have a leg length difference?” I inquired.

“Oh sure, I had a shoe with a big honkin’ sole and everything,” she told me. Phew. “Do you mind if I see it?”

She didn’t and kindly directed me to where I would find the shoe on the floor in the other room. As I was scanning the room, looking for the shoe, she yelled from the other room, “I hate that thing.”

“I can imagine that you would,” I replied.

I brought the shoe out to the living room; it was still a pretty good match for her present leg length discrepancy post-op. I wondered aloud if, by trying to walk with a flat foot yesterday (without a lift) she was compromising her balance in a way that may have contributed to the falls. With my gaze focused on the knuckles of my thumbs over her medial malleoli, I said, “I’ll just ask that we try that shoe on for a second to see if it is still successful in evening out your leg length discrepancy.”

Then she wept…uncontrollably.

She really hated that shoe. I should have asked why.

Hyperbole?

half glass full: we are living each day – hopefully to its fullest potential

half glass empty: day by day, we are all dying slowly (some faster than others, some more predictably)

.    .    .    .

I get it. This is not going to resonate with everyone (anyone?). My typical patient has multiple comorbities, is incapable of leaving their home due to challenges with their mobility and has varying degrees of pain (often not their primary complaint). They are weak, alone and (often) depressed. They are scared and fearful of the uncertainty that awaits them. This is not everyone’s typical patient, but it is mine.

As I reflect back on my metamorphosis these past few years from who I was to who I am, I realize that (for better or worse) my way of being with patient’s has been most informed by my working with those with terminal conditions, weeks/months before their inevitable transfer from home- to palliative-care.

Most clinicians recognize that patient’s who receive palliative care deserve a dignified level of care that is often absent in typical settings. This care often emphasizes the clinician’s efforts to gain trust through inter-personal interactions and being present in a relationship that both the patient and the clinician goes in the direction of the other.

What would physical therapy care look like if every PT worked to earn patient trust, rather than assuming it is conferred on them by title, degree or position?

What would physical therapy look like if we interacted with each patient as if they were dying?

Expectations of Actions, Not Results

I recently entered the home of an 88-year-old woman that, as Dr. Kyle Ridgeway, PT, DPT mentions in a recent post, “everyone dreads.” She is ornery – but I would be too. She cannot hear well, yet has no hearing aids, so is shut off from TV, radio and most conversation on the phone – which prevents her from talking with her children who live 3,000 miles away. Most of her friends are dead. She has grown accustomed to living alone, yet now she has visitors daily (strangers from an home care agency) to address venous ulcers. She mentioned that she has had falls in the past, prompting a PT referral which triggered a visit from yours truly. She spent the first 20 minutes of my visit yelling at me about how disgruntled she is with her doctors, the upkeep on her home, the daily intrusions… These are all variables that I have no control over and they will certainly confound any progress that I try to make with this patient, but my expectations need not change. After all, I only have expectations of myself – to simply walk into each home being courteous, respectful, reflective, quiet (when appropriate), and poised.

Before I left her home, I apologized for interrupting her day and openly empathized with how challenging and disruptive my visit must be. She (surprisingly – in turn) apologized to me for being “such a grumpy old lady” – she was now empathizing with me. In one hour, something special had happened: not only was I able to stand in her shoes, but she was also able to stand in mine. We developed something mutual, something to share.

Today, I plan to enter her home gently and to kneel beside her chair again, as I did the first day. I plan to yell at her politely, but slowly, so she can hear me. I plan to let her complain as long as she needs to before steering the conversation toward something that could be recognized as physical therapy. I plan to serve as I can as a purposefully courteous, respectful, reflective, quiet (when appropriate), and poised medical professional. Hopefully, she is willing to give something back and join me again in that space where therapy might happen.

Time will tell – after all, the outcomes are out of my control.