From the Pond: Illiterate

We are underbred and low-lived and illiterate; and in this respect I confess I do not make any very broad distinction between the illiterateness of my townsman who cannot read at all and the illiterateness of him who has learned to read only what is for children and feeble intellects. We should be as good as the worthies of antiquity, but partly by first knowing how good they were. We are a race of [small]-men, and soar but little higher in our intellectual flights than the columns of the daily paper.

On Tuesday, I had an hour to spare between patients, so I elected to grab an old friend, my composition notebook and a pen and sit down with a cup of hot tea at my local coffee house. As I was adding a couple packages of sugar to my drink, I saw her out of the corner of my eye and hoped she wouldn’t see me – the eatery is large enough that if I could quietly find my way to the other side, she wouldn’t likely see me.

In less than 20 seconds, she was standing by my side and encouraging me to join her at her table with her friend. Without much recourse, I fulfilled my social obligation and followed her to her table where she was sitting with another. They are both physical therapists. They both work part-time. Both are former colleagues from the outpatient clinic where I last worked.

As I sat down, each briefly glanced at the articles in my hand. One said, “What is that for?”

“Just doing some studying between patients,” I responded.

“Why? Are you taking a course or something?” she inquired further.

“No,” I continued, “but I listened to a really fruitful podcast recently and I came to realize that my clinical reasoning skills were insufficient compared to those in the field with academic and clinical experiences that exceed our own, so I decided to really hunker down and work on…”

She interrupted me. “Oh, so you are just doing it to be smarter. Okay.” Her and her friend then returned to their conversation about their christmas shopping, the challenge of finding good-babysitters and how smart their respective children are. I sipped my tea and stared at my unopened book, realizing that I was about to waste the next 45 minutes of my day due to the forces of social convention.

Neither know who David Butler is, nor have they any understanding of what neuroscience has begun to inform us about the pain that each of our patients experience. Yet they continue to practice, attend the minimal number of weekend courses required to keep their respective licenses and are happy “helping” those in need..

*quoted passage from Walden

From the Pond: Virtue

“The rich man — not to make any invidious comparison — is always sold to the institution which makes him rich. Absolutely speaking, the more money, the less virtue; for money comes between a man and his objects, and obtains them for him; and it was certainly no great virtue to obtain it.”

In 4 years, I plan to open my own physical therapy clinic.

In the state where I will practice, reimbursement is poor: less than $40 per visit for patients covered by workers compensation/no-fault insurance and no more than $50 per visit from any private insurance company. Still, PT-owned practices continue to thrive.

But at what cost? Most clinic-owners require their therapist’s to provide “care” to 3-4 patients per hour. Others only have therapists available for evaluations and re-evaluations, leaving the patient in the hands of physical therapy assistants (PTAs) for day-to-day “treatment”. Hands-on care and one-on-one time with the patient is reduced in some settings, abolished in others. Working in home care now, I am no longer in a position to judge these clinics, or their owners. I can only judge myself and my own inadequacies when I tried to care for my own patients with such high expectations of productivity.

When I decide to open the doors to my own clinic, I need to determine how I wish to run my practice; what I want at home will dictate what I do at work. Do I want a bigger house? Would I rather have a waterfront home? Perhaps a home with more property or privacy? Will I buy a boat and (if so ) what kind? Would I prefer a wristwatch of better quality than my Timex? Will I be tired of driving used automobiles with small 4-cylinder engines?

My lifestyle at home will decide how many patients I must see per hour, how many times I must see a patient per week, and how many hours I must work per day/week.  It will determine if I have the privilege of treating my patients myself, or if I must necessarily hand-over their care to another – less qualified clinician – after completing their evaluation.

In the end, I will have to choose between selling myself to my clinic or something else altogether…being virtuous.

*quoted passage from Walden

From the Pond: Laws of Nature

I smirk and occasionally roll my eyes when I meet the therapist who informs me that they “treat the whole patient”. This implies that they have an special understanding or insight as to of how ‘the whole patient “works.”‘ Such a understanding, of course, is not available to them, but they have convinced themselves otherwise.

.     .     .     .

Most therapists have 30-60 minutes at a patient’s initial evaluation to obtain knowledge of a limited number of variables that may impact a patient’s pain experience; they may have an adequate understanding of even fewer. Over the weeks that might follow, the therapist will often learn more about the patient; sometimes that knowledge helps them understand the patient more, sometimes less. It is with that limited knowledge and understanding that the therapist is to develop a plan of care to shepherd their patient toward a positive outcome.

If we knew all the laws of Nature, we should need only one fact, or the description of one actual phenomenon, to infer all the particular results at that point…

Patients with chronic pain are nomadic people, moving from one professional with a seemingly plausible explanation for their symptoms – each with their own approach to treatment – to another and another.

Each clinician has a different formula or calculation that they make when they are completing as assessment; each clinician’s respective calculations are developed from a foundation of the literature and research that is (in an of itself) lacking. Unfortunately, a large percentage of clinicians who treat patients with chronic pain symptoms have no familiarity or understanding of that literature.

…Now we know only a few laws, and our result is vitiated, not, of course, by any confusion or irregularity in Nature, but by our ignorance of essential elements in the calculation. Our notions of law and harmony are commonly confined to those instances which we detect; but the harmony which results from a far greater number of seemingly conflicting, but really concurring, laws, which we have not detected, is still more wonderful. The particular laws are as our points of view, as, to the traveller, a mountain outline varies with every step, and it has an infinite number of profiles, though absolutely but one form. Even when cleft or bored through it is not comprehended in its entireness.

*quoted passages from Walden

From the Pond: Of Tedium and Ennui

Hippocrates has even left directions how we should cut our nails; that is, even with the ends of the fingers, neither shorter nor longer…

When I was in physical therapy school, the first thing that I was taught was how to assess the patient’s posture with a plum line. Which shoulder is higher? Does she carry her arms the same way on each side? Are his hips level? Are the knees in line?

When I began post-graduate courses I learned how to influence some of these postures with exercises/activities to restore symmetry. For instance, there are purported ways to correct for lateral shifts and an assortment of breathing exercises to reduce pelvic and thorax incongruencies. Contract relax and muscle energy techniques can seem to improve a patient’s static posture as well. Of course, a few days later, the patient often returns for their next visit presenting with the same ‘deficits’ as the visit before.

Most frustratingly for the clinician, sometimes the patient feels better, sometimes they feel no different, while other times the patient feels worse. The therapist would like for the patient’s report of symptoms to strongly correlate with the carry-over of symmetrical static postures from the visit before, but this happens less often than most would care to admit.

Now 15 years into this career that I have chosen, I remain fascinated by how the body can move in a seemingly innumerable number ways and combinations, yet every guru that I have every met or learned from claims that they alone know the way to make things right. Despite the unidentifiable variables and confounding experiences/beliefs that a patient brings with them into each therapeutic encounter, therapy clinics nationwide often take every patient and place them into the same one-size-fits-all bio-mechanical algorithm in an effort to improve posture and efficiency through the endless pusuit of symmetry. Each asymmetry (of course) has it’s own label/diagnosis/classification, each of which come with their own prescribed activity to correct that which is flawed; if one guru’s evaluative/treatment technique don’t work, surely the clinician can learn more from another.

Even still, I will work with the patient’s nervous system to allow it to find its own way.

…Undoubtedly the very tedium and ennui which presume to have exhausted the variety and the joys of life are as old as Adam. But man’s capacities have never been measured; nor are we to judge of what he can do by any precedents, so little has been tried.

*quoted passages from Walden

From the Pond

When I heard this To The Best of our Knowledge podcast, I felt compelled to read Walden. The selected readings on the podcast were at the same time both beautiful and poignant; they somehow conjured within me a sort of need to read the book to discover what I had long ago missed.

So, I purchased a cheap, un-annotated version for my e-reader and began to read.

I kept Homer’s Iliad on my table through the summer, though I looked at his page only now and then. Incessant labor with my hands, at first, for I had my house to finish and my beans to hoe at the same time, made more study impossible.

It took longer to read Walden than I had expected. There was my job, the kids, my studies, social engagements, mowing the lawn, cleaning the house, running errands…in the end, I was left with only a few minutes every night to flip through a few pages of this book before falling asleep with my e-reader in hand.

3 months (and a mere 250 pages) later, I am finished.