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01/08/2018

Master Clinician Storyteller - Episode 7

Why do we cling to clinical "Lampposts"? Is that a good thing or a bad thing?

 

---Transcript---

JOHN

Today we have a guest who is one of my teachers and one of the thought leaders in the field, you know, physical therapy and rehabilitation sciences, who's, who has contributed a lot of different ways and um, he's not gonna like me doing this, but I'm just going to kind of tell you a little bit about what he does, what his position is. Dr. Phil sizer is a fellow of the American Academy of Orthopedic Manual Physical Therapist. He is a professor at Texas Tech University. He's the associate dean of research. He is a program director for the ScD program in physical therapy and the director of the clinical musculoskeletal research laboratory. He's also on faculty in the Phd Program of Rehabilitation Sciences. Beyond that, I know a little bit about Phil, he plays the guitar and he's got a great singing voice.

JOHN

04:32

He's got a wonderful family and he is constantly, constantly trying to make a difference in the world. So I get the opportunity to fill out. I know you're listening to all this to um, you know, to introduce you that way and thanks for. Thanks for having this conversation with me because I'm like, I'm just a big fan and I know I've been one of your students for a long time, so thanks for joining us. All right. Well, you know, one of the things that you have kind of brought all of us around, all of us faculty and the in the I am and in many other colleagues come around the world is this concept of a lamppost to lamppost. You know, it's a great image. Um, tell me a little bit, tell us, tell all the listeners a little bit more about what exactly is this, this concept of a lamppost in current, in the current profession.

PHIL

05:26

Great question, John, because I've been doing this since 1980 and got licensed in eighty five and I've seen an evolution in our practice are great evolution. We gone from being people delivered protocols to making great clinical decisions and then going on to extra as clinical reasoning and all these important metrics to success in the clinical or patients. And what I've noticed is that one of the things that really encompasses this time, especially with all the demands from the practice and how payments systems require, we spend less time with more patients. We meet certain, you know, um, hallmarks are milestones and financial success. And as a consequence, we're always looking for new solutions and trying to find ways to make it work better, both on a clinical reasoning level and also on a fiscally print level with, with our, our clinical function and think what ends up happening with that is that, uh, we ended up being in this little bit of a pressure cooker from the start of the day at the end where I was kind of chasing those yellow lights, trying to get through all of our cases, get through the schedule and then sit down and get our notes written so that we get home to the family and just try and find closure and all those things.

PHIL

06:43

So it creates kind of an instantaneous desire for us to get down to the brass tacks pretty quick. I mean, that's, that's typical for all of us. Not a bad thing. It's just a thing we've got to deal with it. And so along the way I've found that therapists have to find ways to quickly access the measures that will give them a higher level of expertise and they'll go through a, you know, exercises so to speak, or activities, so to speak to the combat or what they do, but they need something that's fairly expeditious. So we're constantly looking for those new lamp posts that light the path in front of us and make the journey more efficient. I wouldn't say easier but more successful. And, and, uh, so we're looking for ways to eliminate the path. And the lamp post imagery came to me to kind of illustrate my own experience and trying to light the path in front of me.

PHIL

07:37

And so I think what we've seen in our profession, professional experiences that clinicians find that lamp posts to wrap their arms around and get comfortable with so that they can have a path illuminated in front of them. And then after awhile the light gets a little dim and they go to the next lamppost and wrap their arms around it. And then that gets a little dim after a few years. And we've seen this pattern not only with clinicians but also in stepping back and looking at the patterns in the profession itself. And we see that a cropping up with different things that become popular, become important to the practice. And um, we've seen it across, you know, that every four to seven years we see a new lamp post emerge that people wrap their arms around to light their path. And you know, I think what that's taught me to be mindful of is thinking about how clinicians can better integrate instead of hopping from one post to the next.

PHIL

08:36

And that's always the challenge I give to my colleagues is we don't throw one thing out for the next thing. But rather try and find ways to make different things work together. And what that does is conduct the notion of expertise to me, his expertise becoming really, really, really, really good at something. Or in other words, getting really good at that present lamppost were underneath. Or does it mean learning how to know when to use the right thing at the right time with the right patient under the right circumstances. And when does to adjust what we're doing based on each and every patient experience my mind, that's expertise. So perhaps it's about rallying the different lamp posts around us to know when to use which one for under what circumstance. So that's always been important for me and um, I'm trying to understand how to perfect it for myself and also share that idea with others to get them thinking in terms of when things can work best and defining their expertise that way. And then using the literature in the skill sets they develop to help us support that at the right time with the right patient. There's not one right Arrow that's going to solve everybody's problems that we'd might fire, but rather a collection of arrows. I'm learning how to organize those arrows in the quiver and make that work best for us.

JOHN

09:51

It's great because the image that you're, um, in the imagery is often used by teachers to help to help people get their heads around it. And it's almost like a narrative, right? It's a way of seeing it. So I love this concept of a lamp post and this idea that we, that colleagues are going from one lamppost to the next in order to try to get some comfort around something that's easy to see, cars light a light, essentially shines light on something and wouldn't it be great. And I think this is what you're saying is that if we can, if we can build upon the light, gathered from one light post to the next and transition it rather than going from one to the other human nature to go from wondering whether that's judgmental, it's all of us, right?

JOHN

10:36

I think it's, um, something that we look for in trying to find that next thing that's going to help us better serve our patients problems and you know, be more efficient, effective in treating them. And so it's not a bad thing, it's just a thing, right? So perhaps we can step back from them looking at our own patterns of adopting different techniques and find ways to bring those things together.

JOHN

10:58

So what is the, you know, so what, how is it then with the Gimme? Let me ask it this way. Give me some examples or what examples, if you noticed about kind of common lampposts in your, in your history, right? Because you say you've been doing this for a long time. It's evidenced by the greenest in your beard, so-to-speak. Thanks Phil. I got some do. I mean what w give me some, uh, give us some examples of what you've seen over your profession. I can address that fairly well. And we can see, for example, that

PHIL

11:31

came back, there was work hardening and then different types of exercise approaches and the manual therapy came around. A manual therapy grew slowly but it became more and more of a trend for clinicians to seek that level of expertise and plugging in with their patients. And then manual therapy. Um, you know, my colleagues came back from IFOMPT where they were saying one of the discussions around the table was, do we really need manual therapy? I just find that universe because it was the International Federation of Orthopedic Medicine and that was just recently, just this last time. And we even wrote an article on that recently. I worked with our colleagues, uh, uh, in, in New Zealand and across the us to, to kind of craft a response to that, but it really is about, um, so that's a good example of someone like a group of people abandoning a light post to go something else, entering it even.

PHIL

12:23

Oh, I get it. At the same time we see this, the surfacing of pain science right in, in the social media and certain discussions around different tables about it maybe being a, you know, trumping or mother a superseding manual therapy. And I stepped back and go, wow, those are all great tools. Yeah, work hardening. It had some trouble. We don't look at that, but exercise a sensory motor control is another one that emerged and then has gone up and down based on different trends and literature which can be shaped by the populations or samples that were, that were sampled. There's all kinds of factors that influence those outcomes. And so rather than see a, you know, one being replaced by another, why can't we ask when and where do, which to what extent to use with which patient and when do they fit? For me, that comprehensive, very comprehensive clinician is when develops the expertise to pull each arrow out of the quiver and use it when it's the right time to hit the target and it's not so much one being more important or less important in the other, but it's when and to what extent with which patient.

PHIL

13:30

So pain, you know, pain science. We've been using that model for years. I've had the privilege to work with Gabor Racz and Prithviraj here at tech who were instrumental in world institute a pain and a work. They did some pioneering work in catheterization and those things. And so we've been utilizing that model for years now. It's more popular and more, um, more well communicated. But does that mean it's new or that it necessarily replaces something else? Why can't they be used together? Why can't they be used in different, to different degrees? Depending where I'm dealing with acute recurrent or chronic pain sensitized patient, why not make decisions that become more um, multi-faceted or more textured based on what the patient's needs are rather than trying to find that one golden era that's going to carry me to my next successful with my patient. Well, uh, you know, it might be related to what you said early on is that, you know, we're being crunched in a clinic. You know, colleagues are constantly figuring out what can I do, and it may seem, and I think you're alluding to this, is that human behavior would suggest that, well let me, you know, it's a heck of a lot easier to just get one magic Arrow then to try to sort through your quiver to figure out which is, which it seems,

JOHN

14:52

it seems when you say expertise is the ability to kind of grab the right Arrow at the right time means a couple of things. What is your quiver needs to have a, a, a complex array of arrows. You're, you need some arrows in all factors in, in what you alluded to is the manual therapy side. The sensory motor training and or and or exercise and what that means to different colleagues. Understanding pain science mean really it's about having a full quiver of arrows and knowing which one to grab [inaudible]

PHIL

15:33

imagery that I that I've used to help my colleagues understand how they might fit together as this like this. We have patients who are troubled. Whatever condition they're facing, it's like they're a sailboat that's gone off course. They blow off course in the law or they have at the further off course there, there pointed in the wrong direction. You're drifting in the wrong to the wrong distance off course, so really I want to bring different tools to the table to try and help them get back to some degree or fully on course to use manual therapies. The rudder and I use that to turn the boat back in the right direction and that gets them pointed in the right direction and reduces function, irritation, pain that may be affecting them at that time and in Central America controls the wind that fills the sales. That empowers them to get back on course and then pain science in intervention.

PHIL

16:22

If necessary or what calm the waters, it makes the journey smoother so it's not like one replaces the other. They each have a role and they've got to get the patient back on course. Well, the way I arrive at the systematic approach to doing that could either be a by random selection somehow evolving into that just by chance, just by somehow trying to assemble that myself, which is not a bad thing, but it's just sometimes cumbersome because there's a lot to sort out or I I enter into a petridish. I enter into a organized educational and informative and training model such as a fellowship or a residency or something that helped me systematically under someone's direction in organized routine, repetitive way, become exposed to the decision I can need to do it part time. I can do it full time, but that kind of investment sharpens, sharpens the whole process and helps me do it under someone else's influence routinely to become better at it and more efficient at it. So that's why I've always encouraged people to seek that kind of an educational experience because it helps them reach that target better.

JOHN

17:30

Right, no, that makes sense to so, so you know, the, the couple of topics. One is the lampposts and knowing that our, that as a profession in any healthcare provider right now is trying to make their way in a increasingly challenging times with regards to the study of productivity and at the same time a lot of us get into it because really there's a fascination with how it works. We have a hunger for knowledge. I'm organizing that knowledge in a way that is, is a cumulative and builds upon one or the other, which is different than necessarily abandoning one from the other. Boy and I can remember, and it's funny, I'm going to say it this way, but I remember first right out of school I took a John Barnes myofascial release course. Remember that you probably took a lot of people encounter that. Yeah. It was just kind of a thing to do at the time and then, you know, and I can even, even from my vantage point now, I've been down the road a while, is looking back and say, you know what, there's probably, there was some value to some of that training that I received.

JOHN

18:35

In other words, some these things, a lot of these things belong somewhere in the story, although I have abandoned that lamp posts on many, many times in my career. There are times when I still come back to those things because it just seemed like what the patient needed the time. So the concept of this, of a, of a lamppost, what we'd like to do, Phil, if you're willing, is way to wrap this one up, but we just want to continue a process of, of coming back to this concept of a, a lamppost series because, you know, anytime you shine some light on a topic, I think our listeners are going to just be a little bit more informed on the topic and that'll allow us to continue some, uh, interesting and engaging conversations. Uh, that, uh, I am sure that our listeners will be interested in.

PHIL

19:25

Great and I appreciate your questions and opportunities to reflect on them and, and share on that. Let's do it some more and I look forward to maybe talking about those different laminates and find where they fit and how we make it work together and that kind of thing. So exactly, exactly. And you've got some fascinating research going to in laboratory, so there may be some interesting topics that can find their way to our listeners ears even before they hit the, uh, hit the print. All right, my friend. Hey, thanks Phil for having, uh, for joining us today and, uh, we'll look forward to the next time. All right, cheers.