Talking a good game!

Every day on social media, I see experts telling us how we should be managing our patients.

I see some saying that we need to use various manual therapy treatments. I see others explaining how we need to find diverse and novel ways for our patients to move.  

And 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 expert suggestions are actually used in the real world, and how many are just talking a good game online.

Now, I don't know about you, but my time as a physio is ALWAYS limited.

For example, in my NHS role as an Upper Limb Extended Scope Practitioner in an extremely busy orthopaedic outpatient department, I see on average around 20-25 patients a day, and I get between 20 minutes for a new patient and 10 minutes for a follow-up.

When I work in private practice, I have a bit more time, with about 40 minutes for a new patient and 25 minutes for a follow-up.

In a usual working day I am seeing patients back to back with rarely any gaps, apart from the odd cancellation or DNA, or a rare 30-minute 'comfort' break, which is usually just long enough catch my breath, have a bite to eat, and take a piss.

And then let's not forget all the notes, reports, and emails that also need to be done during the day.

So it's fair to say that most days I'm busy as hell... and I'm sure many of you reading this are also.

This has been my usual working routine as a musculoskeletal physio for years, and I know it's a fairly common workload across the profession, and there are even others who have even less time and even more patients to see

Priority's

This working schedule means I have to be very realistic in what I can and can not do with 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 thinking by those with no real-world clinical experience or who sit in their academic ivory towers.

In the average new appointment, I have to make my introductions, take a detailed and thorough history, ensuring I give time for the patient to speak, as well as asking all the questions I need to, whilst also attempting to build rapport and a therapeutic relationship.

I then have to do a full and thorough physical exam, checking movements, neuro-vascular status, and pain provocation signs and symptoms.

I then have to give my feedback, opinion and advice on their possible diagnosis, answer any questions the patient may have, offer reassurance, correct any misunderstandings and address any concerns or fears.

Finally, I need to formulate a plan offer some advice and guidance on ways to treat and manage their issues.

So I don't know about you, but I find it hard to find the time to breathe, let alone do half the things the social media experts say I should do!

Delusional

To think I have the time to offer things such as extensive soft tissue massage, joint mobilisations or manipulations, or stick them with some needles, and still be able to all the above is utterly delusional.

To think I can spend the time with my patients in the gym exploring lots of interesting, novel, and unique ways to move is just applied functional fiction.

And to think that I have the time to sit quietly and listen effectively to a person's deepest, darkest fears about a condition or painful issue, and then have the time to explore all the issues, barriers and ways and means to address these pure psychoses.

Keep it simple

That's not to say I do not attempt to do ANY of these things before you all go and jump on the accusational bandwagon, I just find myself doing hugely modified, simplified versions of all the above.

But more importantly, this limited time means I have to stop doing things that don't help my patients much, becuase I can't justify spending time on things that offer 1% improvements at the sake of the things that may get 10-30% improvement.

This often means that I follow my three simple golden rules...

1. Help them understand what's going on
2. Get them moving
3. Get them stronger

This means I rarely find time for ANY passive treatments such as manual therapy, electrotherapy, or taping, and this is one of the reasons why I question and challenge therapists who do use them.

I simply can not work out how any therapist working in these settings can spend their time and limited resources on these kinds 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.

I also can not work out how therapists have the time to explore all the psycho-social factors affecting their patients. This doesn't mean I don't try, its jsut that I feel I only scratch the surface 99% of the time and do very little to address them as the online experts advocate.

I also can not work out how some therapists have time to design and plan a kick-arse periodised rehab program that covers all the aspects of strength and conditioning. I often find myself picking just one or two exercises that work the area in question, using simple compound-based movements. And these are usually done with the basic principle of... "do as many of these as you can for 3-5 sets, 3-5 times a week, depending on how it feels".

Criticised

Now I often get criticised and challenged by many for this simplistic approach, which is fine.

But what pisses me off is that many think because I keep things ridiculously simple that I don't care about people getting better, or dont recognise or understand the complexity or nuances of pain, rehab or psychology... which is just not true!

I am just trying to be honest in an online world where so many seem to talk a good game, and I'm pretty certain that most don't do half of what they say they do!

I am just trying to be realistic in recognising that many healthcare professionals simply can not offer in-depth, individualised, detailed management in the strained, overloaded, pretty shitty working environments they find themselves in.

So when I see 'online experts' complaining about the simple approaches in physiotherapy, criticising them for their lack of individuality, and simple thinking... 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 actually really fucking difficult.

Do not let others fool you into thinking simple approaches mean you know less, work less, or get less results.

Do not let others fool you into thinking that complex approaches are more effective or more skilled.

Do not let these knobheads take us back to the days when we focused too much on the details and missed the bigger picture.

I will finish by asking us all to please try to be a little bit more honest and realistic in our descriptions and explanations about what we do with patients.

Let's stop talking a good game about what we SHOULD do, and start talking about what we ACTUALLY can do.

As always, thanks for reading

Adam