Default Aggressive

May 14, 2018

I straddle the clinical and coaching worlds. In some respects, the professions are extremely similar, you just operate on different ends of a spectrum. I like that I work in both worlds because it gives me a way to work with people in many different ways and always pushing them from recovery to optimization. People need to get better. Beyond that, people need to get a problem solved. If you work in both or either worlds, people are really coming to you and seeking your advice about how to solve a problem. This is a fundamental part of understanding working with people. If they don’t feel like you are solving their problem, they are going to start looking elsewhere for help. 


I am not here to argue about what to do to people. That is an argument about methods. I don’t care how you work with people. I don’t really even care if it is terribly scientific or not. Let us not forget that the most reliable effect is the placebo effect. I understand some people aren’t going to like that statement but if you evaluated how you work with people, I can guarantee there are methods you use that don’t pass the placebo controlled double blind magical unicorn gold standard peer reviewed scientific research journal requirements. You use them because in your experience, they have helped people solve the problem they came to you about. 


Now that we have that out of the way, I want to tell you a story. This is a story of a patient of mine who had a hip replaced. I have mentioned him before in a few different settings. If you have ever been to one of my lectures, you likely have heard me discuss him. This man, in his 70’s, has been a patient of mine for a while. We worked together before he had his hip replaced. We knew it was coming as the pain was exquisite, but we did our best to keep him active and maintain function. Just about two years ago, he was no longer able to walk from his car in the parking lot to work without excruciating pain. He went in to see an orthopedic surgeon and had the hip replaced in a short time. 


After the hip was replaced, he went to all the stand rehab for post-surgical hip replacement. To be fair, this is not the world I live in as a clinician, so I am not real familiar with all that entails. What I can tell you is that when he came back to me after all of this, he could not extend his hip at all (his ability to extend his hip was compromised before surgery) and he could only reach about to mid shin when he tried to reach down and tie his shoe. He did tell me he could have been better about working on stuff on his own, but in the end, his goals had not been met. He had went to his post-rehab follow up appointment with the surgeon and expressed his concern about not having his goals met (actually, he had less movement than pre-surgery, but the pain was gone). He was told to go to the gym and work it out. To be fair, this is his recollection of the conversation, but that is not terribly specific advice if it is true in any way. 


So now what? After explaining all this to me, the only thing he wants is to tie his “f*cking shoes.” These are his exact words. The frustration in his voice is real. When he finally had enough, it was about 15 months post-surgery when I saw him. This is a lesson in listening to your patients. He is not coming to me because something hurts. He is telling me he has a very specific goal he wants to accomplish. The previous people he had worked with did not help him accomplish his specific goal. This means I have to make sure whatever I decide to do with him is taking him closer to achieving his goal. If he does not believe what I am doing is going to get him to his goal, he will become frustrated and look for someone else to help him meet his goal. This is not rocket science. 


I do not know the surgeon who replaced his hip. I do know a few other surgeons, so I called one of them and explained the situation. I wanted to know, at this point in time, how aggressive I could be to help him get to his goal. He said just about everything is on the table. He told me not to force the hip into too much extension (20 degrees or so). Other than that, get to work. That’s all I needed to hear.

About one minute into our first session, all he said to me was, “No one has been this aggressive with this hip.” I am just doing what I feel needs to be done to get him to his goal based on the information he has given me and after consulting with my surgeon friend. I am not doing anything complicated. You want to tie your f*cking shoe? Then we are going to tie your f*cking shoe. 


As with anything you try to do, there is always a roadblock. With this particular patient, it was Medicare. I wish we all worked in a magical wonderland where people just handed us money and we could do whatever we want. Some of you operate cash practices in areas of the country where people have extra money and are willing to pay out of pocket for services. That’s great. Many of us practice in an alternate universe where we are bound to the rules and regulations of some all seeing eye like in The Lord of the Rings. 


For those of you who don’t know, this means after a certain amount of time, I have to release him from my care, even if we haven’t reached the goal. We had him to a point where he could finally touch his shoe laces. I sent him off to a guy I know who I assured him would do a great job picking up where I left off and guiding him to a strong finish. I even had a phone call with the guy I was sending him to, explaining it is okay to be aggressive and help this patient reach his goal.


I didn’t see him for a while. One day he called my clinic and wanted to make an appointment. I did not know what to expect. As with anyone you send a patient to, there isn’t always great communication after you pass them off. I didn’t know what to expect. When he came into my office, he wasn’t happy. He was back to where we were when we started. This is partly my fault as I look back. I see now that I don’t think I gave him clear enough instructions on what he should be doing. I am not sure I left him with things to do that were simple enough to do at home without having to purchase extra equipment. All that being said, I was still a bit irritated he had slid backwards. 


Now it was time to get even more aggressive. I warned him things were going to get real. He said, “Whatever it takes.” That is the kind of patient I like to work with. I went back to the beginning and we have been attacking his hip with the fury of a thousand suns. I do not have a secret technique or patented method. We just take the hip where we want it to go and do a bunch of active work around the position. We have been deadlifting and sand bag squatting and he has even been able to take a wider stance (this was something else that was bothering him, but was secondary to his original goal). 


After a couple weeks, he tied his shoe. He was stunned. He hadn’t tied his shoe in two years. I thought we were going to hug but we shook hands instead. Then he looked at me and said, “Now we have to get a f*cking sock on my foot.” Time to take it up a notch. I have a bit of a reputation as being aggressive with people. I feel like either, as a group, clinicians don’t expect a lot out of people or as clinicians, we feel like we need to treat people as fragile pieces of glass. It is probably a little of both. The other important part of this second round is that I have been more clear about what I expect from him between visits and how to do just about everything I have him do at my clinic in the comfort of his own home. If I can’t send him home with a concise and straightforward list of things to do that don’t take any investment on his part besides ten to fifteen minutes a day, I will lose. 


What was the point of this rant? The point is the importance of listening to your patient and what they want. They are coming to you for a reason. What made this particular patient excellent to work with was that he was not coming in because something was in pain and the goal was just to get out of pain. That is a difficult situation to be in as a clinician. It is much easier to develop a clear path to a goal when it is measurable and tangible. A person saying, “My back hurts and I don’t want my back to hurt,” is a goal, but it is not well defined and the path to the end of the goal will be difficult to measure and define. There are a lot of confounding factors involved in resolving pain. That is for another time. When someone says, “I can’t tie my shoes and I want to tie my shoes,” we have clear beginning and end points to the journey and we either get there or die trying. It just makes it easier to see where you are going. 


So to wrap it up, once you have an understanding of what the person wants, you have to articulate to them, in simple language, how you plan on taking them from A to B. If at any time along the way you do not feel like you are pointing in the right direction or they don’t think you are pointing them in the right direction, you have to pull the car over and unfold the map. If you don’t, you may lose the person because they are no longer convinced you are taking them to the right place. Maybe you realize you were driving east but you really needed to be driving south east. That can be a big deal when you are trying to arrive at a particular destination. 


Here is a collage of where we have been so far:



Be sure to take a look at the ebooks in the shop and the books section of the website. A lot of how I work with people is available there for purchase. 

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