June 11, 2018

Recently, I had a new patient who is a veteran. When he was filling out the patient intake form, under the question, "injury origin," he simply wrote, "Afghanistan." See below:


There is a lot to unpack with this seemingly simple statement. From the beginning, you know this is not going to be straightforward. There is going to be some complications to the problem he is coming to me for. There will be layers to the injury beyond just the physical. There will be things contributing to this injury that are  related to things he is dealing with psychologically from his time of service (in this case, multiple deployments). On the surface, this has the feeling of a very complicated issue. When you start to peel things back, yo may find it is more straightforward than you thought. What you are going to see is treating people is really about treating people. Think hard about that statement before you read on.


This post is really about principles. It is about the things I have found to be important when working with people over the years I have been in practice. Granted, it is only been eleven years, but I feel I have changed my approach so much since I started. I started to gravitate towards certain things when working with people and began to carve out principles I like to think I abide by when I see a patient (particularly when they are new to my clinic). What I have found is this approach has given me much more clarity when I think about the problem and person has come to me for and helped me simplify my approach when I make a plan for the problem they present with. I will get to more of why this guy came to see me in a bit, but first, here are the five things I have found to be the most important when I start working with someone. Much of this stems from me viewing myself as more of a consultant/coach/clinician when I am helping a person solve a particular problem. Take a look at the list and think about how you approach things.


 As you looked through my list of five principles, what did you think? Did it make you think about how you talk and work with a new patient? Did it make you reconsider anything you currently do? Is there something you think is worth adding or subtracting?


Let me explain each a bit from the beginning. First, listen. They have taken the time out of their day and money out of their pocket to discuss a problem with you that they can't solve on their own and are looking for your help. I know the whole "biopsychosocial" model of pain is all the rage these days, but I think it is stupid to think you are inventing something new by coming up with a word that describes listening to all the concerns a person has about their problem and anything that could be contributing to the issue beyond the physical and anything in their life that can be keeping them from getting the relief they are looking for. To me that is just called paying attention when someone is talking to you and try your best to empathize with their situation (believe me, though, it is not easy to empathize with every situation you come across). Then it is about making a connection on some level with the person to show them you are listening to them and that you understand what is happening and you think you have a solution to the problem (or don't have a solution and direct them to someone you know who may have a solution, you can't help everyone and not everyone is actually looking for help. I know that sounds strange, but practice for at least ten years and let me know how this plays out). 


The second principle is important because it gives you insight into their thought processes related to the problem and any rabbit holes they may have gone down already and if they found anything useful. It will help you start to piece together some information about what may or may not be helpful and anywhere they may have run into a dead end. You may find they had a good idea but didn't know how to execute it properly. You may find they have tried things you were going to suggest but didn't get any results. You may also find out they have done nothing because they don't think they are allowed to try and solve a problem on their own because they don't have a fancy degree. All of this is helpful as ideas take shape in your head. 


The other part of that principle is equally important. What are any issues in their life that may keep them from moving forward in a positive way. You have to at least scratch the surface of any psychological or social factors that can be a roadblock to recovery. Sleep, food, relaxation, all of these things are beyond important. Social support, how they feel about the injury, how they feel about their chances of making a recovery; all of this matters. Gray Cook once said a lot of being a good clinician is helping someone overcome their doubt with your confidence. I have found this to be very true over the years. This is why I don't care what method you use. This is why I am never going to argue with you about methods or technique. You can have all the letters behind your name you want and you can go to every technique seminar under the sun, but if you can't develop a meaningful connection and relationship with a patient and show them they can improve, it is all bullshit. 


Principle three is up to you. Assess them. Assess the problem. I don't really care what assessment you use. You may even have your own that is an amalgamation of things you have learned over the years. It doesn't matter as long as it gives you usable and repeatable information and a way to check back on where you where when you start to make progress. 


The fourth principle also leaves you a lot of wiggle room. This is what makes principles an effective way to think about things. People in the chiropractic world (and I'm assuming the PT world and any world where people are helping people) love to argue about who has the best method. This is all a pissing contest for lack of a better term. None of that matters. What matters is if you are moving the needle in the right direction and if the principle behind what you are doing has some evidence to back it up in case people start to ask you questions about what you are doing. Not only is the patient curious (particularly if you help them when no one else was helping them), but if you operate in the world of insurance, what you are doing has to be defensible in some way. Whatever you do also has to move the needle in a positive direction and it has to move the needle fairly quickly (at least up front). You have to show them you listened to their problem, thought about it, and came up with a solution that seems to be solving their problem. There is no faster way to lose someone than to not solve their problem (or at least show you are headed in the right direction). 


This is where principle four and five tie into each other. You need to understand the importance of simplicity. Complexity is the path to dependence. I have to give you things that are easy to understand and can be accomplished at home with either things you already have available or with very minimal investment. You will never understand the situation people are truly in. You can not ask them to spend tons of money on this gadget or that shiny new object. You also can't fill your clinic with things that are totally out of reach for your patient base or can only be done by spending more money at your office. Don't get me wrong, I like money as much as the next guy, but I think it is more important to teach a person to take care of themselves to the best of their ability with the resources available. If it isn't easy and they have to buy a bunch of stuff to do what you are asking, the likelihood of them doing what you ask is going to decrease. 


To circle back and finish up, why was this guy here in the first place? He had arm and hand numbness, tingling, and pain. It had been on and off since Afghanistan and there is documented disc issues that could be contributing to the symptoms. Why he came to me is because the arm bothered him when he mowed the yard for the baseball field at the high school he coaches at. After I evaluated him and worked with him once and gave him easy things to do on his own, he reported a 50% reduction in his symptoms when he mowed. I met all five of my principles and he is happy and feels confident we are moving in the right direction. 


Got a problem you could use help with? I do that online as well. I know rural Iowa isn't always a convenient place to get to. Check it out here:

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