Dear Future Physician

I was recently asked by Dr. Mark Cucuzzella to provide his medical students with some insight from my experience as a PT working with the elderly.  The following is my response...

Dear Future Physicians:
I am writing you to offer some observations that I hope to be helpful for you in caring for people.  I am a physical therapist (PT) who works with adults who are homebound.  PT's help people be as mobile, functional, and independent as they can be.  There are many factors that can limit patients' abilities, and it is our job (along with yours) to figure these out and provide ways to optimize their abilities and their participation in meaningful life activities.

This is not an easy task, especially from the medical standpoint.  I have seen what your life is like second hand.  My wife is an Emergency Medicine Physician.  I have been alongside her at every step of her career.  I recognize that being a physician is very challenging.  People aren't getting any healthier, Dr. Google "knows" more than you do, and patient gratitude can seem like something of the distant past.
Yet, I want you to know that your work still matters.  As a PT, I often interact with patients right after physician visits.  This is a unique perspective as I get to see how interventions, bedside manner, and education impact patients.  Now I've only been practicing since 2011, but I can confidently say that physicians still have a tremendous amount of influence in patients' lives.

Some people still trust doctors and do what they recommend!

I know it sounds crazy given your experiences in the hospital/clinic, but some, if not most, patients really do trust you!  Nearly every day, I make recommendations to my patients, and by far the most common response is, "Well, my doctor said...".  Physicians are able to influence patients exponentially more than most other healthcare providers.  I know there are exceptions to this and differences among generations.  Yet, I don't want you to lose sight of your power.

"With great power comes great responsibility."
-Benjamin Parker, Spiderman

Your responsibility (and mine) is to: 1) assess patients, 2) identify dysfunction/disease, and 3) negotiate an action plan for ongoing care.  The third role is often the toughest one for all types of clinicians.  How do we develop an action plan that is simple, understandable, effective, and empowering?

I feel this is a big reason why figures such as Dr. OzMark SissonRobb Wolf, etc., are building such massive audiences.  Regardless of what you think about their health philosophy, these public figures are providing something that people are seeking.  You, Future Physician, can do the same.

Physicians often have to give the "bad news" - diagnoses with Diabetes, Lung Cancer, or Osteoarthritis.  However, with the bad news can come good news.  With almost any condition, patients can and should be empowered to take charge and be proactive about their situation.

I will go through a couple scenarios that PT's often encounter when patients are not empowered, with a discussion and recommendations after each.

Scenario One

"I can't do that because I was told 23 years ago that I had _________ (insert any degenerative condition)." -Frank

People need to hear how their body works and how it can recover in a clear and concise manner.  Frank's statement is very common to PT's as many of our patient's have been given a diagnosis through imaging that was perceived as a death sentence.  And there lies the problem, Frank's perception of his back may be more debilitating than his back itself.  Based on interactions with Frank, one could be led to assume Frank does not believe that:
  • The pain he is experiencing is complex and is more than just damaged structures/tissues - Why Things Hurt
  • His MRI doesn't necessarily indicate what's causing his pain. ("You Are Not Your MRI")
  • He can reduce his pain and regain function despite his positive findings on the MRI.
Frank's response screams "Thought-Virus".   The "Thought-Virus/es" that's infiltrated Frank's mind will more than likely limit his potential to recover.

Action Point: Stop Thought Viruses

People's beliefs or ideas have a tangible impact on the human experience.  This is being demonstrated in current pain research as peoples' pain levels and physical performance have improved through neurophysiology education.  Our thoughts and beliefs matter and shape our experience!
"Pain is the vehicle that brings most people to the clinic. We need to give meaning to the individual’s meaning about their pain that they have already created, bringing their thinking into alignment with what we really know about pain. We must convey the right messages from the start to reduce the risk of chronicity." -Dr. Erson Religioso III, DPT, FAAOMPT
Our beliefs commonly come from people in positions of "authority."  Dr. Oz and Dr. Google have high authority in forming people's beliefs about their body, but so do you Future Physician!  What a PT tries to drill into someone's head for months, you can convince them of in seconds.
I encourage you to:
  • Learn how to Explain Pain to your patients.
  • Prevent Thought-Viruses and empower people to take charge and do something about their health (That's if lifestyle modifications are effective given their diagnosis).  Empowering education is key.  Yet, you probably won't have time to explain proper nutrition, impact of posture on back pain, and effect of sleep on insulin sensitivity.  That's why you should...
  • Develop a network of professionals you know, trust, and believe in (not all PT's, chiropractors, personal trainers, nutritionists, etc. are the same).  Refer to these professionals and ensure that the patient knows you believe in that professional.  There's a big difference between, "I'm going to give you a referral for PT to see if we can help out with your back pain." and, "I'm going to send you to John Doe, PT.  He has a great track record of helping people out with your issue and will be a tremendous service to you."  The latter statement already sets the patient's positive expectations which can help their outcomes.

Scenario Two

"I've fallen 3 times in the past week.  I'm just losing it." -Betty

Aging is inevitable.  Yet, each individual can have great influence in how he or she ages.  Osteoporosis, sarcopenia, frailty syndrome, and frequent falls, may be minimized with prevention.  Yet, patients must believe that they can and know how to age gracefully.
I believe the healthcare system has done a great job in emphasizing active lifestyles to minimize the effects of aging.  Millions of people exercise regularly in some way shape or another.  Yet, many people:
  • Focus on the quantity of activity rather than the quality of activity.
  • Do not move in a way that actually stimulates positive adaptation.  Walking and seated soup can exercises will only get them so far. (See "Why PT's Should Consider the RKC)

Action Point: Emphasize Quality Movement & Exercise

Quality before quantity should be our aim.  There are definitely exceptions to this.  For the most part, people need to move well before they move often.  As movement quality increases, movement quantity (and load) should increase.  Here's what physicians can do to encourage their patients to age gracefully:
  • Emphasize the need for a "Movement Practice".  There's a huge difference in "practicing movement" and "working out".  The former typically focuses on quality and the latter focuses on "the burn".  Refer to a trusted, experienced professional that knows how to get people moving well.  A referral to a trusted PT for development of a personalized exercise program would be a great start.  Other alternatives may also be helpful - MovNatBarbell TrainingKettlebell TrainingTai ChiQigongYoga. (Be sure to ensure that the instructor is experienced in working with older adult clients before you refer.)
  • Emphasize the benefits of lifting heavy things.  Lifting heavy things with good technique can be one of the best things we can do as we age.
  • Encourage patients to move their joints through their full range of motion daily.  I like to tell my patients to make a point to go from standing - to their belly - back up to standing at least once a day.
  • Discuss footwear.  The quickest way to help someone improve performance can sometimes just be a change of footwear.  Some people need corrective shoes/orthotics to help with their specific deficits.  Thick, squishy, high heeled shoes should not be the norm.  If no major deficits are present, shoes should provideprotection but also allow for perception.  The inability to perceive and sense the ground with our feet has a direct impact on our performance.  This is key for older adults as they often spend much of their time in shoes that negatively impact their performance.  Recommend wide toe boxes, limited slope from back to front, flexible sole, and a little bit of cushion.  The degree of slope, flexibility of the sole, and amount of cushion will depend on the patient.  It is best to refer to a knowledgeable professional to assess them on what would be appropriate.

In conclusion, thank you, Future Physician, for what you do.  You have invested a tremendous amount into your career and other people's lives.  I hope you don't lose sight of the tremendous influence you have on your patients or of the importance of interprofessional teams to support your patients' health.

*My fellow clinicians, feel free to add anything you think would be helpful to the comments section.  Specifically, I would love to hear from any physicians on how PT's can work more effectively with our physician counterparts.


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