This month I decided to put me feet up and support the voice of my fellow colleagues. I get contacted by many clinicians, of all levels of experience, wanting to chat about where they should take their career. Many are sat at a crossroads unsure of which way to turn, with some even considering leaving the profession. I suspect many of my colleagues in other countries experience the same. So, I decided to step aside and let someone else do the talking. Grab a cup of tea and have a read through this month’s guest blogpost – it’s one heck of a perspective.
First off, I want to thank Paul (feel a bit weird about calling him the naked physio) for offering me to write a guest blog on his… blog. After our discussion, Mr. Naked Physio suggested that it might be valuable to give the perspective of a recent university graduate entering the private practice workforce. I thought about it for a while and considered whether I actually had anything interesting or valuable to say as a recent graduate. After a period of reflection, I decided against discussing overdone topics such as the efficacy of treatment modalities like manual therapy. Instead, I decided upon the rather confrontational and provocative perspective of biomedicine, the ease of finding strong opinions on the internet counter to my university education and the incentivised manual therapy perspective of ACC in New Zealand.
The Pull of Biomedicine
Universities find themselves in the unenviable position of trying to adjust curriculum to match an everchanging physiotherapy landscape without also throwing the baby out with the bath water. However, all you have to do is spend some time on twitter, Instagram or listening to podcasts and you will quickly find many influencers challenging existing traditional physiotherapy approaches and discussing physio in a way that really resonates – a focus on simplified patient centred care where the subjective interview is a way to learn the patient’s story and what they value. The evidence base has demonstrated for over 30 years the importance of working collaboratively (Schon, 1983) and considering the psychosocial aspects (Waddell, Main, Morris, Di Paola, & Gray, 1984) and it still felt like an afterthought. Like hey, don’t forget to consider the person too!
In contrast, I learned that the subjective was the place to gather biomedical information so I could proceed to the endless amounts of special tests (I wasn’t even sure what information I was learning from positive tests). For example, we had this acronym for the subjective SSSSNNIIPPPIRRDDD (that’s not actually it, I just remember a couple of the S letters stood for site and severity), we were taught special tests including Hawkins and Kennedy, empty and full can tests, O’Brien’s compression, belly press, sulcus sign, Neer’s, apprehension and relocation tests. It was a real surprise to me to find research that questioned the reliability of most of these tests (Hegedus et al., 2012; Salamh & Lewis, 2020) and the vast range of neuroanatomical structures in an around the shoulder that show the high sensitivity of these tests but cloud their specificity (Dean, Gwilym, & Carr, 2013). Don’t get me wrong, I don’t think it was a complete waste of my time learning these special tests, I just think it demonstrates a weird emphasis university seem to have on historic physiotherapy practice.
What about Pain?
Upon graduation, my pain knowledge included the difference between radiculopathy and radicular pain, I knew the pain gate theory and a bit about fibre types and diameter, but I still thought there was a strong relationship between tissue damage and pain. I didn’t really grasp that pain was an output of the brain. Not very helpful in my actual practice to reassure patients if I don’t understand pain myself. Seems kind of fundamental to being a physio to me. I was concerned about how I may have contributed to heightened vigilance in the people I assessed and treated, telling them they had scapular dyskinesia, poor standing posture and the myriad of other normal human movement variations. When I went back to scour through lecture notes thoroughly I was able to find some messaging about the importance of the biopsychosocial (BPS) model, though this was only framed in the context of chronic pain. However, when the exams and lecturers steered me towards focusing on information like the Q angle, Maitland, McKenzie and McGill approaches, contracting transverse abdominus( TAB) and so on, it was easy to overlook. One of the worst things on my impressionable student mind was how lecturers repeatedly said things like “if a patient tells you it hurts when I do X’, tell them to stop”. Initially I really took that to heart. But what if the patient’s mental health revolves around that activity, what if it keeps them healthy? What about the papers that say it’s ok to engage in activity with pain? (B. E. Smith et al., 2018; B. Smith et al., 2017) How about instead we focus on load management, change technique or keeping them involved in other ways when this isn’t feasible.
A paper I read recently by Carr & Bradshaw, (2014) really illustrated my frustrations as a recent graduate. I felt like I got taught the intricacies of physiotherapy rather than the fundamentals that are in line with the evidence base. In modern times, some things are very easy to google, and some things are very difficult to learn online. I could easily learn how to teach someone to bird dog from YouTube. What’s really hard to learn? Communication, Motivational interviewing. If I don’t learn the clients why and how story, if I can’t explain why movement is important or reassure patients that their pain isn’t serious (pathology) or don’t make the exercise fit their preference, why would they do my super-secret TAB exercise?
Teach me the difficult stuff where I need some mentorship. Why do I have to memorize structural anatomy when I can google the muscles of the hand (rather than memorizing) while my patient’s in the room. We can then discuss hand anatomy together rather than me talking at the patient. What was frustrating was all the time and effort spent on learning things I could teach myself or things that seemed endlessly important but were of less value.
What I have found helpful in my practice, are platitudes and analogies such as hurt not harm, muscle guarding described like ‘moving with a handbrake on’, papercuts are painful but there is very little tissue damage and the saying “the best exercise is the one that gets done.” These and others I have had to learn myself from reading and watching Cognitive Functional Therapy (CFT) resources.
The challenge of private practice
Upon entering the workforce as an MSK physiotherapist it became quite apparent that as a student we weren’t prepared for the reality of private practice. The pay for service model of physiotherapy is the basic standard practice. Therefore, it would appear there is a financial incentive to see people. I have found this tricky and conflicting as I believe that it is important to empower people to self-manage, providing them with reassurance that things will improve with gradual re-introduction to activity rather than telling them I need to “fix their alignment” or “work out muscle knots.” Ironically, this goes back to communication, something that I wasn’t really taught at university, but had I been, I feel I would have been better prepared to have those conversations. The stark reality was feeling pressured to meet KPIs that focussed around client numbers, retention and billable income. This didn’t just add stress on me but I also felt I was doing a disservice to the people I was trying to help.
I’d love to say I am completely altruistic and only care about patient wellbeing, but I can’t. I’d also one day like to be at least a bit more financially comfortable. One of the current situations I face is trying to find work that aligns with the evolving evidence base, not work that requires acupuncture and hands on skills as highly desirable. The PNZ website appears to support this work ethic by consistently advertising courses on the Mulligan concept, manipulative therapy, and dry needling. It can be a perilous place trying to navigate CPD and EBP as a new graduate physio. If I’m honest, I feel conflicted about parting with my money and committing time to something like communication techniques when it doesn’t really seem like it will benefit my career, particularly if PNZ advertises courses in high cost low value care that appears to be dictated by the fee for service model.
Now I appreciate that it may appear that my university experience was all doom and gloom, it wasn’t. University was a great experience, I feel really lucky to have been taught how to appraise research and to think critically, which is a reason I am writing this blog. To question everything I was taught and grow professionally. The lecturers were great, they taught us skills in critical thinking and reasoning skills, and emphasised the importance of individualised care. I also think the hospital and respiratory components were great and modern. During placements I felt confident to safely screen patients for early mobilisation, deliver the active cycle of breathing techniques and more.
If I were to sum up my time at university, I would say that I valued everything I learnt, I developed skills in critical thinking and clinical reasoning and valued the placements, but the nitty gritty of anatomy has not been all that helpful in practice. Teach me the stuff that really affects patient outcomes like communicating well and pain and tissue healing relationships rather than the 5mm leg length discrepancy or the minor disc bulge, which if explained poorly will have a negative impact on patient outcomes. I just wish the emphasis was a little bit different, especially behavioural change and pain education. For the other new grads out there, I know it can be frustrating but keep up the good fight. There are some good courses out there such as cognitive functional therapy, which I have read a lot of the research around and it has really challenged my current understanding. Once the dust settles on Covid-19 I intend to get on a course. For now I’ll stick to reading research and engaging on social media which I often find can seem to be more focused on what not to do (which isn’t very helpful as a new grad).
To finish this guest blog on a positive note, I think one of the best parts about being a new graduate is we aren’t attached to any particular technique and are well positioned to evolve alongside physiotherapy practice.
There we have it, thanks to my guest blogger (who wanted to remain anonymous) for this month’s contribution. Reading their blog certainly made me sit back and consider the multi-faceted challenges that we all face in the profession.
Thanks for having a read
Carr, D. B., & Bradshaw, Y. S. (2014). Time to flip the pain curriculum? Anesthesiology, 120(1), 12–14. https://doi.org/10.1097/ALN.0000000000000054
Dean, B. J. F., Gwilym, S. E., & Carr, A. J. (2013). Why does my shoulder hurt? A review of the neuroanatomical and biochemical basis of shoulder pain. British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2012-091492
Hegedus, E. J., Goode, A. P., Cook, C. E., Michener, L., Myer, C. A., Myer, D. M., & Wright, A. A. (2012). Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2012-091066
Salamh, P., & Lewis, J. (2020). It Is Time to Put ‘Special Tests’ for Rotator Cuff Related Shoulder Pain Out to Pasture. Journal of Orthopaedic & Sports Physical Therapy, 50(5), 222–225.
Schon, D. A. (1983). The reflective practitioner: How professionals think in action. London.: Temple Smith.
Smith, B. E., Hendrick, P., Bateman, M., Holden, S., Littlewood, C., Smith, T. O., & Logan, P. (2018). Musculoskeletal pain and exercise – challenging existing paradigms and introducing new: an educational review. British Journal of Sports Medicine, 1–6. https://doi.org/10.1136/bjsports-2017-098983
Smith, B., Hendrick, P., Smith, T., Bateman, M., Moffat, F., Rathleff, M., … Logan, P. (2017). Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. British Journal of Sports Medicine .
Waddell, G., Main, C. J., Morris, E. W., Di Paola, M., & Gray, I. C. M. (1984). Chronic Low-Back Pain, Psychologic Distress, and Illness Behaviour. Spine, 9(2), 209–213.