By David Cohen – a leading Sydney physiotherapist
Bill Gates once said that your most unhappy customer is your greatest source of learning.
As a therapist, our patients come in seeking answers to one or all of their problems. Some patients come in to the clinic and are bad historians, giving you almost nothing to go on with your subjective interview. Other patients come in who just know what is wrong with them before you even ask them a question. All they want is confirmation that their hard work sifting through Google, the physio, was worth their time. Then you get the odd patient who comes in and leaves having more questions than you have answers. This week I had all of these patients! Now what did I learn about these types of patients?
Lesson 1: Your patient can know just as much if not more than you so always remember that
Early in the week one of my patients came in with all the clinical signs of adhesive capsulitis (aka frozen shoulder) – night pain, reduction in range of motion, capsular stiffness into external rotation and abduction, and pain on horizontal flexion. But before I could do my examination they told me “I have been looking up on Google…” and before they finished I interrupted them and said “so what do you think it is”. The internet, and specifically Google, has become a powerful tool for information gathering, however to the untrained professional it can be a vehicle of negativity and confusion. After my examination of their shoulder, it was indeed frozen shoulder as they had correctly identified using the internet. The patient then asked all the right questions about all the treatment options available, however was confused as to what is the best approach. It is our job as therapists to sort out all this information and find the key to unlocking the patient’s problem(s) and this is usually done by “test, treat, retest, wait and see”.
Lesson 2: Your subjective interview can be helpful but physical examination is much more important.
I was fortunate to have a student physiotherapist with me during the week when I was consulting two young patients. Both these patients had something different wrong with them but were very similar. When asking them to tell me why they came to physio they gave me hardly any information. Despite rewording the questions all the information I had to go by was that one had pain in the knee and the other in the foot. Earlier in the day, my student voiced his biggest fear was not knowing where to start his assessment if the patient was a poor historian. After a thorough physical examination, I concluded that one had strained their lateral collateral ligament of the knee whilst the other had pes planus (flat feet) with a peroneal longus tendinopathy. After seeing these two patients (they so happened to be one after another), I discussed with my student what we had seen and to his amazement even with the worst patient historian you can still figure out what is going on simply by “look, move, feel”.
Lesson 3: As a therapist (and retail staff) you are not an expert in a specific sport, unless you are.
After seeing this patient I now understand what Bill Gates was referring to. This patient was a skier and my with my background of skiing including one trip when I was 4, another when I was 12 and using a cardboard box whilst in the Himalayas, my experience was next to nothing. They had come in after getting their boots fitted with complaints of bruising of their toes as a result of skiing. The boot fitter had told them that their hamstrings were “tight” and this was causing dysfunction whilst skiing. With my limited ski knowledge, I tried everything to recreate what they would do whilst skiing before changing my plan and just assessing their movement pattern. It turns out their hamstring flexibility was excellent however, their hamstring strength was poor to say the least having to pull their toes up to their shins just to get extra strength. After recommending the patient to strengthen their hamstrings to resolve the issue, they asked if I knew any physios that were skiers to confirm what I had found and translate that to skiing. Our job as therapists is to identify dysfunction in movement patterns and translate that into performance in a specific sport. However not all of us have experience in various sports, especially the winter sports in Australia that involve snow (even if you can call Australia’s snow, snow) and it is important to be in contact with various coaches that understand the sport better than you in order to learn from them.