The 5 Foundational Skills of PT

In the diverse and fast-moving world of travel PT there are countless clinical settings and patient presentations that will confront you.   Across the board there are 5 essential clinical skills that every therapist, travel or otherwise, need to cultivate.  

1. Systematic Thinking

Any long time reader of my writing will find this redundant, but repetition in this case serves as emphasis.  Developing the ability to think systematically drastically improves clinical outcomes in all therapy settings.  Without it the patient in front of you is shrouded in a confusing haze composed of disparate tidbits of clinical data.  Past medical history, red flags, yellow flags, pathognomonic signs, fear avoidance behaviors, CPR’s, DTR’s, ROM, MMT, RPE – OMG!

Developing a framework around which to construct your thought process cuts through that fog and simplifies. The success of Maitland, McKenzie, and the SFMA is evidenced by this. 

When El and I first took both the SFMA course we were dizzy with green, yellow, and red boxes zipping around our heads (take the course and you will understand – worth every minute).  But with practice the overarching thought structure begins to take form in your mind.  You now have a direction to go with your evaluation and assessment.  A uniform lens through which to see your patients. 

This skill takes time and repetition to build.  When I began as a new grad PT I was fortunate to have had two extremely anal CI’s who drilled systematic thinking into my thick skull.  I spent the first year or so of my career writing out each step in my evaluative process, for every patient.  Being of average (ok, below average) intelligence I relied heavily on the written structure that I provided for myself.  As my experience grew patterns seemed to lift off of the page.  I could add and subtract from the overall scheme without getting myself lost in the cloud of clinical information I was computing in my dull brain.  Now I can walk into any patient evaluation confident that I can provide them and effective and valuable service.  And I don’t even need my notes… most of the time.

2. Skilled Hands

The power of human touch is well documented and largely underrated.  In this case I am not simply referencing the various manual therapy certifications out there, though they too are important.

A hand gently resting on the knee of a fearful patient.  Using body contact to stabilize a painful post-op joint. Laying a reassuring arm around the shoulders of an exasperated and confused client.  These are all examples of skillful hands at work –  providing a healing power that our dry clinical research will likely never fully understand.

Placing your hands on a patient invites a sort of closeness – intimacy even – that is absent in other medical settings.  It can disarm, down-regulate, and desensitize.  Eliminate fear, communicate understanding, and instill confidence. 

Now, there is an obvious benefit to obtaining extra training in manual therapy.  Training yourself to understand the 5W’s (Who, What, Where, When, Why) of manual treatment, will inevitably lead to an instinctive and perfectly performed “How.”

Here are a few of the options out there for more formal training:

• COMT via Maitland
• CMPT – via The North American Institute of Orthopedic Manual Therapy
• MTC – via Evidence in Motion
• CSMT –  via the International Spine and Pain Institute
• CFMT – via the Institute of Physical Art 

Intentionally develop your hands.  As clinical instruments, but also as a bridge through which you can communicate to your client.

3. Pain Science

No matter the clinical setting that you find yourself in, the common denominator is pain.  Chronic, acute, or otherwise, it is present in nearly every patient population and is one of the greatest problems facing our nation today (we would not have the current opioid problem without first having a pain problem). 

Being an effective communicator of what pain truly is and how, through a few basic and simple steps, your client can reduce or eliminate their pain is an immensely valuable tool.  Every therapist in the country must make this a cornerstone of their treatment if we ever wish to be the go-to musculoskeletal profession.   This is one area in which WE MUST DO BETTER!

Here are a few resources to check out:

This video is a great jumping off point for anyone new to pain science and its evolution in the last decade or two:  

• Check out Adriaan Louw and his Medbridge courses
• For clinicians: Explain Pain  and Explain Pain Supercharged.  Both are must reads for any forward thinking clinician.  
• For patients: Explain Pain handbook
• Read and consume everything you can by the NOI Group

4. Pay Attention

“You know Im really not that smart.  I am just really good at seeing how the pieces fit together.”

Dumbfounded by how efficiently my CI had diagnosed and treated the patient before us, I couldn’t help but mutter in astonishment, “Holy Cow!  How did you do that?” The above was his response. 

My CI, a local legend to the PT crowd in Kentucky, was in the process of teaching me the most important lesson of my professional life. 

As I have alluded to in the past and above, I am not the sharpest tool in the shed (just ask my wife).  I worked my butt off to get into PT school (and barely did so) and I worked my butt off to graduate.  New concepts and ideas do not come naturally to me.  When my roommates would spend 5-10 total hours on something I would be putting in 5-10 hours a day for days on end, just to get the same grade. But once I heard those words from my CI things began to fall into place for me.  Drawing connections between concepts, treatment paradigms, complex clinical presentations, adaptive social behaviors, they all began to link up. 

The distant corners of my brain housing all of these disparate, and often fleeting, details began to link up. “What fires together, wires together.”  Before I knew it I was recalling implications of clinical research and minute pathoanatomical details that I never would have been able to recall before had I not connected it to some other fact in my brain.

The difference between a great clinician and an average one is pattern recognition. 

Now that I have been a professional for a few years I have worked along side some clinicians who get unbelievable results out of their clients.  They look at a client that I have been fumbling around with for weeks, only to zero in on the exact corrective technique in a matter of minutes. It seems their ability to see certain patterns is far superior to mine.

Enter the 10,000 hours rule. For those of you who are familiar with the work of Malcolm Gladwell the 10,000 hours rule will be nothing new.  For the less initiated the quick and dirty is this: It takes roughly 10,000 hours of Deliberate Practice to become an expert in any one topic.  Now, the number of hours required has largely been debunked: read this, but the concept of Deliberate Practice has held strong in the research.

What does this mean for your career?  Pay Attention!  Deliberate Practice is focused effort aimed at improving results, understanding past struggles, and progressing skills forward.  Without it the patterns will never appear.

There are no more “easy” patients.  No more “Oh he is just another TKA.”  Each patient is different from the next.  True, to the ignorant observer they may all seem alike, but to the finely tuned expert there are massive differences that can be learned from and understood. 

5. Empathy

As I draw to a close I feel I am almost at a loss for words in describing the importance of empathy.  It is not because I do not find it inherently valuable.  After all I would not have included it here if I did. However, it is because the fact exists that I have to mention it at all that miffs me.

Empathy, as defined by professor Google, is “the ability to understand and share the feelings of another.”

Empathy has become one of the new “Hot Topics” in the PT twittersphere.  A profession wide reconstituted effort to take patient perspectives into account more.  CSM 2016 featured the first ever Patient Panel and even our good buddy Dustin at Senior Rehab Project did a Podcast featuring one the guest speakers (worth a listen).

The only conclusion that I can draw is that somewhere along the way, as a profession, we valued IQ over EQ.  We spent too much time drawing up clinical prediction rules and determining likelihood ratios, forgetting how to relate with actual human beings.

Emotional Intelligence, or EQ (made famous here), is about as clear and simple a measure of “are you a good human being” as you can get.  Sure, like IQ there are folks who are super emotionally in-tune and others who are sociopathic.  But there are ways to improve EQ, that make it slightly different from IQ.  A conscious concentrated effort, as described here, can really begin to make a difference.

Every client that comes into our office is doing so carrying their entire world with them.  Their hopes, fears, memories, perceived realities, thought viruses, motivations, frustrations, and social influences both good and bad.  They, like us, are complex messes of emotion, perception, thought and physical form.

Taking the time to develop your ability to relate to each and every client, no matter how seemingly unrelatable, will not only make you a far better clinician, but a better person as well.

 

The development of these skills lies on a continuum.  Each one serves as its own rabbit hole where tumbling downward somehow results in a steady upswing in your abilities to treat and relate with patients.  There is no end to your growth in these areas, only improvement.  After all “you don’t know what you don’t know,” and that is true at every step along the way.

 

Written by: Stephen Stockhausen