Balancing Best Practice and Business in Physical Therapy Practice
Balancing Best Practice and Business in Physical Therapy Pr…
If you have struggled to balance what you feel is best practice in pain care and the business demands of the setting you're in then this e…
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June 2, 2024

Balancing Best Practice and Business in Physical Therapy Practice

If you have struggled to balance what you feel is best practice  in pain care and the business demands of the setting you're in then this episode is for you.  We had Andrew Rothschild in for a chat and we discussed this and how you can maintain high value care and meet the demands we all face in the business of healthcare.   We talk about when it may be time for you to leave and find a better fit for you as well.


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Transcript

[00:01:34] Mark Kargela: Welcome to the podcast, Andrew.

[00:01:37] Andrew Rothschild: Thanks for having me, Mark. It is, uh, it really is an honor to be here. Uh, all the, uh, all the physio podcasts out there. Uh, I used to listen to so many and, and have narrowed it down to four now on my, on my iPhone and, and yours is number one.

[00:01:53] Mark Kargela: I mean, that's, that's high praise, man. I appreciate that. It's always humbling to come across physios. And I respect all the work you're doing. I know you work with, uh, the Erson religioso and do some great things online. I see your work and your, your opinions online. We obviously share a lot of views on some things and we'll talk about those today.

So thanks a ton for that. Great. Great to have you on the show. I thought today we'd have you on and talk about some of the common issues that we're seeing with some of the younger clinicians that, um, are coming up. I, you and I talked before this, it's a tough world to grow up in as a physio with social media.

There's a lot of pulling folks in 14 different directions. And I often see clinicians. Who are [00:02:34] struggling to figure out things and we're going to get into the social media piece. But first I wanted to, one question we had in our community and one kind of challenge that one of our community members had was he was working in a clinic and really trying to develop maybe a different way of practicing.

Some of his colleagues are, I guess, seem to be more professional. Passive care and, and doing things a bit, which again, it has its place, um, but he was struggling because he wasn't seeing patients for as many visits. He wasn't, uh, you know, getting as many productive units, I guess, as his colleagues who are approaching it differently.

Um, and the discussion was around, well, hey, natural history is going to take care of this thing. Why should I be intervening in, you know, over medicalization? I think those are fair concerns. I think for sure. What are your thoughts on when, when physios who are trying to maybe practice with more person centered views and understanding natural history?

I know you just had a discussion in your company about this, so I'd love to hear kind of your perspectives on it. How, how would you kind of advise a clinician who's kind of toiling with the [00:03:34] struggles of, hey, natural history and all these things, yet I'm an employee of a, of a company and I think there's a lot of value we can still provide within natural history.

What are your thoughts on that?

[00:03:44] Andrew Rothschild: Yeah, I would agree a hundred percent. Um, I think it's definitely a tough position to be in. And I find myself also in that position somewhat as well from time to time. Because, uh, you do feel that pressure sometimes of, you know, you have to meet, we know the business realities. Uh, if you work for a private practice, you work for corporate, there are no, no, regardless of how you look at it, there are.

business realities of having to, you know, cover your expenses, get salaries, you know, everything else. It's, and we know that reimbursement is going down pretty, pretty consistently from, from many insurance companies. Um, physios coming out have increasing school debt. which is a big issue in our profession.

We all want to get paid what we think we are [00:04:34] valued at. So, and those are big things. And especially with larger companies, there's a lot of other expenses that the average clinician doesn't know about. The things that go into, you know, being being a company, whether it's a small company or even a larger company.

So it is, it is that you have that pressure of, you know, how do we get paid? We get paid by seeing patients. I mean, that's sort of the, the reality of it. Um, and then the challenges at the same time, if you're a conscientious clinician, uh, which people, if people are involved in your community, people are.

active on social media. It's very likely they are a very conscientious clinician, and so they want to do what's best for their patients. They want to, um, get to have the most up to date information. So that's that can be, you know, they're not always on the same wavelength in terms of how they apply to each other.

So you don't want to over medicalized. Things like back pain we know are very often very over [00:05:34] medicalized. Um, so it is really a balance and it's always somewhere going to be somewhere in the middle, right? I mean, you can go to the extreme if you're on the extreme of just like natural history, take us course and seeing patients incredibly infrequently.

It's going to be very hard to stay in business. Um, but the other end, if you're seeing patients unnecessarily, it's also not good in terms of driving up healthcare costs. It's not necessarily a good reflection on quality of care. It's not necessarily good for the patient because there's a lot of, you know, what, what kind of value are they getting in terms of what they're having to pay out of pocket, even with health insurance, all these kinds of things.

So, uh, the short answer is, is truly somewhere in the middle. And the longer answer is you have to apply a lot of these things. This is the same for any kind of evidence based practice. You have to apply that to your individual patient, right? You have to see what's going to best fit their needs. Um, Some of that could [00:06:34] be, you know, depending on what the situation is, what is their, what are their other health related, uh, contributing issues, other comorbidities they might have, other kinds of health issues, other types of lifestyle issues they might have in terms of exercise, sleep, nutrition, all these types of things that we know go into a good comprehensive plan, but also can affect every type of musculoskeletal condition out there at the same time.

So while the treatment that they might need for their musculoskeletal condition might have a very large natural history component to it. It does not mean that your intervention is not going to be effective in other ways. The other side of that coin is that what is the cost of not doing any intervention?

Cause sometimes, even though the treatment might not necessarily speed up the recovery process for a particular condition, It also can prevent it from getting worse. And sometimes the lack of treatment can actually make something worse or cause someone to seek out [00:07:34] other types of interventions, which could be a riskier, be more expensive.

See nowhere near as effective and kind of, and kind of send them down a potential, you know, wrong path, so to speak, but then you can also have, uh, the treatment that you're doing, working on cardiovascular fitness, working on general strength, working on balance. I mean, we talk, you know, a big thing with older individuals, I'm not trying to stray too far off topic, but, you know, fall risk sarcopenia as you get over the age of 60, you know, Doing these kinds of things, you know, even if you're treating them for low back pain, there's no reason why you can't work on leg strength, power, um, you know, things that help them get up off the floor, help them get up out of a chair, improving balance, you know, working on lateral hip strength is an important component from a balance standpoint.

So you can address all these things, which may or may not have a direct impact on the thing that they were coming to see you for, but are going to be a big impact on their overall health. So I think that's where you can really justify. [00:08:34] Um, treating someone with a certain level of frequency, even in the context of natural history, um, with, with a certain condition that it may not change it that much.

[00:08:44] Mark Kargela: Yeah, I couldn't agree more. I think there's a lot of value we can provide within our care that, yes, natural history is going to tend to, you know, do its thing. But there are people who may not be doing things that are encouraging natural history. They may be Continuing to overload or under load or do things that don't really maximize the trajectory towards that.

And again, people are going to, you know, nitpick. Well, we don't have perfect evidence on, on that. But that's again, the N equals one situation that you have in front of you. You have a person in front of you. Who you can see are we making progress? Are we getting them closer to their goals? Are we getting them more to life?

Are they able to you know, gain some of the other secondary benefits from our care? So completely agree. One diagnosis and we kind of mentioned it before we went on there And I think it'd be valuable for folks to kind of kind of look at okay like lateral elbow pain. It's a [00:09:34] common one We'll see You know, latter epicondalgia, you know, and we know there can be various things that, that are impacting that if you have somebody with that, who walks in the clinic, cause the, the, the research, as you mentioned, you know, it doesn't really appear that regardless of what we do, it's going to really speed things up greater than eight to 12 months.

Um, I liked what you said about in, if we just decide to say, Hey, yeah, eight to 12 months and we'll, you'll be fine and go on your merry way. I think we really put patients at risk, right? I'd rather a patient be hanging out with me where I'm not going to be invasively invading their, their body with, uh, you know, scalpels and things.

I'm not saying there isn't a time and a place for it, of course, but I think obviously we sometimes over intervene. When, if we just gave natural history a chance, um, I think sometimes injections obviously have some sketchy support for, for their use in certain scenarios as well. But if you have somebody with that that's coming in the clinic, lateral elbow pain, what, what would be some things as far as some ways you'd, you'd kind of still [00:10:34] give that patient value, person centered care, and yet still, you know, having an employer or a manager who's, who's pleased that you're, you're, you're still maintaining.

Somewhat of a productive workload.

[00:10:47] Andrew Rothschild: Yeah. And that's a good, that's a good example because, um, it can be a fairly common condition. I think one, one part of it too, is also the differential diagnosis of that condition. Cause it can, there's a couple of things that it could also be referred from the neck, right? And even if it's not a direct. uh, cervical referral.

There is research that's out there that shows that about 30 percent of people who have lateral elbow tendinopathy have some underlying cervical component, whether it's actually active painful neck pain or not, but some sort of maybe mobility restrictions, soft tissue restriction in the cervical spine.

You also need to differentiate between like a radial nerve entrapment and those kinds of things, which can certainly change the prognosis and change the treatment. So the [00:11:34] differential diagnosis piece is, I think, really, really important for all. Uh, musculoskeletal things. Um, but with like lateral elbow in particular, the other piece is still important is somebody's comorbidities, health status, uh, those kinds of things make a big difference on the prognosis as well.

Someone who's diabetic, someone who's a smoker, that's going to significantly change, uh, that timeframe from a recovery standpoint. And so that information makes a big difference in terms of how we, uh, educate the patient and help set up their expectations for recovery. Because if they're, like I said, someone who's a little older, someone who's diabetic, and they're like, how long is this going to take?

Well, that six months to a year might actually be on the low end, uh, for someone like that, because if we know how well they're, they're going to be healing also depends on how well their diabetes is controlled, met other medications, how what their lifestyle is like from an exercise standpoint. Um, but I think given all that, You know, we have a [00:12:34] conversation with a patient is letting them know up front.

This is likely how long this condition might take to heal. It does not mean you're going to be here for that long or seeing me for that long. But just so you know, from the beginning, this is how long it really might take to get a significant, you know, 85, 90 percent recovery. However, during that time, we can certainly work on things like improving strength, improving your tolerance to the things that are painful, gripping, lifting.

You know, opening jars, all those kinds of things that are very classically painful with that type of activity. Uh, that type of condition, you know, symptom modulation, you know, we can help reduce some of that, that pain level from a certain level down to a much more manageable level, improve your tolerance to exercise for a lot of people, uh, not just with, you know, lateral elbow tendinopathy, but they will have avoided or be avoiding lots of activities that are painful.

And we know that. Yeah, for a certain point, you may need to minimize some of those things that really exacerbate the symptoms. But usually [00:13:34] it's, it's sort of the gradual exposure to those types of loads and stresses that is really important to from a recovery standpoint and from a functional improvement standpoint.

So really giving them permission to be able to move and realize that they're not necessarily causing Any significant damage with a certain level of discomfort and a certain level of activity. Um, I think that's a huge key. I mean, the education piece, I think people type, I think it's easy to gloss over the education piece as something that's not a skilled treatment, but I think it's so valuable, like you alluded to before.

In that without that people can, or left their own devices to kind of seek out. Information, and that can be from not, you know, not very reputable sources, whether it's through Dr Google or other people, other people on on the Internet, Instagram and YouTube and these kinds of things we know the kind of people, uh, that are potentially out there that might be some might be well intentioned.

I think some are not so well intentioned on can lead [00:14:34] people astray and to do it into other things that are really not helpful and potentially harmful. So I think one of our jobs as PTs is to be really well informed about all types of things, not just in terms of what we do, but some of the stuff that's out there too.

We can give people the best information so they can make the best informed decision. And you can really still justify treating these patients. You know, sometimes just once a week, once every two weeks for, you know, sometimes a few months. So they may get in, you know, You know, 6 8 10 visits. But instead of getting that in within three, four weeks, you're spreading that out and you're also, because we know of the recovery times, you're really seeing them through different stages of the recovery and different levels of function and helping them adapt along the way, especially for someone who's maybe working at a higher level that wants to get back to a higher level of maybe physical activity, sport, those kinds of things.

So it's more, you're giving them a lot of independence, but you're also guiding them versus like. [00:15:34] over me intervening, I think.

[00:15:36] Mark Kargela: Definitely. Excuse me. Definitely. I agree with that. I, I think, you know, there's, there's this difficulty with the, you know, these false dichotomies that exist on social media, and we're going to get into that. I think one other thing that when we have people that were kind of supervising the recovery, we're, we're checking in with them, like not just physically how they're doing, but we see how they're coping, how they're managing, like, you know you see people where you can just see the frustration, the anxieties, the depressions and things like that.

And to me, those are often the biggest trajectory predictors of anything. I mean, the research supports so much that, you know, psychosocial factors. So just checking in with people as they're recovering. And like you said, sometimes we can move to once every two weeks, three weeks or something to where we're still kind of having touch points with that person, making sure everything's going well.

You know, early on, it's the whole calm it down. Maybe you're doing some supportive things. Maybe you're doing some joint protection stuff or some, you know, maybe even using [00:16:34] some, some things that they can use to kind of avoid, you know, continuously aggravating things and then just building things back up.

We know tendinopathies especially kind of are a load game. You got to eventually get them tolerating load and it's going to be a process over time that. As you mentioned, as long as we're honest up front, I haven't met a patient who's like, you know, I've definitely had patients not the most excited to hear that it's going to take, you know, 6 to 12 months or 8 to 12 months.

Um, but the honesty of it and I've had frank discussions with people and said, you know, there's going to be a never ending line of people who will line up to say they can fix this sooner. And you're more than welcome to. Um, you have that, if you want to give an opportunity, I'm not going to stop you from doing it.

It's just, there's ample research and I've seen this time and time again with patients that it's probably going to take this, this time period. And I think we can do some good things in here. And you know, some patients might explore some other things and that's fine. But I think, um, more often than not patients are pretty on board with your honesty.

And, uh, I've had earlier in my career, you know, when I wasn't really well versed on the research [00:17:34] and evidence, you know, I had this six to eight weeks and things are going to be better. Just that generic tissue healing thing. And then. Definitely setting up yourself for some failure with, with patients with like a tendinopathy or things where we know that's going to be a longer term process.

I want to circle back a little bit to kind of the employer's perspective, right? I think there's probably some less ideal examples out there, I guess, of folks that are really layering on extreme amounts of passive care and things that maybe aren't super evidence supported. But I think there's some passive modalities, be it driving, needling, be it, you know, uh, various, uh, other, uh, interventions that can help modify the pain experience to help people maintain engagement in their valued pursuits of what they need to do at work or home or in life that they want to do.

How do you see that as an, as an employer? I, I maybe, I don't, I'm not. I don't believe you're in business ownership per se, but I think you, you have, you know, some standing in your company. I know they invite you to speak on some of these topics. I'm just curious if you're kind of looking down on this from as a, [00:18:34] as a business owner, obviously, I think as a business owner, we have a responsibility to try to provide the best care possible that isn't just financially motivated, that's, you know, person motivated, because I think we, if we point our self to that, I think our business builds, because that's going to provide a lot of goodwill in the world and people will be, you know, rewarded with their trust and, and, you know, return when pain, unfortunately, as it does in life, returns.

So what is your thoughts on, on the perspective of somebody who's a business owner or practice owner Um, who's trying to navigate this similar natural history versus the demands of running a business and keeping things financially viable.

[00:19:11] Andrew Rothschild: Um, and I have, I have the advantage of, I've been, you know, I've been doing this for 18 years. I've worked for a physician owned clinic. I've worked for three corporate practices, two private practices. I mean, my most recent, I worked for a private practice for over 10 years. Uh, the owner just retired and now we're under the umbrella of [00:19:34] a larger company.

And I'm in the position of being a clinical director, kind of running our practice, just trying to keep it. Uh, run the way it did under our, our owner. And you know, his mindset and something that, uh, some of them, we know, both know Jerry Durham has said is that, you know, if you, you treat the patient, you take care of the patient, the.

The business will kind of take care of itself. You know, that will drive all your business metrics if you treat the patient the way they deserve to be treated. And that's something I really do believe. And it's always like a fine line. Now I've been in corporate situations that were really, uh, not great for me in the way that I, uh, approach patient care and it, and it conflicted and it didn't end well, um, because there was that really significant, uh, pressure for volume.

And I think there's a lot of clinicians who find themselves out there in those in those situations where there may be expected to be seen seeing, you [00:20:34] know, three plus patients an hour. And I think that's a very unfortunate, um, thing for patient care. I think it's very unfortunate for our profession. So that's those are the situations that you know, if, if clinicians find themselves in and they really, it's really enough of a struggle that it's affecting them from a personal and professional standpoint, it's certainly worth considering trying to find another type of situation.

I think that's the, it's not an easy solution, but I think that's a solution people need to consider from their, for their long term mental and professional, um, health. Because that's a big thing that's also driving a lot of burnout in our profession. Um, I think the other part of it is the challenge of, and I've also seen this in a couple different corporate entities, is that they tend to look at things sometimes on a week, a weekly basis.

Like, what are your numbers this week? What are your numbers that week? And that can be very, you know, that short term type of thinking, I think is not always a great option either. [00:21:34] You know, if you see somebody too frequently in a short period of time to drive to make those weekly numbers look good, that could be a turn off for a lot of different patients from a financial standpoint.

From an outcome standpoint, there are a lot of insurance issues nowadays where they are really cramping down on the number of visits they they give. And if you burn through somebody's insurance in a time frame where that doesn't allow for adequate healing, that could have a negative impact on their recovery.

And so it also just how their their their perception of you and your practice. Um, and I think it's, you know, your patients are sometimes your best marketing sources, right? I see patients. I've seen patients for years, thankfully for different things, but then I see their friends and I'm seeing their family and I'm seeing their, their, their neighbors, like these kinds of, these networks are very important and not just from a, again, a business marketing standpoint, but you treat people well, that will have a big difference longterm on terms of [00:22:34] down the road, You know, again, your business, because patients will seek you out because you've done, you've done them, you've done by them in the right way.

And kind of like you said before, you know, I tell younger clinicians, like it's not our job to tell people what they want to hear. A lot of our conversations are telling things that they don't want to hear. But like you said, they, the most people will, will value that and respect that and appreciate that because you're not selling them something that's not really going to work just for.

just for money, you know? Um, and I think also going back to what you said earlier, there, there is, there is value in, you know, I'm, I got, I did my manual therapy fellowship. Um, in 2012, and there's a lot of value still in the hands on care, um, even some of those, those, you know, quote unquote passive things, because we also do know there is stuff beyond just what's [00:23:34] happening at the tissue level from a, from a, from a manual therapy standpoint.

Um, there's, there's a lot of that. Trust building that comes from manual therapy. It feels good patients that helps patients buy in and appreciate what you're doing. You know, it's the challenging the perception of physical therapy being quote unquote pain and torture. You know, so you go in, you give them something that they want, give them something that they like where it feels good.

That's going to help kind of build, build that trust, build that therapeutic Alliance, which we know has a positive outcome, a positive, um, uh, effect on a, on a good outcome. Um, And it'll also help, you know, it's a combination of giving people things that they want and also giving more of what they need sometimes.

But once you give them a few things they want, it's much easier to say, Hey, now we need to do this because this is really the stuff that's going to help you from a long term recovery standpoint. Um, so, you know, having said all that, I think this is a, making this a very roundabout [00:24:34] answer, but, um, you know, in terms of that balance with the, the, the pressures.

Um, of maybe certain of certain productivity numbers, you're still seeing the patient, you're still providing education, you're still providing maybe manual therapy, you're still providing exercise. So you're giving them very high value care. Um, and it may not be, again, from the frequency that may, you know, if there's a corporate pressure to see people three times a week, uh, at a certain point, I think there's a, there's a rationale to challenge that with, with potentially your employer, because it's also looking at the number of visits, the, the duration, the, the, the evidence.

You know, if a, if a, if an employer was challenging me on one, I'm seeing somebody at a certain level for a certain frequency for a certain condition. I have a lot of data to support my clinical decision making. Um, and so then, then it comes down to, um, having that, you know, [00:25:34] having that conversation with whoever needs to have that conversation and see how well it goes from a support standpoint.

And it's. You're not being supported as a clinician when you're providing high quality care. This kind of goes back to my earlier point is that maybe that's also not the right fit for you too. And so, and that's a very challenge when you're a young clinician, you have debt, you don't want to be without a job.

It's hard to find that, that, that, that's the right spot sometimes. But sometimes it takes a little bit of. You know, you really don't know sometimes how well the places fit for you, for where you work until you've, you know, especially when you're pretty new and unless you've tried out a couple of them.

[00:26:13] Mark Kargela: Yeah, sometimes the best way to find the right spot is find a few wrong spots and better identify what the right spot is for you for sure. I would wholeheartedly agree. I think there's, there's opportunities to really have show you that you're really providing care that's highly supported. It's not like you're going way off the playbook of best [00:26:34] practice, evidence based care, especially if you're getting you're pressured.

And I agree, there's a time and a place where eventually. If you're portraying and, and, you know, backing yourself with all these, uh, things that we spoke about and you're not getting that support, then yeah, maybe there's some tough decisions that need to be made on the clinician's part and, um, and, and, and maybe finding that right spot for you.

For sure. Let's bring this to what we talked about a little bit earlier and, and it, it goes to social media because you and I had a little bit of a chat about this before we went on air. It is a tough world and we've had this discussion a little bit in other episodes of younger clinicians and some of these really false dichotomies, it's either this or that.

And we mentioned Jeff Moore, you know, one of our friends and a great influence here in our profession. So it shouldn't be this or that. It's an and thing, right? It can be an and thing in our profession and being able to kind of, you know, Understand the nuance of things [00:27:34] instead of making these massive polarizing dichotomous, false dichotomous statements on on best practice and what you should do or what you shouldn't do and and then really, I just don't enjoy how we portray other folks, even if I don't agree with the way somebody is practicing, I'm not going to You know, insult them personally or call them, you know, you know, demeaning names and stuff like that.

I don't think that serves anybody personally, but it's out there and it is what it is. I'm wondering what's your advice or thought process when you see social media evolving to what it is today? And then you've been out for a bit as well to where how do you see, you know, younger clinicians best navigating the minefield that is social media?

[00:28:15] Andrew Rothschild: I think it's, it's very tough, you know? Um, I've, I've gotten caught up in things myself. Yeah. Even if, even as a seasoned clinician, cause it's, you know, we have certain beliefs, we have certain biases and when they get. challenged and maybe challenged in a negative way, uh, or there's things [00:28:34] out there that we were considered to be not really appropriate care.

It's hard not to get upset by it. At the same time, I find social social media, twitter, instagram podcasts have been incredibly valuable. Uh, for me, even as a clinician in my growth, just cause you have access to great clinicians that you would otherwise not have access to from all over the, all over the world, Australia, England, you know, here in the States, um, you have, you have access, you know, to authors of research papers who will post their stuff, or if you can contact them, they'll send you it for free.

So you don't have to try to reach it behind a paywall. Um, so you had these great clinicians. Um, That, you know, are out there having conversations and giving information that you can really, uh, grasp and incorporate, uh, into your, into your practice and into your knowledge base. But at the same time, you also have people with very strong opinions, people who are very charismatic.

Uh, they can easily [00:29:34] sway, uh, opinions into another, into other areas. And a lot of these clinicians I think are very well meaning. A lot of them are, you know, have done a lot of great work, whether it's research or have a lot of experience in clinical practice. And so as a young clinician, when you, when you don't maybe have the experience or, uh, the full knowledge base, it's, it's hard to know who sort of to, you know, hit your horse to, uh, who to believe, who's right, who's wrong, where's this and that.

And again, the answer sort of is. It's, it's, it's, it's, it's. It depends, right? It's, it's either or. It's all of it. They're all kind of right. They're all, nothing is a hundred percent. Um, you have to kind of figure out a little bit for yourself and, and explore. And I think you have to quite certainly, being open-minded and being accepting of a lot of different beliefs, not being too entrenched in one kind of camp.

I think that's been a problem historically. Maybe a little less so nowadays with physical therapy, when there was the sort of the guru. driven, [00:30:34] uh, aspect of PT practice. You had like your Maitland camp, you had your McKenzie camp, you had your Paris camp, all your other different camps. And it was very like us versus them, uh, kind of approach.

And I think they all have merit. They all have great things about them. None of them are completely comprehensive. They all are lacking in certain things. And I did my fellowship through the Ola Grimsby Institute. Um, we didn't get it really into anything with sleep related or other types, you know, certain things we didn't get into the nuances of pain science, sort of, as we know it now, it was a much more sort of.

pathological tissue specificity driven, uh, model, which again is very valuable in some ways, but also not valuable in other ways. It could be, um, overly, if people overly go into that approach, you can be missing a lot of stuff from the psychosocial aspect of, of people's experience. Um, so I think it's, you know, kind of like what Bruce Lee said, in that you kind of figure out what works for you and discard what doesn't work and then kind of [00:31:34] work it into your own sort of what your, what your own sort of values are and what your own experience has taught you and see how that applies best.

And so it's a little bit of trial and error, I think, um, with all these different things and kind of seeing what works for your patients. And you have to constantly be sort of reflective in your practice, um, without being overly, you know, it's, it's easy to get, you know, You know, when, when something happens good, that is because of what you did on the same side of something doesn't go well, it's not always because of what you did.

Um, so you have to kind of be able to take a little step back, I think, and approach it sort of agnostically in, in how you're treating patients and kind of really seeing what works from your approach, because in some patients, you know, maybe they don't need any hands on stuff and you can be a very much high exercise component person, but in some people, it actually made their art.

Conditions where it's really not appropriate to do a lot of exercise. Um, depending on what, depending on, and also [00:32:34] depending on what the individual's expectations are, what their beliefs are. So it is tough. It is tough. And I think part of it is when people post stuff, the other thing is you need to also research it for yourself.

You know, you can post little tidbits from an article, which sound really good. But when you go into the actual article, it's a lot more nuanced than what that person may have claimed online. Um, the quality might not Be actually representative of what the actual, um, information is, and may not truly be as positive as it sounded.

Um, it's, this is a funny example of, I remember this is years ago when it was, I think it was a Brit, a local British, Uh, tv station was talking about an article in which like two alcoholic drinks were just as effective as like, you know, strong pain medicine for, you know, for pain relief and it was presented in a positive light as a Hey, look, you know, you got two beers and you don't [00:33:34] have to, and it's just as effective as, you know, strong, uh, opioid pain medication.

I went and looked at the article and it was a negative article. It actually led to increased alcoholism as a result. You know, so it's like, no, it was presented very positively, but the actual article was not positive at all about, about the conclusion. So I think that we're just as guilty of that too. Um, especially when something meets our bias.

We want to present it in the positive light. Um, so I think that's the hard part is for clinicians. You want to pick, you want to, it's finding people who to trust, right? I think that, I can't remember who said it, but it's like, there's so many, People out there, you can't possibly read everything yourself either.

It's just too much. But if you find certain, um, authors of research that seem to be very, very consistently good and thoughtful and unbiased, um, and follow them, people, the same thing with people on social media. You'll find certain people who present things very, [00:34:34] uh, you know, or less biased, at least very thoughtfully, and it's really more following them more than the people who are on the extremes of either one or the other.

[00:34:44] Mark Kargela: Yeah, it's, it is, it is hard and it comes down. I think you, you mentioned a few things there with like this whole reflective practitioner thing. I think thinking about your decision making and what you're doing and kind of being purposely reflective on, you know, it doesn't mean you have to do it with every single decision you make, but maybe you pick some cases where you're really thinking about your decision making.

I mean, we should be doing it within every case a little bit of the evaluate. Hey, is this the right decision? Am I getting the right response? Um, what, did I have some bias going into this decision? You know, having some of that, we call it that metacognitive where you're thinking about your thinking and really having that process.

And to me, it's, it's, you're not going to be able to learn that in school. I just, it just doesn't happen. That's not the place that you learn that on the front lines in the clinic. I feel, and I've been this clinician where out there, I didn't have anybody helping me develop that [00:35:34] process. I felt for a good eight to 10 years prior to I got in the fellowship, the clinical process thing was just.

Toss a chunk of, you know, the, you know, the bucket of mud against the wall, see what sticks and having no idea with what parts of that mud we're making the change. And then really getting more honed in with a good clinical reasoning, critical thinking framework really allows you to kind of zero in on that and become a much more effective practitioner.

And it comes down to, to me, mentorship and Excuse me, maybe you get mentorship in a formal program like a residency or fellowship. It's great if you have the options to it, you have the access to it, you have the finances that allow it. I think students are in a challenging situation where, you know, they're coming out with some significant financial load and burden when it comes to student loan debt.

And then to, you know, I have these discussions with students like, you know, regularly and like, I'm thinking about a residency, but man, I got to take a significant pay cut. And, and I, I don't pretend to think I'd always be able to make that decision. I, you know, I think sometimes, [00:36:34] you know, you, you take a little pay, pay decrease, but it's man, that to me, it's like, you're, you're, it's an investment in significant opportunities for, for growth.

What, what's been your experience with mentorship and where do you see that fitting into Especially when you have this dichotomous no or yes, yet, yet in the clinic, it often becomes, it depends and it depends, depends on a clinical process to be saying in this N equals one situation with this person, with where they're at psychosocially, with where their condition is at severity, irritability, all those things that we think about, what's the best decision I can make today.

That's a hard situation to grasp when you don't have somebody to kind of help guide the way. What's been your experience with mentorship when it comes to that, developing those processes that you spoke of?

[00:37:18] Andrew Rothschild: I think mentorship is key. Um, I think it's so important. I think it's, it's hard. For young clinicians, again, depending on what their employment situation is, does their employer offer any kind of mentorship type, uh, structure, like a true structured mentorship? I [00:37:34] think a lot of places will claim, Oh yes, we have mentorship.

Meaning there's somebody there who's an older clinician that you can ask questions to, but it's not really like any kind of formal structured program. And that's one thing I've done, uh, where I work, uh, several years ago, kind of started developing being sort of a A very structured, with a six month structured mentorship program if we hired.

new grads kind of bring them along. Um, so they weren't just thrust into a high volume of patients. It was they start off at a lower volume. We spent several hours a week, one on one meeting, going over cases, going over specific conditions, these kinds of things. Um, But like I said, not a lot, not a lot of places will offer that specifically.

So certainly for, you know, people coming out, new, new clinicians, new grads, I think that's really important to ask, uh, your potential future employer about if they have any kind of program like that. I think another big advantage of social media, uh, and just technology over the last, you know, 10 years has been, um, the development of online [00:38:34] mentorship programs.

Like I said, I'm, I'm involved in one. Um, with Dr. Urson Religioso, I know you're involved in one, there's ICE Physio, there's a whole handful of ones out there that are all really, really good. Um, so there's those kinds of opportunities which are, which come at a much lower cost. Um, and people who are willing to sort of put in the time and effort outside of work to really, uh, work with younger clinicians and, and help them along.

I think that's a big, um, a big advantage nowadays that wasn't available when I was coming out of school. Um, and I think it's so hard, you know, that's one reason why I sought out sort of a residency fellowship is that I, I do very well with, with structure. So you can take a lot of weekend courses and get a little bit of information from all of them.

You can always find, you know, some good nuggets from any weekend course, I think, but how do they all fit comprehensively into a. clinical reasoning framework. It's just sort of like you're just piecing things [00:39:34] together. And for some people that might work, but I think for a lot of people having some sort of, um, consistent framework, uh, consistent clinical reasoning process that goes throughout the entire sort of curriculum, I think is really important.

Um, and that's something that I said, it took me a while. I was out for four or five years before I started getting into a sort of residency fellowship and even, you know, expanding beyond that because it is, it's, it's, my knowledge base has improved so much since then just from other types of things. Um, I think, and I think it's people are, people seek out, I think what quote unquote, the sexy stuff is manipulation, dry needling.

I mean, those are the most popular courses, um, in any I'm sure kind of program because it's, it's, it's fun to do. Um, you know, I think patients, See, see some value from it, but it's it's still not nearly as important as I think clinical reasoning, um, differential diagnosis, I think, because if you don't have those two right, [00:40:34] everything else after that is going to be so much less effective.

You know, knowing manipulation is great, but knowing when not to do it and when it's really inappropriate to do it is really important. Um, that could be a difference between a very serious situation happening or not happening. Um, But it's also like if you don't have that clinical reasoning process, that good evaluation process, that really affects the quality of the treatment going down, down the road in terms of if you're going on the right path or not.

And also being able to correct if you realize you're on the wrong path, how to kind of correct back into it, because we're all going to do that regardless. We're all going to miss some things or, or things are different than what we thought going in. But if you don't have that framework going in, I think that's, that becomes really a detriment in terms of your clinical practice.

The other part of it is some of the other quote unquote soft skills, like the patient management skills, like how you talk with the patient, how you, the type of questions you ask, how you ask questions. [00:41:34] Um, you know, with a patient, you know, in terms of growing that, that, um, that clinical relationship, I mean, these things are, you know, I didn't get that stuff taught in school, I didn't get that stuff taught in residency or fellowship, you know, so I think those kinds of, you know, some people are naturally just very good at it.

I think some people can just need to be taught it a little bit better. Um, because it can, it can still be a skill, just like anything else. It can, you can still get better at, at doing certain things, but managing that, it's the managing the patients, you know, managing expectations, you know, these kinds of things that adapting to different types of personalities, you know, the motivational interviewing, you know, all these different little things that we can learn and how to sort of.

Incorporate them in, uh, to a, to a, to a treatment plan, I think, is having someone who can sort of help you navigate through that stuff is really, really important.

[00:42:26] Mark Kargela: It's, it's so hard to, to get, and I know it was hard for me to coming up to see the value of those soft skills [00:42:34] that you, you speak of, cause I definitely fell to the allure of manipulation. We didn't have dry needling, but that seems to be the, the, the popular thing. And again, it's not wrong and it's just, but I think I sometimes wonder if clinicians just need to see that.

That's not the secret sauce of what we do. Um, it can definitely be a, a benefit and it can help patients navigate things, but I just remember seeing master clinicians, you know, folks that are really highly respected and practice on a high level. And they didn't often do much of that fancy, like stuff that, you know, gets thrown out on social media.

They were just supremely in command of the patient encounter and the, and really amazing at establishing great, excuse me, relationships with patients. that were fully bought in and fully engaged and invested in. They were creating clinical scenarios where they were, you know, masterfully demonstrating these soft skills to be able to get a patient who's in them, who are in a really good relationship, strong relationship of trust, um, and [00:43:34] using that expertise, but also giving the stage for that shared expertise where they're really incorporating the patient's unique values and the patient's unique goals and the patient's unique psychosocial status and weaving that into an encounter.

Uh, I, I definitely that's the whole reason we created our online community is because I just don't think one there's Opportunities for all students and and folks coming out to get into a residency and fellowship. It's improving. It's expanding Don't get me wrong, but there's some obviously financial things and different things that Just that aren't able to do it.

So we need to give clinicians and I would agree modern day and age where you can Create online communities, weekly office hours, where we're talking about cases and, and doing all these things and bouncing ideas off and, and helping guide clinicians on some of these tough situations. Cause again, I, I, I think they start developing this process.

And to me, it doesn't mean that the toolbox we're throwing everything away, but I think it really streamlines it to where you're not feeling like you need a million tools. You can have, you know, some tools that really work well for [00:44:34] you and your, you know, your worldview and your biases that we all have as clinicians.

Um, but it's, you really can weave that very specifically to the unique situation in, in front of you. Has that been your experience with it too? Is, have you felt like there was a need to add more letters or tools after your name as you've developed these processes? Or has it been more, you know, honing in on these kind of, like I said, soft skills?

[00:44:57] Andrew Rothschild: Really, it's been, it's been the soft skills. And I think, I mean, just speaking for myself, it was never about adding letters or that kind of stuff. It was really always about the knowledge and the information. You know, I just I just want the information. I want the knowledge. You get the letters. That's great.

Whatever. Um, it speaks to maybe putting in some time and effort and of course money into something. But, you know, it's you can have the letters and still not be a better clinician if you don't know how to apply it appropriately. You know, I think at the end of the day, it's really about acquiring the information.

Um, it makes me think of like, are you familiar with Seth Godin? [00:45:34] He's like the,

[00:45:34] Mark Kargela: Yeah.

[00:45:35] Andrew Rothschild: and he, cause he has his like special, like he has his MBA program, but you don't get an MBA, you know, If you don't actually get an MBA, but you get a hell of a lot of knowledge and information, all these kinds of things to apply in a business standpoint, because his sort of philosophy is the same thing.

Um, I think a lot of, a lot of clinicians look for things to get letters after the name, which again, it's, it's good to, you know, if that, if that's a motivating factor to increase knowledge, then great. But at least for me, that's never been my thing. It's just more getting the information. And I think, you know, for me now, it is really those acquiring those, some of those soft skills, those patient management, things like.

You know, someone like you watch someone like Peter, Peter O'Sullivan, and he's just a master with the soft skills and talking to patients and getting at these things. And it's just, you know, it's like seeing a great standup comedian. Um, it makes it look so effortless, but you know, it's been years and hours of practice and failure and repetition and changing it up.

And, you know, it's hard because [00:46:34] you, it's, With patients, you have to change every time, right? Every half, however often you're seeing patients, if it's every half hour, it's, you have to change it, the style every half hour, right? Cause it's, how is that patient, uh, how is that patient's personality compared to yours in terms of how they receive information, how they, some people want to be told what to do, right?

Some people want you to fix them. Some people want to be, You know, they have their own opinions and you have to kind of navigate how to, how to approach that in terms of not being too maybe, um, uh, you know, controversial in terms of like going, you know, challenging them too much with certain things. And sometimes you realize you need to challenge those, those certain people to help them change their beliefs.

So it really is the, that's the art part of it too, because there's no real. specific guide on how you're going to do this. So I think that's been my thing lately. You know, my last, you know, I guess half, you know, third of my career has been really trying to improve those kinds of things, [00:47:34] um, in terms of really understanding, you know, people's psychology, patient management.

Uh, I think that's been a big key for my, cause again, the, the, the quote unquote, hard skills. You know, it's, it's, it, they're definitely nice. It's great. You know, I, I do dry needling. I do manipulation. I do all these things, but it's, that's sort of like, I'm trying to think of a good, a good metaphor for it, but, um, it's kind of escaping me right now, but it's like, that's the tool while it's important to have the tools so you can kind of, you can apply different things and you can adjust if certain things that you would do isn't necessarily working.

If you don't have the foundation, again, it comes back to like the foundation of people skills, clinical reasoning, you know, everything else, everything else becomes so much easier once you have these things, but it's a really hard, it's hard to teach it. I think it's hard for clinicians to, to seek it out.

Um, and it's hard to [00:48:34] implement sometimes it's very hard to do. And it can be, I've gone through, um, A lot of pain dealing with patients and failing a lot, especially when, you know, with things like pain science, when I was first really getting into some of that stuff and trying to convey that information, I had a I had a lot of crashing burns on that one and you just, you just learn from it.

Um, but yeah, it's important.

[00:48:58] Mark Kargela: yeah, I would definitely share the lumps that you've taken and that's part of being a clinician, right? There's going to be times where things just don't go well. We have cases that man just head South despite our best efforts. And, um, I always share some of the, my pain science, similar crash and burns that you speak of.

Um, and it comes down to, again, the. I think we all have to have our journey of realizing that maybe it isn't a tool and technique and I would encourage those of you who are listening, just find some folks that are, you know, feeling like they're practicing or that you see that are practicing at a level you want to do and just see if you can hang out, talk to [00:49:34] them, you know, uh, shadow them in the clinic, maybe say, do you mind if I grab like 30 minutes with you on zoom?

I have some patients. You'll be surprised how, you know, generous a lot of folks are with their time to, to, to help you kind of get your bearings and maybe prioritize where you need to go to start really getting to where you want to be as a clinician, I think. For me, my journey was, I definitely wanted the knowledge.

I wanted to be the guy that people referred people to. And I thought for me, it had to be more courses, more things. And a lot of it being more focused on the hard skills, right? The technical stuff that we speak of. Um, when I really think, you know, definitely being technically sound is, is important, but I honestly think it's probably more 75 percent of how do you establish a relationship with somebody who believes, trusts, you know, And it navigates in the some of the challenges that they're dealing with, with pain, um, in a way where you're supporting them and they're, they're able to start knocking things down that get them back to the values that they want to live by Andrew, we could talk about this stuff and talk shop, you know, probably for [00:50:34] another couple of hours, but I want to respect your time.

And I just wanted to thank you so much for, uh, For your time today, if folks want to see you online or kind of get to know kind of what you're all up to, where can they find you

[00:50:45] Andrew Rothschild: Uh, best place is either Twitter or Instagram, A Rothschild PT. Um, that's the easiest place to find me. And, uh, kind of like you said, I could talk about this stuff, uh, for hours and days, Mark. And I think I could echo what you just said about, you know, with younger clinicians reaching out. Thanks people who like, like yourself and myself.

If clinicians reach out to me and ask questions, that is You know, that, that motivates me. You know, I will, I will give up time, uh, to, to, to reach out and, and, and talk to people because that's, that's, that gives me, that gives me energy too. Um, and you'll find a lot of clinicians will, will, will be that way as well in terms of they, they just, they're just, we're, some of us, uh, seasoned clinicians are just, You know, we love to find those young, motivated clinicians who just want to learn.

I mean, [00:51:34] that will give us energy. And that's the kind of people we want to, we want to talk with and work with and kind of help, help grow and develop, you know, so I can't emphasize that enough.

[00:51:43] Mark Kargela: and we'll link Andrew's contact information in the show notes and definitely echo what you're saying. That's it's. That's what kind of brings me. I mean, I love patient care. Don't get me wrong. I still work with patients primarily, but I really enjoy the whole mentoring of clinicians and seeing their growth.

And hopefully as you've listened to this podcast, prevent you from maybe encountering as many of the lumps and crash and burns as Andrew and I both experienced in our career, but that's how you grow, right? You, you, you hopefully get mentors who can help you. Avoid some of the, the maybe missteps and things that they've had along their journey.

And that's what, you know, kind of paying it forwards all about. Uh, so thank you all for listening this week. If you're listening on a, uh, audio device, we'd love for you to subscribe to the podcast. If you'd even leave a review, that would be huge for us. Um, that helps us spread some of this message to maybe some other clinicians who are struggling to kind of figure out their grounding in the profession as they're coming up.

Um, if you're watching on YouTube, we'd love if you subscribe, [00:52:34] um, maybe like us especially so we can get this distributed to more people. But we'll leave it there this week. We'll talk to you all next week.

Andrew Rothschild Profile Photo

Andrew Rothschild

Physical Therapist

Grew up playing competitive soccer including two years in college at Mary Washington. Underwent L4/5 fusion for spondylolisthesis in December 2000 at age 23. This experience piqued my interest in physical therapy as a career. Have been practicing now for 18 years. Completed a manual therapy Fellowship through the Ola Grimsby Institute in 2012. Has taught con-ed courses through IAMT and part of a mentoring group with Dr. Erson Religioso teaching Modern Patient Education which incorporates pain science, general exercise principles, mindfulness, sleep, and nutrition. Part of Untold Physio Stories Podcast. Currently clinical director for the Virginia Center for Spine & Sports Therapy in Richmond, VA