Physical Therapists: Balancing Personal Philosophy with Clinic Culture

Mark Kargela: 0:00

So what happens as you're working a job, especially if you're a new grad, somebody early on in your career and man, everybody around you just isn't quite practicing the way that you would like to, you feel like maybe things are a little bit dated and how they're practicing, you're really struggling to really gain some good relationship through your colleagues and you're not sure if it's the right place for you. So this week I wanted to do a little bit of something different. I've been getting some questions from some of our listeners and actually got question from somebody in our Modern Pain Pro community. In this video, we're going to talk about how you can make your first job a successful job, even if it isn't exactly the environment you foresee yourself practicing long term. Let's get to it. This is the Modern Pain Podcast with Mark Kargela. So first you want to make sure before you take this job that you understand what you're getting into. I think that should be common sense but I know looking back I took a job right after school that I kind of regret taking. It was my first offer. I was extremely nervous. I just wanted to have a job. I just wanted to know I was going to get a paycheck. I was going to be graduating. So it was a lot of stress on my part and I didn't do a lot of due diligence to really study. Was it a good fit for me? What was the philosophy? All these things. So before you take your job, you should make sure you're having some understanding of what you're getting into. And by that, What is the clinic's philosophy one? You can just see what are they marketing themselves as how are they portraying themselves in the community? If you're not someone for instance, who's a fan of dry kneeling yet, you know this clinic That's what they market to the public and say that's what you're gonna come in for and receive here at Smith physical therapy Then it's probably not a good fit for you. So you have to understand That kind of going in and one of the analogies I always use is if you're going to be trying to sell salads, you're not going to be someone who wants to work at McDonald's. It's not a good practice context for you to be able to really get to the clientele, the context, the environment that's going to really let you excel. If that's the mode of practice you want to get into you want to know what their specific approaches are. So What are they Mackenzie approach? Are they more hands on manual therapy approach again? Dry needling. Are they more they use a lot of modalities? Are they cupping scraping taping? And yeah, I'm not going to get into discussions on what's right or wrong. We know and we'll talk later in the video about there's a lot of options for changing pain short term, but we need to look bigger picture than that. And overall the decision you need to make is this something I can coexist with because often you're not going to find something that perfectly. Lines up with everything and every practice pattern you want to have in your practice, especially early on you, unless you're somebody who's going to go out and have the brave pursuit of starting your own practice and coming right out of the gate. I don't always recommend that just because you're going to be on your island right off the gate and sometimes that can really limit your growth and get you into a confirmation bias. But I do know some clinicians who've done it, who've jumped into their own clinic and they've really leaned on communities, social media, really networking with other colleagues to get that kind of mentoring and guidance as they're trying to find their way in the clinic. First off the other thing I would also look at is does this clinic and will your manager. give you the freedom to practice a little differently. So again, if you're not feeling like you perfectly a hundred percent align, so will they allow you to have some freedom to practice maybe a little bit differently than your other colleagues there? Most managers I think are really not wanting robots, although there is some benefits of knowing a consistent product that a client's getting coming into a clinic. But if it's a situation where you don't a hundred percent align with every little treatment strategy that's utilized by other folks in the clinic, then you might want to ask your manager, Hey, I really respect the fact that you do X, Y, and Z treatment, but I do have some interests in working with complex pain or working with some more persistent pain populations. Or maybe I just want to incorporate psychologically informed care into my practice where I'm going to be incorporating those strategies. Would that be something that would be okay? So that kind of lays out what you need to know before you start your job. Okay, so now let's move on to you've started your job and you're in the trenches with your colleagues. Let me share a story of mine that kind of hits to what not to do in these situations. So one thing I would definitely not do is come in trying to really push for change. As a new person who hasn't had a lot of experience there, a lot of loyalty, that hasn't built up a reputation in that company or someone who should be A new person, just think if you're in a job where somebody who just starts is just trying to recommend how you should change your practice. And unfortunately, that's exactly what I did when I moved to a practice back closer to my home. Some of my colleagues might be listening to the podcast. And when I came in there, the manager at the time really had pushed me to come in and really institute a more, evidence based way of getting after things. I'd just come out of fellowship. So I really thought I was hot stuff. And thought I was really, practicing at the top of the heap. And that was probably my ego a little bit. And now granted fellowship gave me a lot of great clinical reasoning, critical thinking, and some evidence based principles. But I also look back and the colleagues that I started practicing with were doing great. They were also keeping up with research. They practiced differently than I practiced. They weren't very manual therapy heavy. They were more maybe exercise heavy, but at that time. I was such believing that I had the solution with this manual therapy and exercise test, treat, retest. And again, some of these principles are great to have, but to come in there and I remember giving a presentation at the, one of the staff meetings and basically said, this is how we should be practicing. We shouldn't be just willy nilly throwing a bunch of treatments at people and letting them go out and hoping that things get better. We need to use a more methodical clinical reason process. And again, I don't necessarily not believe those things, but I really went in there thinking that and I could see how it would come across like. You're doing it wrong. I'm doing it right. Do it the way I do it. And just think about that as somebody who comes into a job, trying to recommend some massive changes and things doesn't mean that you don't think, Hey, maybe there's some ways we can integrate some more clinical reasoning principles, critical thinking principles or some different treatment strategies. But I would not try to introduce those right out of the gate with a company or with a group of people. You want to start really getting to know the group of people you're around and really try to establish some good trusting relationships. So just because an approach isn't our approach doesn't mean that it isn't helpful. Now again, we could probably argue that why things work is probably a little bit more Detailed or complex than just we're realigning joints or we're releasing fascia or we're doing some whatever dated theory that's out there. And again, we don't need to challenge that theory. We can be okay that there's other ways of getting outcomes that are beyond the ways that we've been traditionally taught or the ones that we've been taught to use. So we can just look past those dated narratives and theories. And again, I'm not saying we have to be happy with them. And we may not try to, introduce some ways of kind of thinking things a little bit more deeply as we get a better relationship and establish ourselves in a clinic. So if it isn't that way that they're talking about, what can we learn about our colleagues when we see them applying this theory or data theory in action? I think you can learn a lot and if you're just ready to shelf your ego and not get so caught up on the fact that, yo, you're using a data narrative that's wrong, you should never use it. Now, again, if it's not a narrative that's really founded in any semblance of science, and in fact, we think it's harmful or something, that's a different story. I'm talking about narratives that, yeah, they're not necessarily the ways we know things are happening, you know that strength isn't what's really changing when we improve somebody with strength training again We don't need to nitpick and do those type of things. We need we can start seeing Okay, if maybe whether using dated theories or explanatory models But what can we learn from our colleagues in action? One of the things I think we can learn is that there's a huge amount of contextual effects around interventions. Research has told us over and over again that the contextual effects, the things that surround our inventions are very impactful on how successful that intervention may or may not be. So again, we can look back and then how does that clinic Marketing the intervention. I'm not going to get into whether marketing is right, wrong or in between, but that just gives us an idea of what expectations a patient's coming into the clinic with. So what's the context that patient comes in the clinic? They've been exposed all these marketing materials. Maybe they have a word of mouth from somebody they know and respect. That's really saying that this something or other intervention fix them or whatever it may be. So understanding that may be a huge thing, especially clinics who have established themselves in a clinic often have Word of mouth really churning regular referrals and return patients and friends and family coming in who are going to probably have an expectation of around whatever approach that person has, whether it be well founded in science or not. And then how do our colleagues portray the intervention? Do they provide explanations, again, whether scientifically correct or not, that seem to produce positive expectations? One of the things that I always would be frustrated with as I was an early career clinician is I felt I could technically replicate a technique. Exactly the same as my mentor or the person I was watching clinician wise yet I wasn't getting the same outcomes as that person and it really had me frustrated It's one of the things that made me almost want to quit manual therapy until I understood contextual effects and what they Did do a heck of a lot better than I did is they had supreme confidence, you know early in our career if you're super confident I'd almost be more worried than if you have that imposter syndrome and feel like you don't belong and that you're not good enough and you just You're going to portray that a little bit non verbals and maybe even verbals for me. Sometimes I definitely came across Not confident, not somebody who 100 percent was believing 100 percent of what I was trying to produce in the treatment session. So again, patients are going to read that. We know clinicians who are confident, who portray their interventions more confidently, who create theatrics in a performance, I guess you could say, around an intervention that really gets a patient thinking, Man, they really know what they're doing. They found something that's wrong with me and they're going to fix it. And again, we don't necessarily like that language, but that can really produce powerful outcomes for a therapist, even though The intervention itself and the theory behind it may not be as special as we think it is. So what you can do is take these observations and then instead of, again, we don't have to use the same exact theory. We don't have to use the same exact explanatory models, but you can look to employ some of those non verbals, that confidence building, the way that therapist is communicating and really establishing good rapport with a patient and use it within our own practice and with our own theories and with our own delivery of interventions. Again, we don't have to perfectly agree with everybody else. And I'm sure, I think it's healthy not to always perfectly 100 percent agree. That's what allows us to question each other and grow and not always just sit pat with a world of confirmation bias around us. But again, we can do it tactfully, respectfully, and professionally. And it doesn't mean just because we don't 100 percent agree from people that we can't learn from others and some of the other ways that they achieve outcomes. So again, how do you interact with your colleagues? Are you somebody who's visibly resistant to their thoughts and methods? It's not going to make you a lot of friends and it probably is going to isolate you in clinic. So instead, why don't we compliment them on their practice in a way that your conscience can handle? It doesn't mean that you have to say, yeah, that fascia really got released or you really realign that pelvis or whatever theory that you don't necessarily agree with. But you can do something complimentary to say, Hey, Mrs. Smith, man, I saw her come in the first day and a week later or two weeks later, look how good she's and that's awesome. Good for you. And you just compliment your colleagues. I think it's helpful to do that. We've all as clinicians struggled and it's nice sometimes to have our colleagues just point out some of the good outcomes we're having, because we all have less than ideal outcomes. We have patients in our practice that are always getting the experience we'd like them to have or the outcomes we'd like them to have. One other thing you can do is offer to shadow them. You can say, Hey, if I have some downtime, would it be okay if I hung out with you and just see what you do day to day. Again, this is where you can see what kind of contextual effects. They're employing in their practice and maybe see what you can model in your own practice But again that opportunity to shadow and that offering or up or asking of shadowing is one way to show that you respect your colleagues And it, again, gains a better relationship with them. Doesn't mean we have to be, again, 100 percent in line with everything that they're saying or doing. But it definitely gives us the opportunity to learn and see just some of the patient communication aspects and the other things that might be outside some of the traditional dated theory that you're not 100 percent in agreement with. As you've hopefully built a good relationship with everybody in your clinic, you feel like you've earned some freedom. And I would, again, say if you really employ these strategies on the front end, I think you get given some slack to practice in some ways that might be outside the norm of that clinic and then focus on learning from each and every patient with your new focus. So now you can't take 180 degree turn from what your clinic's doing and all of a sudden say, I think kneeling is terrible. It's not right. We shouldn't be doing it yet. All your colleagues are doing it. That's an unprofessional way to go about it. And it's probably a way that will get you not working there very quickly. But there's again ways where you can focus on the things you have control and maybe just seeing if you can start introducing. Hey, maybe I'm going to employ some psychologically informed strategies within my practice and see if you can't start having people take notice of what you're doing. Just try to be an example, what you, just like you observe clinicians and see, man, they really were able to make a change in some things. Your colleagues will notice that in you if you're patient with it. One way to get them to show some respect or to gain some respect for you is your ability to make headway in some traditionally difficult cases or complex pain presentations. One thing, and I've been guilty of this as a clinician myself, is this back office discussions, where as clinicians, one of our defense mechanisms, when we get cases that just make no sense, we're struggling with, is we blame patients. We call them the energy vampire. We call them the complex patient, the difficult patient. Whatever other horrible way that we often describe patients and again, It's not that we don't want to help folks and different things of this But it's one of those things that when we don't understand things and it's too complex for us And it's not fitting our theory. It can't be us. It's more of a defense mechanism It must be the patient's fault. But of course, it's likely more of an us issue So when you hear some of those conversations, maybe you can say, Hey, you know what? Strangely enough, and you might think I'm weird for this. I really enjoy working with some of those difficult situations. So if you don't mind, I'd love to, if you ever feel like you're having one of those situations to maybe toss them on my schedule. I really enjoy some of those cases. Now, early on in your career, you may not want to offer that for every patient because you don't want to fill up your schedule with a lot of complex cases. It's good to have some non complex patients just to make sure you're balancing out some of those chronic complex cases. One, because sometimes you're going to be having a case, so if it's all complex chronic issues, you may have struggles to be finding a lot of good outcomes, and that might make you feel and question yourself and your worth as a therapist. I think we all go through it. I definitely still go through it when I have a caseload that's really full of a lot of difficult, challenging cases that I'm not maybe. Having as much success as I'd like to have the other thing too. I'd look at is as you take on more of these cases, lean on your community, maybe social media where you're in some groups where you can bounce ideas off of each other and talk and get support. It may be a group of clinicians that you graduated with who are in similar mindsets with you. Maybe it's a group of clinicians locally, or maybe it's something more formal like our modern pain pro community. Regardless, you need a sounding board and a support network to work through these cases, especially if your colleagues in your clinic aren't going to necessarily practice the way you do and won't maybe have. as many suggestions and pointers to apply the way that you're wanting to practice. Know that you are going to have failures. This is the real world. We work with real people who aren't going to land on social media highlight reels, even under the most expert guidance of the most expert clinicians. That's just the reality of what we work with in clinic. I think there's this false belief that we gain these clinical skills where we're just some sort of superhero that can swoop into even the most difficult, complex situation and really save the day and make people have these 180 degree turns. in their journey. Now, sometimes that happens and while is that rewarding, but I've definitely you look at any clinician and you hang out in their practice. You will see patients who aren't getting great outcomes. There's just too much that exists sometimes outside of our, and I would say maybe more often outside our clinic door that impacts our ability to make positive change with clinics. Does it mean that we don't try to give them their 100 percent of our effort and guidance and things? No, it just means that We sometimes have to strip ourselves of this massive pressure to have amazing outcomes. We're going to put 100 percent effort and give every patient our undivided attention and effort. There might be times where it just isn't in the cards. There's, it's just not a perfect situation. There's things that are influencing the outcome outside of our treatment walls and outside of things that we can affect that are really driving things in a negative direction. But the other thing to know is you are going to have successes where other therapists have given up, or other clinicians have given up. People will take notice of this. Your colleagues will gain the respect and may even look at you as an excellent resource for them. When you stake one of their patients who is struggling, who they were so frustrated with because they didn't really understand complex pain presentations and psychologically informed care and person centered care. Maybe they start integrating some of that in their own practice, but also maybe they start being a regular referral source for you. And really enjoying your presence in the clinic because they don't maybe prefer to work with that complex presentation or that type of patient load. And you're somebody who's become somebody they can lean on and help them de stress their own practices. And your supervisor is probably going to continue to give you leeway and freedom to further develop these approaches and then, hey, maybe next thing you know, you're developing a pain program in your clinic. Next thing you know, maybe you're really, talking at in services in your clinic to really help other clinicians gain some of the expertise that you've developed through learning from your patients. Again, you're not going to get that demanding it on the front end, especially as a new grad or early career clinician, but I would even argue as somebody new to a setting. You got to earn your chops and earn your respect, and you're not going to do that by demanding it out of the get go. You have to get yourself dirty and in the mud with your other fellow clinicians, respect what they do, even if it isn't 100 percent of what you do, and try to foster and build relationships with them that allow you to gain some of that experience, allow you to gain some of that confidence from your supervisors and your fellow clinicians in you, and then you can start making some headway into some initiatives that might move into different directions of how you treat and how your clinic as a whole treats. So I hope you found this helpful. If you did, I would love it if you could like or subscribe on YouTube, or if you're listening to this on the podcast, I'd love if you could rate, review on our podcast. That's how we best grow this podcast and help more clinicians and help more patients better understand and treat pain. This content was created by real questions from our listeners and viewers. So if you're listening or watching this and you have questions that you'd like to see an episode created about, drop a comment or message us on social media and we'll make an episode about what you're looking for.

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This has been another episode of the Modern Pain Podcast with Dr. Mark Kargela. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modernpaincare. com. This podcast is for educational and informational purposes only. It is not a substitute for medical advice or treatment. Please consult a licensed professional for your specific medical needs. Changing the story around pain. This is the Modern Pain Podcast.