Unveiling PT's Hidden Curriculum: Communication, Mentorship, and Beyond

Mark Kargela:
0:00

Welcome back for another episode of the Modern Pain Podcast. This week, I had the chance to interview Seth Peterson. Seth wears many hats as he is a private practice clinic owner, clinician, and researcher. In this episode, we discuss how physical therapy school trains you to be a safe practitioner and doesn't necessarily prepare you to be good. It's mentorship that helps us navigate some of the situations we face in clinic that Seth discusses.

Seth Petersen:
0:20

So you can whip out the dry needling or whatever it is and I think there's maybe some value to that but what you find out when you're in the clinic if I think we talked about this before we recorded if you're being humble is that really I think you have to keep an open mind not everyone responds to the same thing.

Mark Kargela:
0:38

Seth talked about some of the concerning perspective. Some are taking when applying manual therapy in their practice. It was concerning to hear, to say the least.

Seth Petersen:
0:45

I saw someone talking about what they did. I think it was around manual therapy. I can just turn my brain off. When I do it and I thought, man, that's such a horrible message that you can just turn your brain off. And there are people agreeing with them and you could see that there was a comment. From at least one physical therapist that said, yeah, and that's why I'm switching professions.

Mark Kargela:
1:05

We spoke to the importance of learning good communication skills and how that simply is not taught in physical therapy training programs.

Seth Petersen:
1:11

Another huge thing is the first thing that popped into my mind when you asked that question was communication. I don't think that gets stressed hardly at all in PT school. And part of that might just be time. But even as I say that right now, I'm thinking it's such a huge part of clinical practice that we should make more time for it or integrate it throughout, the curriculum in some way

Mark Kargela:
1:34

Seth published an article on this. And we talked about how continuing education often has a lack of evidence for many of the interventions that are taught.

Seth Petersen:
1:40

we'd compare that to what does the clinical practice guidelines say about that intervention. And is it recommended? And then if it wasn't in the clinical practice guideline, we'd go to the next level and say, can we find a single systematic review anywhere that supported it? And I would say the results weren't good.

Mark Kargela:
1:55

Don't forget to check out our community@modernpaincare.com forward slash community. To get access to discussions members only content and training. And more. Now onto the episode.

Announcer:
2:05

This is the Modern Pain Podcast with Mark Kargela.

Mark Kargela:
2:09

Welcome to the podcast, Seth.

Seth Petersen:
2:10

Yeah. Thanks for having me, Mark.

Mark Kargela:
2:12

Always good to talk with you, my friend. I've known Seth, gosh, since fellowship days. And that was back over 10 years ago, which is hard to believe. But yeah, the time flies clinically for sure. I'm 20 years plus in the clinic. I know Seth you're creeping up towards that number, I believe. But for those of the audience that don't know you, Seth, if you could introduce yourself a little Yeah, sure. A, clinician in private practice. That's what I do full time. I have a, in my outpatient practice is called The Motive that's in Oro Valley, Arizona, just north of Tucson. So yeah, I've been, actually a little less than that. I've been out 11 years from PT school but seven years since fellowship. So I jumped in, maybe have a unique story there doing residency and then fellowship right out of the gate. Yeah, so that's what I do. I've had the, pleasure to be involved with a few papers and then be involved. Teaching here and there with a few PT programs and with a con ed company that I started a few years back, the movement brainery. Yeah, We'll definitely link to that because Seth's got some quality content and his con ed company students has done some mentorship and teaches some coursework, which would highly recommend you all check out. Also very impressive with the publishing and balancing all the things we talked about. Seth also has two kids and is married and a busy individual yet manages the balance at all. So very impressed with that. One of the papers you talked about and wrote about with Matt Erb, Todd Davenport, which I think is a great paper spoke to this role as becoming like that clinical chameleon and clinic. And that's something I remember talking about in class. Physical Therapy School. We'll link the paper. It's called From Idea Cults to Clinical Chameleons, Moving Physical Therapists, Professional Identity Beyond Interventions. I'd love if we could unpack that a little bit of just what as the challenges of what PT education can provide. And, I think sometimes we bang on PT education and it's, and there might be some, reasonable things to criticize, but it's a challenge to get folks ready to be safe practitioners. Let alone very skilled, clinicians. I think those are two different things. But can you speak to a little bit about the challenges as folks are coming out of physio school and maybe ones you faced? As you were coming into the profession of maybe what you thought in school and then what you saw and have learned as you've got a lot of experience under your belt.

Seth Petersen:
4:19

I think you're right, Mark, and we have to couch DPT school for what it's intended purposes. It's graduate safe clinicians. And I think just for a really long time as a profession, we've maybe put it up on a little bit of a pedestal where. We think, okay, you can graduate, you can do everything. You did your rotations and you think you understand what you're, your CE guy, what, the guy in the clinic that you shadow or the girl, you understand what they're doing. So you're a PT and then you take a few content courses and, it's like you're Batman with his utility belt, just putting things in the utility belt as time goes on. So you can whip out the dry needling or whatever it is. And I think there's maybe some value to that, but. What you find out when you're in the clinic, if I think if you're, we talked about this before we recorded if you're being humble, is that really, I think you have to keep an open mind. Not everyone responds to the same thing. Even when it, you talk about exercise in the research, talking about exercise. What's your definition of exercise to throw so many things into the hat, but for a patient that might look a thousand different ways. And so finding the right. Thing for the right individual, I think, is where the expertise comes in the clinic and where we should be focusing as time goes on, rather than trying to focus on, acquisition of a specific new modality or. Something like that. And the intention with that paper, how it started off as idea cults is I think, unfortunately, the, discussion in physical therapy sometimes just drifts towards this is there's one right way to do things and we just go from one pendulum to the other pendulum first, it's, you can't do any manual therapy and it should all be exercise. And if the patient requests one thing. Then while they're wrong, and so we should tell them why they're wrong rather than maybe just being a little more humble and what can I do to help that person on that day? And it might look different for everybody.

Mark Kargela:
6:06

Yeah that's the challenge, especially in the dawn of dawn, but it's social media has been around for a bit, but with social media, these idea cults take, quite a bit hold as far as like this, and I, we've, I've talked, we've had Jared Powell, we had Derek Griffin who released an episode here soon, it'll probably be out by the time folks are listening to this episode, but that speak to the challenges of being a young physio. Thank you. of trying to understand, to see all these influencers, authority figures in our profession, just going at it in social media of and then what is this young clinician left to think about as far as what am I, is it right to do this? Is it wrong to do this? And then you get into this kind of cultish behavior around interventions. And then lo and behold, the person that's not involved in that cult is patients. Often they just sit on the sidelines and good God, this. physical therapist struggle to agree on anything. Where do you sit on that kind of challenge as a young clinician when they're trying to look at the landscape of all these idea cults? What would you recommend? They do as far as to navigate that pretty challenging waters that are social media and some of the idea cults that are out

Seth Petersen:
7:05

Yeah. As far as answers to that's going to be tough. I'll try to circle back around to it, but I just, for a second, want to agree with you how huge of a problem that is. First, I just, an example recently, and I don't want to throw anybody out on the bus here, but from social media, I saw someone talking about what they did. I think it was around manual therapy. I can just turn my brain off. When I do it and I thought, man, that's such a horrible message that you can just turn your brain off. And there are people agreeing with them and you could see that there was a comment. From at least one physical therapist that said, yeah, and that's why I'm switching professions. So I think there's this, it's easy to drop down this rabbit hole of cynicism where, okay if I'm not going to use my brain, then why do I want to even be in the profession? So I think. And that triggers a memory of in P. T. School. I had a friend that did, and he ended up going into neuro, but he did an outpatient P. T. Rotation. And he said he didn't want to go into that because it was so easy. And I remember having the exact opposite experience. So I think, yeah, first you need to, like we talked about, be a little humble, try and foster that humility. And I think mentorship is probably the only, Answer. You need some external force looking at what you're doing in the clinic and giving you feedback about that, patients don't really know what to expect patients. They, we've all had experiences where they have an experience with a physical therapist and, it didn't really go well and then that's their impression of what physical therapy is. So patients don't know walking in a lot of times what to expect. I don't know that we can fully invest everything in the patient, but that's a huge chunk. And then, again, having a physical therapist that can look at you and give you some feedback about what you're doing. I think that combination, that's as close as you can get to a solution to that problem.

Mark Kargela:
8:51

Yeah. Wouldn't it be nice if we just had a little black and white solution to, to get people through this. I think there's just a bit of human nature that goes on as far as we try to, Clutch onto our security blanket of this is the way to do it. And this is what I would make sense of this complexity we see in the clinic. Yet we see such a wide variety of opinions and folks. And I have full confidence that if we wouldn't a lot of clinics, there'd be a lot of happy patients and the myriad of idea cults that are out there. But I think we fail to see the big picture of maybe there's some secret sauce that. is contained within all these, modes of operation that we could learn from and better leverage and treatment. But I love if we could circle back to manual therapy, that's always the eternal debate. And I've had my challenges probably have had probably out of frustration for some of my over reliance on very dated theories and ways of looking at manual therapy. Yet, We do have these clinicians who are like ready to not put their hands on a patient who are just like this. It's worthless. It's low value care. It does nothing yet. We have patients who value it significantly. And I think properly positioned can be a Helpful way to navigate somebody back in their life. What has been your experiences? You've seen clinicians. I know you mentor a lot of clinicians. I think you probably have students that probably roll through your clinic. And then you obviously are pretty active on social media. We'll obviously link that on the show notes as well. What have you seen in, in kind of the manual therapy landscape, how that's pendulums have swung back and forth over time?

Seth Petersen:
10:13

Yeah, I know you're a little bit about your background. You're from Michigan, right? So the, when I think of Michigan, I think of really pathoanatomical. Kind of history there and osteopathic, instruction and I had to, mine just, I got lucky. I think from the beginning that, it was brought up in the Maitland model. So at the end of the day, Maitland has this wonderful. Concept of the semipermeable brick wall, which if no one's heard of, it's on one side of this, if you imagine a semipermeable brick wall on one side is the theory, the, book knowledge, anatomy, what the research says, and on the other side is the patient sitting in front of you and they interact with each other. But at the end of the day, probably the most important thing is the actual thing sitting in front of you that individual. And so I think I, I've always stayed grounded in that. But yeah, what have I seen lately? If I reflect back on the younger clinicians, the. They do seem, honestly confused. When I think of a recent mentor, we had gone through a mentorship. They talked about neck pain and they never did any manual therapy on the neck. It was just, they didn't feel like it was evidence based they didn't know where to start and and coming from my background, I'm like, man, it's really challenging with the neck, especially if you don't do, you don't put your hands and do any sort of manual therapy on someone's cervical spine. It's. I think it's tough. I think that's such a low hanging fruit in some of these things. Manual therapy for the spine is in every clinical practice guideline to some degree. So it's not an unreasonable thing. It's evidence based. I don't know. I feel like you should, at least put it in its place as having some value, especially if the patient Request it, right?

Mark Kargela:
11:47

Yeah it's, I think there's this way it gets positioned sometimes it's just dependency creating. thing where we just have patients who are coming in for a spa treatment and getting, a rub or a crack. And I'm sure there are some bad examples of that in any profession. I'm sure we can look around and and, Talk to some of the frustrating things we've heard of, other professions and within our profession as well. No, no professions innocent. I've also had my patients early in my career where it was very much, manual therapy primarily. And I'm stuck in like hands on jail with people because they, I wasn't skilled in understanding the big picture of the context and getting people off tables and really focusing on life stuff. Yeah I agree. I think sometimes, it's, it is low hanging fruit that positioned well. With a good narrative behind it and not spinning some sort of sense of frailty and fragility and fault faultiness of a patient can be a nice way to get somebody moving forward and things. I don't still puzzled why people get so ruffled over it, especially when culturally we have a cultural full of patients, often not all because, of course, we're going to find out specifically each person in front of them. We'll have a conversation and tailor care specifically them. But yeah, We do have a general cultural belief that hands on care has value. Roger Carey, I think, and Fiona Moffitt put a paper out, or it was within a text, I think, manipulating practices that spoke to just the over time cultural value of touch. Yet, as physical therapists, we're getting to this point where everybody needs to be self efficacious. We should never do anything that could have any risk Of dependence. What have you seen as far as that whole debate on dependency versus self efficacy around manual therapy and how do you see that, materializing in your practice, both past and present?

Seth Petersen:
13:24

Yeah, I think that's a good question. And you bring up a good point. Anytime I in an ideal world, anytime I do a manual therapy technique, I'm already thinking about how, can this patient do that at home or replicate this in some way at home. So if it's, if I have, five different ways that I could approach that patient. Through maybe a manual therapy based approach going through my head. I have a hierarchy of this is the easiest for people to replicate at home. And this is the hardest for people to replicate at home. I'm going to start with the thing that's easiest for them to do and then shift down depending on what they respond to. So I think that's maybe a good way to, to do it. As time's gone on, I think maybe I've also been a little bit more forgiving as far as that goes to the patient. So if let's just say that the average number of visits that I see somebody with neck pain is like eight visits. Is it so bad if I do manual therapy? And the patient can't replicate it at home as long as they still get better in eight visits. And they understand at the end of the day that it, this is, the general prognosis. This is what to do if it comes back. Maybe they have a few things that they can do to keep it from returning or they can resolve it on their own. But I guess maybe as long as they have a good, like you said, narrative about what's happening. What the condition is that it's not a life threatening thing. In most cases, I guess I just don't see it as that big of a deal. So I guess that's I'm like with you or I see those discussions and I'm, I don't know, I don't see it as a huge issue.

Mark Kargela:
14:53

Yeah, I think it gets to be a big issue when there's controversial. Takes on it, which sometimes social media, that's just the nature of the beast as far as controversy equals views and clicks and things like that. And again, I don't think, I think it's good to have healthy debate around interventions. I think if we just cruise the way we were cruising early on in my career where manual therapy was very much a paternalistic. Guru Jedi hands pursued. And there's still, I think, and I know Jason Silvernail, now we're gonna have him on the podcast. He's going to have a paper coming out on what is good hands. Cause I think there is some value in, in how you use your hands as far as not just like putting your brain to sleep. So the clinician you spoke to as far as having some conscious thought of how you're applying and using hands on care with pain science involved and with current understandings of mechanisms of manual therapy involved without, Some of the dated narratives, but yeah it's, it is just, I agree. I get, I'm puzzled why it's such a massive debate. And again, I think some people just get so cultish and, tribal with their beliefs around it that I think, again, patients get left in the sidelines, like scratching her head. Like these people don't know, can't agree on anything, which I just. I don't think it's always the best look, but again, I think it's healthy to have debates around any intervention, especially ones that we are, our pet interventions, be it manual therapy, be it exercise. I think there's equal criticism to go around. I think there's this belief that exercise is somehow something that every patient is going to adopt in their lifestyle. And for a lot of patients, exercise is the least interesting thing for them or something they're not going to want to pursue. So you have to figure out ways in their life that movement can fit in with all this said, Seth, Mentorship, and we've talked about this and we've all both been fortunate to go through a lot of great mentorship to navigate this type of muddy gray waters. One, the clinic is full of it. And as far as this. A lot of things that were taught in school is very black and white, but there's a lot of certainty. We look at things as like this closed system where there's, we're going to come to this treatment decision. That's going to be a very much A or B and we choose A and A is the right answer. And again, there's, that's the best way we can educate to get people to be safe clinicians, like we said, but Where do you see mentorship fitting into? Maybe where does it fit into your practice in your history and your development, and where do you see it fitting in for clinicians who are trying to navigate social media and all these different confusing things? And then also facing a clinic that doesn't replicate The A, B, C, or D of that, that PT school makes them fill in on these test sheets, which again is I'm not banging. I'm part of PT education. So I get it. But where do you see mentorship fitting into that challenge?

Seth Petersen:
17:23

Oh man. It's an essential part. I guess as someone that. It was brought up having mentorship going through these, individual programs and then trying to seek it out. I still like, I alluded to this when I, messaged back and forth prior to this. It does baffle me how People don't have that at all and they don't seek it out. So Anders Ericsson has his framework for developing expertise and he primarily looked at like musicians, but for that development of that I'm blanking on the the term that he coined to discuss that, but it was. Essentially, getting feedback from someone that is at a higher level than you are is necessary. So if you're trying to move up to a higher level of practice, you need someone that's at that higher level of practice to coach you. It's not unlike if you watch, star wars, how Yoda is there to help, teach Luke Skywalker a little bit about the force and move him up a little higher level, you need Someone to coach you to get to that next level. It's it's otherwise it's virtually impossible or it would take you a substantially longer time to get there. So I guess I, I always struggle with that. I think maybe one thing that was even valuable in fellowship is recording, your cases, whether you do an evaluation, just so you can look back at yourself and see what are you doing unconsciously so you can provide some level of self critique. Even then, obviously that's not quite as good because there are things that you don't know or ways that you could do things. But it's still, one thing that people could do. But again, you don't really hear about that happening too often.

Mark Kargela:
18:55

You don't, as you've Gone through mentorship. I think sometimes there's this belief I know for me, mentorship, I thought, Oh man, I'm going to learn just these amazing technical skills, which is again, part of it too. There's nothing wrong with being better technically in our craft, but what are some skills you think that you didn't recognize were a necessity to being a really good clinician early on in your career that you, as you've gotten into mentorship and as you've been able to be around some very high level clinicians that maybe you undervalued, or maybe didn't take into account as much as you, you thought or that you do now. Any techniques or skill or any more skills that you think would be fit that?

Seth Petersen:
19:30

Yeah, what you alluded to with Jason Silvernail and having the good hands, I think that's important. I do think once you get past a certain level, It's probably, you're trying to go from 95 percent of what you're, what the benefit is to 99%. It's like that you're scraping from, 1 or 2 percent of improvement where, okay, maybe that's not as much juice to squeeze as there would be moving to something else. So maybe background knowledge, how we manage a patient case. I think that's a huge part of why you see in the research, how fellows. Fellowship trained clinicians in the U. S. get better outcomes with their patients, is probably just managing the case really well. So that's a huge chunk and that includes things like differential diagnosis, understanding, how to move a person along through their trajectory and minimize the chance of flare ups and things like that, and usher them as quickly as possible to functioning, getting out of the clinic. So I think that's a big piece. Another huge thing is the first thing that popped into my mind when you asked that question was communication. I don't think that gets stressed hardly at all in PT school. And part of that might just be time. But even as I say that right now, I'm thinking, it's such a huge part of clinical practice that it should, you, we should make more time for it or integrate it throughout, the curriculum in some way, I'm not in academia, but I think that Should be really huge. When I started in clinical practice. I think I was lucky again that I had a mentor that appreciated the value of communication and he would point out the things that he was doing to enhance the effectiveness of what he was so like walking into a room with a patient with a migraine or. Some level of central sensitization to dim the lights a little bit and change the tone of his voice, or if there was a patient that was really excited in the clinic, he would raise up to meet them and the response and they teach this in psychology is the patient if you're both at this hyper level. As they start to calm down a little bit. So there are little things like that that you can use ways that you phrase questions that just becomes surrounds and permeates everything that you do in the clinic.

Mark Kargela:
21:34

Yeah, that, that is fortunate to have that early on. I think for me, I was always so frustrated, like I felt like technically I could replicate some of the technical skills for some, higher level clinicians. Yet my outcomes weren't the same. I wasn't thinking about dimming lights or how my tone of voice was or how confident I was portraying it or what narrative I was producing around the intervention I was about to provide to somebody. Obviously we provide narratives that are founded more in science and reality versus some of the challenging narratives that exist out there across more than just physio, of course. But. Communication. I would highly agree. I think that's the biggest thing that I think has been the separator of really great clinicians and a good clinician. You can be good technically and get outcomes with the great clinicians, especially being able fortunate to be mentored by some of the similar conditions you have as far as just seeing how they command the treatment encounter and really are able To gain that kind of therapeutic alliance with the patient to where the patient is fully invested and on board with kind of what's going on. Obviously that sometimes even with the best clinicians that may, there's challenging therapeutic relationships that are going to exist even with the best. But, where do you think students can go like young, younger physical therapists to hone those, communication skills? Mentorship definitely being one. Is there any, been any like. Oh, be it courses, be it kind of things you've read up on or kind of topic areas that you felt have helped you develop yourself in that area.

Seth Petersen:
22:57

Yeah, we we also had a viewpoint in JSPT talking about communication and Michelle Kleiner and Maxi Mechuk helped with co authoring that and John Wolf, who's, my mentor earlier in the practice, who now is a PhD in psychology. So they're all, moved in a similar area. Todd Davenport was another author on that. So we talked about. How really there's this lack of, it's challenging in physical therapy. There's a lack of courses like that. And part of the reason I think realistically, I don't know that we mentioned this in the paper is that people don't sign up for those courses. I don't know if you know what your experiences and speaking with other clinicians, but for the most part, people hear about communication. They think I can talk, patients seem to like me. So check I have communication already nailed down. And it's weird because like psychologists, that's all they do. They don't ever reach a point where they think, Oh, I've got communication nailed down. It's a lifelong thing that you can continue to improve on. So we put forth this idea. Okay. What, maybe what you can do is focus on, being more mindful in the clinic and be more reflective, and maybe this ongoing process of being present in the moment and reflecting on that. Can help you develop over time and then there are some, courses that you can take that will teach you approaches that you can integrate in your practice, like motivational interviewing or whatever it might be. And those are out there. I guess I would encourage people to just look outside of PT if you want to do that. And just real quick, just to circle back, cause this popped into my head. And in terms of the skill pieces, you were talking, Mark, where, you know, if we can sit and imagine, put ourselves in the patient's shoes and just think, what kind of provider would you like to have if you had a primary care doc? And I think a lot of us have had visits with primary care docs, maybe in the not too distant past where you're sitting there, what kind of doctor do you want to come into the room? You want someone that's going to. Listen to you, understand you that's going to be, a skillful in how he communicates with you, but you also probably want a skillful doctor. So you want someone that, you can imagine if you had the first and then the first thing, and then he went to do a physical exam, and you could feel his hands trembling. And he's like, how do I use this reflex hammer? And he hits the wrong thing. You'd immediately lose confidence in him, even though he'd already set this groundwork before and the opposite's true too. If you had a guy that walked into the room. Like I wrote a blog post not too long ago about a cardiology experience I had where the guy just stormed into the room, didn't make any eye contact and was like, basically asked, what do you want and sat down and it was just immediately like a turnoff. I just want to leave the room. This guy doesn't care at all about what I'm coming in here for. So you need both. And yeah, communication's huge, just to circle background. There's not a lot of courses there, but looking outside of PT is probably the best way to do it.

Mark Kargela:
25:44

Yeah, I would agree. The communication piece is such a huge thing. And just like you said, mentorship and shadowing some clinicians who do it well, and take a note on what the habits, how they set up conversations, how they look at it. I tell students regularly, you have to look at your communication as an intervention. Like you should treat it no differently than, your manual therapy, your choice in words should be just as, hard thoughts as far as how you're thinking about what choice of technique you use because they can have, I would argue, even more power than our technique sometimes in certain contexts, you mentioned a bit about continued education that is the wild west, as you've already written about in some of your paperwork, I'm wondering if you can maybe give a little bit of a summary of that paper, what you found when you examined continue education and physical therapy. And then we will solve the issue of why physical therapists won't take courses that come like you already alluded to in communication. I joke, of course, because I wish that was possible. But I'm wondering, maybe we can speak to what we think might be some ways to help therapists value things beyond just the latest thing in the Batman's tool belt approach that you mentioned earlier.

Seth Petersen:
26:48

Yeah. So we did, I was the chair of our Con Ed committee and. It was interesting. My reflection in that role was in Arizona. We had a specific requirement that the course had to be evidence based. And so when you're actually looking at a course, how do you determine whether something is evidence based? It's really challenging. And so I spoke with the other, members in the committee. These are the people that when you apply for a course that are looking at the course, and they were all using totally different definitions of what evidence based was. Some people just looked at the references. Some people use their own personal knowledge and experience, but there's a lot of pressure. Is what I experienced personally. So you would get to that point like, all right, I don't think I should approve this course. But it takes a lot of guts to just say, Nope, I'm going to reject them because they paid money. There's a kind of an expectation that you're going to approve them. You just give it a cursory overview. And so that prompted us to look at, courses throughout the U S and see what's the result of this, our courses really going through this process and, is it making a difference that we, so what we did was we compared courses that went through CEU locker, which is like a virtual. Course application process, 12 states use, it's really the only way that we could think of to do it. There are courses like California, New York, which are, obviously huge states. That have their own application process. And so it's opaque. So we decided to use CEU Locker, and then we looked at those courses that are approved on CEU Locker, which were publicly accessible. We constantly looked at it for a year and then compared what the description of that course was. So if it was about I don't know, a therapeutic exercise course for low back pain, we'd compare that to what does the clinical practice guidelines say about that intervention. And is it recommended? And then if it wasn't in the clinical practice guideline, we'd go to the next level and say, can we find a single systematic review anywhere that supported it? And yeah, I would say the results weren't good. It wasn't necessarily specific, but just across the board. It was about if I remember, it was about half the time that something was supported in either a clinical practice guideline or a systematic review, which I thought was pretty bad if you consider the low bar that they had to clear. So any systematic review out there at all. Now, should that number have been a hundred percent? I don't think so. Probably not. I think you can make a case that, okay, you have a new idea. It's supported. You can make a scientific you can provide some sort of theoretical support for what you're teaching, but that probably shouldn't be half of our courses that are doing that. And there are a lot of things that have been taught for decades that don't have that support. So it was surprising. And then maybe an ancillary finding on our, the thing we were just talking about, Mark, is that communication courses. made up a very small minority of PT courses, despite the fact that of all of these subsets, of course, they were the most supported by evidence.

Mark Kargela:
29:40

Yeah, that tends to be what we see out there on the communication front and trying to get folks to, especially when there's going to be like, case centers where therapists have to act out things there. They won't. They much rather. From what, for what I've seen, do the more technical, break up and practice technique, which has its place. Of course, there's nothing wrong with that. It's just, I don't know how much longer we need to beat the technique horse. And I think, you can be good at a pretty specific, a subset of techniques doesn't need to be a myriad of things. I think for me, and I don't know how it's been for you. I think the toolbox has shrunk as far as the volume of tools needed versus just really honing. to apply that to, as you mentioned, to the unique person in front of you that day with how they're presenting at that moment. Is that what you've found with your practice?

Seth Petersen:
30:25

Yeah. Yeah. If, fellowship, you get taught a million ways to do the same thing. And ultimately you just end up picking the thing that's the most comfortable for the patient that you've gotten the best at. And that ends up, you could have three techniques and pretty much that covers 99 percent of all patients. Yeah, it's nice to maybe think of, have that background, but yeah, I'm with you.

Mark Kargela:
30:46

So let's get into a bit about the future of our profession. I think, speaking of physical therapy the roles we play we used to be very much under the kind of the. I guess supervision or and monitoring of, it was very much dependent upon a physician's referral that, we weren't going to see anybody unless the physician referred them. Direct access. Obviously, Arizona being one of the more, forthcoming states to really push and get that pass through to have direct access that puts us in a role where we're almost serving is like a primary care musculoskeletal practitioner. And then we had some great information coming out of the Department of Defense where we have physical therapists in the military really serving as primary care musculoskeletal practitioners. I'm wondering where you sit on our view on your view of where we should be pursuing our place in health care as a primary care musculoskeletal practitioner, what kind of barriers do you see existing in that pursuit?

Seth Petersen:
31:39

Yeah. That's a super interesting discussion. You could probably talk about for for a long time, the definitely are. And if you look at the history, I think that's, I had a historical essay that was published at PTJ, which I never thought I would say, but it started from actually looking at what's the history Of clinical reasoning in the profession. When do we start talking about that? And as time went on, I started to look more and more as well. Clinical reasoning really didn't as a term didn't come into being into like the late 80s. So what they mostly focused on before then in the journals was things like diagnosis was a big one. And so if you go back to our founding as a profession explicitly prohibited diagnosis. And then fast forward to, by the late 70s and the 80s then the military started to Allow their physical therapist to do what they called red flag screening for low back pain. They trialed, that program around that time, and then it was really successful. And so the military has been at the forefront of this and using physical therapists. And from, the firsthand accounts of physical therapists, I know that we're in the military, like Dan Roan and have these descriptions of they were. The primary care providers for musculoskeletal conditions and they were ordering imaging and physicians for the most part, even in some cases were demoted in their role because they overordered imaging and things like that and slowed things down. As time's gone on, you can see that we've assume that role in the military. I think it would be amazing. And I'm a huge proponent that physical therapists in terms of what we're allowed to do. Legally be expand. So we're allowed to order imaging. I think it's crazy that we can't all order x rays and MRIs for our patients. And they have to go through a physician that half the time doesn't know what's going on or what the musculoskeletal condition is, or what the, research says about that specific imaging modality where the physical therapist probably knows more. That seems crazy in the private sector, but I will say that. Physical therapists in the military do have additional training. So I think there probably does need to be some expansion or program or something that we can do just to tack on that maybe allows us to do that. And strengthens the knowledge, because I think if you're like me, the majority of physical therapists out there, probably their level of knowledge about most of these things is pretty low about maybe if you're talking about, a systemic approach, talk to them about the endocrine system. Things like that, what would you do for ordering, lab tests, or, when should you order a specific imaging, approach after, say, you suspect a stress fracture with, at what time point and how reliable is it? And so there's a lot of background information. I think needs to know, but I think we can get there pretty easily. And I'm a huge proponent of a physical therapist. Improving their knowledge in that respect. Like we talked about earlier, I think this is one of those things, maybe like communication that PTs need to improve on.

Mark Kargela:
34:30

Yeah, the approach to primary care definitely think there's a lot of opportunity. We have obviously healthcare system. barriers as well when it becomes very much a turf war that patients aren't best served, like you said, we got, physical therapists who have to put patients through this, another copay to a physician, another delay of three weeks and their diagnostics. And, we could speak to a lot of the inefficiencies and, cost ineffectiveness of some of the systemic stuff, but we have some work to do and thankfully we have the APTA and other folks working on these pursuits. I know Arizona has been doing a good job of kind of pushing that forward at the forefront and we have other states. I think Wisconsin's doing more formal approval of imaging. I think there's others that are doing that. So some exciting things on the horizon and hopefully things that will better serve people in pain who are Needing more efficient, cost effective health care in their world. Seth, I want to respect your time. I really appreciate chatting with you today. I'm wondering if you could talk to folks about where they can get in contact with you or look into some of the training that you provide.

Seth Petersen:
35:32

Yeah. So Twitter, X handle at Dr. Seth PT, the continuing education company that we run is called the movement brainery, if you're listening to this. We have a intentional exercise course coming to Phoenix in May. That's always a good one talking about more of the clinical reasoning that underpins our decisions as far as that goes. And we have a primary care PT course. You can just take online to brush up on some of the stuff that we talked about. So yeah, that, that would be the best way if you want to email me. Probably the fastest is just hello at the movement, brainery. com.

Mark Kargela:
36:05

Yeah, I would definitely recommend checking that out. It's some quality education. I've have seen Seth's work and have been always impressed with quality of the product and teaching some things that physical therapists need to get in there clinical practice. If you want to take your practice to that more expert level, definitely would recommend those courses. Seth want to thank you so much for your time today. Thank you again for all the work you're doing and staying as busy as you are publishing and moving the our scientific body of knowledge forward in the profession. So thanks for that.

Seth Petersen:
36:34

I appreciate it, Mark. Thanks for what you do too.

Mark Kargela:
36:37

All right, everybody, if you can subscribe wherever you're listening to this podcast, that would help us spread the word if you're watching on YouTube, if you can subscribe there, maybe even give it a that'll help us spread the word to help other clinicians who are struggling to develop themselves as more of that expert for those in pain that we see day to day. I'll leave it at that this week. We'll talk to you all next week.

Announcer:
36:56

This has been another episode of the Modern Pain Podcast with Dr. Mark Cargilla. 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.