Working in Musculoskeletal outpatients was always the way I envisaged my career ever since embarking on my BSc in Physiotherapy.
After graduating from University the first thing I did was trawl the internet searching from a MSK Physio job that would employ a newly qualified physio without any expirence other than a few 6 week placements making use of a clinical educators Physiotools login credentials!
I felt like I knew everything. I wasn’t super confident or arogant but I knew how to use theraband, I knew 3 sets of 10 and I knew that rolling your knees from side to side would eliminiate chronic back pain…………..
So how did I go from being so sure that I knew how to eradicate someone’s musculoskeletal aches and pains to being a nervous wreck dreading going to work. I would consistently check my colleagues diaries to ensure they had patients at the same time as me so that I wouldn’t be overheard, in the event that I would be the only clinician seeing patients I would take my patients in the room next door and shut the door, I would wish and hope that my patients would not turn up and my heart would sink at the moment the late arrival checked in at the reception desk.
I’ve never been the most confident person in the world but within a matter of weeks of qualifying and working in my first MSK post I started to find myself suffering from anxiety like I’d never felt before. Surely this wasn’t normal. All of my colleagues knew what they were doing. They knew how to diagnose everything. They knew how to treat everyone. I knew nothing. They knew it all. How could I possibly ever be like them – I wasn’t cut out of this.
Friday nights were my escape. Over 48 hours not thinking about my job. Except that never happened. I’d spend the entire weekend thinking about the referrals I’d already skimmed for the following week. TMJ Pain, Chronic cerviogenic headaches, Sciatica for 3 years, neck pain following a car accident. Youtube became my go to – I would watch videos of manual therapy techniques that I would apply the following week. Asking someone for help represented weakness. Why should I be asking someone how to do my job! I watched countless hours of youtube videos on how to perform certain treatments. I had no idea why they would help but atleast that would appease the patient and make them feel like I knew what I was doing!
But that didn’t prepare me for the questions.
“Do I need a scan?” – Yes, no…maybe I don’t know – loads of people have scans they must help!?
“So do I just have to live with this?” Probably yeah your old – I can’t fix you so yes you do
“It’s wear and tear – it will never get better will it, why would exercise fix wear and tear?” Nope probably won’t but my job is to press print on this printer and get you out of here as quick and painlessly as I can
“My never is trapped and it needs freeing can you massage it away?” I think that’s what I’m here for – sure you’ve had raging radicular leg pain for 3 years but what it’s been missing is a 10 minute massage off an inexperienced 20 something year old
I had no idea how to answer my patients questions. What worried me more though was what on earth do my colleagues think of the explanations I am giving. Afterall the only thing separating me from my patients was a pair of curtains! Everyone know’s that curtains block all sound…right? When Wendy is telling me all about how her low back pain is stopping her from being intimate with her husband and she’s worried she will end up in a wheelchair nobody else hear that because the curtains were there…
It’s only now looking back I realise I was suffering from imposter syndrome. What I still don’t know is why? Was it just me? Does everyone feel like this?
As I have devloped in my career the phrase I have found coming out of my mouth more than ever…”I don’t know the answer to that”. 21 year old me would NEVER say that. 21 year old me would explain the acromion was hooked shaped. 21 year old me would explain that the discs are like jam donuts. 21 year old me would rattle off the biggest load of shite that sounded vaguely plausible in order to field the impossible questions I was being faced with.
My favourite game became will the patient DNA my appointment before I give up on them. I feared others reading my notes. I feared peer reviewing my patients with senior clinicans in case my knowledge gaps were exposed for everyone to see. I hated being presented with possible solutions from my colleagues to apply to my patients when really in my head I was screaming “Take this patient off me I don’t have a clue what I’m doing..I know it. The patient knows it. Even you know it! HELP ME!”
I followed the same structure to every appointment – Subjective – Objective – Heres your diagnosis – Let me go and print a sheet off Physiotools and let me book you in for 3 weeks.
The patient would come back 3 weeks later – “How is it..no different…did you do your exercises? Yes.
Now would be the point to press where it hurt because I didn’t have a bloody clue what else to do!!
Patient comes back..How was it..better for 2 days but now it’s back again…Ok I’ll do it again.
Patient comes back..How is it…the same as before. Ok here’s some different exercises. See you in 3 more weeks in the mean time I will ask someone for some advice (reluctantly)
“So what have you tried up to now” – Physiotools. Pushed on it, put some ultrasound on it. Massaged it. Told them to try pilates. I’ve done everything!
“Have a look at X and if that hurts get them to do exercise Y” Ok will do….
When the patient came back and I assessed the SIJ or palpated for hypomobility at L4 I’d still be clueless about what to do next and that would be the start of let’s see who’s going to crack first – you not turning up anymore or me telling you to go and see your GP for pain relief.
So why did it change? Well losing my Physiotools login helped! I can’t stress enough how much I feel that Physiotools holds patients back! Sure for an acute problem providing some simple exercises whilst natural history takes it’s course can be helpful and a print out may be relevant but I maintain that the vast bulk of MSK outpatient caseloads is occupied by persistent musculoskeletal pain. Peristent pain which isn’t likely to get better through a sheet of paper or a quick massage every 3 weeks – peristent pain which I could help with by being me! A thinking feeling person – the exact same as the person sat in front of me!
I started to listen. I stopped talking. I started to show empathy. I started to be a person who would listen and seek to understand what was impacting the person sat infront of me. What mattered to them! Meaningful patient centred goals. Understand where they had been, what made them tick, what concerns they had that I could help address.
I stopped thinking I could diagnose everything. I realised my book of special tests was no longer as special as the title made it seem to be. It was a special waste of £20 that I would never see again because it didn’t help me help people!
I started to realise I was in the business of treating people and not body parts. I sought to understand communication – I started to listen closely to what my colleagues would say and what was succesfull and what wasn’t.
I began to realise that no physio I had ever worked with and will ever work with will help absolutely every patient in their caseload. Infact I started to realise that shit sticks. The words that some would pass on to their patients would stick with them and maybe would get them off their caseload but in the long run encourage chronicity. Since the first time I heard the word iatrogenic (if you don’t know what this means look it up!) I recognised the role we play in a patients journey.
Maybe not everyone feels the way I have. Maybe not everyone can be comofortable with diagnostic uncertainty. But being a good Physiotherapist is not being a good ‘diagnostician’ or a good manual therapist. Being a good physiotherapist is about so much more.
If you ever find yourself in the same position I have been…fearing others overhearing what you’re saying…dreading your next consultation….worrying that you’re not cut out for this…believe me you’re not the only one. Working with people is the most challenging thing you could possibly do and 3 years of undergradute study and even 20+ years of clinical experience won’t prepare you for your next appointment because ever person you meet is totally different. Every person you meet has their own unique set of goals, beliefs, perceptions, values, barriers, enablers that you should try to seek to understand.
Discussing patients over a set of notes will not allow you to understand those things. Closing your mouth – open your ears and being an empathatic person will help you.
Be brave, find a mentor – find someone you aspire to learn from – ask for help – don’t suffer in silence and fear every day of clincial practice. Ask questions – seek to understand – read!
When I abandoned physiotools and opened my ears and shut my mouth the thing I started to hear at the end of more appointments than ever before was ” I feel better already!” – something I never ever heard after trying the manual therapy techniques I discovered from trawling youtube.
People are complicated recognise that. I challenge you next week to try and help someone without following the Physiotools model of care.
Good luck – stay humble, be kind and recognise you’re not the only one who feels like this.
Until next time
Matt – The Honest Physio