Top 5 Fridays! Top 5 Mistakes New Clinicians Make with MDT

I learned the "ugly guy coming in to kiss you" from Carl's new mentor, Dana Greene, PT, DipMDT

Today's guest post is from a former student of mine, Dr. Carl Calabrese, DPT. Carl interned with me well over 1 year ago and spent the first year out of DPT school working with one of my favorite MDT Diplomats, Dana Greene.

Top 5 Mistakes New Clinicians Make with MDT

I’m now 1 year out after gaining my DPT. I have been practicing since about day 1 from graduation and
I feel in that short year I have come a long way. I am fortunate that the college I went to was heavily
dosed in MDT so I had a solid background before any of my internships. I was also blessed with being
around some great MDT certs. and diplomats during my internships and now work for an MDT faculty
member. I learn something new every day and that’s like gold. I think even early on I was a victim of
these 5 simple yet sometimes overlooked things. We all want to fix the complex patient that no one
else was able to, but I can guarantee you won’t do so if you are committing these costly mistakes.

1.) Posture-

I know when I was in school it was drilled into our heads that posture is the very first thing you must correct and I undoubtedly allowed that to go in one ear and out another. (edit - really Carl, even with me as your CI?) I wanted to get to the good stuff the meat and the potatoes if you will. My thinking was yeah posture got it, now how do I fix these people? I have previously been at fault of this and it wasn’t until a very specific patient did I realize how important posture really is. How many times do you have a patient centralize or abolish with repeated end range movements and think, "I’ve nailed this?" They come back the next visit and report no change even with them reporting they are doing their HEP. You retest and sure enough these people present exactly the same. It must be the magic of your presence or the fact that you didn’t notice that they were sitting in your waiting room hunched over like Quasimodo. My point is do not expect good results unless you are ready to consistently reinforce posture. I start session by critiquing my patients’ posture. You wouldn’t tee up a golf ball sideways so why let them do cervical retractions with poor posture?

2.) HEP frequency

As a young professional, it is often difficult to criticize patients on their repetitions of their HEP. Countless times I can recall having patients coming back on the second visit stating that they don’t have the time to perform the exercises as frequently as prescribed. The next question after, "Well how many times a day were you able to do it," is most definitely, "How do you feel as compared to the first time I saw you?" 

Don’t be surprised when they say no different. This is your time to re-educate on the importance of frequency and repetition and not say “well try and do more.” It’s your job as a professional to brainstorm how the patient can get in the frequency of the exercise. It can be as easy as instructing them to double up before and after work, or as complicated as dissecting their environment to find a time and/or place for them to do their exercises. Once the exercise is reconfirmed to be the correct exercise I often tell my patients that I can’t help them if they don’t do these things on their own.

“Readiness to change precludes education and intervention”-Lorimer Mosely

3.) Not being comfortable saying I don’t know

Right out of school, often clinicians find the need to have the answer to everything. It took me a little while to realize that even the best clinicians do not have all the answers. I have found if I am not 100% confident in where I am heading after the first visit or if I make a drastic change, I tell the patient, "This is my hypothesis and you are going to test it for me."

Make sure you have sound rationale for your decision and explain that to the patient. Give them the warnings signs and instructions to stop if you are wrong but they respect you more when you are honest. I tell every patient, "I have no problem being wrong but we won’t know if you don’t try." They now are helping you figure out the problem while taking control of their symptoms and in the long run they will all respect you more.

4.) Abandoning movement too soon

Don’t be afraid to have them do 50-60 repetitions of a certain exercise before you try another. Consistently jumping from one load or direction will both confuse the patient and yourself. A novice clinician skips steps like a master clinician, but has no rationale to do so. Often, I would find in my cervical patients that the patients would plateau with retractions so I immediately went to retractions with extensions. Sometimes it worked out flawlessly and others it was a disaster. My thought was I just exposed a lateral component….SB, SB, SB…..NE what? That intermediate step of self OP is important at times! If you are not in end range retraction you will not be in end range extension! As we all know end range is where the magic happens. Now we are back to changing loads and directions until both you and the patient are frustrated.

5.) Utilizing the history and objective findings to educate

Take the extra 5 minutes to be thorough and explain why avoiding the provocative positions, repetition of the exercise, and maintaining correct posture are important. Go back relate it to THEIR complaints so they are now accountable for THEIR actions. Also it works well with that difficult patient that does not exhibit that aha moment with movement that I’m sure everyone can relate to. 

A perfect example would be a case from last week; I evaluated a lady and she was seen by a shoulder specialist because she had “shoulder pain.” Retractions abolished her pain completely after 30-40 reps. I gave her that as homework and when I asked her do you have any questions? Her reply was simply “Ok, so what are we going to do about my shoulder?” After contemplating running for the hills at that point I said this is your shoulder exercise and I’ll show you why. I initially took her shoulder gonio measurements (yes goniometry still exists) her shoulder ROM improved on average 30 degrees in all directions as well as better resisted shoulder testing. It wasn’t until then she got the "aha moment" and was then on board.

Great post Carl! We take for granted as more experienced clinicians the steps we can skip and what our experience has taught us. As long as you learn and adapt from your mistakes, anyone can be the excellent clinician they strive to be.

Keeping it Eclectic...