Pain That Wakes Us Up At Night

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Dr. David

Hey, welcome to the Stay Healthy El Paso Podcast. I'm your host, Dr. David Middaugh, physical therapist, and I've got a special episode for you today. I've got with me here Lilly. Lilly is my physical therapy student. She's in her last week of her final clinical rotation. She's about to become Dr. Lily soon here. As long as everything goes fine with this podcast and we don't automatically fail her… I'm just kidding.

But no, she's doing fantastic. I was so happy that she agreed to do this little interview, to help out any students out there in physical therapy school, that are looking to do a clinical internship at a manual therapy clinic like we are. Or a private pay clinic, otherwise known as a cash-based clinic. Because we're both, we're a private pay manual therapy clinic.

I just wanted to get her thoughts, and her honest answers, on what her experience was like. So that if you're thinking of doing something like this, then you can have it straight from Lilly here. So, without further ado, hi, welcome, Lily. So, let's get into it. What were you expecting? Prior to coming to this clinical rotation, you knew about us a little bit already, you explained about how you heard through some friends, about us. What were your thoughts prior to coming?

Lilly

Yeah, like you said, I had heard about you, and my big sister in the PT program actually did her internship here. She said great things about it. She said she learned so much. And also, when I was at my second rotation, my CI actually recommended you to one of our patients who needed some orthopedic work. So, I just heard all around great things from you. And I didn't know what to expect, it being private pay, and just manual therapy. I didn't know how you could just do manual therapy for the whole hour or whatever. But I was expecting just something new and something really good. I didn't know what to expect actually.

Dr. David

Cool. I always just think some people get nervous or concerned, because it's not your typical setting with insurance and your gym settings as well, sometimes people come into the clinic here - because you actually visited us before starting your clinical rotation - and most people that come in for the first time, they're like, where's the treadmill? Where are all the weights?

Lilly

It’s very different here. But I have a massage background. So, it being small and intimate. It's very familiar to me with being a massage therapist. So, I wasn't turned off at all. I actually was welcomed by it. And it was cool. I knew it was going to be different.

Dr. David

And we only take students in their last clinical rotation. What did you feel? How did you feel that that went for you? Did you feel like that was a good thing? Or like it maybe should have been different? What are your thoughts on having to come here on your last clinical rotation?

Lilly

Well, I'm definitely glad I had the experience from prior rotations, before coming here because I mean, this is a hard rotation. So just even being able to talk to people about having to pay out of pocket, and not using their insurance. Having that experience from being able to talk to people, and have rapport and all that from other rotations, helped me out.

And then of course, like some of the orthopedic background that I had, and being comfortable with bodies, that helped me out too. But I honestly wish I had this rotation first, just so I could continue to use all the skills that I learned here at other clinics, so that I could better help them. I felt that, learning what I learned here now, and then looking back on the experiences I had with other patients, I could have done so much more with them.

But I mean, obviously I feel like I needed that experience first to get here. And now just having this experience I'll just be better whenever I start as a clinician, so I feel it's appropriate.

Dr. David

Yeah, I can see that for sure. Here in the clinic we weighed, do we want to take students, earlier in their clinical rotation, part of their education or later. And the main reason that we decided to take a student at the end was because, at the beginning, you're probably aware of how to go to metric measurements, do manual muscle test, do other special tests, but you just don't have that many reps doing it.

Because we are teaching students here pretty advanced stuff, we'd rather spend our time on the advanced stuff, on the cool manual therapy stuff, instead of like, here's how you get force on a muscle test. We didn't want to spend a bunch of time doing that. We figured it's probably best if they do that in another clinic on their first or second rotation.

But I went through that myself, actually. My first clinical rotation was at a pretty strong manual therapy clinic, and so I know what you went through where you're like, I wish I could have applied this but what I ran into was my second clinical rotation, and the one after that was not manual therapy based. And when I wanted to implement manual therapy techniques that I was comfortable doing my CI that weren't trained in manual therapy weren't comfortable allowing me to do it. They couldn't monitor the effectiveness of it, they didn't feel comfortable putting their license on the line, in case something bad happened with the patient, and they weren't familiar with it.

So, they weren't sure of what the side effects could be, if any. It was a little frustrating on my end, but I'm glad that you made it this far. So how do you think this whole experience, going through clinical rotation here in a in a manual therapy clinic? How was this beneficial for you and your practice as a future PT?

Lilly

All this was awesome. I'm so glad that I had this experience because, I mean, you went through fellowship training and you had five extra years of advanced training after PT school, and I got your Cliff Notes. So, I got that specialized training in a shorter amount of time. And, yeah, I'm not going to be as advanced as a fellow, but I have that training. And that some of those techniques that they use, I feel comfortable with.

I probably won't ever get to that level that you are until I go through the program, but at least I feel confident and I know that my skills are way, way more advanced than I ever could have imagined, especially with manual therapy. I just know that I'll be a better clinician overall. I feel confident just talking to people that I run into in everyday life that aren't patients and they have problems and they say yeah, you know, I can't play soccer because I have a meniscus tear, and I don't want to have a surgery. And I say, come in, have some PT. Because this is what we specialize in, and I'm going to help you avoid surgery and you don't have to have the surgery. Let me help you.

If I hadn’t had been event here, I wouldn't have been as confident to say that. I would have done the usual PT stuff, but now it's a lot more specialized and customized. So, I just feel like, I know I'm better off having this experience than if I had never had it.

Dr. David

Nice, awesome. I'm just going to inject what I went through as a student going through my clinical rotations, and once I figured out that I wasn't inpatient material. I didn't know honestly, when I started my clinical education, I went into it with an open mind saying, maybe like inpatient, maybe I'll like neuro, maybe I'll like outpatient. I didn't really know and then once I discovered manual therapy, outpatient orthopedics, I fell in love with it.

I had an inpatient rotation and absolutely did not like it. I did not like dealing with bodily fluids of any sort. This wasn't my thing. Wound care? Forget it! So, I got deep into the outpatient part of things. But it's just so difficult to get specialist training throughout, and then I felt like all my outpatient clinical rotations were very similar and I didn't really learn much. I felt like I learned more about coding for CPT codes. You know, how to manage three, four plus patients all at once and allegation, tech and assistance.

Although that's a valuable skill, it's not like directly clinical in my opinion, it's more so, I mean, it is clinical in the sense, but it is more managerial, like managing people, which is important for the health of the patients that you're responsible for. But as far as doing a technique or learning a new exercise or patient education, explaining something to a patient differently. That's not something that I quite got when I did three outpatient orthopedic rotations which are all very similar.

Lilly

Yeah, no, this is a whole new world. It's elite. It's specialized, for sure. The manual therapy, and I'm just grateful that I got the opportunity to catch a glimpse of it, and see if I want to further my education become a fellow on that now, who knows? But you're right. I forgot how fresh and green I was during the first rotations and we were talking about CIs having to say, this is where the going is, and just getting reps in, in doing range of motion and all that basic stuff. I'm glad I had that elsewhere because we were able to focus on the good stuff. And we were able to get into the meat of orthopedics and manual therapy. So, yeah, it's been awesome. Being a part of that.

Dr. David

Good. So, what do you think was the hardest thing for you to learn here?

Lilly

Definitely doing manual therapy on Dr. David Middaugh. I'm pretty small and he's pretty big. So, the mismatch of our bodies, it worked out, for sure. Every time I really had to adjust to his body type. But I think that also helped me, because patients that we get in everyday life, they're going to be bigger than you, or they are smaller than you or whatever. So, you have to be able to adjust and modify. I definitely got really good at modifying. Working with you specifically.

But yeah, I think also just building up my endurance to do manual therapy for a whole hour, because we are used to doing it on one body part, and then that's it, you do 30 seconds to a minute. But now you have to be efficient and be able to run through different parts of the body and building my endurance to be able to do an hour, I think I was pretty comfortable with it.

Also saying that I have the massage background but being able to work on a bigger body type and do manual therapy for an hour. That was that was pretty hard. Also, discovery visits here were hard. Being able to talk to a patient and explain to them and educate them.

The way that we educate here, I think it's really cool. We pull out pictures from the netbook and show them exactly what's going on in their body, show them how this happened, and then being able to talk to them in the way that they're going to listen to respond. I learned that from Dr. David here, and that's something that I didn't think I'd ever learned at a PT clinic.

Dr. David

Yeah, you know, for context, a discovery visit, is basically like the initial consultation or just meeting the patient for the first time and letting them know we can help them or not so that they can decide if they're going to work with us, you know, hire us and begin treatment with us.

And it's a critical visit just because we're building a relationship, we’re diagnosing their problem, doing our physical therapy, diagnosis, and then setting some expectations about how we can help them out, and what to do, and if you think of like a sales talk, that's kind of what it is. It's not in the sense of a car salesman.

I think whenever I say the word sales, people automatically think of a cheesy car salesman. But I mean, you could talk about it. It's literally just sharing your knowledge with somebody.

Lilly

Yeah, I think that was like, the biggest thing. We have such a large knowledge base and people don't know that stuff. For us, it's common knowledge, especially other PT students and other PT programs. But when you start telling them like, hey, yeah, I worked with cadavers, and I looked at this tissue in real life, like I see in your body, and I was able to see it and you share that with them. They're like, wow, you know that you went through that.

And that's part of you selling even though you're not trying to be cheesy, like you said, but it is kind of dabbling in sales, but it's just being genuine and sharing what you know, which is, we know a lot about the body but I think the difference here is you're trying to get them to buy in and actually take money out of their pocket because they're not using insurance here. And that I think, was kind of hard for me at first but with the right coaching and getting reps, I was pretty confident after about like six weeks or so.

Dr. David

Yeah about halfway through. She did a 12-week clinical here just to give you the context, and the first half was pretty much like familiarizing yourself with, getting grilled all the time.

Lilly

I was in the hot seat a lot.

Dr. David

Quizzed, checking her hands-on skills. From a clinician perspective, from a CI perspective, like her instructor, what I was doing during those first six weeks was gauging how fast she can go, how much information can she take, how good is she applying what I'm teaching her, so that they can determine how fast can I let her loose on clients independently.

From the get-go, she was touching patients and doing special tests. I was getting her involved in feeling certain things, doing some of the treatments as well. But as far as me stepping out of the room, because we do treatments in rooms, we're essentially in one room. We're not an open clinic so I can keep an eye on everybody as we're doing stuff, so it's a little tricky from a clinician, from a CIO perspective, because I don't want to be a fly on the wall the whole time. It's kind of awkward when it's just a small room and a table and the therapist, so I needed to feel confident that Lily could step in handle business.

I could step out and she's got it from beginning to end, and she aced that. She did really good. But it took a lot of coaching and training and her part on her part, just putting in the effort and making sure that that she was confident, and we had a lot of discussions about confidence along the way too. That was a big concern of mine.

You definitely have to come in with a certain level of confidence and be ready to stand on your knowledge base and your skill level.

Lilly

And then go home and practice. For sure. Because I did that a lot.

Dr. David

Tell us more about that. What was it like for you? I mean, how much time? How do that go?

Lilly

I remember when of the things you gave me a packet on how to prepare before I even got here. And one of the things that I read was practice your mental manual therapy skills 5 to 10 minutes every day. I really took that to heart. I was like, No, I really, really need to practice this. So, I'm looking at a massage table at home, a treatment table, and I remember, the first week I would go home, and I would write down concepts, like mechanics of the neck, or the sacrum, just to get those concepts down. That way whenever I come in, and I have to talk through with Dr. David and tell him like, no, this is where the restriction is. I know because this is how it moves, and this is how it works.

I'd have to visualize that at home. That way I can come in here and be able to say it without looking like I don't know what I'm saying. I practice the knowledge of it, and then also practice on my husband. I would work with him and he loved he loved it. He loved me being here because every day I would go home, and he thought it was a massage, but I'd be looking at joint integrity and assessing stuff.

So yeah, at least every day. And then whenever on the weekends, I'd be with my family and work on different body types. I know we talked about that too, how that was important. So, my niece and nephew got some hands-on work too. And then everyone wanted me to work on them. So, everyone liked me being here.

Dr. David

Yeah, what she's referencing to is just how you have to adapt your body size, your hand, your body shape as well, to the person that you're working with. Which is obviously going to probably be a different size and shaping you. And like she mentioned a while back, about how I'm a big guy. I'm 6’2, over 200 pounds and Lilly is 5’2 or 5’3?

Lilly

Yeah, 5’3

Dr. David

She is a lot smaller than me and getting her to do a lumbar technique or a thoracic technique is pretty challenging to kind of wrap your arms around me. It's a big deal for her to find adaptations trying it on different people because she felt like she was failing all the time around me. Trying to do like a thoracic manipulation or something but she could probably go knock it out easy on somebody her size.

Lilly

Or my niece and nephew, they loved it. They're like pop my back.

Dr. David

How old are they?

Lilly

One is 15 and one is 13.

Dr. David

So, they are on their way to being an adult. They're little mini adults.

Lilly

But I did have that click. I think I even mentioned to you, how I had been practicing and practicing, and then one day I was practicing on my husband and it was like my hands were just doing it automatically. It was like an epiphany because I finally had that psychomotor score. I was like, I got it finally, I think it was on the neck. Because that was one of the parts that I felt comfortable early on. And I was like, I just know how to do it now. And I felt so happy and it wasn't right away. It wasn't even like after a week, it was like maybe after three weeks. It just clicked where it's like, I finally got that manual skill down.

Dr. David

That's definitely how it works out where it needs to come on with multiple reps, you have to just keep going. That's why I tell people practice at home. Even while you're here, practice at home before, and then even when you're here. Practice at home when you're not here. Just that you're heavily involved in it. You're thinking about it. I mean, you should literally be dreaming about doing manual therapy.

Lilly

Yeah, for sure.

Dr. David

So, we talked about the hardest thing. What do you think was easiest thing about being here?

Lilly

The easiest thing for me personally, since I have a massage background was the soft tissue mobilizations. I always felt pretty comfortable whenever a patient came in. And they're like, Oh, it's over here in this area. And after I had done the usual mobilizations, or even the soft tissue work, that you had showed me, I was able to implement strategies that I do, and I was able to treat them and help them in a way that I felt was pretty effective.

Soft tissue work, for me has always been pretty easy. And then just talking to people, that's a big thing here. As PTs we have to establish a relationship, but in order for them to want to come in, something that you taught me was, make it fun for them. Engage them and start talking about stuff so that they get their mind off of you literally grabbing their bone and moving it so you're able to work freely.

So that was pretty easy for me just having that connection with patients and I really enjoy that. I love talking to my patients and talking about their dogs or their work, or whatever is going on. That was nice. It wasn't too hard.

Dr. David

I love that part about this, the way that we do things. Because we see clients completely one on one, for an hour most of the time. And you really do develop almost like a family type relationship with clients. I mean, you were just telling me before this, how you had one client who had a death in the family and then, as we record this, we're in the middle of the Coronavirus lockdown so everybody's gone through that as well.

So, it's been stressful for patients coming in here. And they come to you, I haven't even talked to some of these patients so barely talked to them. The ones that you're working with just at the introduction, and then when they walk in and for the subsequent visits, they barely Say hi to me, and they are ready to go work with you.

Lilly

Yeah, they're my patients for sure.

Dr. David

I think that's pretty cool. You develop that relationship.

Lilly

We've been through a lot together, and I think I was there emotional support. Whenever this happened, like the Coronavirus and people shutting down, I think they were kind of emotional support for me too. Some type of normality. So, it worked both ways.

Dr. David

What would you say was your favorite part of this clinical rotation?

Lilly

My favorite part, aside from learning all these advanced techniques was for sure getting treatment. Dr. David would have to show me the techniques and I actually had a sacral shift, and I didn't know. I had low back pain, but I'm a mother of a three-year-old, so I always thought like, Oh, it's just because I had a kid and it comes and goes, I just have a little back pain for the rest of my life.

Then he's showing me this how you assess, with leg length discrepancy, you look here and he's like, you got a sacral shift. And I was like, wow, fix it. He definitely put his hands on me a few times. I even had a knee problem, and you helped me out with that, and I think even a neck problem. So that was cool. It was like getting some treatment out of it.

Dr. David

Yeah, for me, it's needed because well, obviously, so that you feel good while you're working with patients. Last thing I want, is for you to be in pain doing that. But you also learn a lot from getting the treatment to see, and to be the recipient today to get a therapy. Somebody who knows what they're doing, putting their hands on you. Compared to somebody who's learning how to do this stuff, to see what it should feel like to feel the joint move to because you have a different mind going into this.

Unlike somebody who's not in the medical field or isn't familiar with the type of mental therapy stuff that we do. They're not really paying attention to what to look for, but you've been living and breathing this stuff for years now. Being inserted in PT school. So, you're very aware of what joint we're on, how we're moving it, what muscles influence, and all the surrounding topics regarding rehabilitating it.

I see it as like, even if you didn't have a problem going on, and you do some of these techniques to use so that you can feel it. That's pretty much how we progress through things. Whenever I'd show you a manual therapy technique, I'd say I do it to you, and then you do it to me, or somebody else, so that you can know what it's supposed to feel like.

Lilly

And it helped me out. Because since I had the experience of feeling it. First off knowing what the pain was like, and then knowing what the treatment was like, and feeling better afterwards, I was able to explain it to my patients better. That way they know what to expect. And I could even just have a story to relate to and say, Hey, I started working out here.

I started doing some deadlifts, and I was always scared of using the bar, it's so heavy and I've never been a gym rat personally. I'm more of like, let's go around and dance or do an activity, more cardio stuff. And here I had to learn the importance of strengthening. And I mean, obviously, we know that in PT, but it was at a different level, it was more, I think you have a CrossFit background. It was like Olympic style lifts, and I started doing deadlifts here and my pelvic shift, it shifted again, even though he had fixed it.

We went through treatment, he helped me out with it, and then I had a story to tell my patients like, hey, look, this is what happened to me, and we could relate on a different level. It was cool having that experience and it was a tool for me to use with my patients.

Dr. David

I hadn't mentioned this to you, but yesterday, when we ended the day, we were covering an ankle technique. And we covered a few techniques. One of those was an ankle technique, and I hadn't reviewed that technique for myself, for probably a year or more. We went to the technique and my ankle felt looser. You only did it on my right and as the evening progressed, and even this morning, I didn't realize how stiff my ankles were, until I've had my ankle loosened on the right. Because of my left ankle feels stiff now and I didn't realize how stiff it was. If I move my dorsi flex, I can feel my right ankle move up better here and walking down the hall here in our building.

I'm like, man, my left ankle feels way stiffer than my right! So even for me it reminds me of how life is, like how we forget that we have all these little issues and we live like that. I've been running. Since all the Coronavirus stuff, I've been running more. I think since I've been running, I probably missed 5 or 10 degrees of dorsiflexion. I'm a little angry now. So, we have to get you to fix me. Since it's your last week here.

Lilly

Yeah, it's important to maintain your body. Right? I think that's the reminder. We all have to take care of ourselves.

Dr. David

Yep. All right, we're almost done here. I’m going to ask you one more question for wrap up. So, what would you say to a PT student that's thinking about doing a clinical rotation at a manual therapy focused clinic, or a private pay clinic? One of the two, or combination the two, like we are here? What advice would you give, or what kind of heads up would you give them?

Lilly

So definitely, be confident, especially at this setting, and then just own your knowledge. I think I was telling you earlier. No, your (bleep)

As a student, just know your stuff. I think coming in here, we all feel like we know anatomy. But Dr. David would put me on the hot seat, and he'd be like, so what's the insertion here? And what's the nerve here? How does it move here? And I really had to just think and say my answer. And he's like, are you sure? Are you sure? Then I would second guess myself. And he's telling me to look it up. And I was right.

He was just making sure that I knew my stuff. I think that's the biggest thing. Just be confident. Never stop looking at your textbooks, never stop learning, and be open for sure. Because a lot of the things that we've learned that are like common concepts in PT school, were challenged here. And I know that one of the things that we had talked about was like conscious competence, and unconscious competence, and all these other ones. What I felt I knew, coming into this world, this kind of exclusive world of manual therapy and fellowship training, you have to be open to different concepts, or seeing them in a different perspective.

I would say, own your knowledge, but at the same time, be open to looking at it in a different way. Because you never know what you'll be limiting yourself to learning, if you don't open yourself. I just took everything like, Okay, let me just accept it as it is, so I can learn the concept. Then I think we talked about this too, also kind of be able to question it and say, Is this the truth? I would just say, keep those things in mind and you'll do great here.

Dr. David

Yeah, I love it. I think that pretty much sums it up, with the best way to come in is with an open mind. And I ran into that my first clinical rotation. I was always a good student. I learned all the orthopedic stuff really, really well in PT school. I didn't really know about the different schools of thought in PT, because I was oblivious to it. I just didn't know, and I was one of those students. I remember, I'll never forget the first week or two of PT school. One of the professors said who here has had PT? I looked around and almost everybody raised their hand except me.

I had never been in physical therapy, so I didn't really know what it was fully like, besides my volunteer hours. So, I was unaware. I never hung out in the PT clinic for more than I needed to. So anyways, when I went to my first clinical rotation, I was bringing in all this stuff that I learned from PT school in orthopedics, and it was a manual therapy clinic and I almost butted heads with my clinical instructor, that's just kind of my personality.

I was wanting to tell him. I wanted to be right, is what it was, and he was the same. I'm so glad. His name is Paul Payjack. He did a good job of standing his ground against me, and f getting in my face sometimes. I’d be like, this is how it is, I'm telling you. Once I finally said, all right, I'm going to let go of what I think is right, and just trust you fully. Because you're the PT and you're very studied and all this stuff. I was able to start to feel certain joints move that I could never feel before. Or see movement in a way that I hadn't seen.

What I remember telling myself is, even if it's completely wrong with what they're showing me, I'm just going to do it, to at least get a good grade to pass my clinical rotation. But if we know what's the worst, I'll learn what not to do. So, I went into it with that kind of mentality and it changed my life. I still do this to this day, I have an open mind about things because there' are very few things in my opinion, where there's like a hard and fast black and white like this is the right way to do it.

Definitely in physical therapy. There are multiple ways to do things and rehabilitate people and learn and everybody's just unique and different in their learning styles and their body types. So, it needs to be all taken on an individual basis. So, keeping an open mind is a is a huge deal. Thanks for sharing that appreciate it.

Lilly

Yeah, no problem. You guys are welcome.

Dr. David

Any last words before we wrap up? Or do you feel like you got it all out?

Lilly

Yeah, I mean if you guys come here, you guys are definitely not going to regret it, and you guys have been better PTs and I will definitely trust you. Way more if I'm ever your patient. If I know that you had a rotation here.

Dr. David

Oh, thanks a lot. Appreciate your time. Hey guys, thanks for listening. I appreciate you listening and if you're a PT student out there, and you want to do a clinical rotation at our clinic specifically, you can give us a call at 915-503-1314.We are selective with who we take. There's an application process, so heads up on that. And of course, you have to, okay that with your university, with your clinical, whoever's in charge of clinical, at your university. So, get on it soon, it's not something that you can do last minute, on a whim.

You have to plan it ahead and make sure you have all the paperwork lined up, and we do that on our end as well. And then we need enough time to take you through the interview process. We usually have a few applicants as well, and we can only take a select few at a time. So, make sure you're on top of that. But other than that, I wish you the very best day and I hope you are learning a lot. Have a great day Buy bye.

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