N=1

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N=1 has turned into a symbol,  a representation meaning to treat a person as an individual, as a unique complex being that has personal factors and history that make them who they are. (see the mountain stream analogy via Aaron Swanson.) When we speak about treating the person in front of us we can say “N=1.”

This is being championed by many groups. The “Pain Science crowd” certainly incorporates individualism and biopsychosocial constructs.  Cause Health is bringing awareness, and I’ll also recommend Neil Maltby’s blog: Becoming More Human. Continue reading

Split brains and causation

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There’s gotta be a reason. You can’t have an event pass by you without knowing why, right? Right.

“Well, you know, the weather made it hurt. It’s all that rain…”

“My back is hurting today, I was at a family BBQ and I stood for an hour yesterday, so…”

“The knee feels much better, I think it was the tape you put on there.”

Post Hoc Ergo Proctor Hoc. After that, therefor because of that.

Making a reason for things is not conscious, often. We always see cause and effect as a truth. If we’re wrong, it’s confabulation, not a lie. It’s “only human.” See a quote below from some of the Split Brain research: Continue reading

A Year In Review: II

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We have seen large changes over the past year from personal perspectives here at the PTBT. The posts have continued… a host of topics following our varied and changing interests.

The transition from student-blogger to practicing-clinician-blogger is an interesting one. You must walk the walk. Cerebral idealism, philosophical concepts and metacognition are affronted by the real world N=1 scenarios, workplace pressures, time constraints, technique and exercise challenges and more comorbidities than you can shake a stick at.

“You wrote about how you should interact with this type of person/case, now they are in front of you.” Writing and reflecting on how to treat has kept the ship pointed in the right direction. Through the process of trying to form a thought, and even a thought that another person might understand (we hope!) you develop a skill for reduction. Reduction to the fine points. Continue reading

THE role for Physical Therapists

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There is a clash between knowing that biomechanics and structure are not 100% responsible (ie. a 1-to-1 relationship) for pain, and the fact that (from an Example I got from Mike Eisenhart) some one with a poorly moving C5-C6, (as best we can tell the difference and as valid as our hands may be) has a risk factor for future neck pains and problems.

No. Not causative, but a risk factor.

Continue reading

Treating in the low socioeconomic climate

My clinic serves a low socioeconomic area. Now, I am sure that there are any number of stranger work conditions, treating in a gang-controlled area, for example, but the conditions and problems of low socioeconomic status (SES) are a niche unto themselves.

Almost everything “straight ortho PT” gets thrown out. Low SES throws a wrench in the gears.

From our clinic perspective, it means lots of un-managed chronic conditions, high cancellation rate and difficulty with adherence to HEPs. Transportation to the clinic is a large issue because it has a cost (either money or time) to the patient that is often a deterrent to coming to appointments. People prefer not to wait for the bus in the cold. Continue reading

The Meaning of Cost in Value

We associate many things with money. One example: If it costs more, it’s better.

Money is not just a physical item representative of some good or service.  It has meaning past trade. Having more money does not just mean that you can accumulate more things. Socially, it states that maybe you have accomplished more, are a better decision maker, make better behavior choices, etc. It possesses status and other cultural attributions. Not a surprise. You know this.

The $15 beer will taste superior to the $1.50 beer. It just does, because we know it’s better. It’s contextual priming. That’s why blinded taste trials are often so interesting, because the context is removed and you are left with a singular sensory organ (taste organs of the tongue and mouth, yes and olfaction). Continue reading

The Person Sitting in Front of You

I saw my patient walking up to the door as I pulled up to the clinic. A tall and very thin woman. She was heavily dependent on her rolling walker, I saw that immediately. It struck me. Saturday hours at the clinic were supposed to be simple post-op patients. Quick in and out’s. I think I was even slightly pessimistic at this first glance…because I could tell she was struggling. I estimated this was more work than I bargained for at 8:30 am eval on a Saturday. Four weeks status post a Continue reading

Who is Satisfied?

How are we going to do this?

In other industries customer satisfaction is part of the delivery, but not directly tied to product price. Companies are “paid” by happy customers with more business (referral, word of mouth, etc), or market leverage to increase the cost of service (increased value of product) with customers happy to pay that increase due to increased value, to them.

This works in a market system, where individuals are in charge of their monetary decisions. But that isn’t health care.

In a move towards payment for outcomes, where will customer satisfaction have a role? (we don’t know whether we will be paid better for better outcomes, or paid a set fee for an average expected outcome and it’s up to us to beat that average… who knows)

Is there any talk of adding customer satisfaction directly to payment? Sometimes that’s all we have. No significant change in patient status, but a very satisfied customer with the care, service, advise and input given. Perhaps they leave with an understanding of their condition, ways to manage it and strategies to avoid deleterious effects of their disease/dysfunctional process… but no change in ROM, strength or patient reported outcome measures. Continue reading

On the subjective nature of pain

Image Credit: "Inverted qualia of colour strawberry" by made by Was a bee. - Original strawberry's image is from Image:Fragaria_Fruit_Close-up.jpg uploaded by User:FoeNyx,and original man's image is from Image:Munemitsu Mutsu 2.jpg uploaded by User:Ueda.H,and I User:Was a bee combined it in one image.. Licensed under CC BY-SA 2.5 via Commons - https://commons.wikimedia.org/wiki/File:Inverted_qualia_of_colour_strawberry.jpg#/media/File:Inverted_qualia_of_colour_strawberry.jpg

Image Credit: “Inverted qualia of colour strawberry” by made by Was a bee. – Original strawberry’s image is from Image:Fragaria_Fruit_Close-up.jpg uploaded by User:FoeNyx,and original man’s image is from Image:Munemitsu Mutsu 2.jpg uploaded by User:Ueda.H,and I User:Was a bee combined it in one image.. Licensed under CC BY-SA 2.5 via Commons – https://commons.wikimedia.org/wiki/File:Inverted_qualia_of_colour_strawberry.jpg#/media/File:Inverted_qualia_of_colour_strawberry.jpg

Some things in life are definite. Some are definitely not. And some are somewhere in between.

Same goes in healthcare and medicine. When you see a hyperactive deep tendon reflex or produce an upper motor neuron sign via Babinski or Hoffmann’s, its pretty obvious. Usually, there isn’t much debate about its existence. There may be some back and forth about the degree to which it exists or to its implications; but, again, most parties will agree “that just happened.”

Same goes for an infected wound. One look, maybe one smell, most people can agree about the degree of bacterial colonization (i.e. infection or no). We can take this further with abnormal heart sounds, clubbing of the digits (indicative of lung/heart disease), or yellowing of the sclera indicating jaundice. The list can go on, but it doesn’t need to. There are a host of objective signs that indicate the presence of disease or pathology. We can even go further with laboratory diagnostics and imaging studies to attempt to confirm or rule out suspicions about the presence of a disease processes.

We have quite a body of information and resources at our disposal when trying to figure out what is wrong with the patient sitting before us. Even more than that, we have gained enough knowledge to decipher and utilize people’s reported symptoms, their subjective report, to aid in this process. As fraught with bias and inaccuracy as an individual’s own perception of their situation could be, we still have found ways to weed through the minutiae and find bits of key detail that aid in the diagnostic process. It could be how long their symptoms have been present, or what activities exacerbate their symptoms. You might ask, “Do you have any popping or clicking? Or feelings of instability?” Or if the patient reports numbness or tingling in a certain area. All of these details paint a little more of the broad picture of the patient’s condition. And one of the most helpful details when painting that picture Continue reading

Experience and the Experiment

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“Dad, let’s do an experience” my 6.5 year old said to me this morning. “Let’s see how far away these walkie-talkies can go and we can still hear each other.”

“Do you mean experiment?” I ask. “Yes, ex-per-i-ment” she says. We go over its pronunciation a few times. It’s a mix between my daughter having no front teeth and that she just gets her word choices mixed up now and then. Experience. Experiment. It’s an easy one to slip up on, plus they could be viewed in the same category in her head. “I will have an experience and learn something.” “I will do an experiment and learn something.” Same thing, basically, to a 1st grader.

So, you can see this question coming: Do you get Experience and Experiment mixed up? Continue reading