Jack of All Trades...

Master of none?  Of some?  Of one?  Of a few?

One of the great things about being a physical therapist is the variety of things available to you.  Numerous settings are available to work in - schools, hospitals, nursing homes, clinics, sports teams.  You can work with a narrow age of ranges like birth to three years old or the geriatric patient or the whole spectrum of age, gender, and a variety of levels of ability, disability - both physical and intellectual.  In my office alone, there are physical therapists who primarily focus on sports/orthopedics, others who primarily focus on developmental rehabilitation, and a specialized physical therapist who works on infant feeding.  Variety is the spice of life, right?  

Some days, the list of diagnoses between all the patients on my schedule looks a lot like: knee pain, knee pain, ankle sprain, knee pain, knee surgery... repeat.  The mechanisms of these injuries for knee pain and ankle sprains might vary - soccer, soccer, gymnastics, jumping, soccer, soccer - or not that much maybe. Some days that’s just how it is.  Not a whole lot of variability in the body region where pain is occurring. Not a lot of variety in age groups.  I've had days where I've seen only girls between age 12-15.  And I generally see eleven patients in a day, so that's a lot of "luck" to have so much congruency between patients. 

Because of how sports seasons work, there’s a tendency to see clusters of athletes from the same sport at once - like soccer players when their season is starting, baseball players at a different time.  We don't see many football injuries in middle of December, and it's rare to see a skiing injury in August. Teammates bumping into one another at the clinic is not usually a good sign, particularly if they have the same type of overuse injury, but it definitely happens.  Last winter, when 3 swimmers from the same team showed up with shoulder pain, it seemed imperative to reach out to the coaching staff and see if we could help the whole crew.  

So while I really do love days like this because I’m a sports physical therapist and I love helping kids get back to playing their favorite sport, there are days that are also quite different.  Days where the diagnoses on my schedule look like this: chronic regional pain syndrome, post concussion syndrome, post-op meniscus repair, broken humerus, knee pain, scapular dyskinesia, ankle sprain, osteomyelitis of the shoulder post irrigation and debridement, post-illness deconditioning.  When this happens, there's also a much wider spectrum of mechanisms of injury - like for these - skateboarding, soccer, trampoline park, fell off jungle gym, marching band, swimming, "my brother tripped me down the stairs", insidious/unknown, cancer.  The injuries and conditions can be much more variable and require a lot more knowledge and skill to treat. I love this, too, but it makes me think a lot about my strengths and weaknesses as a PT.  At the end of the day, all of them are trying to get back to something, usually a sport or activity of some kind, which means guiding them through restored function in more important things like going up and down the stairs or getting off the toilet- but after that boring stuff (kidding), we get to play soccer or basketball or hop scotch in the clinic. 

I’ve been thinking a lot about this second type of day and had this blog post almost entirely drafted when Lenny Macrina, who I've previously written about here and here, posted this on his twitter: "Hey PTs, if you could treat one only type of patient presentation for the rest of your career, what would it be?" (Side note, I'm currently running for the office of President of the Lenny Macrina Fan Club).

In high school we took career placement testing that suggested I should become a farmer.  In my head I thought - that's the most regimented routine EVER.  Up at sunrise with the chickens, milk the cows, maybe some change with seasons but overwhelmingly very similar day to day.  No thanks! I never considered being a dentist because I didn't want to look at people's teeth all the time.  Gross. I definitely didn't want to be a podiatrist, because I really don't like feet. Gross times a million. I didn't want to do any sort of work that was repetitive in nature. So thankfully, I don't get stuck treating tons of ankle sprains, and when the occasional one does, I make sure they're good about washing before I get near them.  I always knew I needed variety, which is what this post was about in the first place... and had to respond to Lenny's tweet: "Why Lenny?!?! This week my upcoming blog post is about days where all the patients have similar body part ailments or conditions versus days where they're all over the board.  Variety is the spice of life! I'd go nuts with the same all day."

I really, really love the variety. but I also recognize that by seeing this variety, does this mean that I've become a jack of all trades, capable of doing something to help everyone but not being really good at helping anyone in particular?  Is this a problem for PT practice that we don't really have to specialize much beyond our setting of practice?  

For me, there are certain patient types and conditions that I'm really interested in.  I primarily focus my continuing education on those areas.  Some injuries and conditions are simple to evaluate, simple to treat, quick to get the patient back to their normal self.  Some just aren’t. And, as I think I’ve said before, though physical therapy is based on science, there is definitely an art to it.  There is an art to connecting with people, encouraging behavior change and convincing people to exercise who normally wouldn't.  But beyond the connections, there is a real need to have a good understanding of the human body, the relevant components to a person's injury and to the needs of their activities, and to how the body heals. 

There are basic skills any physical therapist would use to evaluate the majority of their patients. We would assess their range of motion and strength and probably palpate some body regions to assess irritability of the tissue and mobility of a joint, and then maybe some special tests to identify certain tissue structures that may be involved.  And then we have to be more specific, like I mentioned earlier, in further assessment techniques and treatment options based on the needs of that individual person. 

So... should every PT be treating a case load that has so much diversity in diagnoses and patient presentations?  Should I be?  I do... but... should I?  Is it OK that I'm a Jack of All Trades?  

I'm here to say that I think this makes us even better.  If I only treated post-op ACL reconstructed patients every single day - but their sport or daily life needs vastly differed - and their concomitant injuries included many other things like meniscus pathology or PCL injury or traumatic fracture, I don't think I'd be as good at rehabilitating that patient population as if I worked with patients with all kinds of hip, knee, ankle/foot injuries playing a variety of sports.  And truly, a patient with an ACL injury is one of my favorites - but it's because of the duration of recovery and connection to the patient that I like it, along with the ability to use a whole lot of different treatment tactics with them! If I only saw kids with concussions, my vestibular rehabilitation skills would definitely improve - without question - but at what cost?  What would be lost by specializing in a specific patient population?  

So, the next time I need a physical therapist for myself, I’m going to ask them what they like to study and learn more about.  Do they choose to do continuing education on hip pain, while I'm experiencing hip pain, that they may have seen the most recent evidence of what they should consider for my care?  And also, do they treat a variety of patients, or only people with hip pain.  But most importantly, do I like them?  Can we connect at all?  Because truthfully, a lot of the time, I don't think it matters quite so much what we know or study or who we've treated the most, but how we interact with our patients and empower them to move forward.

Jack of All Trades, Master of None?  Fine by me.