Pain & Function: What doctors don't understand & what people don't understand about doctors

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Brent Stevenson

photo: vladkramer

I have an immense respect for doctors and their knowledge base.  They go through rigorous training in medical school to learn how the body works, how to fix it when it is broken and how to keep it alive when it is dying.  On a daily basis doctors help their patients with a wide variety of medical issues from diabetes to cancer and from pregnancy to Parkinson's.  We need them in our lives because our society just cannot function properly without them.  That being said, I would like to share my experience and stories in dealing with doctors from the perspective of a physiotherapist that has:

  • 10 years' experience working with injured clients (including many doctors) that have battled through public and private medical systems, specialists, tests, etc
  • 5 years' experience working as a physiotherapist within a large family practice doctors' office in a building with the UBC Medical School and every different medical specialty available in British Columbia
  • 2 opportunities to help teach 4th year UBC medical students how to do proper back assessments
  • A personal history of numerous injuries, trips to the doctor and hospital

The purpose of this post is not to make doctors look bad, it is to help the general public understand what they should and should not expect from their doctors and the medical system as a whole.  Doctors are very smart people, but they don't know everything, and most of the time they work in a model that doesn't allow them to help you in a thorough or timely manner; we should not be mad at doctors for this, we should just adjust our expectations and understand that a doctor might not always be the one with the best advice or treatment for your ailment.

When something hurts and doesn't go away after a couple of days or weeks most people will search the internet for their symptoms and then likely visit their doctor to try and figure out what is going on.  The focus tends to remain on what is the problem.  People feel temporarily satisfied because their doctor has given them a name or 'diagnosis' for their pain and prescribed them a drug for their symptoms, but this satisfaction with 'what' wears off when they realize that it still hurts and they don't understand why.  As a physiotherapist I routinely get clients handing me their doctor's diagnosis written in chicken scratch on one of their referral pads.  Many clients feel that little piece of paper is gospel and now that their doctor has 'solved the problem' and found a diagnosis my job will be that much easier in trying to fix them.

In reality most family physician's knowledge level about musculoskeletal pain and injury is based on a combination of their very limited training in medical school and personal experience.  I have found most GPs will simply diagnose their patients' aches and pains with the most common issue that affects an area like:

  • Tendonitis, bursitis, epicondylitis, sacroilitis 'itis' just means inflammation of a particular tissue.  They change 'itis' to 'osis' when it persists for a long time

These diagnoses should and usually will come with a referral to a physiotherapist, massage therapist or chiropractor because they are deemed "Soft Tissue" injuries and fall outside of the doctor's area of expertise.  You should not assume that your doctor knows much more about your injury than what to call it.  He may know more than you about anatomy, injury and healing, but that does mean he knows why you developed pain or how you should treat it.  He does know that rest and some pain killers will likely make it feel better, but you are much better to enlist the help of someone whose training has been specifically focused on pain, injury and rehabilitation like a physiotherapist.  Most family physicians that have worked with a physiotherapist will readily admit that a physio's knowledge base is far superior to their own regarding orthopaedic pain issues...that's why they refer people.

In most places around the world now physiotherapy is considered primary care, which means you do NOT need a doctor's referral.  In Canada, a visit to the doctor's office is covered by your government healthcare plan, but a visit to the physiotherapist's office may cost you some money so the tendency is visit the doctor first.  This is a practice that costs our healthcare system a lot of money and costs people their time.  Starting with the healthcare professional that likely knows the most about your condition will save you time and your province money.  Your physiotherapist will advise you if medical attention is necessary, but most of the time it is best to keep you out of the medical system.

Your doctor learns down to the cellular level how every system in your body works, but never learns how the body as a whole should actually move.  He can probably explain more to you about the physiology of how a muscle contracts than how your shoulder actually works.  He can likely explain how Tylenol makes things hurt less, but couldn't teach you the proper way to stand, sit, walk or run.  We are active, dynamic beings that ask a lot of our bodies on a daily basis.  We sit at desks, or stand at counters all day.  We lift, bend, push, pull and walk just to get through daily life, but medicine tends to treat us like a collection of static pieces.  They know how to assess if pieces are broken (X-Rays, MRIs) and they know how to put them back together (surgeries), but they don't really understand how we functionally use all the pieces together or how one piece genuinely affects another; that is what physiotherapists are for.

Doctors strongly support the notion of 'Evidence Based Practice' or the idea that their actions are guided by sound research.  I think most people would agree with this premise, but the big draw back to me is that it creates a bias towards the practices that are easier to research and produce high levels of evidence, in particular medications and surgeries.  I find it tends to make doctors very black and white thinkers when it comes to musculoskeletal pain:

  • I can't see anything damaged on an MRI or X-Ray
  • There's no strong evidence on how to treat back pain
  • It must be a "Soft Tissue" injury (in other words the medical system can't help you)
  • Maybe drugs will help

A good physiotherapist has to train to understand everything that doctor's don't because we are the ones that have to work with the actual person mentally and physically to put them back together and get them moving again.  Many times there are too many variables to control to fully research the effectiveness of physiotherapy because we use a variety of treatment tools that can be subtle and individual to the practitioner.  We understand how the stability of individual ribs will affect your shoulder, how the stiffness in your hips will make you hinge in your back, or how the scar tissue from your C-section with restrict your movement.  The biomechanics of the body is a real thing but it can't be captured on an MRI and doctors just don't have the time to understand it and that is why we have physios.  Physiotherapy is a profession that should preach clinical mastery more than research based practice because human movement is not black and white.

From the patients' perspectives, they still see doctors at the top of the hierarchy, especially 'the specialist.'  People that have had pain for a long time tend to hold on to the notion that there is someone out there that holds the key to their problems.  They have worked with their GP and a handful of allied health practitioners, but they have to wait 6 months to see this one special doctor so she must have the answer.  In the pain world these doctors are usually a physiatrist, a rheumatologist, an orthopaedic surgeon or an anesthesiology pain specialist.  In my experience, once patients actually get to see their specialist they are disappointed ninety percent of the time.  Physiatrists tend to do an assessment and write a report back to the GP, but don't do much for the patient.  Rhematologists give some advice and sometimes an injection, but are rarely game changers.  Orthopaedic surgeons are good at surgery, but once they feel they have done their job, you shouldn't count on them for much.  Anesthesia pain docs will perform nerve blocks that can seem like miracle workers one time and symptom treaters the next.  These doctors can be invaluable to the right patient, but I just emphasize to my clients to not get their hopes up and not to sit around in the medical model when there are lots of 'non-medical' therapies that might be better for them.

My advice to anyone that will listen is to be the leader of your own healthcare team.  Research what you think is wrong with you and keep your own healthcare record of what you experience and who you have seen about it.  Talk to friends about who you should see and build a team of allied health workers around you like a physio, RMT, chiro and naturopath.  Go to your GP for things you know she can help you with, but not with everything.  Utilize different professionals' skills and judgements and don't put blind faith in doctors.  They are very smart people, but they don't know everything.  If you have to go through the medical system and wait for tests and appointments, remember that 'the squeaky wheel gets the grease.'  Be polite, persistent and sound a little desperate and you will get through it faster and unscathed.

If you would like to renew your faith in doctors, their training and just why we need them watch the video below, the story will captivate you.

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