Early on in your career, especially if you specialize early like I did, you tend not to ask as many questions of yourself and your clinical decision making as you should.
It's a natural progression and roller coaster ride of a career - check out David Butler's great reflections on his own roller coaster ride.
Here are questions that I ask myself every once in a while, sometimes I like the answers, and sometimes I do not.
1) Am I practicing the same way now as I was 4-5 years ago?
- through your career you should experience some paradigm shifts
- some will be subtle, others will be large
- some like Pain Science, may initially turn out to be ground breaking, but then you have difficulty integrating it into your clinical practice
- one of my favorite things to hear from former patients is just how different my exam is, or my explanations, or my HEP (or how much lighter I am with manual therapy)
- once you're far enough in your career that you can see patients from many years ago, hopefully they will tell you that things are different
- in the end, if you're doing things the same way now as you were 5 years ago, it might be time for a change
2) Why am I doing this assessment?
- why are you looking at breathing patterns?
- not to say you should not be, but you should know why (from a tone or physiological basis)
- are you looking for scapular position or a rotated innominate?
- so far, the research is not in line with 1) changing positions of bones with manual techniques or exercises 2) either one of those things actually causing pain
- if the answer to the above question is, "I learned it from a course/instructor/a blog/etc," that is not sufficient for clinical decision making
- if there is not evidence behind the assessment, the least you could have is reasoning based on a scientific explanation
- in the end, does the assessment or test immediately direct your treatment or is it provocative just for the sake of it?
3) What does this technique do?
- patients will probably ask you this regularly so you probably have a practiced answer
- even though I have been on the neurophysiologic bandwagon for years, I find myself watching old videos from just a year ago and my explanations are continuously evolving and changing based on what we know (is not happening)
- what we know is that techniques work, and your choice of technique should probably be based on the ones you are comfortable with, practiced and good at explaining
- the actual technique and exercise most likely does not matter according to research - that may not sit well with you - and it didn't with me at first
- rapid responders will respond rapidly if you
- are empathetic
- have positive interaction
- choose a movement and treatment strategy that is novel
- reassure them and get them moving again
- in the end, what the treatments do is get patients moving and feeling better (not only pain, but confidence as well)
4) Do I force treatments or explanations on patients that confirm my biases?
- I am very guilty of this
- some former patients who enjoyed my pathoanatomical explanations from a decade ago did not buy into my more modern neurophysiologic ones
- in order to feel better about my own explanations, sometimes I tried to hard to convince a patient I didn't need to go to town on their ITB or piriformis, or give them a pathoanatomical diagnosis
- in the end, if you lose your patient on the first visit, they're going somewhere else and you probably lost referrals from their provider and their friends/family
- be flexible, if you see your patient's eyes glazing over, or they flat out tell you it doesn't make sense, wean them into more modern approaches slowly
5) Is what I believe in line with the majority or a minority of my peers?
- this can be taken several ways
- you're a sheep and follow whatever trend is popular (core, breathing patterns, IASTM, etc)
- you're a radical and your beliefs are so far to the right of the curve, no one has caught up to you yet (may be both good or your system is just based on assumptions)
- you don't want to be a sheep, as the average clinician probably means well, but is probably lacking in the clinical reasoning department
- if you're too far right, your theories may never catch on, or worse, can never be proven and you're left with outcomes based purely on theory, like asymmetries that explain every condition known to man
These should be things you reflect on regularly and revisit often. If you are too sure of something, just wait, it will probably change. One of my colleagues likes to say, "If I hear someone say they know 100% where the pain is coming from, that's a red flag to me."
Avoid systems that have you go all in and don't play nice with others. Focus on systems that compliment your own, (or give you one in the first place I suppose). Clinical reasoning is what makes the toolbox. Once you have some efficient reasoning, then you can expand the toolbox, not the other way around.