My articles are not designed to replace medical advice. If you have an injury or other concerns I would recommend seeing a qualified health professional. 

The last time I posted was back in April 2019, it really has been a while!

What with trying to live, work, continually study to progress professionally and personally, whilst trying please everyone in my life (work, boss, family, significant other and friends) but myself!
 
Experiencing the loss of a loved ones, the pandemic, nearly dying from covid-19 myself, being redeployed and here I am, time really does fly…

Mel Robins was right! No one cares (apart from your parents if you are lucky enough to have them in your life mine was my mother) and no one is coming, the only person who can rescue you is yourself! I KNOW and believe no -one will take better care of you then Allah (God, or whatever you have faith in) and yourself.

What we are told and perceive to have “Lack of time” (I may touch on lack of resource also).

One of the phases I constantly heard being thrown around was “are you managing your time appropriately” or my favourite, “lack of time” it really pisses me off.

First of all time is a concept which is man-made and before the Big Bang there was no such thing as time according to the theory of relativity. In fact we have been conditioned to conform to a system which is governed by THEIR concept of time and what is dictated as a priority.

Physicists, philosophers have often thought of as time being something “we experience time is psychologically real…. but time is not fundamentally real, they are artificial constructs/ perspectives of the human mind”

Whether the concept of time or lack of time is real or not we all to some extend have been conditioned to conform to a system which is governed by others time and not our own….

​I never started to work as a physiotherapist because I was worried about time I became a physiotherapist because I love making a meaningful difference to others.

I am still to this day not sure how I became a physiotherapist. I remember doing my first year of my Sports Sciences degree at Brunel (2006) buying a jumper with the print at the back of the jumper saying physiotherapist instead of sports scientist (don’t ask me why I have no clue). Looking back perhaps I was manifesting this into existent without knowing…

Other times I feel other influences have paved my way. Whatever the true jump start was, I know I thrive off helping.

I have heard many describe health care professionals any things,

• "a pillar of strength to those who have lost faith"
• "a light at the end of the tunnel that seems dark"
• “unhelpful, they didn’t listen”
• “they rushed me out and didn’t want to help”

Despite having my own issues with vulnerability, I managed to mask how I felt, got lost in other people’s pain, because I found it easier to help others in need than deal with my own stuff (time & hindsight has given me this clarity).

Having a natural predisposition to being; kind, helpful, and caring does help, I don’t like the idea of seeing anyone or anything suffer if something can be done. Helping others gives me a sense of purpose and meaning, it has also taught me perspective and gratitude.

But I have realised without boundaries this can be risky, and unhealthy.

I learned it’s a good thing to show signs of vulnerability. But what I didn’t know at the time was, you need to figure how who you can share this with (Brene Brown helped me make sense of this, you should check out the marble cup people), so I got burnt and learned this the hard way personally and professionally.

I realised no one’s kindness is truly altruistic, most people’s kindness is transactional, YEP let that sink in for a hot minute.

I know! Transactional kindness is a thing, some do it intentionally some do it unintentionally, I feel it links to Freud’s theory of secondary gain (more about this later) in a more lateral way rather than related to a particular illness.

Helping others, self-sacrifice with no knowledge of what boundaries are and how to keep them is a dangerous thing!

The problem with this (caring etc) in the context of working in the NHS means you yourself either suffer in order to maintain the standard you choose to have or you give up conform and fall in line, like the rest of them and eventually become empty.

You keep getting told: be careful what you say, how you say it you don’t want to end up being “boxed ".In the field of health-care once you’re “in a box” it’s over, it’s harder to fit in or get the recognition or job promotion you’re after.

I find this really odd, why do people feel the need to categorise you or put you in a box, just so they can label you? Are we all not striving for the same thing?

The other thing I also hear often “we don’t have time”, although some say its not about money to a degree it is. In my old clinic we got paid per new client & NOT per contact, this would explain why we were pushed into seeing a lot of new patients (obviously don’t get me wrong people need to be seen, I understand this) & discharging fast.

So how do you create time to give the care you wish to give?
Also what kind of care is the best care?

Creating time isn't easy...!

Staying back late means not getting your time back or being paid for over time, it also means you are not recognised by your colleagues as being proactive or going above and beyond and exceeding expectations. Instead in this environment you are seen as “not managing your time and case load, the one who stays late”.

Patients don’t realise this (why should they) but when a health care professional chooses to spend more time with you it’s not because you have time it’s because you have given up your time; your lunch break, giving up your admin time or choosing to see the next patient late. By choosing to do the above means you are staying back at work late going home late or go into work before your shift to complete necessary tasks (notes must be complete within 24 hours, legally).

This reminds of the famous quote “you are free to choose but not free from the consequences of your choice”. I wonder when you weigh up all the options do you really have the freedom of choice or just the illusion?

It is frustrating and overwhelming sometimes knowing your time is restricted because work (those who have never worked at grass routes level) feel 15-20 minutes is enough time to greet your patient, assess, educate, treat and have your hands washed, notes complete clinic room cleaned in time for your next patient.

This is worse unfortunately for the GP’s their contact time is being reduced to 7 minutes per patient and each patient is only allowed to talk about one thing on each visit

I understand if we spend less time with each of our contacts / patients this means more time for; cleaning, having the notes written up/ letters complete, more people will be seen. Because more people always need to be seen in the NHS.

But at WHAT COST…… reduced time means mistakes can be more easily made, often this is sometimes certain things can be missed resulting in never event occurring.

​For those of you who do not know what imposter syndrome is, it is defined as “high achieving individuals who are marked by an inability to internalise their accomplishments and a persistent fear of being exposed as a “fraud”. Imposter syndrome cam develop when one “underestimates their own vales, skills, and accomplishments”.
Apparently imposter syndrome is more commonly seen in college students, medical students and high level professionals.

I guess this makes sense! I often feel undeserving of what I have achieved or I don’t recognise my accomplishments. I am aware my perfectionist and over achieving mentally or wanting to be good enough doesn’t help.

I am also dyslexic and dyspraxic (neuro-divergent) so this does and doesn’t help, I need time to make sense of things and not make mistakes, I get cognitively more tired than most (long covid has made this worse) which is why having more time and space helps (which you often don’t get at work). Plus I like taking care of my clients/patients properly.

Couple my own limitations (which I know I need to learn to keep in check) with working in an environment which is not nurturing will take its toll

This means as a clinician you need to be regulated yourself to have the capacity to recognise when your patient isn’t and recognise that you will need to, stop “physio red flag screening” and be prepared to:

• get close
• make eye contact
• Actively listen! Do not listen to respond or fix
• be curious and seek to understand not fix
• show empathy
• listen again
• offer warm affection (with consent) 

In order to decide if the person is right for you and if they are not, then where to sign post them next.
This can be extremely hard, when work dictates how long you should spend with someone (when you are meant to be an autonomous practitioner) and your diary is so full you barely have time to drink water because this would mean you need to create non-existent time to urinate…. !

  Good or poor therapeutic alliance can have an impact on patient experience and treatment outcomes.
​
I found my time working for the NHS was a double edged sword, we are extremely lucky to have a national health service which is free for all at the point of access. I certainly know first hand what it means to live in a country with no NHS, insurance or money to seek treatment when needed. However this wonderful service does not how to take care of their staff so their staff can take care of others. The demands, targets, statistics at times requires staff who work at a grass roots level who go above and beyond to stay back late from work (in my case) unpaid and unable to claim those hours back. 

The service relies on their staffs caring nature and good will, which is NOT an inexhaustible well. The unfortunate case is because the system is not designed to work with you but against you and because the public do not understand the purpose of the this system many who go above and beyond for their patients will go onto suffer; compassion/ empathy fatigue also known as clinical burnout, burnout syndrome, moral distress, occupational burnout, secondary traumatic stress syndrome.
 
Part of what contributes to this problem is the non existent additional time needed to complete administrative tasks such as;

• Calls to other health care professionals
• Formulate letters, emails
• Deal with a patients 2nd, 3rd, 4th, 5th referral, or refer patients onward
• Return patient phone calls
• Complete mandatory training- which sometimes is unnecessary but is done just to tick a box and if for lip service
• Reflections as evidence of your CPD – which requires space and time to understand your thoughts and feelings then articulate this in such a way that is acceptable as evidence. 

Of course all of this is done whilst running between three or maybe four different clinics in different areas, seeing up to a 100 patients or more seen each week. Note this figure is subject to change and does not include the patients you over see in the group education or exercise classes, which are about 6-7 every 30 minutes (sometimes due to incorrect bookings can be 9), by the end of the day you could have seen nearly 65 patients which used to be the case on Fridays.

In addition to this you are expected to manage all these tasks with 30-50 minutes of admin once a week, should you book additional time for admin for the above tasks or to see a complex patient longer then you are perceived you should. The initial perception and response from anyone in the department colleague, manger or some of my mentors is; you are not managing your case load and or time effectively. There is a general consensus that if anyone else can magically complete all necessary above tasks (I haven’t included everything) within this given time frame why is it that you are unable too. Secondly, the next response is well do you know other trusts have less time and see more patients. Like this is a good thing. 

​The fact is Rome was not built in a day and no, no one is the same and no one functions the same. But large cooperation’s will try to push you into a box calling this equality, diversity and inclusion. They seem to forget that Equality doesn’t mean you treat everyone the same and expect them to reproduce the same outcome.
 
Equality, fairness, inclusion diversity means so much more, it means getting to know your staffs needs, tailoring what support and training you provide them. Most importantly understand how to take care of your staff because not everyone will be able to produce the same output or function the way you want just because everyone else seems to be able to do it.  Equality, diversity and inclusion and most importantly fairness in the workplace is multifaceted, and varies from one work place to the next. Take a look at this image for instance not everyone is the same but when they get treated the same inequality can still exist…

Extra time means you can pick up on clinical flags and decide how base to action these. Here are some examples of different types of flags;

• RED- signs of serious pathology
• ORANGE- psychiatric symptoms
• YELLOW- beliefs, appraisals and judgement , emotional responses, pain behaviours (including pain and coping strategies aka Capacity for resilience)
• BLUE- perceptions about the relationship between health and work
• BLACK- system or contextual obstacles
• Other - Expectations, function, Goals, Level of knowledge, and the list could go on.
​
Time allows health care professionals to help a patient build a short term secure base of attachment so that we are able to explore what is really meaningful to them. Sometimes this means giving reassurance, praise, care (love /affection) a high five when necessary. If none of the above can happen because we do not have time then it will really be difficulty to create tailored treatment plan/ intervention that is meaningful to the patient let alone a strong therapeutic alliance.

​This concept is well documented, known and understood by many yet no mention of this topic at university, or by your colleagues. Until YES you've guessed it when you start showing signs of cracking.

Nothing is NEVER what it seems extraxt from Troyer (2007) Differential Diagnosis of Endometriosis in a Young Adult Woman With Nonspecific Low Back Pain!
​
When you see a 25-year-old female with 5 year Hx (history) on and off pain with sudden onset of severe left-sided lumbo-sacral, lower quadrant, buttock, and thigh pain.
She had pain on flexion and prolonged walking or sitting.
No eases
Disturbed sleep & awoken with pain
Bowels -NAD (nothing abnormally denoted) 
Bladder last 2 years Increased urgency and frequency

Objective examination (O/E)
reduced flexion with pain EOR (end of range) extension was clear.
Power 4/5 for Bilat Lower limbs
Reduced sensation 
Passive straight leg raise (PSLR) did not reproduce her leg pain only back pain,
Reflexes KJ & AJ both bilaterally present
Full passive range of motion (ROM) at the Hip
Negative Patrick's test.
Low BMI (body mass index)

Investigations -
MRI of lumbar NAD (nothing abnormally denoted)
Urine analysis negative for infections

Family Hx 
Strong Family Hx RA (rheumatoid arthritis) and hypothyroidism

Result
Turns out the nonspecific or mechanical low back pain is NOT THE PAIN DRIVER, this young lay had Endometriosis and left sided ovarian cyst....
You learn something new EVERYDAY!
For those that do not know endometriosis is, it is a COMMON gynaecological disorder in women between 25-30 and can mimic musculoskeletal symptoms and manifest as nonspecific low back pain. This is why you should always be thinking outside the box, because nothing is ever what it seems. Not ever patient who turns up at your door step will have MSK issues as the MAIN PAIN DRIVER (which I will be doing a reflection on another reflection/blog). Definitely a useful and one remember when you are deferentially diagnosing a patient :)

Article:
Troyer (2007) Differential Diagnosis of Endometriosis in a Young Adult Woman With Nonspecific Low Back Pain. Physical Therapy, Volume 87, Issue 6, 1 June 2007, Pages 801–810,

Link: https://academic.oup.com/ptj/article/87/6/801/2747261

Update- January 2019
​When I read this article it later came in handy when I came across a patient who actually presented with something very similar. We are currently working on their MSK issues - whilst they are being investigated to rule out other possible causes such as:

• Ovarian cyst
• Fibroid's
• Endometriosis

Update- March 2019 
They have been discharged from my care to continue managing their MSK low back pain with a graded exercise program and to stay under the care of gynecology for further management of their ovarian cyst and fibroid's.  

So by now you should have some kind of understanding of what we do and why we are the way we are....

There are multiple factors that contribute to the way we respond and the way we are. This doesn’t necessary mean it’s a bad thing it just means how you are, what you do and how you or your client/patient has coped thus far has served a purpose. It’s got you or your client/ patient safely to this point, and now it may no longer be serving you.

Remember, there is so much more to life than just training to look good etc. It’s about finding out your why, what does this mean to you. When you know yours or your clients/patients why then it becomes easier to find the right strategy to break those OLD hard wired patterns and instil new ones. More often than not as a coach, personal trainer, therapist we also need to recognise our own bias, triggers, thoughts, patterns and beliefs break them and learn to keep them in check.

It is important if you are seeking change you need to find someone who cares and has your best interests at heart. It is also important as a therapist, coach or trainer to screen your patient, client appropriately and understand where they are and what they need.

I guess what I am saying is in order to deal with patients / clients it is important to be equipped with more than just knowledge on exercise prescription for example treating low back pain or deal with weight loss or gain.

I believe the missing link between each scenario boils down to many factors below is just a short list:

• Attachment trauma- see John Bowlby for further information
• Learned helplessness
• Fear of failure
• Low self-esteem and or confidence
• Shame and or guilt
• A sense of unworthiness
• Overwhelmed
• No support system in place

If you are your client, patient is not changing perhaps you need to go back and re-valuate your screening process. If you do not have:

• A good understanding of your client or yourself
• You are not sure what stage of readiness you or they are at
• You are not sure of what your own or their expectations are
• If you haven’t appropriately set realistic meaningful goals for yourself or them

For example let's consider the concept of learned helplessness.

Learned helplessness is a phenomenon which was discovered in the 1967 by an American psychologist called Martin Seligman who conducted the controlled study, which was later expanded by Seligman and others. The dogs were exposed to repeated bouts of electric shocks who attempted to leave the cage they were in. When the dogs were unable to escape or avoid the painful experience, they quickly learned they were unable to control the situation and learned be helpless.

Scary moment... my first ever blog hopefully one of many! I hope you enjoy the read :)

In my short life span I have met some amazing, compassionate, driven and caring people. Who have enriched my life but yet are unable to recognise the greatness that they have within them. You know the ones I am talking about, their mere presence is oozing with uplifting energy, selfless / endless care and compassion. I have also noticed that these same people at one point or another some if not all did not know how to practice:

• The word no
• Self love
• Self care
• Energy conservation

Seeing this made me genuinely wonder why, where did this type of behaviour stem from. Why do we behave in this manner.

It saddens me to see this kind of behaviour because I know first hand what poor self care, self love and not having the ability to regconise your own boundaries and say no.

I have also noticed that many and including myself tend to disguise our decisions based on the socially constructed concept of being “realistic”. When in fact I believe choosing to use this “I’m being realistic” term is just another way of sugar coating or denying perhaps what you truly feel about yourself. This is known as your self fulfilling prophecy or also your deep core belief.

If your mental chitter chatter often sounds like this:

• What’s the point
• I’m a failure always have been
• Nothing will change it hasn’t before
• Or complete denial I don’t have a problem
• If it’s not broke don’t fix it
• I don’t need to change

Then be rest assured if you have been telling yourself this then your core belief about yourself is what could be holding you back from as Elliott Hulse would say “the best stronger version of your self”

Over time I have noticed the same story takes on many different shapes and forms, you may come across a client who is projecting this story onto you or you are projecting your story onto others about “being realistic”. When in reality if we stopped to understand what we are really feeling we would realise that perhaps our inner child hasn’t had their needs met as a child. These childhood traumas or wounds are what could be causing us to be resistant to change. This resistant to change most often comes from fear of:

• Loss
• Separation
• Abandonment
• Rejection
• Hurt or disappointed
• Being unworthy
• Unloveable and the list could go on.

I am concerned with this subject matter because it astounds me how many children walk around in an adults body still hurt and who have not healed from the wounds of their past. They walk around never knowing who they really are or understanding how they really feel, the term “walking dead” comes to mind.

This negative core belief you or they have about lthemselves, coupled with unhealed wounds and fear has perplexed if not all, many from achieving their true passion, purpose and potential in life.

Other psychologists also contributed to his work that argued attachment is a set of learned behaviors. This tied in with the evolutionary theory of attachment which suggests that children come into the world biologically / genetically pre-programmed to form attachments with others, because this will help them to survive. In fact the first few hours/ days are critical to the child's ability to imprint on another so they are able to form this attachment.

As the child develops later on in life they may go on to develop either one of these attachment personality types;

• Secure attachment style - autonomous
• Dismissive/ avoidant attachment style
• Pre-occupied/ anxious attachment style
• Disorganised/ unresolved attachment style

Poor development can cause a child who becomes an adult to develop and carry

• Poor understanding of what emotions they are feeling
• Inability to Regulate their emotions
• Poor Resiliency / bounce back ability

Why is this or why should this be relevant when it comes to being a doctor / personal trainer/ coach / physiotherapist / osteopath?

If a patient has poor resiliency for instance they may be less likely to manager their flare ups well

Understanding your clients perdispositions and stage of readiness is necessary if you are going to embark advocating change.

Another reason why you may encounter resistance to change is:

• You don’t know what your expectations or their (clients/ patients) expectations are
• You haven’t managed yours or your clients/ patients expectations.
• You wasn’t present to pay attention to what you are feeling or what your patient / client is telling you
• You havent regconised that your client may need to learn healthy coping strategies for self management

Don’t freak out don’t beat yourself up!
Their is always another way :)
Want to know more? click here for part two....


References
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