The Beyond Pain Podcast

Episode 58: Elon vs Trump, PT vs Chiro - How to Navigate Disagreement in Healthcare

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Summary

In this episode of the Beyond Pain podcast, hosts Joe Gambino and Joe LaVacca discuss the complexities of disagreements in rehabilitation settings. 

They explore how communication can break down between patients and providers, the importance of understanding treatment options, and the need for clinicians to navigate patient expectations effectively. 

The conversation emphasizes the significance of empowering patients while also addressing their concerns and preferences in care.

Takeaways

  • Disagreements in rehab can stem from miscommunication.
  • Patients often accept treatments without understanding them.
  • Clinicians should ask questions to clarify patient needs.
  • It's important to validate patient concerns without judgment.
  • Not every treatment is suitable for every patient.
  • Empowerment in care can lead to better outcomes.
  • Patients should feel heard in their treatment journey.
  • Communication is essential for effective patient-provider relationships.
  • Clinicians must balance patient desires with evidence-based practices.
  • Understanding a patient's lived experience is crucial for effective care.

Joe Gambino (00:01)
Welcome back in to the Beyond Pain podcast. I am one of your hosts, Joe Gambino, and I am here with the other half of the show, Joe LaVacca You can find us both on Instagram at Joe Gambino, DPT for myself and at strength and motion underscore PT for Lavaca over there. Hopefully he upped his coffee game this morning after my my story on Instagram. And then you can also find this podcast on Instagram as well beyond pain podcast. And you can find this on YouTube if you want to look.

Joe LaVacca (00:19)
did not.

Joe Gambino (00:29)
at our faces and hear us talk and laugh. Cups of Joe, my God, Joe, give it to me. Man, PT, yeah, underscore PT. You see, this is why I can't add the things about us in here because I mess up the fricking intros. I gotta keep it short and sweet. Look at me. Look at me, I was trying to go back, Joe, I was trying to go back. ⁓

Joe LaVacca (00:37)
Yeah, well, it's at cups of Joe's underscore. Is it a cups of Joe's answer? think yeah, underscore PT. Yeah. Yeah.

You

It's all good, man. It's all good. You did. ⁓

You did put me on call on Instagram this morning. I was intimidated. I did not step up the coffee game. And if anything, I am currently in Colorado. I will be heading to the office right after our podcast today. And Courtney is also in LA soon to be coming back this evening. So when I travel and when Courtney travels, as you can imagine, it's not like you're stocking your fridge. So

Joe Gambino (00:57)
Hahaha.

Mmm.

Joe LaVacca (01:16)
There was very little supplies to even consider upping a coffee game today. So I was actually going to go out and like maybe get, you know, get something, get like a latte or something, you know, so that way I can at least impress you and then pour it in, you know, like one of Courtney's cups, but I don't even have the car. She took the car to the airport. So I would have had to Uber back and forth. It would have been a pain. So I'll try to impress you next week. Where am going to be next week? I'll be back home next week. Maybe I'll try to use my frother next week.

Joe Gambino (01:21)
I see.

Ha ha ha ha ha.

Hmm nah not worth it not worth it

Joe LaVacca (01:45)
and

see if I can whip something up extra special.

Joe Gambino (01:50)
Okay, okay, I like it. I look forward to that. We'll see what you come up with for the, know, we'll let the listeners know how you do. All right, well today we're gonna be talking about disagreements in rehab across the board. So why don't you kick us off and start that convo.

Joe LaVacca (01:55)
Yeah. ⁓

Yeah, so inspired by the events going on over the last 48 hours, how our president and the richest man in the world seem to be in a little bit of disagreements with one another. Things are getting a little chippy, maybe, depending on your political views, entertaining. ⁓

I have been following this and sort of just staring at my phone with my jaw dropped every couple of hours when they get on and start tweeting. It did remind me of probably something that's been on my mind for a little bit. And I'm sure clients listening, PTs listening, healthcare providers listening, and you and me can all relate to

things not always going according to plan in a relationship, even when you seek it out, even when you're paying for service, even when you're giving each other all your undivided attention, communication can break down over really the smallest things, the focus that we'll take today is what to do or how to address disagreements in care. And maybe we can start with what happens

when we are not necessarily in agreement with what a doctor is saying for their client. And I'll start us off with just two examples from this week. One client who I had yet to meet was emailing me about his knee, some persistent knee issues. And he was asking me about all these different treatments that he could potentially try to alleviate his pain.

Now I'm a little bit reluctant to give advice to someone that I've never met or never evaluated. So I just sort of kept kicking questions back to him. Well, what have you been told? What have you tried in the past? And to some degree, maybe this would inform our initial evaluation when we met together, he came back with, well, I finally went to the doctor and my doctor recommended, ⁓ I think it was shockwave to his knee.

And from more recent podcasts that I've been listening to, I sort of pushed back or maybe pushed against people going to shockwave therapy, especially as a first line of defense for any type of pain, specifically, guess, tendon pain. So when I said to him, well, that's interesting. What do you think is the benefit of shockwave or what did your doctor explain to you about shockwave?

Here's the answer I get. It is the number one most common answer. He didn't, I don't know. So I said, okay, imagine coming to physical therapy and having no idea why you were coming, no idea what physical therapy is. What would you do in that case? maybe ask friends, maybe Google, maybe chat GPT, ⁓ maybe at least, you know, come up with the idea that I've been to PT before, so I have some other experiences.

So it is really interesting to me, A, how doctors referral sources can recommend treatments without explaining them and patients nod in acceptance without understanding what they do if they do really anything at all. So have you recently, I know I'm sure you have lots of stories to share, come up against a referral source

Joe Gambino (05:26)
Mm-hmm.

Joe LaVacca (05:44)
recommending a treatment that you don't necessarily agree with.

Joe Gambino (05:48)
⁓ I have not recently had anything, pop up like that. The, the bigger ones that I've seen is, ⁓ people either seeing like, ⁓ another provider either in tandem or prior to me. ⁓ and then this person coming in with information that I feel like does not benefit them in a sense, you know, kind of like a poor understanding and, you know, posture is kind of like one of those examples or.

You know, like the feel or need for, you manual therapy or ultrasound or whatever that is. So there's, there's some nuances there. ⁓ But, you know, I definitely had cases in the past where doctors are prescribing whatever it may be. And I have found very, very often that usually even if it's just, they went to go see for a checkup and they didn't necessarily. ⁓

prescribed anything specific like shockwave or ultrasound or some sort of modality, but then just sent them to physio. There's no real understanding for why they have their pain or what the evaluation from the doctor really was. And they come with a whole lot of questions and sometimes frustration because the provider before just felt like, I was in and out. He did like a couple of little things and then told me to go to physical therapy. Right. So I that kind of falls in line with what you're saying there ⁓ as well.

Joe LaVacca (07:06)
Yeah, I think the most important thing for clinicians listening or for even clients going to different providers is to not be attacked or judged for making any decision in your care, right? That's what you have you and I for. That is what you have your doctor for. So it is not your fault. I do know and I have been guilty of, know, especially in the past, you know, saying, well, absolutely not. Shockwave is a complete waste of time. Why would you do that? There's no evidence for it. Blah, blah.

Joe Gambino (07:17)
you

Joe LaVacca (07:36)
And I realized that that just creates more mistrust. So the kind of question approach has been much more beneficial at just calming down the interaction and then coming up with an exchange. So that client can say, well, the doctor just said we've tried everything and they thought it was worth maybe a shot at shockwave.

To which I tell people there's three factors I always kind of consider. There's time, there's cost, and there is, ⁓ let's even say, narrative. So time, you're gonna have to go find a provider now that does a particular treatment. If it is a quote unquote special treatment, like shockwave.

Joe Gambino (08:13)
Hmm.

Joe LaVacca (08:20)
The shockwave machine costs money. So in theory, if I'm the only one in New York City offering it, I can charge whatever I want. It's a short treatment, so I can do a billion a day. I actually got an email. I don't know if this is where like all this chat GPT stuff gets a little weird for me and this all internet gets weird for me. After I was talking to that client,

I had someone like cold email me on, do I want a shockwave machine like for my office? And basically the selling point was not how patients are getting better. It's the revenue for the clinic that they were able to generate. So I just deleted that email. But then the third one is the narrative, right? So if we have another treatment that's building dependency for you to go across town,

Joe Gambino (08:52)
Hmm.

You

Joe LaVacca (09:10)
to let's say Jersey across state lines or into you know somewhere else some people fly places for this type of stuff all right you're becoming disempowered and the next question of tried everything so this couldn't hurt well actually it can hurt shockwave does hurt I know many people and I know we're picking on shockwave but you know you can insert any treatment here it could be dry needling it could be shockwave it could be ⁓

Surgery, you you name it. It does hurt the treatment is a trauma itself So on top of that you're already in pain You're getting a painful treatment whatever the case is and now you're falling into the fallacy that I did try everything when All I have to do is say great. Give me the list of what you've tried and then it's very similar to what you mentioned well, you know, we worked on my posture. We worked on some manual therapy

Joe Gambino (10:07)
Mm-hmm.

Joe LaVacca (10:08)
⁓ you know, I tried anti-inflammatories, I tried, ⁓ injections. I tried this, I tried that. And I'm like, well, what do want to get back to? ⁓ running, lifting, jumping, cutting. I'm like, well, it doesn't seem like you were ever on a program to progressively run strength train. And what about things like your nutrition, your other health and wellness, your work, your job, your relationships? no, no one's ever asked me about that. Great.

Joe Gambino (10:25)
Mm-hmm.

Joe LaVacca (10:36)
So good news, you haven't tried everything just yet. We can do a lot more, but it is a tricky conversation to manage. Have you ever had like a disagreement that didn't go well?

Joe Gambino (10:49)
⁓ As far as between me and a patient.

Joe LaVacca (10:53)
Yeah, like you're tweeting about the patient, the patient's tweeting about you. You know, they're saying you're the worst PT ever. You would have never made it in PT if it wasn't for them. And you clap back with like a picture of their true coach. Well, you've never been accountable one day in your entire life. And I have the records to prove it. You know, just kind of the stuff we're seeing on CNN, MSNBC and Fox News right now.

Joe Gambino (10:59)
Yeah.

Yeah.

Well, I will say, I mean, there are definitely times where, and I think, ⁓ you know, I kind of brought up posture is one of those things that people come in and usually, you know, a lot of times if someone's seen somebody, a bunch of people in the past, they come in with, you know, they've been told a whole bunch of things in the past and, know, there's, there's kind of the way that they're viewing themselves and the injuries. So I've had people come in with, with, know, like, my posture is causing this pain and that pain. And, you know, which is fine. You know, I never.

When someone's telling me X, Y, and Z, telling them whatever they've learned in the past is incorrect. But, know, I, I acknowledge what they've said. I validated it, but then add a layer on top of it. Right. And kind of my interpretation of it. And there's been a few times where, ⁓ it didn't end up like going poorly, but we just couldn't align on, on values and how I was seeing it. Right. Like they wanted something that was going to target these things. The things that I was talking about didn't, you know, they didn't like it. Right. So then we're like, okay, well.

then maybe I'm not the person that's going to be able to help you. Maybe you need to find somebody who's going to treat you in the way that you have and you're expecting. And you know, that's kind of how the process went and they did and they were able to go see somebody. have no idea how it went for them. But you know, that's kind how I kind of go about those things. And it's not about, you know, again, I'm not the person that's going to be able to see every single person. They're going to be people that are in a fit to see me. And if there is a ⁓ non alignment between my philosophy and the person in front of me's philosophy,

Then it's going to be very hard for them to trust my process to do the things that I'm telling them to do, because if it doesn't, if they don't, you know, man, this is exactly what I need. Then they're probably not going to do it. They're probably going to think that, you know, they're just not going to get the outcomes and then go back to like, well, you didn't treat me the way that I wanted. And it's probably going to blow up in my face more so than it would be if I just had the upfront conversation with someone and said, you know what? I'm not the person for you. So I've had that and I'll give you one, ⁓ one story.

that was kind of similar to the online tweet debates that are going on. I had ⁓ somebody when I was in New York, I was treating out of a buddy's gym in Queens. And one thing that I always do is whenever I have interactions with people and there's like a learning thing, I always use it for content purposes, right? Like I don't like, I'm not gonna go on and be like, I had X, Y, and Z person tell me this and then I do this, right? But you know, we were going over and there was an educational point that I gave them.

Joe LaVacca (13:35)
Yeah, right.

Joe Gambino (13:44)
so I took a like a quote from that put it on Instagram and put it out as content and then I get an email like a Couple hours later or maybe was a text. I was like, my god, you called me out on Instagram blah blah blah and then like went into like ⁓ like, know ⁓ in you like when you were asking me questions in the interview you were asking me about my medical history and you just assume that I had like

all these things like diabetes and stuff like that. Like that's, like you were profiling me. I was like, no, I need to know your medical history to treat you. And I didn't even talk about you in the post. It was just an educational piece that other people could learn from. So I didn't go very well. And obviously we didn't we didn't work together ever again. But yeah, you know, that stuff like that happens, I guess, as part of part of the journey. You know, not everyone sees that. I don't think so.

Joe LaVacca (14:41)
Yeah,

no, totally. mean, and I think this always goes back to the idea too that, hey, look, communication is a two-way street, right? I can be misinterpreted, my client can be misinterpreted, ⁓ and it happens.

even though as much as I try not to let it happen, ⁓ more than I would want it to on a monthly basis. And I had a client recently who was ⁓ referred to me from another provider. And I guess this kind of will segue into, you know, the things that clients want now and we might not necessarily be in agreement with.

So she came in with some long standing foot pain, was a little bit worried about the pain based on her history. So.

long story short, there ended up being, you know, ⁓ misdiagnosis. She ended up with a sort of bone infection had to get, you know, some of the bone actually resected out of her foot. So yeah, very traumatizing. You see multiple providers, you know, everyone's sort of telling you, yeah, go load it, go do this, do your shock wave, do your dry needling, do manual therapy. And then, you know, lo and behold, it turns out she has a bone infection.

So I would be a little bit hesitant to just go all gung-ho and everything. Now the thing that we had the advantage of though is, well, according to her most recent scans that she came in with, there's no infection. Everything had healed well.

Joe Gambino (16:05)
Hmm.

Joe LaVacca (16:19)
But now we're sort of dealing with a foot that has 30 % less of a bone in it. So I don't really think it's fair to say, well, this foot's gonna be 100%. Clearly you just don't have as much tissue there. So I don't know if it'll ever be as strong, as mobile, as flexible. I actually don't even know if it will be pain-free ever. However,

Joe Gambino (16:24)
Mm-hmm.

Joe LaVacca (16:44)
The one thing that she really wanted was a lot of, you know, manual therapy and like in-person coaching. And I told her that, look, with the way my schedule is, and this is, this is a me issue. And I always tell this to clients. This is not your fault that I only work in the city Monday, Tuesday, and Wednesday. This is not your fault. I'm a single dad. This is not your fault. I'm in a long distance relationship. So the best use of our time should probably be.

the skills that I offer and the skills that I'm most comfortable with. Other than that, you can get a massage from somebody much cheaper.

than what you would pay me. So why don't we use that? Or why don't I teach you how to do some self mobilization to your foot? Why don't I teach you how to use your lacrosse ball, tennis ball, foam roller, massage gun, you name it, because I strongly believe that if you know what you're doing, you're going to have a pretty similar outcome than if I did it or you did it or ⁓ you did it to yourself, right? So as we're going through the process, you can already tell like true coach really isn't for her.

Joe Gambino (17:35)
Mm-hmm.

Joe LaVacca (17:52)
She's working with some other trainers. When we would meet, it would always be this like, well, I want more exercise, but I want more manual therapy. But there was so much fear in the movement.

Joe Gambino (17:53)
Mm-hmm.

Joe LaVacca (18:08)
and things that maybe I was addressing backwards, but I was like, look, if you're coming in and saying that you're anxious and you're depressed, I'm not going to be like, well, hey, cool. Let's hop on the bank. Let's go. Let's just hit five minutes on the bike. Thank you for sharing your anxiety and your depression with me. So I always think that those are flags that I really want to address and just make sure people are okay when they open up those things. But again, I think that's really important.

Joe Gambino (18:26)
Mm-hmm.

Joe LaVacca (18:34)
I can teach you a foot exercise in three minutes, but if you're depressed and then going home and not sleeping and not being as productive at work and then not managing your relationships and then, you know, then the funnel starts to trickle down. So anyway, she ends up going back to another doctor and then I get a text message and she says, Hey, look, I just want to say, I'm not going to come back and see you. ⁓ but thanks because, because you told me my pain was all in my head.

⁓ and that you didn't do any like therapy or whatever else. it actually turns out it's not in my head and I need surgery again. So I'm scheduled to go back into surgery, you know, in April. She did not tell me like what she needed surgery on, what they were going to do, how they were going to do it. ⁓ but again, like that was just one of those ideas of she wanted something that either I couldn't provide or didn't think was a priority. And

Joe Gambino (19:15)
Mm-hmm.

Joe LaVacca (19:32)
You know, unfortunately I lost her. I'm hoping that her surgery went well. It was supposed to be a couple of weeks ago. So when we're not managing other personalities like doctors or personal trainers, people obviously come in with either their history, their experience or their preference. And what have you done in that situation when things don't necessarily match up?

Joe Gambino (19:37)
Mm-hmm.

Yeah, it kind of comes back to what I was saying before, where it's just how do we create, know, how can I educate that person? Right. So again, it's not, you know, if it's something that they're looking for, I always try to think about, you know, how can I give people what they want in the context of what they need? So I'll trade from Randphone. That's a great, great quote. So if somebody is like, yeah, you know, well, I really value this.

Joe LaVacca (20:14)
Mm-hmm.

Joe Gambino (20:22)
whatever it is, maybe it's a type of workout, maybe it's a particular modality, you know, like, I mean, I can't do manual work, maybe they need something very, you know, they want something very specific. And I don't feel like it's the highest priority, but I know that if it was in there in some degree, that it would create value for that person and buy in and it most likely help the outcomes, even though my bias says that it's probably not going to be the biggest thing that helps. So I will find ways as long as everything else fits and.

they jive with my overall philosophy and I feel like I can truly help that person. I will find ways to sprinkle in the little things that they like and then make sure that it's wrapped around all the stuff that they need in order to help make sure that everything is kind of as strong of a program or a rehab plan or whatever that looks like for that person to get them from where they are to where they want to go. So that is in essence, as long as they are a true fit for what I do, that's how I kind of work those things in and I have those conversations because I always think it's really important to.

make that person feel hurt, right? Like if someone came to me, it was like, yeah, hey, Joe, I really, really, you know, need to have squats in my program. Like I love them so much. And but then I'm like, well, you know, like with all their pain and stuff like that, maybe it doesn't, it doesn't make sense. ⁓ well, I've probably found some sort of unique way, you know, maybe it's like a shorter range of motion or it's a box squat or something, right? That's going to make him seem like they have it in or maybe like high intensity stuff, but they're not quite there. How can I modify something?

to get their heart rate up and give them what they want sooner. And if it is something like, hey, you know, they do like, I don't know, mobilization with bands and I don't really think they need it, I can still find ways to slide it into their program as like a warmup or something like that to make it feel like they're getting what they need. Cause I think that person needs to be heard. If you just say like, nah, you know, that's not the best thing for you. I'm going to give you something else and just completely ignore what you said that you wanted or felt like you needed. I think that's going to cause friction between us. And then again, I think it's going to end up not helping that person in the long run. So.

That's a quote that I always come back to as if I can give someone what they feel like they want, but also give them what they need. And I think that's the kind of best case scenario for me, because everyone always has their own personal preferences or thoughts on what they feel like they need. And you have to trust that they do know their bodies a little bit as well.

Joe LaVacca (22:36)
Right. Yeah. And maybe we should call the podcast that because I think we both reference that phrase from my grand phone so much. ⁓ What you want, what you need. ⁓ But no, think, I think you put it really well. I, I, I do think that, you know, while it is our job to guide and be as, let's say amicable in the process, it isn't our job to always say yes to something either.

Joe Gambino (22:42)
Hahaha

Yes.

Joe LaVacca (23:04)
So there is that sort of balance where going back to the idea of what is my skill set. And if people do want manual therapy, then okay, I actually tell them, you know, I understand why you want that. It makes you feel better. It shifts. Okay. And honestly, this is probably where I still put on my rock tape hat just a little bit.

because the beautiful thing about the rock tape courses we used to do, and these were the instrument assisted courses. This wasn't the taping courses or anything else like that. Rock tape did have a, and they still do, think, instrument assisted course for manual input, let's say. But the basis was more, we weren't doing anything to the tissue. We were sort of just doing more to your nervous system.

Joe Gambino (23:50)
Mm-hmm.

Joe LaVacca (23:51)
Because your nervous system adapts very quickly a lot of these treatments would go very quickly and there would be super easy to do so in the stance of manual therapy, I probably would say is more often than not what people you know think they need to get better. I'll really implement a lot of the test and retest with them. So your shoulder hurts your back hurts your knee hurts. Okay, I'm gonna do this super light treatment.

Joe Gambino (24:18)
Mm-hmm.

Joe LaVacca (24:19)
for about 30 to 60 seconds and then we're going to test and retest your motion again. How did it go?

more often than not, feels even a little bit better. Okay, great. Well, now we know we can make some sort of quick changes with very quick inputs. You don't need to roll around on the floor for, you know, 25 minutes, or you don't need to maybe do so much stretching before your workout, because our assessment is also showing that you're not moving through your knee. ⁓ you are showing signs of weakness on this side. You are showing signs of atrophy in the shoulder. So the more time we spend doing

things that won't address those specific qualities, we're missing out on our session together. So I try to show people how quickly that they can change their perceptions or change their nervous systems with just very specific inputs. And that's usually pretty empowering because then it can take up a lot less of our session versus 25-45 minutes of full body work.

And that's obviously not what you or I do. I mean, you're not even really capable of doing that anymore. And I just choose not to ⁓ in the environment that we're at. So it's about like...

I think bringing that back into the empowerment, always asking, well, what do you think those treatments do? Like a client that I'm going to see today, she asked me if I do adjustments. Um, cause obviously the clinic on that lots of chiropractors. said, well, I mean, I guess I could do a couple. What were you thinking? And you know, the narrative of, yeah, I just feel like my back is out and you know, I really could use someone to put it back in. And I was like, great, why don't you tell me a little bit more about that? What makes it go out? How does it, you know, how does a technique I do

Joe Gambino (25:39)
Mm-hmm.

Mm-hmm.

Joe LaVacca (26:00)
put it back in. You know, I just came back to, well, you know, I hear that sound and I'm like, well, yeah, my shoulder makes a sound. My knee makes a sound. My wrists make sounds when I move. Does that mean that they go in and out? no, of course not. Okay. So now maybe this is also just one of those things that joints make sounds. Do you remember who first? So then you can kind of start like actually peeling back a little bit more of the layers.

And then the end of the conversation was I had never even thought about any of this. I was just going and getting pop click and I was like, great, I can, I'd probably teach you how to do it to yourself if it really gives you benefit. But then what we want to think about is then saying, if you are feeling better.

Joe Gambino (26:30)
Hmm.

Joe LaVacca (26:39)
How can we now load you, move you, groove you, teach you something that's gonna now move you further, further away from being dependent on someone else? So she was actually really excited about that idea. And she was like, wow, this is, really appreciate this conversation. So I do think that conversations are there to be had. It's just a matter of how we approach them. So clients, know, ask questions, clinicians ask questions.

Joe Gambino (26:43)
Mm-hmm.

Mm-hmm.

Yes.

Joe LaVacca (27:04)
and then just give some space to listen to each other. And then I think it'll be a lot smoother process to then collaborate on care because you put it beautifully. think we think we're experts in people's body, but we'll never be more expert than them. And it is their lived experience that we're trying to change, not force our experience on them. So I thought your point was perfect.

Joe Gambino (27:09)
Mm-hmm.

Exactly.

Thank you. And I think that is a perfect way to wrap things up. So I'm not even going to add on top of that. I will just let you take us home.

Joe LaVacca (27:37)
All

right. Well, we hope you enjoyed this episode of the Beyond Pain podcast. Joe, love you listeners. We love you. And don't forget to tune in next week where hopefully we'll be inspired by more political madness. Take care, everyone.

Joe Gambino (27:49)
Yeah.